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American Academy of Pediatrics
Commentary

Neonatal Antibiotic Use: How Much Is Too Much?

Dustin D. Flannery and Karen M. Puopolo
Pediatrics September 2018, 142 (3) e20181942; DOI: https://doi.org/10.1542/peds.2018-1942
Dustin D. Flannery
Division of Neonatology and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Pennsylvania Hospital, Philadelphia, Pennsylvania; and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Karen M. Puopolo
Division of Neonatology and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Pennsylvania Hospital, Philadelphia, Pennsylvania; and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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  • Abbreviations:
    AUR —
    antibiotic use rate
    NEC —
    necrotizing enterocolitis
  • Antimicrobial stewardship efforts benefit the individual and the community by improving patient-specific outcomes as well as decreasing the overall burden of antimicrobial resistance. Antibiotic stewardship can also save the health care system substantial amounts of money through decreased pharmacy costs, decreased inpatient use for antibiotic-resistant infections, and decreased frequency of antibiotic-associated adverse events.1 In NICUs, infants are frequently exposed to antimicrobial medications as prophylaxis against infection, as empirical treatment of suspected infection, and as targeted treatment of confirmed infection. Most neonatal antibiotic treatment is for suspected rather than proven infection, and researchers in several studies suggest that antibiotics are overused in both term and preterm infants.2–8 Evolving concern for unintended harm from neonatal antibiotic exposures has energized interest in the general principles of antimicrobial stewardship.3,5,9–13 Stewardship recommendations and quality collaborative programs support the appropriate use of antimicrobial agents in the NICU.14–17 Single centers report variably successful impacts of neonatal antibiotic stewardship interventions on the use of antibiotics for term infants who are at risk for early-onset infection, on the overall use of antibiotics across gestational ages, and on appropriate choice and duration of antibiotic therapy.18–21 In recent analyses using large multicenter data sets, researchers find small but significant declines in overall neonatal antibiotic use and in extended use in the absence of confirmed infection among preterm infants.5,22

    Where do neonatal clinicians go from here to affect comprehensive national antibiotic stewardship? To understand how much antibiotic use is too much, we need to know where we are and determine where we should aim to go. Schulman et al23 helped inform where we were starting in a report using a cohort of 52 061 infants cared for in 127 NICUs across California in 2013. The researchers reported the antibiotic use rate (AUR), which was defined as the total number of patient days that infants were exposed to at least 1 parenteral antimicrobial medication per 100 patient days. Their findings provided a wake-up call to the neonatal community: overall antibiotic use varied 40-fold, with a median site-specific AUR of 24.5% and a range of 2.4% to 97.1% of patient days. Regardless of the NICU level of care, the AUR was unrelated to rates of proven infection, necrotizing enterocolitis (NEC), surgical volume, or mortality. These findings have been widely interpreted to represent practice variation beyond biological patient variation. In this issue of Pediatrics, Schulman et al24 revisit the AUR in a cohort of 223 196 infants cared for in 137 California NICUs from 2013 to 2016. Compared with 2013, the AUR declined by 21.9% in 2016. Declines in AURs were more robust in centers that participated in recognized external antimicrobial stewardship programs than in those centers that did not (28.7% vs 16.2%), and lower-acuity centers had more variation than centers that provide complex quaternary care. Certain themes persisted in this study. Center-specific AURs still varied substantially, although the AUR range narrowed to a range of 5.6% to 57% of patient-days by 2016. The AUR remained unrelated to rates of proven infection and NEC. In contrast to their previous findings, post hoc analyses of 2016 data revealed that a higher AUR was correlated with higher surgical volume and higher mortality rates among quaternary-care centers, driven primarily by 3 centers with the highest AURs. Finally, the authors observe that the cut-point for the lowest AUR quartile among complex-care centers was 14.4%. With no explanation for higher AURs, they suggest that this might be the place we should aim to go.

