Reduction in the use of diagnostic tests in infants with risk factors for early-onset neonatal sepsis does not delay antibiotic treatment
BACKGROUND: Despite a low positive predictive value, diagnostic tests such as complete blood count (CBC) and C-reactive protein (CRP) are commonly used to evaluate whether infants with risk factors for early-onset neonatal sepsis (EOS) should be treated with antibiotics.
STUDY DESIGN: We investigated the impact of implementing a protocol aiming at reducing the number of diagnostic tests in infants with risk factors for EOS in order to compare the diagnostic performance of repeated clinical examination with CBC and CRP measurement. The primary outcome was the time between birth and the first dose of antibiotics in infants treated for suspected EOS.
RESULTS: Among the 11,503 infants born at ≥35 weeks during the study period, 222 were treated with antibiotics for suspected EOS. The proportion of infants receiving antibiotics for suspected EOS was 2.1% and 1.7% before and after the change of protocol (p = 0.09). Reduction of diagnostic tests was associated with earlier antibiotic treatment in infants treated for suspected EOS (hazard ratio 1.58; 95% confidence interval [CI] 1.20–2.07; p <0.001), and in infants with neonatal infection (hazard ratio 2.20; 95% CI 1.19–4.06; p = 0.01). There was no difference in the duration of hospital stay nor in the proportion of infants requiring respiratory or cardiovascular support before and after the change of protocol.
CONCLUSION: Reduction of diagnostic tests such as CBC and CRP does not delay initiation of antibiotic treatment in infants with suspected EOS. The importance of clinical examination in infants with risk factors for EOS should be emphasised.
- Weston EJ, Pondo T, Lewis MM, Martell-Cleary P, Morin C, Jewell B, et al. The burden of invasive early-onset neonatal sepsis in the United States, 2005–2008. Pediatr Infect Dis J. 2011;30(11):937–41.
- Stoll BJ, Hansen NI, Sanchez PJ, Faix RG, Poindexter BB, Van Meurs KP, et al. Early onset neonatal sepsis: the burden of group B Streptococcal and E. coli disease continues. Pediatrics. 2011;127(5):817–26.
- Kind C. Care of neonates whose mothers are colonised with group B streptococci. http://www.neonet.ch 2002.
- Polin RA, Committee on F, Newborn: Management of neonates with suspected or proven early-onset bacterial sepsis. Pediatrics. 2012;129(5):1006–15.
- Verani JR, McGee L, Schrag SJ. Prevention of perinatal group B streptococcal disease – revised guidelines from CDC, 2010. MMWR Recommendations and reports: Morbidity and mortality weekly report Recommendations and reports / Centers for Disease Control 2010;59(RR-10):1–36.
- Benitz WE, Han MY, Madan A, Ramachandra P. Serial serum C-reactive protein levels in the diagnosis of neonatal infection. Pediatrics. 1998;102(4):E41.
- Escobar GJ, Li DK, Armstrong MA, Gardner MN, Folck BF, Verdi JE, et al. Neonatal sepsis workups in infants >/=2000 grams at birth: A population-based study. Pediatrics. 2000;106(2 Pt 1):256–63.
- Ottolini MC, Lundgren K, Mirkinson LJ, Cason S, Ottolini MG. Utility of complete blood count and blood culture screening to diagnose neonatal sepsis in the asymptomatic at risk newborn. Pediatr Infect Dis J. 2003;22(5):430–4.
- Newman TB, Puopolo KM, Wi S, Draper D, Escobar GJ. Interpreting complete blood counts soon after birth in newborns at risk for sepsis. Pediatrics. 2010;126(5):903–9.
- Murphy K, Weiner J. Use of leukocyte counts in evaluation of early-onset neonatal sepsis. Pediatr Infect Dis J. 2012;31(1):16–9.
- Hornik CP, Benjamin DK, Becker KC, Benjamin DK, Jr., Li J, Clark RH, et al. Use of the complete blood cell count in early-onset neonatal sepsis. Pediatr Infect Dis J. 2012;31(8):799–802.
- Ascher DP, Becker JA, Yoder BA, Weisse M, Waecker NJ, Heroman WM, et al. Failure of intrapartum antibiotics to prevent culture-proved neonatal group B streptococcal sepsis. J Perinatol. 1993;13(3):212–6.
- Bromberger P, Lawrence JM, Braun D, Saunders B, Contreras R, Petitti DB. The influence of intrapartum antibiotics on the clinical spectrum of early-onset group B streptococcal infection in term infants. Pediatrics. 2000;106(2 Pt 1):244–50.
- Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recommendations and reports: Morbidity and mortality weekly report Recommendations and reports / Centers for Disease Control. 2002;51(RR-11):1–22.
- Stocker M, Berger C, McDougall J, Giannoni E, Taskforce for the Swiss Society of N, the Paediatric Infectious Disease Group of S: Recommendations for term and late preterm infants at risk for perinatal bacterial infection. Swiss Med Wkly. 2013;143:w13873.
- Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589–96.
- Gaieski DF, Mikkelsen ME, Band RA, Pines JM, Massone R, Furia FF, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045–53.
- Kermorvant-Duchemin E, Laborie S, Rabilloud M, Lapillonne A, Claris O. Outcome and prognostic factors in neonates with septic shock. Pediatr Crit Care Med. 2008;9(2):186–91.
- Escobar GJ. What have we learned from observational studies on neonatal sepsis? Pediatr Crit Care Med. 2005;6(3 Suppl):S138–45.
- Hashavya S, Benenson S, Ergaz-Shaltiel Z, Bar-Oz B, Averbuch D, Eventov-Friedman S. The use of blood counts and blood cultures to screen neonates born to partially treated group B Streptococcus-carrier mothers for early-onset sepsis: is it justified? Pediatr Infect Dis J. 2011;30(10):840–3.
- Lieberman E, Lang JM, Frigoletto F, Jr., Richardson DK, Ringer SA, Cohen A. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics. 1997;99(3):415–9.
- Puopolo KM, Draper D, Wi S, Newman TB, Zupancic J, Lieberman E, et al. Estimating the probability of neonatal early-onset infection on the basis of maternal risk factors. Pediatrics. 2011;128(5):e1155–63.