Management of Late-Preterm and Term Neonates at Risk for Early-Onset Sepsis.

Abstract

The management of patients at risk for a low-frequency but serious illness poses many challenges for health professionals. Neonatal early-onset sepsis (EOS) in late-preterm and term neonates is a classic example of such a low-frequency serious condition. Faced with the possibility that such an infant, even if well appearing, can develop EOS, clinicians have traditionally erred on the side of treating with antibiotics until the EOS is ruled out by some combination of a continued normal clinical examination, negative blood cultures, and negative rapid diagnostic test results. A liberal antibiotic treatment strategy resulted in a large number (as high as several hundreds) of infants being needlessly treated with antibiotics for every neonate with true EOS. This strategy has been relatively easy for clinicians to follow because the burden of administering a short course of antibiotics is relatively low, and the adverse effects of antibiotics (eg, emergence of antibiotic resistance, altered microbiome) are not immediately apparent or dramatic. In contrast, most clinicians have experienced in their careers or heard about newborn infants with catastrophic consequences or even death from EOS, especially during an era when group B streptococcal infection was more common than today. Thus, there was significant overtreatment of infants as well as much interinstitutional and interclinician variation in the frequency of antibiotic use for neonates at risk for EOS. In recent years, this calculus of weighing of a possible catastrophic event that occurs at low frequency against the invisible and delayed hazards of antibiotics has changed. Nationally and internationally, alarms are being raised about the hazards of antibiotics, the widespread emergence of bacterial resistance to antibiotics, and the drying up of …