The American Association of Pediatrics released newly updated guidelines for evaluating newborns for risk of early-onset sepsis.
The AAP guidance distinguishes infants by gestational age at birth and provides new evidence-based management options. The reports update the current epidemiology, microbiology and recommended empiric treatment of early onset of sepsis(EOS).
Early-onset sepsis (EOS) remains a serious and often fatal illness among infants born preterm, particularly among newborn infants of the lowest gestational age. Studies have revealed that antibiotic exposures after birth are associated with multiple subsequent poor outcomes among preterm infants, making the risk/benefit balance of these antibiotic treatments uncertain. Currently, most preterm infants with very low birth weight are treated empirically with antibiotics for risk of EOS, often for prolonged periods, in the absence of a culture-confirmed infection.
The AAP Committee on Fetus and Newborn and the Committee on Infectious Diseases revised the AAP guidance on early-onset bacterial infection in the clinical reports Management of Neonates Born at ≥35 0/7 Weeks’ Gestation With Suspected or Proven Early-Onset Bacterial Sepsis and Management of Neonates Born at ≤34 6/7 Weeks’ Gestation With Suspected or Proven Early-Onset Bacterial Sepsis.
Multiple clinical risk factors have been used to assess the risk of early onset sepsis(EOS) among infants born at ≤34 6/7 weeks’ gestation.
Criteria for preterm infants to be considered at a lower risk for EOS include the following:
(1) obstetric indications for preterm birth (such as maternal preeclampsia or other noninfectious medical illness or placental insufficiency),
(2) birth by cesarean delivery,
(3) An absence of labour attempts to induce labour, or any ROM before delivery.
Acceptable initial approaches to these infants might include (1) no laboratory evaluation and no empirical antibiotic therapy, or (2) a blood culture and clinical monitoring. For infants who do not improve after initial stabilization and/or those who have severe systemic instability, the administration of empirical antibiotics may be reasonable but is not mandatory.
Infants born preterm because of cervical incompetence, preterm labour, PROM, chorioamnionitis or IAI, and/or acute and otherwise unexplained onset of non-reassuring fetal status are at the highest risk for EOS. In these cases, IAI may be the cause of preterm birth or a secondary complication of PROM and cervical dilatation.
The epidemiology, microbiology, and pathogenesis of EOS differ substantially between term infants and preterm infants with very low birth weight (VLBW).
Highlights of the reports are as follows:
- Infants born at ≤34 6/7 weeks’ gestation can be categorized by level of risk for EOS by the circumstances of their preterm birth.
- Infants born preterm by cesarean delivery because of maternal noninfectious illness or placental insufficiency in the absence of labour attempts to induce labour, or ROM before delivery are at a relatively low risk for EOS. Depending on the clinical condition of the neonate, physicians should consider the risk/benefit balance of an EOS evaluation and empirical antibiotic therapy.
- Infants born preterm because of maternal cervical incompetence, preterm labour, PROM, clinical concern for IAI, or acute onset of unexplained nonreassuring fetal status are at the highest risk for EOS. Such neonates should undergo EOS evaluation with a blood culture and empirical antibiotic treatment.
- Obstetric and neonatal care providers should communicate and document the circumstances of preterm birth to facilitate EOS risk assessment among preterm i
- Clinical centers should consider the development of locally appropriate written guidelines for preterm EOS risk assessment and clinical management. After guidelines are implemented, ongoing surveillance, designed to identify low-frequency adverse events and affirm efficacy, is recommended.
- The diagnosis of EOS is made by a blood or CSF culture. EOS cannot be diagnosed by laboratory tests alone, such as CBC count or CRP levels.
- The combination of ampicillin and gentamicin is the most appropriate empirical antibiotic regimen for infants at risk for EOS. Empirical administration of additional broad-spectrum antibiotics may be indicated in preterm infants who are severely ill and at a high risk for EOS, particularly after prolonged antepartum maternal antibiotic treatment.
- When blood cultures are sterile, antibiotic therapy should be discontinued by 36 to 48 hours of incubation, unless there is clear evidence of site-specific infection. Persistent cardiorespiratory instability is common among preterm infants with VLBW and is not alone an indication for prolonged empirical antibiotic administration. Laboratory test abnormalities alone rarely justify prolonged empirical antibiotic administration, particularly among preterm infants at a lower risk for EOS.
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