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Controversies in managing neonatal infections. David Isaacs Children’s Hospital at Westmead Sydney Australia. Controversies in managing neonatal infections. Should I start antibiotics? Should I do a lumbar puncture first? Which antibiotics? Reluctance to stop antibiotics.

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Controversies in managing neonatal infections

Controversies in managing neonatal infections

David Isaacs

Children’s Hospital at Westmead

Sydney Australia


Controversies in managing neonatal infections1
Controversies in managing neonatal infections

  • Should I start antibiotics?

  • Should I do a lumbar puncture first?

  • Which antibiotics?

  • Reluctance to stop antibiotics.

  • How can I prevent fungal infections?

  • How can I prevent coagulase negative staphylococcal infection?


Should i start antibiotics
Should I start antibiotics?

  • Maternal risk factors in early sepsis

  • Clinical examination

  • Laboratory: blood count, acute phase reactants

  • If in doubt, start them


Should i do a lumbar puncture first

Immediate

Biopsy: alters treatment in 25% (Ecoli)

15-40% with meningitis have negative blood cultures

Avoids confusion

Delayed

Respiratory compromise

Trauma

Cerebral herniation

Rare

Should I do a lumbar puncture first?


Lp and possible early sepsis
LP and possible early sepsis

• Baby with RDS:

0.3% have meningitis

1500 LPs to find one meningitis

• Indications for Selective LP

Clinical suspicion

Risk factors (greatly prolonged rupture)

• Wiswell, 1995

169,000 babies: Selective LP would mean delay or missed diagnosis in 16 of 43 babies (37%)


Lp and late sepsis
LP and late sepsis

Traditional data: up to 10% of babies with late sepsis have meningitis

Recent data: 50-60% of late sepsis is with coagulase negative staphylococci

Inclination:

  • take blood culture, urine but not CSF (unless very sick)

  • start antibiotics

  • LP only if blood growing likely meningitis pathogen


Which antibiotics
Which antibiotics?

Narrowest spectrum possible:

• Penicillin and gentamicin

• Flucloxacillin and gentamicin

• Vancomycin and gentamicin

Not third generation cephalosporins

Not imipenem or carbapenem


Antibiotic abuse
Antibiotic abuse

Paper to review:

• European country

• Thanksgiving

• 30 babies treated for Pseudomonas infection with ciprofloxacin

• Used ciprofloxacin because had run out of other options

• Only 4 had sepsis; 26 had endotracheal tube isolates

• Treated for 8 to 30 days


Antibiotics abuse cont
Antibiotics abuse (cont)

• Treating colonisation not sepsis

• Treating for long periods of time

• Using very broad spectrum (and expensive) antibiotics


Good antibiotic practise
Good antibiotic practise

  • Use narrowest spectrum antibiotics possible

  • Treat sepsis, not colonisation

  • Stop antibiotics if cultures negative


Reasons given for continuing antibiotics
Reasons given for continuing antibiotics

  • Baby looked sick

  • Acute phase reactants elevated

  • Cultures might be false negatives

  • Cultures unreliable

  • Culture results not back


Antibiotic use oxford 1984 6 adc 1987 62 727 8
Antibiotic use, Oxford 1984-6(ADC 1987: 62: 727-8)

1984 1986

Mean duration of antibiotics 5.5 days 3.6 days

Weight of antibiotics (g) 202.7 122.1

% treated 50% 42%

Late sepsis 12 16

No. after stopping antibiotics 0 0


Reasons for stopping antibiotics
Reasons for stopping antibiotics

• Baby looked sick

• Courage, other causes

• Raised CRP

• Stop measuring it

• False negative cultures

• Rare in late sepsis

• Results not back

• Go to the lab and ask


How do i prevent fungal infections
How do I prevent fungal infections?

  • Reduce duration of antibiotics

  • Reduce duration of parenteral feeding

  • Prophylactic antifungals


Fluconazole prophylaxis
Fluconazole prophylaxis

(Kaufman et al, NESM 2001; 345: 1660-6)

100 babies < 1000g BW over 30 month period

50 IV fluconazole for 6 weeks

50 placebo

Fluconazole Placebo

Colonisation 11 30

Infection (urine, blood, CSF) 0 10


Prophylactic oral nystatin
Prophylactic oral nystatin

Preterm babies, birthweight <1250g

Oral nystatin 1mL (100,000U) 8-hourly until one week after extubation.

Outcome: colonisation (oropharynx, rectum)

sepsis (blood, urine)

(Sims M et al. Am J Perinatol 1988; 5:33-6)


Prophylactic nystatin for low birthweight babies
Prophylactic nystatin for low birthweight babies

Nystatin Control P

(n = 33%) (n = 34)

Colonised : 4 (14%) 15 (44%) <0.01

Systemic

infection : 2 (6%) 11 (32%) <0.001

UTI : 2 (6%) 10 (30%) <0.01

Pneumonia : 0 1 (died)

Candidaemia : 0 2

(Sims ME. 1988)


How can we prevent coagulase negative staphylococcal sepsis
How can we prevent coagulase negative staphylococcal sepsis?

  • Change question:

  • Should we try to prevent CoNS sepsis?


Coagulase negative staphylococcal neonatal infection
Coagulase negative staphylococcal neonatal infection sepsis?

(Australasia 1991 - 2000)

  • 1,281 episodes

  • 57% of late sepsis

  • Meningitis 5 (0.4%)

  • Mortality 4 (0.3%)


Conclusions
Conclusions sepsis?

  • Antibiotics are an extremely valuable resource

  • Use them wisely

  • Use them sparingly

  • Prevention important

  • Over-vigorous prevention not always wise


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