Neonatal Sepsis

Neonatal Sepsis Goals We will not discuss… Definition, clinical presentation, or specific management strategies of septic infants (Abx, CV support, ventilation, etc. special cases such as CLABSI, VAP, etc) What we will review: identification strategies for the neonate considered to be AT SUFFICIENT RISK for sepsis We will examine recent changes in recommendations based on newer data and innovative approach to real-time decision making

Neonatal Sepsis Goals Examine highlights of the evolution of studies and reappraisal between 2010 and 2016 Touch on about ten published literature reviews and recommendation statements from the CDC and AAP Committee on Fetus and Newborn Understand how this evolution is changing clinical practice

Definitions EOS: Early Onset Sepsis < 7 DOL Chorio Exposed Infants Antibiotic Exposed Infants

Is it Neonatal Sepsis? A Case While on rounds one morning … An artillery firing exercise is under way at a shooting range in Yeoncheon County South Korea

Diminishing EOS Incidence Incidence is the rate of new (or newly diagnosed) cases of the disease. It is generally reported as the number of new cases occurring within a period of time (e.g., per month, per year).

Diminishing EOS Incidence Incidence is the rate of new (or newly diagnosed) cases of the disease. It is generally reported as the number of new cases occurring within a period of time (e.g., per month, per year).

2000s: Overtreating and Overexposure to Abx

2000s: Risks of Unnecessary Abx

2011: Previous Recommendations

2011: Then Footnotes!! * * *

2011: Fine Print

2011: Chorio Suspected Now superseded by Prevalence-driven KP calculator *

2011: Adequate GBS IAP

2011: GBS Px Indicated * *

2011: Inadequate GBS IAP Now superseded by Prevalence-driven KP calculator *

2011

2011

2011

2011

2011

2011: GA

2011: Maternal Temp

2011: ROM

2011 Componenets

2011 Maternal Predictors

2011 Maternal Predictors

2012 AAP Statement

2012 AAP Clinical Report

2012 AAP Clinical Report

2012 AAP Clinical Report

2012 AAP Clinical Report

2012: Skepticism Arises!

2014: Skepticism Arises!

2014: Reprise of 2011 Paper

2014

2014

2014 Clinical Signs in Newborns

2014 Study Cohort

2014 NNT

2014 NNT based on sepsis risk

2014 Reappraisal of Guidelines

2014 Reappraisal of Guidelines

2014 Chorio Reappraisal

2014 Chorio Reappraisal

2014 Chorio Reappraisal

2014 New Recommendations

2014 New Recommendations

2014 New Recommendations

2014 New Recommendations

2014 New Recommendations

2016, May

2016: Clinical Presentation

Now

Is it Neonatal Sepsis? Another Case Oh yes, the rest of the first story …..

Is it Neonatal Sepsis? Another Case One afternoon: Scheduled LTCS at 37+0 b/c of previous classical T-incision; no labor, no fetal or maternal distress; “at risk for uterine rupture” O2 requirement after del room CPAP 0 - 2 HOL: O2 requirement 30%, very sporadic grunting, comfortable WOB, weaned to 25% first 2 HOL 2-3 HOL; develops persistent grunting; CXR c/w RDS; nl glc; CBG shows only a mild resp acidosis, in fact a small base excess; CPAP started Maternal Hx: GBS neg, ROM at time of delivery, no maternal fever or chorio concerns whatsoever Is there a point which justifies starting Abx after BC +/- CBC?

Discussion Who is using the calculator on a regular basis now? Who remains skeptical, and if so, why? What further refinements need to be incorporated in this model of care?

Conclusion: Review of EOS Risk Appraisal and Evaluation Strategies We have seen that a substantial reduction of EOS incidence stimulated a reappraisal of previous guidelines in light of: Concerns for Abx overtreatment Antibiotic stewardship We have witnessed the adoption of KPSRC to aid real time decisions regarding EOS risk based on readily available EMR data Preterm infants < 35+0 who are “chorio exposed” or have maternal risk factors and/or are symptomatic remain evaluated and treated as before

1943 local time, sunset 1956