Supervisors info:
Νικολέττα Μ. Ιακωβίδου, Καθηγήτρια, Ιατρική Σχολή, ΕΚΠΑ
Τσολιά Μαρία, Καθηγήτρια, Ιατρική Σχολή, ΕΚΠΑ
Σιαχανίδου Σουλτάνα, Καθηγήτρια, Ιατρική Σχολή, ΕΚΠΑ
Summary:
Background: Group B Streptococcus is a common bacterium of the gastrointestinal and
genitourinary tract in about 20-30% of women, which is mostly responsible for neonatal sepsis. Any case occurring during the first week of life and especially the first 72 hours of life is described as early onset neonatal disease (EOD), with high mortality rates and urgent need of antibiotic administration. For this purpose, the Kaiser-Permanente model was applied in order to estimate the EOD probability per event by assessing the combination of predicted risk factors and clinical appearance of the neonate.
Aim - Methods: The aim of this study was to record the neonates who had at least one risk factor for the occurrence of GBS-EOD according to the NICE (National Institute for Health and Care Excellence) guidelines and received antimicrobial treatment by the neonatologists in a Neonatal Care Unit and then to assess the estimated risk of sepsis after applying the Kaiser model. Kaiser's estimated EOD risk was also compared to the NICE and American Academy of Pediatrics (AAP) practices. This is a retrospective study, which was carried out based on the database and medical files of the Neonatology Department of the National and Kapodistrian University of Athens, Aretaieio
Hospital, Athens, for the period 01/2018-12/2021. From a total of 3.321 births, 259 neonates constituted the study population based on the recommendations of NICE on risk factors related to the incidence of EOD.
Results: Of the neonates who had at least one risk factor for EOD according to NICE (N=259), 21.2% received antimicrobial treatment in the maternity ward of the study (N=55/259). Only 13.5% of them (N=35/259) had an absolute indication for antibiotic administration according to NICE. In all treated newborns (N=55), the antimicrobial treatment was given in accordance with the NICE criteria in 63.6%, while in 36.4% of them the use of antibiotics was based on personal medical judgment. The latest cases were well-appearing newborns with prolonged rupture of the membranes and unknown
GBS status after 36 weeks of gestation. The study had only one, single case of microbiologically confirmed GBS-EOD which was diagnosed at 36 hours of life, due to appearance of pallor. After applying the Kaiser model to the population of treated neonates, antibiotic use was recommended for only 10.9% of them, without including the neonate with the confirmed sepsis. The Kaiser estimated rate of antimicrobial therapy for neonates receiving antibiotics was the lowest compared to the other practices (p= < 0.00001). The use of antibiotics for the same population (N=55) based on the recommendations of the AAP, was reduced compared to the NICE recommendations (63.6%), being 58.2% for the risk-based strategy and 60% for the serial physical examination (SPE) approach. The only diagnostic method that would not miss the diagnosis of the newborn with the confirmed sepsis was that of SPE. In our study, for neonates treated as probable GBS-EOD cases, the best diagnostic practice was the combination of the Kaiser model with SPE due to the low antibiotic use (13%, N=7/55) and the early detection of the true GBS-EOD case.
Conclusion: Overall, there is still no consensus over the diagnostic algorithm for EOD, however the decision for antibiotic use in Neonatal Units should be based only on official guidelines. The NICE recommendations are associated with the highest rate of antimicrobial treatment, without always detecting all newborns with confirmed sepsis. Single application of the Kaiser model is not recommended as it may be associated with delayed diagnosis of EOD cases. On the contrary, in combination with the SPE practice, the Kaiser model can restrict the antibiotic overuse and lead to prompt treatment of all true cases of neonatal sepsis.
Keywords:
Early neonatal disease, Kaiser model, Risk factors, Antibiotic treatment, Antibiotic overuse
