Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Quality Improvement Article
  • Published:

Standardizing the approach to late onset sepsis in neonates through antimicrobial stewardship: a quality improvement initiative

Journal of Perinatology volume 40, pages 1433–1440 (2020)Cite this article

Subjects

Abstract

Background

Antibiotics are the most prescribed medication in the neonatal intensive care unit (NICU) and there is marked variation in their use. While they are vital for treatment of infections, they put infants at risk for infections with drug resistant organisms, alteration in their microbiome and several other morbidities. Specific guidelines for neonates are often lacking and our NICU is not compliant with late onset sepsis (LOS) guidelines.

Objective

By January 2019, there will be >75% compliance with our LOS bundle for any infant admitted to Tampa General Hospital’s (TGH) NICU undergoing a LOS evaluation at >72 h of life. The bundle includes documented reason for LOS evaluation, appropriate initial antibiotic selection, appropriate initial evaluation considered, and appropriate de-escalation of antibiotics.

Study design

The project was implemented in the NICU at TGH, the academic medical center affiliated with the University of South Florida in Tampa, FL. The multidisciplinary antimicrobial stewardship (ASP) team responsible for the project consists of a neonatology attending, three neonatology fellows, a pediatric infectious disease attending, and two NICU pharmacists. The project was started in January 2017 and all data were collected prospectively. We implemented multiple Plan-Do-Study-Act cycles in a stepwise manner; outcome measures included compliance with the LOS bundle and ASP team recommendations. Our process measures were the documented reason for sepsis evaluation, appropriate initial evaluation considered, appropriate antibiotic selection and appropriate antibiotic de-escalation. Patient length of stay was the balancing measure studied.

Results

During this 20-month initiative, there were 232 infants who underwent LOS evaluation and there were 98 true positive cultures from blood (28%), urine (35%), and cerebrospinal fluid (3%). Commonly documented rationales for treatment of culture negative sepsis were clinical pneumonia (38%) and necrotizing enterocolitis (38%). Common indications for LOS evaluations were increased respiratory support (51%) and abdominal distension (17%). There was improvement in appropriate initial antibiotic selection (70% vs. 94%); appropriate consideration of initial evaluation (63% vs. 94%, respectively); appropriate de-escalation of antibiotics (86% vs. 100%, respectively) and increase in LOS bundle compliance (44% vs. 87%, respectively). The overall antibiotic utilization rate and length of treatment did not change significantly.

Conclusions

Developing and engaging a NICU ASP team improves compliance with late onset sepsis guidelines through the implementation of a LOS bundle of care.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics. 2002;110:285–91.

    Article  Google Scholar 

  2. Puopolo KM, Benitz WE, Zaoutis TE. Management of neonates born at ≥35 0/7 weeks’ gestation with suspected or proven early-onset bacterial sepsis. Pediatrics 2018;142:e20182894.

  3. Puopolo KM, Benitz WE, Zaoutis TE. Management of neonates born at ≤34 6/7 weeks’ gestation with suspected or proven early-onset bacterial sepsis. Pediatrics. 2018;142:e20182896.

  4. Wirtschafter DD, Padilla G, Suh O, Wan K, Trupp D, Fayard EE. Antibiotic use for presumed neonatally acquired infections far exceeds that for central line-associated blood stream infections: an exploratory critique. J Perinatol. 2011;31:514–8.

    Article  CAS  Google Scholar 

  5. Hsieh EM, Hornik CP, Clark RH, Laughon MM, Benjamin DK Jr, Smith PB. Medication use in the neonatal intensive care unit. Am J Perinatol. 2014;31:811–21.

    Article  Google Scholar 

  6. Cotten CM, McDonald S, Stoll B, Goldberg RN, Poole K, Benjamin DK Jr. The association of third-generation cephalosporin use and invasive candidiasis in extremely low birth-weight infants. Pediatrics. 2006;118:717–22.

    Article  Google Scholar 

  7. Cotten CM, Taylor S, Stoll B, Goldberg RN, Hansen NI, Sanchez PJ, et al. Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for extremely low birth weight infants. Pediatrics. 2009;123:58–66.

    Article  Google Scholar 

  8. Kuppala VS, Meinzen-Derr J, Morrow AL, Schibler KR. Prolonged initial empirical antibiotic treatment is associated with adverse outcomes in premature infants. J Pediatr. 2011;159:720–5.

    Article  CAS  Google Scholar 

  9. Coker MO, Hoen AG, Dade E, Lundgren S, Li Z, Wong AD, et al. Specific class of intrapartum antibiotics relates to maturation of the infant gut microbiota: a prospective cohort study. Bjog. 2019;217–27.

