Antibiotics on the postnatal ward A n audit and cost-analysis of current practices Dr Rachel Hayward & Dr Sybil Barr UHW Neonatal Unit

Background Antibiotics for early-onset neonatal infection NICE clinical guideline 149 Risk factor Invasive GBS infection in a previous baby Maternal GBS colonisation, bacteriuria or infection in the current pregnancy Prelabour rupture of membranes Preterm birth following spontaneous labour (before 37 weeks' gestation) Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth Intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth** Suspected or confirmed infection in another baby in the case of a multiple pregnancy ** Table 1 Risk factors for early-onset neonatal infection, including 'red flags'**

Clinical indicator 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 Respiratory distress starting more than 4 hours after birth *** Hypoxia (for example, central cyanosis or reduced oxygen saturation level) Jaundice within 24 hours of birth Apnoea Signs of neonatal encephalopathy Seizures *** Need for cardio–pulmonary resuscitation Need for mechanical ventilation in a preterm baby Need for mechanical ventilation in a term baby *** Persistent fetal circulation (persistent pulmonary hypertension) 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 (International Normalised Ratio greater than 2.0) Oliguria persisting beyond 24 hours after birth Table 2 Clinical indicators of possible early-onset neonatal infection (observations and events in the baby), including 'red flags'***

NICE CG149 Recommendations ‘If a baby needs antibiotic treatment it should be given as soon as possible and always within 1 hour of the decision to treat’ Measure the C-reactive protein concentration 18–24 hours after presentation. Consider stopping the antibiotics at 36 hours if: 1.blood culture is negative, & 2.initial clinical suspicion of infection was not strong, & 3.baby's clinical condition is reassuring, no clinical indicators of infection, & 4.levels and trends of C-reactive protein concentration are reassuring. Consider establishing hospital systems to provide blood culture results 36 hours after starting antibiotics to facilitate timely discontinuation of treatment and discharge from hospital.

Current Audit AIMS: 1.To determine inefficiencies in current practices regarding antibiotics and neonates managed on the postnatal ward 2.To compare current practices with those recommended in the NICE clinical guideline: CG149 Antibiotics for early-onset neonatal infection 3.To conduct a cost-analysis of current practices

Audit Sample size 34 Average gestation Time to cannulation Time to processing cultures Time to authorised blood culture result Number of additional antibiotic doses Number of additional days in hospital Risk Factor% Maternal sepsis35 Prom23 Prem12 Grunting10 Pathological CTG6 GBS6 Neonatal temperature4 Offensive liquor2 Rash2

Results Criteria: antibiotic treatment should always be given within 1 hour of the decision to treat None within 1 hour Average time: 4 hours 48 minutes Mon4h 15min Tues2h 15min Wed6h Thu5h Fri4 h 21min Sat3h 53min Sun7h 30min

Results Criteria: consider stopping antibiotics at 36 hours if blood culture is negative Average time: 12 hours 48 minutes Mon9h 50min Tue14h 13min Wed13h 24min Thu14h Fri6h 58min Sat15h 53min Sun7h 22min

Microbiology Service Working hoursTime Mon h 50min Tue h 13min Wed h 24min Thu h Fri h 58min Sat h 53min Sun h 22min Average time to take cultures: 4 hours 48 minutes Average time to reach lab: 12 hours 48 minutes 48 hours of incubation plus 1 hour for authorisation 66 hours 36 minutes

Cost analysis

Each additional 24 hours of antibiotics on the postnatal ward costs £511 Current study: £12,343 71% of 34 neonates required only 36 hours of antibiotics 34 x £511 x 0.71 = £12,343

CG149 Implementation of CG149 is expected to have the following benefits and savings: 1.Reduced length of hospital stay : earlier diagnostic testing (< 1hour after decision to treat) : cessation of treatment after 36 hours of starting antibiotic treatment 2. Reducing the current length of treatment from 3 days to 2 would result in potential annual savings of : Based on predicted number of neonates per year on PNW antibiotics in 2014: 12/7 x 380 = 651 (380 babies recorded from 1 st January to 31 st July) Predicted 71% of these will only require 36 hours of antibiotics (not 5, 7 or 10 days of treatment) 0.71 x 615 = x £511 = £223,000

Recommendations 1. Cannulation and commencement of antibiotics at delivery 2. Repeat CRP within 24 hours of initial CRP 3. Optimise the collection and processing of blood cultures hour microbiology reporting system