Implementing Other Neonatal Antibiotic Stewardship Best Practices
There are a number of neonatal antibiotic stewardship best practices that have been endorsed by the 2018 AAP Clinical Report in order to safely reduce the unnecessary use of antibiotics in neonates. These include:
- Birth centers should consider the development of locally tailored, documented guidelines for EOS risk assessment and clinical management
- Diagnosing an infection with the use of a properly collected blood or CSF culture, rather than ancillary tests, surface cultures, or improperly collected cultures
- Using appropriate doses of ampicillin and gentamicin for empiric treatment of suspected sepsis in most infants, other than critically-ill infants
- Standardizing the duration of empiric antibiotic therapy to 36-48 hours with negative blood and CSF cultures, unless there is clear evidence of site-specific infection.
CASC Steering Committee members have implemented some of these suggested best practices at their own hospital sites. Below you will find a number of suggestions and linked resources that are grouped by the intervention that was introduced.
EOS Guideline Resources
- Sample EOS Guidelines
Guidelines similar to the Sample Guideline linked below, provided by Dr. Laird, are used at many hospitals. This example is meant to be used as a template for centers to begin creating their own EOS management guideline.
Sample Antibiotic Stewardship and Early Onset Sepsis Risk Calculator Guideline for term and late preterm infants (>=35 0/7 weeks) admitted to the well newborn nursery or Neonatal Intensive Care Unit (NICU).
Neonatal Blood Culture Collection
It is very important to collect blood cultures correctly so that your team can feel confident about identifying early onset sepsis when it is present. Use the guidance below to optimize blood culture collection whenever it is indicated. When empiric antibiotics are recommended by the SRC, draw a blood culture, and utilize ampicillin and gentamicin. Refer to up to date published print or online references for neonatal dosing. Example references include Lexicomp, Harriet Lane Handbook, and Neofax (online versions are typically accessed through hospital licenses or personal paid subscriptions).
General Recommendations for Optimizing Blood Cultures
The Life of a Blood Culture (PQCNC)
Antibiotic Choice and Dosing
When empiric antibiotics are recommended by the SRC, draw a blood culture, and utilize ampicillin and gentamicin. Refer to up to date published print or online references for neonatal dosing. Example references include Lexicomp, Harriet Lane Handbook, and Neofax (online versions are typically accessed through hospital licenses or personal paid subscriptions). Additionally, as of the writing of this toolkit, these publications included the most recent guidelines for dosing:
- Reference for neonatal ampicillin and penicillin dosing: Puopolo KM, Lynfield R, and Cummings JJ, Committee on Fetus and Newborn; Committee on Infectious Diseases. Management of Infants at Risk for Group B Streptococcal Disease. Pediatrics August 2019, 144 (2) e20191881; DOI: https://doi.org/10.1542/peds.2019-1881
- Reference for intrapartum antibiotic dosing: Committee on Obstetric Practice. Committee Opinion #712. Intrapartum Management of Intraamniotic Infection, Obstetrics and Gynecology, 2017 Aug;130(2):e95-e101. doi:10.1097/AOG.0000000000002236
Standardizing antibiotic courses to 48 hours or less with a negative blood culture.
To begin with, we audited individual providers to determine the number of days of antibiotics typically prescribed. We wanted to confirm their average antibiotic order practices to determine inconsistencies. The ordering patterns were 2, 3, 4, 5, 6, or 7 days or a variance thereof. Ordering of antibiotics was inconsistent.
Through our work with the CASC group, we became familiar with the evidence for clearly defined antibiotic ordering best practices. We took this information to the Special Care Nursery provider workgroup. This group updated the policy to reflect standards of care based on this evidence. We standardized ordering practices to 36-48 hours with negative blood culture and a clinically improved patient. The group decided if the baby did not clinically improve after 48 hours even with a negative blood culture the standard ordering practice would be seven days of antibiotic treatment.
The proposal for standardized durations of antibiotic prescription was presented to the Pediatric Clinical Section. The policy was approved and adopted. The data reflected standardization of ordering practice and a decrease in AUR. Once implemented, we followed up with individual providers as needed to remind them when their prescribing practices did not meet the agreed-upon guidelines.
– Carri Montgomery (RN, BSN, MSOL), Director of Women’s and Newborn Center, Platte Valley Medical Center
A multidisciplinary team (providers, pharmacy, nursing) agreed to a change in practice so that antibiotics would automatically be discontinued if blood cultures were negative at 36 hours. Next, Automatic Stop Orders were implemented via the Electronic Health Record. Now, if a provider wanted to continue a course of antibiotics beyond 48 hours, he or she needed to write an order to continue them, rather than remembering to discontinue the order. This was a big change in the mindset/workflow of the team and contributed to a culture of limiting antibiotic use when appropriate.
We implemented a couple of feedback loops to let providers know how well they were complying with these new guidelines. First, the pharmacy compiles and shares the AUR run chart on a monthly basis. This information is posted on the unit and is a standing agenda item at our monthly quality meeting. On a more specific level, pharmacy privately informed each respective neonatologist of their antibiotic prescribing percentage relative to their peers. Luckily, we only did this once as it was relatively labor-intensive and our AUR was improving independently of the specific feedback.
– Jeff Homann (Pharmacist), UC Health Poudre Valley Hospital, UCHealth Freeley, UCHealth Medical Center of the Rockies
Quick links to data collection resources are included here. For more information about data collection for Quality Improvement, go to “Creating a Neonatal Antibiotic Stewardship QI Team.” These tools can be uploaded to your computer and opened with Excel.
- Sepsis Calculator Audit Report Template
- AUR Annotated Run Chart Template
- Antibiotic Utilization Rate (AUR) Calculation Guide: FAQ and Examples
- Case review guide
Puopolo KM, Lynfield R, and Cummings JJ, Committee on Fetus and Newborn; Committee on Infectious Diseases. Management of Infants at Risk for Group B Streptococcal Disease. Pediatrics August 2019, 144 (2) e20191881; DOI: https://doi.org/10.1542/peds.2019-1881
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;142(6):e20182894. doi:10.1542/peds.2018-2894
Good PI, Hooven TA. Evaluating Newborns at Risk for Early Onset Sepsis. Pediatric Clinics of North America 66 (2019) 321–331. https://doi.org/10.1016/j.pcl.2018.12.003
Ramasethu J and Kawakita T.Antibiotic Stewardship in Perinatal and Neonatal Care.Seminars in Fetal & Neonatal Medicine.2017;22(5):278-283. PMID: 28735809. doi:10.1016/j.siny.2017.07.001