Antibiotic therapy in Neonatal Sepsis

In this webinar, we shall learn about antibiotics for treating sepsis in neonates
The learning objectives would be: Why rational use of antibiotics? Initial choice of antibiotics? When to upgrade the antibiotics? How long to give antibiotics? What are the best practices we should learn?
Excessive use of antibiotics leads to high risk of antibiotic resistance and higher risk of Invasive candidiasis, NEC and death
Once decided to start antibiotics, let us now learn how to choose the initial antibiotics The initial empiric choice of antibiotic should preferably cover both gram positive and negative bacteria. In India, the bacterial and sensitivity profile of EOS and LOS are similar and hence no distinction is required in antibiotic choice between EOS and LOS The suggested plan would be: For community acquired sepsis, a combination of Ampicillin plus an aminoglycoside could be the empiric choice If evidence of Staphylococcus infection is present such as skin lesions, Cloxacillin can replace Ampicillin For hospital acquired sepsis, a combination of Cloxacillin or Ampicillin and an aminoglycoside could be the empiric choice. The choice between cloxacillin and ampicillin would depend on the prevailing flora of the unit However, it is crucial to avoid 3rd gen cephalosporins, carbapenems and vancomycin as first choice of antibiotics
The next question is when one should upgrade the antibiotics to the next line Consider upgrading in cases of worsening or absence of improvement after 48 hours An early escalation may be considered if the newborn becomes extremely sick or deteriorates rapidly Second line antibiotics should be based on the blood culture report (If available) and based on the sensitivity pattern of the unit
Even though initiation and escalation may be done empirically, do not hesitate to down grade to a narrower spectrum antibiotic once the culture report is available This de-escalation should be done even if the baby shows clinical response Always use only one antibiotic to which the organism is sensitive
In this slide, we will learn how long the antibiotics should be given If meningitis is diagnosed – give for 21 days If blood culture is positive – administer for 10-14 days If blood culture is negative and the neonate presented with severe clinical signs such as shock, sclerema and DIC – consider a duration of 7-10 days On the other hand, if blood culture was negative and the neonate had less severe clinical signs – consider stopping antibiotics by 5-7 days In asymptomatic neonates with only risk factors and blood culture is negative, antibiotics should be stopped immediately In all cases, keep in consideration, the status of clinical signs. Consider stopping antibiotics in a baby in whom the clinical signs were less severe and show a rapid improvement within the 12-24 hours of starting antibiotics.
It is vital to understand to reduce the duration of antibiotics To facilitate this process, certain key steps are essential First step is to collect blood culture reports on time; this can be done by calling the lab or starting a system of online reporting or SMS services Once you get a report – trust your lab; even the best microbiology services have only up to 35% culture positivity rate; if reported negative – believe and stop ABs Getting a faster culture report by using BACTEC or similar automated blood culture systems may help
Do not give antibiotics in certain scenarios: These conditions are certain non-infectious conditions like asphyxia, meconium aspiration and prematurity and low birth weight. Certain procedures like exchange transfusion, central line insertion, endotracheal intubation and phototherapy
Remember few best practices to rationalize the use of antibiotics First, have a written antibiotic policy in the unit and strictly follow it. This policy should state when to give a drug, which drug to be given, how much and how long to be given. The policy should also have the provision to track the organism profile of the unit Second – do not give prophylactic antibiotics and do not give parenteral antibiotics for superficial skin infections Establish correct diagnosis with the help clinical and microbiological support Do not forget to send blood culture before starting antibiotics Prescribe right dose using drug formulary
The take home messages are Have a written antibiotic policy for your unit Send blood culture before starting antibiotics Based on culture and clinical signs, stop antibiotics at the earliest Document: indication, review date and proposed duration Follow right dose and frequency Follow instructions for drug administration
  • Introduction...
  • 1. Learning object...
  • 2. Harms of excess...
  • 3. Initial choice ...
  • 4. When to upgrade...
  • 5. Changes after c...
  • 6. How long to giv...
  • 7. How to reduce t...
  • 8. No antibiotics...
  • 9. Best practices...
  • 10. Take home mess...
 

Introduction

DR. S. VENKATASESHAN
MD, DM (Neonatology)

Associate Professor
Department of Pediatrics
PGIMER, Chandigarh

1. Learning objectives

â–º Why rational use of antibiotics?

â–º Initial choice?

â–º When to upgrade?

â–º How long to give?

â–º Best practices?

2. Harms of excessive use of antibiotics

â–º High risk of antibiotic resistance

â–º Higher risk
      ♦ Invasive candidiasis
      ♦ NEC
      ♦ Death

3. Initial choice of antibiotics

► Should cover both gram + ve and – ve bacteria

â–º Suggested plan
1. Community acquired
      ♦ Ampicillin + aminoglycoside
      ♦ Evidence of Staphylococcus infection: cloxacillin in place
        of ampicillin
2. Hospital acquired
      ♦ (Cloxacillin or ampicillin)* + aminoglycoside

â–º Avoid third generation cephalosporins/ carbapenem/
    vancomycin

*Choice between cloxacillin and ampicillin depends on the prevalent flora in the unit

4. When to upgrade?

â–º Worsening or absence of improvement after 48 hours

â–º Early escalation may be considered if baby becomes
    extremely sick or deteriorates rapidly

â–º Second line antibiotics based on
      1. Culture report (if available)
      2. Unit policy (sensitivity pattern)

5. Changes after culture report

â–º Sensitive to an antibiotic with narrower spectrum
      ♦ Change even if the neonate was improving



â–º Use only one antibiotic to which organism is sensitive

6. How long to give?

â–º Use parenteral antibiotics





*Shock, sclerema, DIC, severe hypothermia, seizures

7. How to reduce the duration?

â–º Collect blood culture reports on time
      ♦ Phone/ online/ SMS

â–º Trust your lab
      ♦ Blood culture positivity rates: 15-35%

â–º Get the culture report faster - use BACTEC or other automated
    blood culture systems

8. No antibiotics

â–º Non-infectious conditions such as
      ♦ Asphyxia
      ♦ Meconium aspiration
      ♦ Prematurity/ low birth weight

â–º Procedures such as
      ♦ Exchange transfusion
      ♦ Central line/ umbilical line insertion
      ♦ Intubation
      ♦ Phototherapy

9. Best practices

â–º Have a written antibiotic policy and follow it
      ♦ When, which, how & how long
      ♦ Track organism profile

â–º Do not give antibiotics
      ♦ As prophylaxis
      ♦  Parenteral route for superficial skin infection

â–º Establish correct diagnosis
      ♦ Send blood culture before starting antibiotics

â–º Prescribe right dose using drug formulary

10. Take home messages

â–º Have a written antibiotic policy for your unit

â–º Send blood culture before starting antibiotics

â–º Based on culture and clinical signs, stop antibiotics at the
    earliest

â–º Document indication, review date and proposed duration

â–º Follow right dose and frequency

â–º Follow instructions for drug administration