    These high-level statewide data are an essential first step in informing practice and policy and should motivate providers and neonatal centers to critically evaluate their own practices. Given the size and diversity of the cohort, these data do provide a reasonable context for centers to understand where they are starting. However, a more nuanced understanding of the AUR will be required before we can determine where to aim to go.

    One important limitation of this study is that it is not used to address whether the observed changes in the AUR were associated with any particular positive or negative outcomes among individual infants, individual care units, or even within the entire cohort beyond the relatively blunt measure of overall mortality. The persistently wide range of AURs and the differences between NICU levels of care suggest that it is unlikely that 1 size AUR will fit all. The AUR might be better informed by detailed data on the center-specific patient case-mix, admission rates, and duration of hospitalization. It may be fruitful for future researchers to report comparisons of culture-mandated versus nonmandated AURs, broad versus narrow-spectrum AURs, and disease- and gestational age–specific AURs. In particular, site-specific surgical case load should not be offered as an explanation for AURs but should be viewed as an opportunity to examine the complex reasons for surgery-associated antibiotic use.

    Nonetheless, it is likely that this study reflects persistent clinician uncertainty regarding the optimal use of antimicrobial agents for infants in the NICU. Some infants need antibiotics. The treatment of culture-confirmed bloodstream infections is informed by professional standards. To arrive at an ideal AUR, neonatal providers will need to come together on issues that currently lack consensus. The authors state that, “…in our experience such blood culture–negative conditions [meningitis and pneumonia] are not likely to be important AUR drivers at most NICUs.”23 We would disagree. Provider discretion in treating sepsis for which the culture result was negative and uncertainties in interpreting cerebrospinal fluid values and in diagnosing ventilator-associated pneumonitis, urinary tract infection, and gastrointestinal conditions short of NEC as well as variation in the use of surgical antibiotic prophylaxis all contribute to the NICU AUR.25–29

    Variation should inform a search for ideal care; it cannot define it. Like their previous work, this study by Schulman et al is a vital contribution that should not be used to define AUR targets but serves as a renewed call for continued progress in neonatal antibiotic stewardship.

    Footnotes

      • Accepted June 28, 2018.
    • Address correspondence to Dustin D. Flannery, DO, Division of Neonatology, Children’s Hospital of Philadelphia, Newborn Care at Pennsylvania Hospital, 800 Spruce St, Philadelphia, PA 19107. E-mail: flanneryd{at}email.chop.edu
    • Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: Dr Flannery was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (award T32HD060550). Funded by the National Institutes of Health (NIH).

    • POTENTIAL CONFLICT OF INTEREST: Dr Puopolo is a faculty member of the Vermont Oxford Network’s Internet-Based Newborn Improvement Collaborative for Quality “Choosing Antibiotics Wisely”; and Dr Flannery has indicated he has no potential conflicts of interest to disclose.

    • COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-0115.

