Karen M Puopolo1,2, Sagori Mukhopadhyay3,2, Nellie I Hansen4, C Michael Cotten5, Barbara J Stoll6, Pablo J Sanchez7, Edward F Bell8, Abhik Das9, Angelita M Hensman10, Krisa P Van Meurs11,12, Myra H Wyckoff13. 1. Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; karen.puopolo@uphs.upenn.edu. 2. Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. 3. Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. 4. Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina. 5. Division of Neonatology, Duke University Medical Center, Duke University, Durham, North Carolina. 6. McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas. 7. Section of Neonatology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio. 8. Department of Pediatrics, University of Iowa, Iowa City, Iowa. 9. Biostatistics and Epidemiology Division, RTI International, Rockville, Maryland. 10. Warren Alpert Medical School, Brown University and Women & Infants Hospital of Rhode Island, Providence, Rhode Island. 11. Department of Pediatrics, School of Medicine, Stanford University, Stanford, California. 12. Lucile Packard Children's Hospital, Palo Alto, California; and. 13. Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Parkland Health & Hospital System, and Children's Medical Center Dallas, Dallas, Texas.
Abstract
BACKGROUND: Premature infants are at high risk of early-onset sepsis (EOS) relative to term infants, and most are administered empirical antibiotics after birth. We aimed to determine if factors evident at birth could be used to identify premature infants at lower risk of EOS. METHODS: Study infants were born at 22 to 28 weeks' gestation in Neonatal Research Network centers from 2006 to 2014. EOS was defined by isolation of pathogenic species from blood or cerebrospinal fluid culture at ≤72 hours age. Infants were hypothesized as "low risk" for EOS when delivered via cesarean delivery, with membrane rupture at delivery, and absence of clinical chorioamnionitis. Frequency of prolonged antibiotics (≥5 days) was compared between low-risk infants and all others. Risks of mortality, EOS, and other morbidities were assessed by using regression models adjusted for center, race, antenatal steroid use, multiple birth, sex, gestation, and birth weight. RESULTS: Of 15 433 infants, 5759 (37%) met low-risk criteria. EOS incidence among infants surviving >12 hours was 29 out of 5640 (0.5%) in the low-risk group versus 209 out of 8422 (2.5%) in the comparison group (adjusted relative risk = 0.24 [95% confidence interval, 0.16-0.36]). Low-risk infants also had significantly lower combined risk of EOS or death ≤12 hours. Prolonged antibiotics were administered to 34% of low-risk infants versus 47% of comparison infants without EOS. CONCLUSIONS: Delivery characteristics of extremely preterm infants can be used to identify those with significantly lower incidence of EOS. Recognition of differential risk may help guide decisions to limit early antibiotic use among approximately one-third of these infants.
BACKGROUND: Premature infants are at high risk of early-onset sepsis (EOS) relative to term infants, and most are administered empirical antibiotics after birth. We aimed to determine if factors evident at birth could be used to identify premature infants at lower risk of EOS. METHODS: Study infants were born at 22 to 28 weeks' gestation in Neonatal Research Network centers from 2006 to 2014. EOS was defined by isolation of pathogenic species from blood or cerebrospinal fluid culture at ≤72 hours age. Infants were hypothesized as "low risk" for EOS when delivered via cesarean delivery, with membrane rupture at delivery, and absence of clinical chorioamnionitis. Frequency of prolonged antibiotics (≥5 days) was compared between low-risk infants and all others. Risks of mortality, EOS, and other morbidities were assessed by using regression models adjusted for center, race, antenatal steroid use, multiple birth, sex, gestation, and birth weight. RESULTS: Of 15 433 infants, 5759 (37%) met low-risk criteria. EOS incidence among infants surviving >12 hours was 29 out of 5640 (0.5%) in the low-risk group versus 209 out of 8422 (2.5%) in the comparison group (adjusted relative risk = 0.24 [95% confidence interval, 0.16-0.36]). Low-risk infants also had significantly lower combined risk of EOS or death ≤12 hours. Prolonged antibiotics were administered to 34% of low-risk infants versus 47% of comparison infants without EOS. CONCLUSIONS: Delivery characteristics of extremely preterm infants can be used to identify those with significantly lower incidence of EOS. Recognition of differential risk may help guide decisions to limit early antibiotic use among approximately one-third of these infants.
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