Repeated clinical assessments surpass a laboratory test screening approach for early onset sepsis

Abstract

Frymoyer et al report the second, sustainability phase of a quality improvement initiative that was begun 5 years earlier at the Lucile Packard Children’s Hospital at Stanford. The initiative replaces the approach of screening laboratory tests and empiric antibiotic treatment for infants at perceived risk for early onset sepsis (EOS) with a solely clinical approach. Managing >20 000 neonates born at >35 weeks’ gestation over the intervention and sustainability phases, laboratory testing and ampicillin use declined substantially in phase 1, was sustained in phase 2, and the approach was safe. With the current extremely low incidence of EOS of 0.34 cases per 1000 live births at >35 weeks’ gestation (7 cases in the 5-year study period) it would be difficult to imagine re-instating the imperfect laboratory screening/empiric therapy approach. Weighing the downsides of screening tests and empiric therapy, the equally safe clinical approach should be considered superior. There are 2 caveats. The defensive culture of neonatal care and parents’ lack of awareness of infection risks during the first days of life should change. Not every instance can be prevented or predicted, but vigilance can be promised. Second, the clinical observation approach in the Stanford initiative and wherever the approach is adopted, is not nothing. It is deliberative, with a prescribed 10 examinations with recordings by a nurse in the first 24 hours of life and was found to be safe when the nursing ratio to neonate-mother couplet in the postpartum unit was 1:3. Article page 263 ▸ Sustainability of a Clinical Examination-Based Approach for Ascertainment of Early-Onset Sepsis in Late Preterm and Term NeonatesThe Journal of PediatricsVol. 225PreviewWe demonstrated the sustained impact over a 5-year period of a clinical examination-based approach to identification of early-onset sepsis in late preterm and term neonates at our hospital. To date, more than 20 000 neonates have been safely managed using this approach, resulting in a 63% reduction in antibiotic use. Full-Text PDF