    References

    1. ↵
      1. Centers for Disease Control and Prevention
      . Antibiotic/antimicrobial resistance. Available at: https://www.cdc.gov/drugresistance. Accessed May 23, 2018
    2. ↵
      1. Cordero L,
      2. Ayers LW
      . Duration of empiric antibiotics for suspected early-onset sepsis in extremely low birth weight infants. Infect Control Hosp Epidemiol. 2003;24(9):662–666pmid:14510248
      OpenUrlCrossRefPubMed
    3. ↵
      1. Cotten CM,
      2. Taylor S,
      3. Stoll B, et al; NICHD Neonatal Research Network
      . Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for extremely low birth weight infants. Pediatrics. 2009;123(1):58–66pmid:19117861
      OpenUrlAbstract/FREE Full Text
      1. Chiu CH,
      2. Michelow IC,
      3. Cronin J,
      4. Ringer SA,
      5. Ferris TG,
      6. Puopolo KM
      . Effectiveness of a guideline to reduce vancomycin use in the neonatal intensive care unit. Pediatr Infect Dis J. 2011;30(4):273–278pmid:21085051
      OpenUrlCrossRefPubMed
    4. ↵
      1. Ting JY,
      2. Synnes A,
      3. Roberts A, et al; Canadian Neonatal Network Investigators
      . Association between antibiotic use and neonatal mortality and morbidities in very low-birth-weight infants without culture-proven sepsis or necrotizing enterocolitis. JAMA Pediatr. 2016;170(12):1181–1187pmid:27775765
      OpenUrlPubMed
      1. Taylor JA,
      2. Opel DJ
      . Choriophobia: a 1-act play. Pediatrics. 2012;130(2):342–346pmid:22778303
      OpenUrlAbstract/FREE Full Text
      1. Escobar GJ,
      2. Puopolo KM,
      3. Wi S, et al
      . Stratification of risk of early-onset sepsis in newborns ≥ 34 weeks’ gestation. Pediatrics. 2014;133(1):30–36pmid:24366992
      OpenUrlAbstract/FREE Full Text
    5. ↵
      1. Cantey JB,
      2. Baird SD
      . Ending the culture of culture-negative sepsis in the neonatal ICU. Pediatrics. 2017;140(4):e20170044pmid:28928289
      OpenUrlFREE Full Text
    6. ↵
      1. Cantey JB,
      2. Huffman LW,
      3. Subramanian A, et al
      . Antibiotic exposure and risk for death or bronchopulmonary dysplasia in very low birth weight infants. J Pediatr. 2017;181:289–293.e1pmid:27908652
      OpenUrlPubMed
      1. Cotten CM,
      2. McDonald S,
      3. Stoll B,
      4. Goldberg RN,
      5. Poole K,
      6. Benjamin DK Jr; Eunice Kennedy Shriver National Institute for Child Health and Human Development Neonatal Research Network
      . The association of third-generation cephalosporin use and invasive candidiasis in extremely low birth-weight infants. Pediatrics. 2006;118(2):717–722pmid:16882828
      OpenUrlAbstract/FREE Full Text
      1. Clark RH,
      2. Bloom BT,
      3. Spitzer AR,
      4. Gerstmann DR
      . Empiric use of ampicillin and cefotaxime, compared with ampicillin and gentamicin, for neonates at risk for sepsis is associated with an increased risk of neonatal death. Pediatrics. 2006;117(1):67–74pmid:16396862
      OpenUrlAbstract/FREE Full Text
      1. Alm B,
      2. Erdes L,
      3. Möllborg P, et al
      . Neonatal antibiotic treatment is a risk factor for early wheezing. Pediatrics. 2008;121(4):697–702pmid:18381533
      OpenUrlAbstract/FREE Full Text
    7. ↵
      1. Azad MB,
      2. Bridgman SL,
      3. Becker AB,
      4. Kozyrskyj AL
      . Infant antibiotic exposure and the development of childhood overweight and central adiposity. Int J Obes. 2014;38(10):1290–1298pmid:25012772
      OpenUrlCrossRefPubMed
    8. ↵
      1. Cantey JB,
      2. Patel SJ
      . Antimicrobial stewardship in the NICU. Infect Dis Clin North Am. 2014;28(2):247–261pmid:24857391
      OpenUrlCrossRefPubMed
      1. Patel SJ,
      2. Saiman L
      . Principles and strategies of antimicrobial stewardship in the neonatal intensive care unit. Semin Perinatol. 2012;36(6):431–436pmid:23177802
      OpenUrlCrossRefPubMed
      1. Vermont Oxford Network
