Antibiotics and the intensive care unit (ICU) environment seem to go hand in hand. Given the spectrum of manifestations that sepsis can have, especially in patients who are smaller, younger, and have lower physiological reserve for any reason, a 48-hour rule out sepsis evaluation with empiric antibiotic treatment while cultures pend is often the ‘safe’ thing to do. However, the increasing data on antibiotic resistance as well as the effects of prolonged antibiotic exposure and their association with fungal infections lends a bit of pause to this almost-automatic step.
Schulman et al (10.1542/peds.2019-1105) describe a cross sectional report on antibiotic use in neonates in 116 hospitals in California in 2017. The outcome variable was an interesting one – the number of neonates with antibiotic exposure divided by the number of confirmed neonatal sepsis cases. This ‘rate’ of neonates exposed to antibiotics per unit of confirmed sepsis, referred to as diagnostic efficiency, essentially indicates the extent of the potentially over-treated population of newborns. This number overall for the entire study cohort was ~41 babies treated per confirmed case of neonatal sepsis (of any variety), further analyzed to be a median of ~69 babies treated per confirmed case of early onset sepsis to a median of ~12 babies treated per confirmed case of late onset sepsis. At first glance, these numbers seem high, and indicate a need to examine antibiotic prescribing practices. However, the next question is – were these antibiotics prescribed per the latest guidelines from the AAP?1,2This would be impossible to tease out at the state-wide level of this study. But it would shed light on potential next steps – i.e. is there a lack of awareness about the guidelines, or are the guidelines just being more cautious? In either situation, it would lead to an institution-level examination of antibiotic prescribing practices, with first an emphasis on following the guidelines, and next assessing the local population findings and patterns of neonatal sepsis. Another uncertainty from the study is how many of these patients had greater acuity of illness, were more premature or were simply smaller, which may play into the increasing trend of antibiotic prescribing. Further, how many of the patients had concomitant surgical or medical diagnoses needing specialist management, beyond newborn care? The threshold for antibiotics in a complex patient is anecdotally lower, and this may be a separate issue to be investigated, within a more homogeneous population.
On reading this study and then reflecting on my experience as a trainee in the NICU and now a physician in an ICU with patients who are medically and surgically complex, it definitely highlights a knowledge gap that is relevant to a practitioner in every field, as antibiotics are quite ubiquitous in our practice. Taking the first step to follow the guidelines and then documenting the circumstances when we ignore those guidelines, follow our “gut” and treat with antibiotics despite the guidelines telling us otherwise would be instrumental. It would also be helpful as investigators to look into antibiotic prescription practices in various patient populations and try to come up with better guidelines directed to those different populations. Doing so might result in less empiric use of antibiotics and better adherence to evidence-based clinical practice guidelines.
References
- Puopolo KM, Benitz WE, Zaoutis TE; COMMITTEE ON FETUS AND NEWBORN; COMMITTEE ON INFECTIOUS DISEASES. Management of Neonates Born at ≥35 0/7 Weeks' Gestation With Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics. 2018 Dec;142(6). pii: e20182894
- Puopolo KM, Benitz WE, Zaoutis TE; COMMITTEE ON FETUS AND NEWBORN; COMMITTEE ON INFECTIOUS DISEASES. Management of Neonates Born at ≤34 6/7 Weeks' Gestation With Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics. 2018 Dec;142(6). pii: e20182896.