Sense about Sepsis

Recent guidelines regarding the evaluation and treatment of early onset sepsis, or the baby who has risk factors, have been widely criticized.

Especially by me! And by me!

The AAP for example recommends antibiotic treatment for all infants born after a maternal history of chorioamnionitis. The statement I wrote for the CPS a few years ago in contrast, did not. We recommended a CBC and close observation alone in infants who had a history of chorioamnionitis, but appeared well. This was based on an incidence among well-appearing infants after an obstetric diagnosis of chorioamnionitis of well below 2%. Of course it is not zero, as babies who look OK at birth might be in the early stages of infection and become sick later. Also there are big problems in the diagnosis of chorio, even in the papers that we cited to make our recommendation.

When we made our recommendations (2007), the difference of opinion with the AAP and the CDC was understandable, there were many unknowns based on the limitations of the data; the AAP/CDC approach was based on a fear of missing real cases, ours was based on a fear of massive over-treatment of relatively low-risk patients (although, of course both ‘sides’ were fearful of the other issue as well).

Now there is a lot more information, and a new publication from 2 of the authors of the most recent version of the AAP recommendation, along with James Wynn, makes some recommendations based on those new data. I think at last (and this is not surprising, given that the first author is the always excellent Bill Benitz) that these recommendations are sensible, reasonable, and likely to do the least harm to the largest number of babies.

They say the following (I have skipped a couple which were of less day to day value to working paediatricians) (EOS is early onset sepsis):

 2. Infants who exhibit persistent, progressive, or moderately severe to severe clinical signs consistent with EOS should receive empiric antibiotic therapy after cultures are obtained. Infants with mild-to-moderate respiratory findings (flaring, grunting, retractions, or tachypnea) immediately after birth may be monitored closely for resolution of transitional behaviors, without initiation of antibiotic treatment unless signs worsen or persist for more than 6 hours.

4. Preterm infants (<34 weeks’ gestation or <1500 g) are at significantly increased risk for EOS…, it is reasonable to continue to stratify risk based on those traditional risk factors. Because most preterm infants have clinical signs of illness, most will qualify for empiric treatment. Preterm infants who appear well and have minimal or no risk factors (eg, no chorioamnionitis, preterm premature rupture of membranes, or GBS colonization with inadequate intrapartum prophylaxis) may be candidates for close monitoring and serial laboratory evaluation.

5. Well-appearing late-preterm and term infants should be managed with close clinical observation, because of the low sensitivity of risk factors in ascertainment of EOS in this group. Efforts to improve ascertainment of EOS cases in this population are commendable, but should not obscure the limited utility of the strategies attempted to date.

6. Even with selective treatment strategies, most treated infants will not have bacterial infection. In treated infants, serial normal diagnostic tests, such as blood counts or C-reactive protein levels, are highly predictive of the absence of infection and should be relied upon (in addition to culture results) to minimize the duration antibiotic exposure. However, isolated abnormal hematological or acute-phase-reactant measurements should not justify continuation of empiric antibiotics for more than 48 hours in well-appearing infants with negative culture results.

I agree totally!

Which is unusual!

I should cut down on the exclamation marks!

The analysis of clinical signs, and that modest respiratory signs can be followed, is a welcome improvement, as are the recognition of the importance of persistently negative lab findings, and the lack of importance of positive lab findings.

UPDATE** after further reading, I have to change this to I agree ‘almost totally’. #4 implies, if I read it right, that preterm babies with serious respiratory illness should all get antibiotics, even if there are no risk factors. But for preterm babies born after c-section for maternal indications with intact membranes and no labour, the risk of sepsis is very close to zero, even if they have serious respiratory findings. This is a substantial minority of our preterm babies and they can safely be managed without blood culture or antibiotics.

I think we should now be able to go forward to an international consensus, based on good data, which will avoid over-treatment of low-risk patients but also ensure that almost all truly septic babies receive timely care.

About keithbarrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
This entry was posted in Neonatal Research and tagged , . Bookmark the permalink.

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