RESUMO
OBJECTIVE: To determine the prevalence of C-reactive protein (CRP) use in early-onset sepsis (EOS) evaluations in neonatal intensive care units (NICUs) across the US over time and to determine the association between CRP use and antibiotic use. STUDY DESIGN: A retrospective cohort study of NICUs contributing data to Premier Healthcare Database from 2009 through 2021. EOS evaluation was defined as a blood culture charge ≤ 3 days after birth. CRP use for each NICU was calculated as the proportion of infants with a CRP test obtained ≤ 3 days after birth among those undergoing an EOS evaluation and categorized as, low (<25%); medium-low (25 to < 50%), medium-high (50 to < 75%), and high (≥75%). Outcomes included antibiotic use and mortality ≤ 7 days after birth. RESULTS: Among 572 NICUs, CRP use varied widely and was associated with time. The proportion of NICUs with high CRP use decreased from 2009 to 2021 (24.7% vs 17.4%, P < .001), and those with low CRP use increased (47.9% vs 64.8%, P < .001). Compared with low-use NICUs, high-use NICUs more frequently continued antibiotics > 3 days (10% vs 25%, P < .001). This association persisted in multivariable-adjusted regression analyses (adjusted risk ratio 1.95, 95%CI 1.54, 2.48). Risk of mortality was not different in high-use NICUs (adjusted risk difference -0.02%, 95%CI -0.04%, 0.0008%). CONCLUSIONS: CRP use in EOS evaluations varied widely across NICUs. High CRP use was associated with prolonged antibiotic therapy but not mortality ≤ 7 days after birth. Reducing routine CRP use in EOS evaluations may be a target for neonatal antibiotic stewardship efforts.
Assuntos
Antibacterianos , Proteína C-Reativa , Unidades de Terapia Intensiva Neonatal , Sepse Neonatal , Humanos , Proteína C-Reativa/análise , Antibacterianos/uso terapêutico , Estudos Retrospectivos , Recém-Nascido , Feminino , Masculino , Sepse Neonatal/tratamento farmacológico , Sepse Neonatal/sangue , Estados Unidos/epidemiologia , Gestão de AntimicrobianosRESUMO
OBJECTIVES: To determine performance of C-reactive protein (CRP) in the diagnosis of early-onset sepsis, and to assess patient outcomes with and without routine use of CRP. STUDY DESIGN: This was a retrospective cohort study of infants admitted to 2 neonatal intensive care units. CRP was used routinely in early-onset sepsis evaluations during 2009-2014; this period was used to determine CRP performance at a cut-off of ≥10 mg/L in diagnosis of culture-confirmed early-onset sepsis. Routine CRP use was discontinued during 2018-2020; outcomes among infants admitted during this period were compared with those in 2012-2014. RESULTS: From 2009 to 2014, 10â134 infants were admitted; 9103 (89.8%) had CRP and 7549 (74.5%) had blood culture obtained within 3 days of birth. CRP obtained ±4 hours from blood culture had a sensitivity of 41.7%, specificity 89.9%, and positive likelihood ratio 4.12 in diagnosis of early-onset sepsis. When obtained 24-72 hours after blood culture, sensitivity of CRP increased (89.5%), but specificity (55.7%) and positive likelihood ratio (2.02) decreased. Comparing the periods with (n = 4977) and without (n = 5135) routine use of CRP, we observed lower rates of early-onset sepsis evaluation (74.5% vs 50.5%), antibiotic initiation (65.0% vs 50.8%), and antibiotic prolongation in the absence of early-onset sepsis (17.3% vs 7.2%) in the later period. Rate and timing of early-onset sepsis detection, transfer to a greater level of care, and in-hospital mortality were not different between periods. CONCLUSIONS: CRP diagnostic performance was not sufficient to guide decision-making in early-onset sepsis. Discontinuation of routine CRP use was not associated with differences in patient outcomes despite lower rates of antibiotic administration.
