NEW YORK (Reuters Health) – Clinical practice in management of early-onset sepsis (EOS) in newborns varies widely across Europe, North America and Asia, new survey results show.
National guidelines also disagree on when to start antibiotics in low-risk situations, and how to decide to stop therapy in high-risk scenarios, Dr. Wendy van Herk of Erasmus MC University Medical Center-Sophia Children’s Hospital in Rotterdam, the Netherlands, and colleagues found.”
A discussion leading to terms of a threshold to treat neonates with low infection risk, prospective studies ofstrategies regarding early discontinuation of unnecessary antibiotic therapy with safety endpoints acknowledging different backgrounds of health care systems, and clear and concise guidelines followed by research to study the impact are mandatory to improve management of term and late preterm infants at risk for EOS,” they write in their report, online January 13 in The Pediatric Infectious Disease Journal.
Up to 15% of term and late-preterm neonates are evaluated for suspected EOS, and 10% receive intravenous antibiotics within the first three days of life, the researchers note. But the incidence of culture-proven EOS in term and late-preterm newborns is less than 0.1%, they add.
To investigate current management of suspected EOS, the researchers surveyed pediatricians and neonatologists and reviewed guidelines from Canada, the United States, the United Kingdom, Switzerland and Belgium. A total of 439 clinicians responded to the survey.
In response to a question about whether they would start antibiotic treatment in a scenario rated “low risk” for EOS, 29% of physicians said they would, 26% would not, and 45% said they would start treatment if the patients’ laboratory markers were abnormal. Nearly all of the respondents (99%) said they would initiate antibiotics in a high-risk scenario.
In the low-risk situation, 89% said they would stop antibiotic treatment before 72 hours. In the high-risk scenario, 35% said they would stop antibiotics before 72 hours, 56% said they would continue treatment for five to seven days, and 9% said they would treat patients for more than seven days.
Overall, 31% of the survey respondents said they would base their decision to start antibiotic treatment on laboratory investigations, while 72% said they would do so when deciding to continue treatment. Most said they would use complete blood count (CBC) and C-reactive protein (CRP), while a small minority said they would use newer inflammation markers including procalcitonin (PCT) and interleukins.
While all the guidelines reviewed recommended treating newborns with clinical signs indicating infection, and re-evaluating whether patients needed more antibiotics at 36 to 48 hours, they did not provide specific advice on treatment when newborns had prolonged clinical signs of infection or high levels of infection markers. All guidelines recommended using CBC or CRP, while only one included PCT.
Dr. van Herk and colleagues also compared the guidelines for each country with the survey responses of physicians from that country, and found most followed national guidelines on when to start or discontinue antibiotics.
“The diversity with regards to duration of antibiotic therapy in higher risk situations raises the question, what are safe strategies to minimize duration of antibiotic therapy without under-treatment of truly septic neonates?” the authors write. “Currently, the duration of antibiotic therapy is controversial even for proven infection. Prospective, international, multicenter trials studying newer infection markers with a safety endpoint may be helpful in answering this question.”