When a preterm infant presents with worrisome signs and symptoms suggestive of sepsis, it is natural to want to draw appropriate cultures and start antibiotics. But if there is a risk for infection in the absence of clinical symptoms (such as prolonged rupture of membranes or a mother colonized with group B streptococci), there is also an urge to start antibiotics especially if the baby is born extremely preterm. But is this a good thing if cultures are negative and the baby does not demonstrate a serious bacterial infection in the first week of life? Would empiric use of antibiotics still make sense in a very low birth weight (VLBW; <1500 grams) newborn given concerns about antibiotic resistance or complications of administering an intravenous antibiotic? Ting et al. (10.1542/peds.2018-2286) opted to look for an answer to this question in a retrospective cohort study looking at duration of antibiotic use in over 14,000 VLBW infants born between 2010 and 2016 in neonatal intensive care units belonging to the Canadian Neonatal Network. The authors looked at various durations of antibiotic use in sepsis-negative infants and their risk of mortality or morbidity characterized by such things as retinopathy of prematurity, severe neurologic injury, necrotizing enterocolitis, or a secondary bacterial infection not related to the original concern prompting antibiotic use). The results of this important study show that each additional day of antibiotic use was associated with an increase in morbidity or mortality, making a great case for antibiotic stewardship.
To help make sense of the lessons that should be taken from this study, we asked Dr. Joseph Cantey from the University of Texas San Antonio and Dr. Adam Hersh from the University of Utah (10.1542/peds.2018-3902) to weigh in with an accompanying commentary. Drs. Cantey and Hersh compare use of antibiotics in the NICU with the controversy over use of oxygen in that we are struggling with just how much oxygen is too much oxygen, and the same now goes for antibiotics in the NICU. They also share thoughts about why a longer course of antibiotics might lead to the complications described in the Ting Study. The authors share with us some thoughts about ways to refine our criteria for who should get antibiotics and for how long—and while they don’t solve this antimicrobial dilemma, they certainly encourage us to be the best stewards antibiotics as we can be. Both the study and commentary are well worth your attention even if you are not a neonatologist as they steward your thoughts about being more aware of the risks and not just the benefits of using antibiotics for your patients.
