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Wednesday 9 January 2019
Challenges and opportunities for antibiotic stewardship among preterm infants

This week WAidid suggests to read "Challenges and opportunities for antibiotic stewardship among preterm infants" published last November 13, 2018 on BMJ.


Antibiotics are the most commonly used drugs in the neonatal intensive care unit (NICU). More than 75% of very low birthweight infants (VLBW) and over 80% of extremely low birthweight infants (ELBW) receive antibiotics for the risk of early-onset sepsis (EOS). Two-thirds of VLBW infants, cared for in the NICHD Neonatal Research Network (NRN) centres, are evaluated at least once for late-onset sepsis (LOS). Clinicians administer antibiotics to ensure the safety of preterm infants, but antibiotic administration is not without risk. An evolving understanding of the role of microbiome in human health has added new, potentially more pervasive and currently unpredictable, risks to neonatal antibiotic exposure. The increased understanding of risk and limited evidence for benefit of antibiotic therapy, in the absence of culture-confirmed infection, demands that neonatal providers examine current practice. Specific drivers of neonatal antibiotic use inform the opportunities for antibiotic stewardship.

The general goals of hospital-based antibiotic stewardship are described by the Centers for Disease Control and Prevention. These guidelines focus on the elements of initiating and discontinuing antibiotics, optimizing infection and biomarker testing, choosing empiric and definitive antibiotic therapy, and limiting duration of empiric therapy.

The authors discuss the aspects of empiric antibiotic use, that provide opportunities for stewardship practice among VLBW preterm infants.

Optimal duration for empiric therapy balances the provision of antibiotic therapy to infants, whose blood culture will grow a pathogen, with minimized antibiotic exposure in those where the blood culture will remain sterile. Traditional 48 and 72 hours’ ‘rule out’ periods are based on daily examination of broth culture. Current blood culture techniques are optimized to detect very low levels of bacteraemia.

Ampicillin, gentamicin and vancomycin are among the top medications used in NICUs across the USA. The most common empiric antibiotic choice for EOS is ampicillin and gentamicin. There is less clarity in empiric antibiotic choice for LOS: methicillin-resistant Staphylococcus aureus (MRSA) screening in NICUs may restrict vancomycin empiric therapy.

There are no standard clinical algorithms to define the continuation of antibiotics in the absence of evidence for infection.

The role of biomarkers, in determining antibiotic prescription and duration, among preterm infants, remains promising but unclear.

The authors concluded that, despite the challenges of implementing antibiotic stewardship in the premature infant, promising strategies, that specifically target this population, exist. They highlighted that much of the focus in antibiotic use among premature infants has been to protect the child from infection, but that protection should not happen at the risk of injury to the uninfected child. Achieving this balance requires standardization of care, measurement of antibiotic use, strong balance measures and continuous evaluation of practices and outcomes.


Sagori Mukhopadhyay, Shaon Sengupta, Karen M Puopolo.

Read more here.