      . iNICQ 2018: Choosing Antibiotics Wisely. Available at: https://public.vtoxford.org/quality-education/inicq-2018. Accessed June 19, 2018
    9. ↵
      1. Kuzniewicz MW,
      2. Puopolo KM,
      3. Fischer A, et al
      . A quantitative, risk-based approach to the management of neonatal early-onset sepsis. JAMA Pediatr. 2017;171(4):365–371pmid:28241253
      OpenUrlCrossRefPubMed
    10. ↵
      1. Dhudasia MB,
      2. Mukhopadhyay S,
      3. Puopolo KM
      . Implementation of the sepsis risk calculator at an academic birth hospital. Hosp Pediatr. 2018;8(5):243–250pmid:29666161
      OpenUrlAbstract/FREE Full Text
      1. Nzegwu NI,
      2. Rychalsky MR,
      3. Nallu LA, et al
      . Implementation of an antimicrobial stewardship program in a neonatal intensive care unit. Infect Control Hosp Epidemiol. 2017;38(10):1137–1143pmid:28745260
      OpenUrlPubMed
      1. Makri V,
      2. Davies G,
      3. Cannell S, et al
      . Managing antibiotics wisely: a quality improvement programme in a tertiary neonatal unit in the UK. BMJ Open Qual. 2018;7(2):e000285pmid:29756072
      OpenUrlAbstract/FREE Full Text
    11. ↵
      1. Ting JY,
      2. Paquette V,
      3. Ng K, et al
      . Reduction of inappropriate antimicrobial prescriptions in a tertiary neonatal intensive care unit following antimicrobial stewardship care bundle implementation [published online ahead of print March 24, 2018]. Pediatr Infect Dis J. doi:10.1097/INF.0000000000002039pmid:29596216
      OpenUrlCrossRefPubMed
    12. ↵
      1. Flannery DD,
      2. Ross RK,
      3. Mukhopadhyay S,
      4. Tribble AC,
      5. Puopolo KM,
      6. Gerber JS
      . Temporal trends and center variation in early antibiotic use among premature infants. JAMA Netw Open. 2018;1(1):e180164
      OpenUrl
    13. ↵
      1. Schulman J,
      2. Dimand RJ,
      3. Lee HC,
      4. Duenas GV,
      5. Bennett MV,
      6. Gould JB
      . Neonatal intensive care unit antibiotic use. Pediatrics. 2015;135(5):826–833pmid:25896845
      OpenUrlAbstract/FREE Full Text
    14. ↵
      1. Schulman J,
      2. Profit J,
      3. Lee HC, et al
      . Variations in neonatal antibiotic use. Pediatrics. 2018;142(3):e20180115
    15. ↵
      1. Bizzarro MJ
      . Health care-associated infections in the neonatal intensive care unit: barriers to continued success. Semin Perinatol. 2012;36(6):437–444pmid:23177803
      OpenUrlPubMed
      1. McPherson C,
      2. Liviskie C,
      3. Zeller B,
      4. Nelson MP,
      5. Newland JG
      . Antimicrobial stewardship in neonates: challenges and opportunities. Neonatal Netw. 2018;37(2):116–123pmid:29615159
      OpenUrlAbstract/FREE Full Text
      1. Klompas M,
      2. Branson R,
      3. Eichenwald EC, et al; Society for Healthcare Epidemiology of America (SHEA)
      . Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(8):915–936pmid:25026607
      OpenUrlCrossRefPubMed
      1. Kronman MP,
      2. Hersh AL,
      3. Gerber JS, et al
      . Identifying antimicrobial stewardship targets for pediatric surgical patients. J Pediatric Infect Dis Soc. 2015;4(4):e100–e108pmid:26407258
      OpenUrlCrossRefPubMed
    16. ↵
      1. Walker S,
      2. Datta A,
      3. Massoumi RL,
      4. Gross ER,
      5. Uhing M,
      6. Arca MJ
      . Antibiotic stewardship in the newborn surgical patient: a quality improvement project in the neonatal intensive care unit. Surgery. 2017;162(6):1295–1303pmid:29050887
      OpenUrlPubMed
    • Copyright © 2018 by the American Academy of Pediatrics
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    Neonatal Antibiotic Use: How Much Is Too Much?
    Dustin D. Flannery, Karen M. Puopolo
    Pediatrics Sep 2018, 142 (3) e20181942; DOI: 10.1542/peds.2018-1942

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    Neonatal Antibiotic Use: How Much Is Too Much?
    Dustin D. Flannery, Karen M. Puopolo
    Pediatrics Sep 2018, 142 (3) e20181942; DOI: 10.1542/peds.2018-1942
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