Dr Arjit Mohapatra

Director, Neonatal servicesJagannath Hospital, Bhubaneswar

MD, DM, FNNF

Guidelines to Antibiotics Therapy inNICU

Sepsis the big killer / morbidity

Economic burden

Antibiotics – Double edged sword

Emergence of resistance

LOS/NEC/Mortality

Fungal sepsis

Increased hospitalisation and cost burden

Background

Empiric therapy -- When infection is suspected but cultures are pending

Definitive therapy -- When an organism has been identified

Prophylactic therapy -- Prevention of postoperative/preemptive infection

Types of of Antibiotic Therapy in Neonates

The early and appropriate initiation of antimicrobial agents in high-risk neonates before the result of blood culture susceptibility

Empiric Antimicrobial Therapy

Risk Factors for EOS(perinatal)

Spontaneous Prematurity/PPROM

Clinical chorioamnionitis,

Maternal intrapartum fever (>38.0◦ C)/UTI

PROM >18 hrs in Preterm, >24 hrs in Term

Single unclean or >3 sterile vaginal examn.

Prolonged(>24hr) Labour, Difficult/Obstructed

Perinatal Asphyxia( 1” APGAR <4)

WHOM

Presence of >=3 risk factors

Presence of foul smelling Liquor

Presence of <=2 risk factors and positive sepsis screen

Strong clinical suspicion of sepsis

Indications to start Antibiotics

Altered behaviour or responsiveness

Altered muscle tone (for example, floppiness)

Feeding difficulties (for example, feed refusal)

Feed intolerance, including vomiting, excessive gastric aspirates and abdominal distension

Abnormal heart rate (bradycardia or tachycardia)

*Signs of respiratory distress/Apnoea

Jaundice within 24 hours of birth

*Seizures /Signs of neonatal encephalopathy

Clinical indicators in Baby

Need for cardio–pulmonary resuscitation

*Need for mechanical ventilation

Temperature abnormality (lower than 36°C or higher than 38°C) unexplained by environmental factors

*Signs of shock

Unexplained excessive bleeding, thrombocytopenia, or abnormal coagulation (INR>2.0)

Oliguria persisting beyond 24 hours after birth

Altered glucose homeostasis (hypo/hyper glycaemia )

Metabolic acidosis (base deficit >10)

Local signs of infection (eg. affecting the skin or eye)

Clinical indicators in Baby

Fever, cough Respiratory symptoms Poor feeding/Lethergy Convulsions/CNS symptoms Temperature instability Abdominal distension Focal sepsis- pus discharge/abscess

Risk Factors/Features for LOS

Choice of antibiotics depends on causative organism , its susceptibility

Data

Local prevalence and sensitivity patterns

What

1. Collect data of isolates and their antibiogramof last 6-12 mo

2.First line antibiotics: combination of common antibiotics covering 60-70% isolates

3.Second line: other combinations to cover 80-90%

Step-wise approach to to form Empiric Antibiotic policy for a unit

Culture positive sepsis without meningitis-10-14days

Culture negative, screen positive, clinical sepsis-7-10days

Meningitis- 21days

How Long

Two negative sepsis screens done at 12 hrs apart

Culture negative , clinically well

Serial CRPs negative/falling , clinically reassuring

When to stop

Alteration of gut colonization

Emergence of resistant strains

Increasing risk of Candida colonization and subsequent invasive candidiasis

Risks associated with empirical administration of broad-spectrum

antibiotics

Increased

Mortality

NEC

LOS

Adverse effects of prolonged courses of empirical antibiotic treatment

Non-specific signs of sepsis and frequent occurrence of culture-negative infections “Clinical Sepsis”

Difficult to obtain adequate blood quantities for culture

Treatment guidelines are often not established for infants, particularly for preterm neonates

Difficulties in dosing and therapeutic drug monitoring due to the limited pharmacokinetic and clinical studies

Unique Challenges in Antibiotic Prescribing in NICU

Antibiotic stewardship refers to a set of commitments and activities designed to “optimize the treatment of infections while reducing the adverse events associated with antibiotic use.”

Multidisciplinary team with goal ...

--to have the RIGHT DRUG

--for the RIGHT PERSON

--at the RIGHT TIME

Antimicrobial Stewardship

Ensure antibiotics are indicated

Select an antibiotic with a narrow spectrum to minimize collateral damage

Use for Shortest Possible DURATION

Re‐evaluate therapy based on culture results, laboratory data, clinical status, etc. De‐escalate/scale down therapy, use narrow spectrum based on sensitivity

Strategies for Improved Antimicrobial Prescribing

Review regimens every 6-12 mo

Avoid Cephalosporins as empiric therapy-rapidly induce ESBL and Fungal colonisation

Reserve drugs such as Mero,Vaco,Linezolid,Colistin,Tigecyclin -should not be used empirically

Remember

Sepsis remains a major cause of concern

Antibiotics remain the mainstay

Appropriate choice of antimicrobial agent

Avoid use of broad spectrum agents

Limit the duration

Scale down (narrow down as per c/s)

No role of Prophylactic antibiotics

Take Home Message

Thank You