NICU Antibiotic Guides Improve Prescribing, Reduce Sepsis

Marcia Frellick

July 31, 2017

Antimicrobial stewardship guidelines significantly cut the number of late-onset sepsis cases in a neonatal intensive care unit (NICU), a study has found.

There was an average reduction of 2.65 late-onset sepsis (blood or cerebrospinal fluid infection at more than 72 hours of life) evaluations and prescription events per year per provider as a result of the intervention.

Nneka I. Nzegwu, DO, an attending physician in neonatal-perinatal medicine at Brigham and Women's Hospital in Boston, Massachusetts, and colleagues report their findings in an article published online July 27 in Infection Control & Hospital Epidemiology.

Late-onset sepsis is a leading cause of death among preterm infants, the researchers write. "It can be difficult to distinguish infections from other disease symptoms in pre-term infants. Timely interventions for a true infection are critical, but unnecessary exposures to antibiotics can result in antimicrobial resistance, increased risk for serious health conditions, or even death," Dr Nzegwu said in a news release. "We are encouraged that antimicrobial stewardship in the NICU is gaining focus and attention." Some children's hospitals have successfully implemented antimicrobial stewardship programs, but programs that are NICU-specific are rare.

In 2011, 1 year before the stewardship program started, the NICU at Yale-New Haven Children's Hospital in Connecticut had an average of 21.2 late-onset sepsis evaluations per 100 days, which dropped to 8.4 evaluations per 100 days by 2016 (P < .0001).

The primary outcome was days of antibiotic therapy both for all and for select antimicrobials. Antibiotic use was already low before the study and fell by 14.7 days of antibiotic therapy per 1000 patient days, a difference that was not statistically significant (P = .669). Still, researchers showed a statistically significant reduction in ampicillin use, the most frequently prescribed antibiotic in that NICU. Its use fell significantly, decreasing by 22.5 days of antibiotic therapy per 1000 patient days (P = .037).

This was likely a result of "limiting the duration of postoperative antibiotic prophylaxis, eliminating the need for antibiotic prophylaxis after a single, uncomplicated urinary tract infection, and setting limitations for duration of treatment for [necrotizing enterocolitis] and early-onset clinical sepsis," the authors write.

The guidelines reduced variability in treating common infections, which helped physicians adhere to best practices 98.75% of the time. No infants with clinical infections developed a recurrent infection after 7 days off their antibiotic.

A neonatal-perinatal medicine fellow led the team that implemented the program in the 54-bed, level 4 NICU. Other members included a neonatologist, a pediatric infectious diseases physician, a NICU registered nurse, a pediatric clinical pharmacist,  and an infection control practitioner. Core members completed training modules on antimicrobial stewardship. Participation was voluntary, and no funding was directly applied to the program's design, implementation, or maintenance.

Guidelines were posted to the hospital's intranet, and the electronic health records system generated a daily report of all prescribed antimicrobials. Stewardship team members reviewed the reports, which allowed timely prescriber oversight and feedback.

A pediatric clinical pharmacist attended patient care rounds to help reinforce key concepts.

The authors have disclosed no relevant financial relationships.

Infect Control Hosp Epidemiol. Published online July 27, 2017. Full text

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