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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 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

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  1. Controversies in managing neonatal infections David Isaacs Children’s Hospital at Westmead Sydney Australia

  2. 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?

  3. Should I start antibiotics? • Maternal risk factors in early sepsis • Clinical examination • Laboratory: blood count, acute phase reactants • If in doubt, start them

  4. 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?

  5. 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%)

  6. 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

  7. Which antibiotics? Narrowest spectrum possible: • Penicillin and gentamicin • Flucloxacillin and gentamicin • Vancomycin and gentamicin Not third generation cephalosporins Not imipenem or carbapenem

  8. 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

  9. Antibiotics abuse (cont) • Treating colonisation not sepsis • Treating for long periods of time • Using very broad spectrum (and expensive) antibiotics

  10. Good antibiotic practise • Use narrowest spectrum antibiotics possible • Treat sepsis, not colonisation • Stop antibiotics if cultures negative

  11. Reasons given for continuing antibiotics • Baby looked sick • Acute phase reactants elevated • Cultures might be false negatives • Cultures unreliable • Culture results not back

  12. 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

  13. 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

  14. How do I prevent fungal infections? • Reduce duration of antibiotics • Reduce duration of parenteral feeding • Prophylactic antifungals

  15. 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

  16. 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)

  17. 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)

  18. How can we prevent coagulase negative staphylococcal sepsis? • Change question: • Should we try to prevent CoNS sepsis?

  19. Coagulase negative staphylococcal neonatal infection (Australasia 1991 - 2000) • 1,281 episodes • 57% of late sepsis • Meningitis 5 (0.4%) • Mortality 4 (0.3%)

  20. Conclusions • Antibiotics are an extremely valuable resource • Use them wisely • Use them sparingly • Prevention important • Over-vigorous prevention not always wise

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