Assuntos
Proteína C-Reativa , Sepse , Recém-Nascido , Humanos , Proteína C-Reativa/análise , Estudos Retrospectivos , Sepse/tratamento farmacológico , Antibacterianos/uso terapêutico , BiomarcadoresRESUMO
OBJECTIVES: To provide a comprehensive assessment of case stratification by the Neonatal Early-Onset Sepsis (EOS) Calculator, a novel tool for reducing unnecessary antibiotic treatment. STUDY DESIGN: A systematic review with individual patient data meta-analysis was conducted, extending PROSPERO record CRD42018116188. Cochrane, PubMed/MEDLINE, EMBASE, Web of Science, Google Scholar, and major conference proceedings were searched from 2011 through May 1, 2020. Original data studies including culture-proven EOS case(s) with EOS Calculator application, independent from EOS Calculator development, and including representative birth cohorts were included. Relevant (individual patient) data were extracted from full-text and data queries. The main outcomes were the proportions of EOS cases assigned to risk categories by the EOS Calculator at initial assessment and within 12 hours. Evidence quality was assessed using Newcastle-Ottawa scale, Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies, and GRADE tools. RESULTS: Among 543 unique search results, 18 were included, totaling more than 459â000 newborns. Among 234 EOS cases, EOS Calculator application resulted in initial assignments to (strong consideration of) empiric antibiotic administration for 95 (40.6%; 95% CI, 34.2%-47.2%), more frequent vital signs for 36 (15.4%; 95% CI, 11.0%-20.7%), and routine care for 103 (44.0%; 95% CI, 37.6%-50.6%). By 12 hours of age, these proportions changed to 143 (61.1%; 95% CI, 54.5%-67.4%), 26 (11.1%; 95% CI, 7.4%-15.9%), and 65 (27.8%; 95% CI, 22.1%-34.0%) of 234 EOS cases, respectively. CONCLUSIONS: EOS Calculator application assigns frequent vital signs or routine care to a substantial proportion of EOS cases. Clinical vigilance remains essential for all newborns.
Assuntos
Sepse Neonatal , Sepse , Antibacterianos/uso terapêutico , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Sepse Neonatal/diagnóstico , Sepse Neonatal/tratamento farmacológico , Sepse Neonatal/epidemiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Sepse/diagnóstico , Sepse/tratamento farmacológico , Revisões Sistemáticas como AssuntoRESUMO
We 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.
Assuntos
Triagem Neonatal/métodos , Sepse Neonatal/diagnóstico , Antibacterianos/uso terapêutico , Estudos de Coortes , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Análise de Séries Temporais Interrompida , Sepse Neonatal/tratamento farmacológico , Gravidez , Melhoria de QualidadeAssuntos
Corioamnionite , Sepse Neonatal , Sepse , Feminino , Humanos , Recém-Nascido , Gravidez , Fatores de RiscoRESUMO
OBJECTIVE: To test the hypothesis that neonatal intensive care unit (NICU)-specific changes in patent ductus arteriosus (PDA) management are associated with changes in local outcomes in preterm infants. STUDY DESIGN: This retrospective repeated-measures study of aggregated data included infants born 400-1499 g admitted within 2 days of delivery to NICUs participating in the California Perinatal Quality Care Collaborative. The period 2008-2015 was divided into four 2-year epochs. For each epoch and NICU, we calculated proportions of infants receiving cyclooxygenase inhibitor (COXI) or PDA ligation and determined NICU-specific changes in these therapies between consecutive epochs. Generalized estimating equations were used to examine adjusted relationships between NICU-specific changes in PDA management and contemporaneous changes in local outcomes. RESULTS: We included 642 observations of interepoch change at 119 hospitals summarizing 32 094 infants. NICU-specific changes in COXI use and ligation showed significant dose-response associations with contemporaneous changes in adjusted local outcomes. Each percentage point decrease in NICU-specific proportion treated with either COXI or ligation was associated with a 0.21 percentage point contemporaneous increase in adjusted local in-hospital mortality (95% CI 0.06, 0.33; P = .005) among infants born 400-749 g. In contrast, decreasing NICU-specific ligation rate among infants 1000-1499 g was associated with decreasing adjusted local bronchopulmonary dysplasia (P = .009) and death or bronchopulmonary dysplasia (P = .01). CONCLUSIONS: NICU-specific outcomes of preterm birth co-vary with local PDA management. Treatment for PDA closure may benefit some infants born 400-749 g. Decreasing NICU-specific rates of COXI use or ligation were not associated with increases in local adjusted rates of examined adverse outcomes in larger preterm infants.
Assuntos
Displasia Broncopulmonar/mortalidade , Permeabilidade do Canal Arterial/mortalidade , Permeabilidade do Canal Arterial/terapia , Mortalidade Hospitalar , Unidades de Terapia Intensiva Neonatal/organização & administração , Nascimento Prematuro , Displasia Broncopulmonar/diagnóstico por imagem , Displasia Broncopulmonar/terapia , California , Causas de Morte , Estudos de Coortes , Inibidores de Ciclo-Oxigenase/uso terapêutico , Permeabilidade do Canal Arterial/diagnóstico por imagem , Feminino , Humanos , Recém-Nascido , Ligadura/métodos , Masculino , Análise Multivariada , Avaliação de Resultados em Cuidados de Saúde , Gravidez , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVE: To explore the association between red blood cell transfusion and necrotizing enterocolitis (NEC) in a neonatal intensive care unit with liberal transfusion practices. STUDY DESIGN: A retrospective cohort study was conducted for all infants weighing <1500 g who received at least 1 packed red blood cell transfusion between January 2008 and June 2013 in a tertiary neonatal intensive care unit. The primary outcome was NEC, defined as Bell stage II or greater. The temporal association of NEC and transfusion was assessed using multivariate Poisson regression. RESULTS: The study sample included 414 very low birth weight infants who received 2889 consecutive red blood cell transfusions. Twenty-four infants (5.8%) developed NEC. Four cases of NEC occurred within 48 hours of a previous transfusion event. Using multivariate Poisson regression, we did not find evidence of a temporal association between NEC and transfusion (P = .32). CONCLUSION: There was no association between NEC and red blood cell transfusion. Our results differ from previous studies and suggest that the association between NEC and transfusion may be contextual.
