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

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.

• How can I prevent fungal infections?

• How can I prevent coagulase negative staphylococcal

infection?

Should I start antibiotics?

• Maternal risk factors in early sepsis

• Clinical examination

• Laboratory: blood count, acute phase reactants

• If in doubt, start them

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?

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%)

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

Which antibiotics?

Narrowest spectrum possible:

• Penicillin and gentamicin

• Flucloxacillin and gentamicin

• Vancomycin and gentamicin

Not third generation cephalosporins

Not imipenem or carbapenem

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

Antibiotics abuse (cont)

• Treating colonisation not sepsis

• Treating for long periods of time

• Using very broad spectrum (and expensive) antibiotics

Good antibiotic practise

• Use narrowest spectrum antibiotics possible

• Treat sepsis, not colonisation

• Stop antibiotics if cultures negative

Reasons given for continuing antibiotics

• Baby looked sick

• Acute phase reactants elevated

• Cultures might be false negatives

• Cultures unreliable

• Culture results not back

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 antibiotics0 0

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

How do I prevent fungal infections?

• Reduce duration of antibiotics

• Reduce duration of parenteral feeding

• Prophylactic antifungals

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

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)

Prophylactic nystatin for low birthweight babies

Nystatin Control P

(n = 33%) (n = 34)

Colonised : 4 (14%) 15 (44%) <0.01

Systemicinfection : 2 (6%) 11 (32%) <0.001

UTI : 2 (6%) 10 (30%) <0.01

Pneumonia : 0 1 (died)

Candidaemia : 0 2(Sims ME. 1988)

How can we prevent coagulase negative staphylococcal sepsis?

• Change question:

• Should we try to prevent CoNS sepsis?

Coagulase negative staphylococcal neonatal infection

(Australasia 1991 - 2000)

• 1,281 episodes

• 57% of late sepsis

• Meningitis 5 (0.4%)

• Mortality 4 (0.3%)

Conclusions

• Antibiotics are an extremely valuable resource

• Use them wisely

• Use them sparingly

• Prevention important

• Over-vigorous prevention not always wise