Antibiotic Use on the Postnatal Ward Inching towards NICE Dr R Morris Dr M Pickup Dr S Banerjee Department of Neonatal Medicine, Singleton Hospital, Swansea

NICE guideline CG149 – August 2012 Antibiotics for the prevention and treatment of early- onset neonatal infection Early-onset sepsis - high mortality and morbidity Wide variation in management of healthy infants at risk of infection Ideal pathway should : prioritise the treatment of sick babies minimise the impact on healthy women and babies use antibiotics wisely to avoid the development of resistance to antibiotics

Aims  To audit 3 key standards set out in the NICE guideline CG149 ① Are infants at risk of infection appropriately identified and commenced on antibiotics? ② Are antibiotics being administered within 1 hour of decision to treat? ③ Are we stopping antibiotics at 36 hours where a prolonged course is not indicated?  Compare results to a previous antibiotic audit completed in 2013

Potential benefits The annual impact of implementing these 3 key recommendations in England - a saving of £49.8 million. Assumptions - The proportion of babies screened for suspected infection was estimated to be 10% (Bedford Russell 2010) The average length of treatment for babies with suspected infection was estimated to be 3 days (2010) Figures based on the NICE guideline - Antibiotics of early-onset neonatal infection: Costings report, August 2012

Singleton Hospital Policy adapted from the NICE guideline CG149 1 Red Flag or >2 non-red flag risk factors for infection warrant investigation and antibiotic therapy 1 non red flag risk factor only - safe to withhold antibiotics and monitor vital signs for at least 12 hours Antibiotics should be administered within one hour of decision to treat If clinically well at 36hrs with negative infection markers and blood culture – stop antibiotics

Method  Random sample of 50 newborn term infants on postnatal ward  Multiple time points between February and April 2014  Included office and out of hour shifts  Clinical data obtained retrospectively from hospital records

Are infants at risk of infection appropriately identified and commenced on antibiotics? 50 babies 11 (22%) had >2 risk factors / a Red Flag All 11 i.e. 100% received antibiotics

Are antibiotics being administered within 1 hour of decision to treat? In 8 /11(73 %), the time of decision to treat was clearly documented 4 (50%) received dose in first hour Mean time between decision – administration = 1.8h Time between request and review - 12 minutes In 6 cases, pediatrician present at delivery & reviewed baby at birth

o 4 infants were thought to have risk factors that required a prolonged course of antibiotics o 1 admitted to SCBU for 24 hours – 5 days o 3 required LP in view of rising CRP – 5 days o In all of the 7 remaining infants (100%), antibiotics were stopped at 36 hours o All 7 remained clinically well o Overall no deaths or major morbidity Are we stopping antibiotics at 36 hours where a prolonged course is not indicated?

Comparison with previous audit in 2013

Conclusions: Clinician review is initiated and undertaken promptly in most high-risk cases Antibiotics are prescribed appropriately in babies with risk factors Although an improving trend is seen, administration of the first dose of antibiotic is taking longer than recommended A remarkable improvement in attitude to stopping antibiotics with no associated increase in in- hospital morbidity

Recommendations: Further improvement with time of administration of first dose Require investment in human resource More midwives on postnatal ward Interim - ? Doctors to give first dose of antibiotics Continue awareness programme Junior doctors Midwifery staff Microbiologist