BY ABDULJALEEL ELSHALWI MAHMOUD ELMABRI ANTIBIOTICS PROTOCOLS IN A NEONATAL INTENSIVE CARE UNITE OF AL-WAHDA HOSPITAL DERNA

Study about local protocol of antibiotic used in NICU and their relations with international protocols

I INTRODUCTION Ideally the antimicrobial agent used to treat an infection is selected after the organism has been identified and its susceptibility established. However, in the critical ill patient, such a delay could prove fatal, and immediate empiric therapy is indicated.

NICU CAPACITY 14 CAPACITY 120BED BIRTH RATE 10 DAILY AL-WAHDA HOSPITAL DERNA

METHODS Study made by pilot method and we depend on data collected  Treatment chart paper for patient admitted in NICU.  Medical statistics office of al wahda hospital.  Data collected for two months and 93 inpatients of hospital.

DISCUSSION Mortality rate of all neonates which entered to NICU during the study (60 days) entered 93 patients dead 7 patients TOTALDEATH 92.47%7.53%

From 93 patient 91 (98%) receive an antibiotic which prescribed by medical staff in 221 times as 7 types of antibiotics (ampicillin, penicillin G, Cefotaxime, Gentamicin, Cloxacillin, Metronidazole, Ceftriaxone, Meropenem )

We found the antibiotics is given as a double and triple regime in most cases, the major two antibiotic consist of penicillin g and gentamicin. In comparison the WHO and NICE guidelines with local protocol it is identically in the type of antibiotics

But in the dose per kg there is was a variation. where ranging from lowest to highest from international recommendation and we notice the frequency of dose was almost given as 12 hour regimes. in brief the regime only 12h in 213 times and 36h in 9 times (no 8h and 6h.24h regime) Penicilline gGentamicinCefotaximAmpicillineCloxacilinMetronidazoleCEFTRIAXONEMeronemANTIBIOTIC AVE. DOSE PER Kg to to to to RANGE OF DOSE

WHO RECOMMENDATION Gentamicin (IM/IV): First week of life : Low-birth-weight infants: 3 mg/kg once a day; Normal birth weight: 5 mg/kg per dose once a day Weeks 2–4 of life: 7.5 mg/kg once a day Ampicillin (IM/IV): First week of life: 50 mg/kg every 12 h Weeks 2–4 of life: 50 mg/kg every 8 h Benzylpenicillin (penicillin G) (IM): First week of life: U/kg every 12 h; Weeks 2–4 and older: U/kg every 6 h Cloxacillin (IV): First week of life: 25–50 mg/kg every 12 h; Weeks 2–4 of life: 25– 50 mg/kg every 8 h cefotaxime 50 mg/kg every 6 to 12 hours

On the other hand about 85.97% of prescribed antibiotics is continued and 14.03% stop or changed

nearly all guidelines suggest relying on data about antibiotic resistance from local prevalent pathogens at the institutional level when selecting empirical treatment regimens and They recommend individualizing empirical antibiotic recommendations according to local antibiotic protocols and local pathogen susceptibility.

Most guidelines are in line with WHO recommendations: NICE, AAP, BMJ and BNFc recommend the use of benzyl penicillin or ampicillin combined with gentamicin as empiric treatment and list third generation cephalosporin as an alternative. Of note, guidelines often state that the aim is to target the most common pathogens encountered in EONS, that GBS and E. coli in HIC *. GBS :Group B Streptococcus EONS early onset neonatal sepsis HIC high-income countries NICE the National Institute for Health and Care Excellence AAP the American Academy of Pediatrics BMJ the British Medical Journal BNFc the British National Formulary for Children. * IPA :lntrapartum Antibiotic Prophylaxis when used by AAP and ACOG,CDC decrease GBS by 1 in 4000

Study : One of two large RCT from the AFRINEST Group compared oral amoxicillin to injectable procaine benzyl penicillin plus gentamicin, in 5 African centers in young infants (≤ 59 days, n = 2333) with fast breathing as a single sign of illness of PSBI* when referral was not possible. In the procaine benzyl penicillin–gentamicin group, 234 infants (22%) failed treatment, compared with 221 (19%) infants in the oral amoxicillin group (risk difference –2·6%, 95% CI –6·0 to 0·8). The results were interpreted to indicate that young infants with fast breathing alone can be effectively treated with oral amoxicillin on an outpatient basis when referral to a hospital is not possible. *PSBI: possible serious bacterial infection.

CONCLUSION  Locally protocol is identically in the types of antibiotic with WHO  Clear difference in the doses upper or lower (frequency, dose per kg, route of administration and age) from WHO protocol  Application of international protocol with out local pathogen resistance identify or lab results  Duration of antibiotic course is not complete for all patient  Medical record is not clear  There is no medical advise recorded after discharge

The big advice “endless talk and no action….” “pipe dreams….” Because of these words, which we found it in the latest articles on Reuters by Medscape, our advice is to accelerate the formation of the National Committee to determine the resistance of antibiotics in hospitals which is operates by local standards based on global scientific rules.

References: *Antibiotic Use for Sepsis in Neonates and Children: 2016 Evidence Update *NICE clinical guideline treatment-in-people-with-suspected-sepsis treatment-in-people-with-suspected-sepsis Reuters Health Information © 2019 Cite this: Big Pharma Accused of 'endless Talk, No Action' on Antibiotic Threat - Medscape - Mar 27, 2019.

Thank you for attention