Brief comments on three existing approaches for managing neonates at risk of early-onset sepsis

Abstract

Background Growing concerns regarding the adverse effects of antibiotics during the first days of life and the marked reduction in the incidence of early-onset sepsis (EOS) are changing the clinical practice for managing neonates at risk of EOS. Strategies avoiding unnecessary antibiotics while promoting mother-infant bonding and breastfeeding deserve to be considered. Main body We compare strategies for managing newborns at risk of EOS recommended by the American Academy of Pediatrics, which are among the most followed recommendations worldwide. Currently three different approaches are suggested in asymptomatic full-term or late preterm neonates: i) the conventional management, based on standard perinatal risk factors for EOS alone, ii) the neonatal sepsis calculator, a multivariate risk assessment based on individualized, quantitative risk estimates (relying on maternal risk factors for EOS) combined with physical examination findings at birth and in the following hours and iii) an approach entirely based on newborn clinical condition (serial clinical observation) during the first 48 h of life. We discuss advantages and limitations of these approaches, by analyzing studies supporting each strategy. Approximately 40% of infants who develop EOS cannot be identified on the basis of maternal RFs or laboratory tests, therefore close monitoring of the asymptomatic but at-risk infant remains crucial. A key question is to know what proportion of babies with mild, unspecific symptoms at birth can be managed safely without giving antibiotics. Conclusions Both neonatal sepsis calculator and serial clinical observation may miss cases of EOS, and clinical vigilance for all neonates is essential There is a need to assess which symptoms at birth are more predictive of EOS, and therefore require immediate interventions, or symptoms that can be carefully reevaluated without necessarily treat immediately the neonate with antibiotics. Studies comparing strategies for managing neonates are recommended.

Neonatal Early Onset Sepsis (EOS) Calculator plus Universal Serial Physical Examination (SPE): A Prospective Two-Step Implementation of a Neonatal EOS Prevention Protocol for Reduction of Sepsis Workup and Antibiotic Treatment

“…Limiting the clinical examination only to newborns with EOS risk factors can lead to missed diagnoses in newborns with no perinatal warnings [ 38 , 39 , 40 ]. We report the case of one patient of the P2 population, with no pre- or perinatal risk factors, who developed a severe form of GBS sepsis that led to his death.…”

“…Though promising, the EOS calculator still has some limitations. Based on the initial assessment at birth, it assigns the category of routine neonatal care to a substantial percentage of EOS cases, which may lack any initial pathological clinical signs of EOS [ 38 , 47 , 48 ]. Furthermore, it may not distinguish symptoms that may be the consequence of a different pathological state [ 38 ].…”

“…Based on the initial assessment at birth, it assigns the category of routine neonatal care to a substantial percentage of EOS cases, which may lack any initial pathological clinical signs of EOS [ 38 , 47 , 48 ]. Furthermore, it may not distinguish symptoms that may be the consequence of a different pathological state [ 38 ]. For example, transient tachypnea of the newborn presents itself with a high respiratory rate and oxygen requirement soon after birth, but following the EOS calculator classification may suggest performing laboratory tests and antibiotics administration.…”

Predicting the likelihood of lower respiratory tractUreaplasmainfection in preterms

“…Multivariable risk-based approaches incorporating perinatal factors have been previously developed to stratify risk for early onset sepsis,27–29 prediction of BPD30 31 and need for retinopathy of prematurity treatment32 in preterm infants. In the current study, we have used perinatal factors to develop three multivariable risk models to be implemented antenatally or immediately after preterm birth with and without admission WBC to predict lower respiratory tract Ureaplasma in infants <33 weeks gestation.…”

Effect of Serial Clinical Observation Complemented by Point-of-Care Blood Culture Volume Verification on Antibiotic Exposure in Newborns

“…Currently, infants at risk for EOS can be managed in the following 3 ways: (i) categorical risk assessment, which is the most traditional approach; (ii) multivariate risk assessment incorporated into a web-based neonatal EOS risk calculator; and (iii) serial clinical observation (SCO) or serial physical examination (SPE) strategies. 1 , 10 …”