Abstract
The onset of bloody stools in neonates often results in antibiotic treatment for suspected necrotizing enterocolitis (NEC). Food protein-induced allergic proctocolitis (FPIAP) is an often-neglected differential diagnosis. We performed a retrospective analysis of antibiotic exposure at our tertiary center from 2011 to 2020 that included three time periods of differing antimicrobial stewardship goals. We compared these data with the conventional treatment guidelines (modified Bell’s criteria). In our cohort of 102 neonates with bloody stools, the length of antibiotic exposure was significantly reduced from a median of 4 to 2 days. The proportion of treated neonates decreased from 100% to 55% without an increase in negative outcomes. There were 434 antibiotic days. Following a management strategy according to modified Bell’s criteria would have led to at least 780 antibiotic days. The delayed initiation of antibiotic treatment was observed in 7 of 102 cases (6.9%). No proven NEC case was missed. Mortality was 3.9%. In conclusion, with FPIAP as a differential diagnosis of NEC, an observational management strategy in neonates with bloody stools that present in a good clinical condition seems to be justified. This may lead to a significant reduction of antibiotic exposure. Further prospective, randomized trials are needed to prove the safety of this observational approach.
Highlights
A total of 114 neonates with bloody stools were hospitalized in our institution from
A total of 43 of the remaining 102 neonates were stratified into Bell IB (42.2%), 50 (49.0%) into Bell II (Bell IIA: 25 (24.5%), Bell IIB: 25 (24.5%)) and 9 (8.8%) into Bell III based on clinical signs as well as radiological and laboratory findings (Tables 1 and 2)
During the 10 year study period, a significant reduction of antibiotic exposure in neonates with bloody stools that were hospitalized in our neonatal intensive care units (NICUs) or neonatal ward was observed without an increase of negative outcome
Summary
The onset of bloody stools often results in the initiation of diagnostic procedures and preventive treatment for possible necrotizing enterocolitis (NEC). Detection of high-risk neonates presenting with NEC as well as immediate initiation of therapy is crucial for the improvement of patients’ outcomes and mortality rates [1,2,3]. The differential diagnosis of hematochezia is broad, including life-threatening diseases such as NEC or Hirschsprung’s disease/Hirschsprung-associated enterocolitis (HAEC) or intestinal malrotation with midgut volvulus. But less serious, differentials include food protein-induced allergic proctocolitis (FPIAP), food protein-induced enterocolitis syndrome (FPIES), gastrointestinal infections, anal fissures and swallowed maternal blood [1,4,5,6,7,8]. NEC and FPIAP are the most common and may serve as examples on each side of the severity spectrum
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