Challenges and opportunities for antibiotic stewardship among preterm infants

Abstract

Antibiotic stewardship programmes aim to optimise antimicrobial use to prevent the emergence of resistance species and protect patients from the side effects of unnecessary medication. The high incidence of systemic infection and associated mortality from these infections leads neonatal providers to frequently initiate antibiotic therapy and make empiric antibiotic courses one of the main contributors of antibiotic use in the neonatal units. Yet, premature infants are also at risk for acute life-threatening complications associated with antibiotic use such as necrotising enterocolitis and for long-term morbidities such as asthma. In this review, we discuss specific aspects of antibiotic use in the very low birthweight preterm infants, with a focus on empiric use, that provide opportunities for stewardship practice. We discuss strategies to risk-stratify antibiotic initiation for the risk of early-onset sepsis, optimise empiric therapy duration and antibiotic choice in late-onset sepsis, and standardise decisions for stopping empiric therapy. Lastly, review the evolving role of biomarkers in antibiotic stewardship.

<p>Pediatric Antimicrobial Stewardship Programs: Current Perspectives</p>

“…41 In contrast to the aforementioned perception, antibiotic courses as brief as 4 days administered to very low and extremely low birth weight infants during the first week of life have been associated with a greater likelihood of adverse outcomes including chronic lung disease, necrotizing enterocolitis, invasive candidiasis and late-onset sepsis (possibly due to antibiotic-induced alterations in the neonatal intestinal microbiome). 36,37,42,43 Per Cantey and Patel, 35 "Neonatologists may be more receptive to implementing changes in their practice if advocated by a well-respected peer rather than ID doctors or pharmacists." Fortunately, increasing numbers of neonatologists are answering the call to advocate for neonatal AS.…”

Neonatal intestinal dysbiosis

“…A follow-up study by the same group showed a 22% decline in NICU antibiotic use from 2013 to 2016 (42,960 fewer antibiotic days) with a greater decline in NICUs with an established antibiotic stewardship program [125]. This and other studies suggest that further benefits may be gained by antibiotic stewardship [123].…”

Infection control and other stewardship strategies in late onset sepsis, necrotizing enterocolitis, and localized infection in the neonatal intensive care unit

“… 35 The choice of vancomycin is directed by concerns for methicillin-resistant Staphylococcus aureus (MRSA) infection, and the predominance of CoNS in the setting of LOS. 36 However, there are multiple studies showing that restricting empirical vancomycin use does not result in increased mortality or morbidity. 37 , 38 , 39 , 40 Chiu et al reported the effectiveness of implementing a restrictive vancomycin use guideline at 2 tertiary care centers.…”

“… 40 Thus, it is prudent to use an antistaphylococcal penicillin, such as oxacillin or nafcillin, along with an aminoglycoside for the initial empiric treatment of LOS. 7 , 36 , 38 , 39 , 40 , 41 , 42 , 43 Vancomycin should be considered judiciously in areas where MRSA is prevalent, or if the culture is positive for CoNS. 41 , 42 , 43 In the setting of a negative blood culture, with optimal collection technique, discontinuation of antibiotics should be considered.…”