  10. Abdel-Hady H, Hawas S, El-Daker M, El-Kady R. Extended-spectrum beta-lactamase producing Klebsiella pneumoniae in neonatal intensive care unit. J Perinatol. 2008;28:685–90.

    Article  CAS  Google Scholar 

  11. Khassawneh M, Khader Y, Abuqtaish N. Clinical features of neonatal sepsis caused by resistant Gram-negative bacteria. Pediatr Int. 2009;51:332–6.

    Article  Google Scholar 

  12. Jenkins TC, Knepper BC, Shihadeh K, Haas MK, Sabel AL, Steele AW, et al. Long-term outcomes of an antimicrobial stewardship program implemented in a hospital with low baseline antibiotic use. Infect Control Hosp Epidemiol. 2015;36:664–72.

    Article  Google Scholar 

  13. Karanika S, Paudel S, Grigoras C, Kalbasi A, Mylonakis E. Systematic review and meta-analysis of clinical and economic outcomes from the implementation of hospital-based antimicrobial stewardship programs. Antimicrobial Agents Chemother. 2016;60:4840–52.

    Article  CAS  Google Scholar 

  14. Patel SJ, Saiman L. Principles and strategies of antimicrobial stewardship in the neonatal intensive care unit. Semin Perinatol. 2012;36:431–6.

    Article  Google Scholar 

  15. Warren S, Garcia M, Hankins C. Impact of neonatal early-onset sepsis calculator on antibiotic use within two tertiary healthcare centers. J Perinatol. 2017;37:394–7.

    Article  CAS  Google Scholar 

  16. Makri V, Davies G, Cannell S, Willson K, Winterson L, Webb J, et al. Managing antibiotics wisely: a quality improvement programme in a tertiary neonatal unit in the UK. BMJ open Qual. 2018;7:e000285.

    Article  Google Scholar 

  17. Dong Y, Speer CP. Late-onset neonatal sepsis: recent developments. Arch Dis Child Fetal Neonatal Ed. 2015;100: F257–63.

  18. CDC. Get Smart for Health Care.

  19. Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney SE, SQUIRE development group. Publication guidelines for quality improvement studies in health care: evolution of the SQUIRE project. BMJ. 2009;338:a3152.

    Article  Google Scholar 

  20. Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics. 2001;108:1169–74.

    CAS  PubMed  Google Scholar 

  21. Piantino JH, Schreiber MD, Alexander K, Hageman J. Culture negative sepsis and systemic inflammatory response syndrome in neonates. NeoReviews. 2013;14:e294–305.

    Article  Google Scholar 

  22. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)-a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–81.

    Article  Google Scholar 

  23. Perla RJ, Provost LP, Murray SK. The run chart: a simple analytical tool for learning from variation in healthcare processes. BMJ Qual Saf. 2011;20:46–51.

    Article  Google Scholar 

  24. Schulman J, Dimand RJ, Lee HC, Duenas GV, Bennett MV, Gould JB. Neonatal intensive care unit antibiotic use. Pediatrics. 2015;135:826–33.

    Article  Google Scholar 

  25. Hysong SJ, Best RG, Pugh JA. Audit and feedback and clinical practice guideline adherence: Making feedback actionable. Implement Sci. 2006;1:9.

    Article  Google Scholar 

Download references

Acknowledgements

The authors greatly appreciate Dr Jane Carver’s editorial review of the paper.

Author information

Authors and Affiliations

  1. Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, TN, USA

    V. Lamba

  2. Wesley Medical Center, Wichita, KS, USA

    S. D’souza

  3. Department of Pediatrics, UM/Jackson Memorial Hospital, Miami, FL, USA

    C. Carafa

  4. Tampa General Hospital, Tampa, FL, USA

    A. Zepf & C. L. Bassel

  5. Tuscon Medical Center, Tucson, AZ, USA

    M. Gutierrez

  6. Department of Pediatrics, University of South Florida Health, Tampa, FL, USA

    M. Balakrishnan

Authors
  1. V. Lamba
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S. D’souza
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. C. Carafa
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. Zepf
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. C. L. Bassel
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. M. Gutierrez
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. M. Balakrishnan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to V. Lamba.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lamba, V., D’souza, S., Carafa, C. et al. Standardizing the approach to late onset sepsis in neonates through antimicrobial stewardship: a quality improvement initiative. J Perinatol 40, 1433–1440 (2020). https://doi.org/10.1038/s41372-019-0577-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41372-019-0577-5

This article is cited by

Search

Advanced search

Quick links