Neonatal early onset sepsis risk calculatorReducing admission rates of well babies at risk of sepsis

Alice StewartService Director Monash Newborn

Overview

• Existing approaches to early onset sepsis (EOS) risk assessment

• Neonatal EOS Risk Calculator: safety & efficacy• Monash Health experience

• Indicator 2 performance• Implementation of sepsis calculator

Are we treating too many?

Under CDC guidelines, percentage of infants being treated with antibiotics ~200 fold higher than incidence of EOS

• 2009: Boston unit treated 8% of well-appearing infants ≥ 34 weeks (EOS 0.4/1000 live births)Mukhopadhyay J Perinatol. 2013

• 2010-2013: in Kaiser Permanente Northern California Network 15% infants ≥ 34 weeks had blood cultures, 5.4% received antibiotics (EOS 0.3/1000 live births)Kuzniewicz Jt Comm J Qual Patient Saf. 2016

Acceptable approaches to EOS risk stratification include:• Categorical algorithms;• Multivariate risk assessment e.g. Neonatal Early Onset

Sepsis Risk Calculator; and• Serial physical examination – babies identified as at risk

through above assessments, or in all newborn babies

Clinical recommendation: 4 types

Clinical Recommendation VitalsNo culture, no antibiotics RoutineNo culture, no antibiotics Every 4 hours for 24 hoursBlood culture Every 4 hours for 24 hoursEmpiric antibiotics Vitals per NICU

Note: no ‘screening’ FBC/CRP pathway

Efficacy: reduction in antibiotic use

First step in implementation: determine local EOS incidence

MH GBS EOS incidence 0.8/1000 live births in 2016 & 2017ANZ data (Singh et al. 2018):EOS incidence 0.83/1000 live births (2012; falling)GBS EOS incidence 0.43/1000 live births (2002 to 2012; static)

Comparison of current risk-based guidelines for prevention of neonatal early-onset sepsis with a sepsis calculator: a retrospective cohort study*Lim R, Stanfield S, Nesbitt G, Stewart A, Barfield C, Tan K

• MMC newborns, Indicator 2 criteria FY2015/2015• 407 babies investigated for suspected EOS – 375 (92%)

received IV antibiotics under existing guidelines• 5 culture-positive EOS cases – none would have been missed• At a baseline EOS incidence rate of 1/1000 live births, use of the

sepsis calculator would have reduced IV antibiotic use by 76%.

*PSANZ 18-20 March 2019

Using the calculator• Use in all babies born at >35 weeks• As soon as possible after birth, when first set of

observations available• Two person check• Document on designated newborn record• If medical review due to change in clinical status:

recalculation of risk score and documentation in progress notes

Management categoriesClinical Recommendation

Management plan

No culture, no antibiotics Routine careNo culture, no antibiotics Regular observations for 24 hoursBlood culture Regular observations until review of BC

result at 36 hours. Daily medical review.Empiric antibiotics Empiric IV antibiotic therapy

• Empiric antibiotics without delay and regardless of EOS score if infant unwell, maternal bacteraemia, or sibling had invasive GBS disease

• Urgent medical review if any abnormal signs/observations• Any baby in equivocal category must be admitted to SCN

Early results

Key messages

• Clinical decision support tool - demonstrated safety and efficacy

• Importance of close observation (ViCTOR chart) and reassessment if clinical status changes

• Expect a period of learning• Plan for post-implementation assessment

Acknowledgments• Dr Ruth Lim• Dr Scott Stanfield• Dr Gemma Nesbitt• A/Prof Charles Barfield• A/Prof Kenneth Tan• Dr Pramod Pharande

• Despina Kotsanas• A/Prof Ryan Hodges• Andrea Rindt• Prof Jim Buttery• Kerrie Papacostas• All Monash Women’s and

Monash Newborn staff