Dr Lucinda Perkins Supervisor: Dr Jean Matthes 08/10/14 Review of Second Line Antibiotic Choice on Singleton NICU and Telephone Survey of UK Practice Dr Lucinda Perkins Supervisor: Dr Jean Matthes 08/10/14

Introduction Sepsis major cause of mortality & morbidity Empirical antibiotic choice based on likely causative organisms Managing and preventing outbreaks of Gram- negative infections in UK NICU’s recommends ‘audit antibiotic use and translate findings into practice change’ ADC Fetal Neonatal Ed 2013;98:F549–F553 National standard for first line antibiotic: CG149 Antibiotics for early-onset neonatal infection: NICE guideline LOS pathogens more varied

Aims & Methods Review of 2nd line antibiotic choice: Flucloxacillin and Gentamicin: WITHOUT central line Cefotaxime and Vancomycin: WITH central line Retrospective analysis of sensitivities of all positive blood cultures since ESBL outbreak in late 2011 Use of microbiology & Indigo reporting systems Comparison of practise to similar UK units via telephone survey of all level 3 units Via microbiologist Ann LewisPrint-outs of detailed sensitivities from Microbiology used for original subset (excluding majority of Staph/Strep) Indigo sensitivity reports used for all others Anthony et al Particular relevance to Singleton ESBL Ecoli outbreak in 2011 One strain of ESBL producing E.coli contributed to the deaths of 2 premature infants Reference: ‘An outbreak of ESBL-producing E.coli in a NICU’ Infant volume 10, issue 1, 2014

Results 64 sepsis episodes 121 (10.3%) POSITIVE 82 blood cultures 39 (32.3%) Contaminants* *identified using VON critera 64 sepsis episodes 59 patients 82 blood cultures 98 organisms 8% (5/59) patients had >1 sepsis episode 24% (14/59) patients had > 1 positive culture 12% (10/98)of blood cultures had multiple organisms Earliest growth Day 0, latest day 102, Mean day 15

Gram Stain of Organisms 4% 28% 68% 3 patients with 5 blood cultures positive for Candida 4 Candida Albicans, 1 Candida sp. Only stated 2 sepsis episodes involved ONLY candida n = 62

Gram Positive Gram Negative

Gram Positive Sensitivities

Gram Negative Sensitivities

Sensitivity to Dual Therapy Antibiotic Sensitive Resistant Not reported Flucloxacillin & Gentamicin 47% 27% 26% Cefotaxime & Vancomycin 42% 3% 55% Gentamicin & Vancomycin 73% 19% 8%

Survey of 2nd Line Antibiotics in Level 3 Units Nationwide (37/45) ‘Cef and Vanc’ includes Cefotaxime x2, Ceftazidime x3

Survey of 2nd Line Antibiotics in Babies with Central Line

Conclusions Significantly more organisms sensitive to Vancomycin than the Penicillins Sensitivity to Cefotaxime largely unknown Recommend change for babies with central access to Vancomycin and Gentamicin Re-audit bloods culture sensitivities & side effects in 6 months Emphasis must remain on recognising early signs of sepsis with prompt administration of IV antibiotics Changing from Gentamicin to Cefotaxime may provide less cover

Reserve Slides The following 5 slides are reserve slides Please note these slides are only included in case a question is asked requiring clarification. They will not be included in the 12 slide presentation

Sensitivities by Sepsis Episode

Resistances by Organism (n=73)

Revised Resistances

Gentamicin Resistance 3 sepsis episodes (excluding CONS) Early onset: Ecoli x1 (ESBL) Late onset: Acinetobacter x1, Enterobacter Cloacae x1,

Second Line Antibiotics