Assuntos
Enterocolite Necrosante/etiologia , Transfusão de Eritrócitos/efeitos adversos , Terapia Intensiva Neonatal/organização & administração , Peso ao Nascer , Feminino , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro/terapia , Recém-Nascido de muito Baixo Peso , Unidades de Terapia Intensiva Neonatal , Masculino , Análise Multivariada , Distribuição de Poisson , Estudos Retrospectivos , Centros de Atenção Terciária/organização & administração , Fatores de Tempo , Resultado do TratamentoRESUMO
Los criterios para la predicción del bajo riesgo de infección bacteriana grave en lactantes febriles son imperfectos, particularmente en los lactantes menores de 1 mes de edad. Nosotros intentamos validar nuevos criterios para la evaluación de recién nacidos febriles. Fueron estudiados 288 recién nacidos con evaluación completa de sepsis, los cuales fueron prospectivamente clasificados de bajo riesgo si tenían buena apariencia, eran previamente sanos, no tuvieron signos de infección focal ni fiebre persistente, recurrente o elevada (≥ 39,0 ºC), conteo de leucocitos sanguíneos de 5-20 x 109/L, velocidad de sedimentación globular, < 20 mm/h y < 10,000 leucocitos/mL de orina. Estos criterios fueron comparados con los criterios de Rochester y las tasas de falsos positivos y falsos negativos se compararon mediante el test de la Z. En 68 recién nacidos (23,6 por ciento) encontramos infección bacteriana grave y, bacteriemia, en 22 (7,6 por ciento). Solo 5 de 68 (uno con bacteriemia) de estos recién nacidos fueron clasificados de bajo riesgo usando los nuevos criterios (tasa de falsos negativos del 7,3 por ciento; 95 por ciento intervalo de confianza 4,7-C11,7 por ciento); mientras que 15 de 68 (3 con bacteriemia) fueron clasificados como bajo riesgo usando los criterios de Rochester (tasa de falsos negativos 22,0 por ciento, 95 por ciento intervalo de confianza 17,5-C27,4 por ciento; p = 0,03 en comparación con los nuevos criterios). La tasa de falsos negativos más baja fue contrarrestada por una tasa de falsos positivos mayor (65,9 por ciento frente a 37,7 por ciento). Los nuevos criterios para bajo riesgo de infección bacteriana grave en recién nacidos febriles tuvieron una tasa de falsos negativos significativamente más baja que los clásicos criterios de Rochester. Estos criterios pueden facilitar el cuidado apropiado a los lactantes menores de un mes de edad que presentan una historia de fiebre.
Criteria for prediction of low risk for serious bacterial infection (SBI) in febrile infants are imperfect, particularly in infants younger than 1 month. We sought to validate new criteria for evaluation of febrile neonates. To this end, 288 febrile newborns with complete evaluation for sepsis were prospectively classified as low-risk for infection if they looked well; had been previously healthy; had no signs of focal infection; did not have persistent, recurrent, or high fever (≥ 39.0 ºC); and leukocyte counts of 5-C20 x 109/liter, erythrocyte sedimentation rate <20 mm/hr; and <10,000 leukocytes/ml of urine. These criteria were compared to Rochester criteria and false-positive and false-negative rates were compared by Z-tests. SBI was present in 68 (23.6percent) and bacteremia in 22 infants (7.6percent). Only 5 of 68 (one with bacteremia) of these infants were classified as low risk using the new criteria (false-negative rate=7.3%, 95percent CI (4.7¨C11.7%) whereas 15 of 68 (3 with bacteremia) were classified as low risk using the Rochester criteria (false-negative rate=22.0percent, 95percent CI (17.5-C27.4percent); P=0.03 vs. new criteria). The lowest false-negative rate was offset by a higher false-positive rate (65.9percent vs. 37.7percent). The new criteria identifying low risk for serious bacterial infection in febrile neonates had a significantly lower false-negative rate than that of the classic Rochester criteria. These new criteria may facilitate adequate care of infants under 1 month of age who present with a history of fever.