Use of a Modified Early-Onset Sepsis Risk Calculator for Neonates Exposed to Chorioamnionitis.

OBJECTIVE: To validate the recently modified Kaiser Permanente early-onset sepsis (EOS) calculator with a higher baseline incidence in chorioamnionitis exposed neonates. STUDY DESIGN: This is a retrospective study of chorioamnionitis-exposed neonates born at ≥35 weeks of gestation with a known EOS incidence of 4.3/1000. The risk and management categories were calculated using the calculator with an incidence of 4/1000. The results were compared with a previous analysis of the same cohort that used an EOS incidence of 0.5/1000. RESULTS: In our sample, the EOS calculator recommends at least a blood culture in 834 of 896 (93.1%) and empiric antibiotics in 533 of 896 (59.5%) chorioamnionitis-exposed neonates when using an EOS incidence of 4/1000. This captures 5 of 5 neonates (100%) with EOS. When using a baseline EOS incidence of 0.5/1000, the calculator recommends at least a blood culture in only 289 of 896 (32.2%) and empiric antibiotics in only 209 of 896 (23.3%) neonates, but fails to recommend empiric antibiotics in 2 of 5 neonates with EOS (40%). CONCLUSIONS: When using an EOS risk of 4 of 1000 in infants exposed to mothers with chorioamnionitis, the EOS calculator has the ability to capture an increased number of neonates with culture-positive EOS. However, this change also leads to nearly a 3-fold increase in the use of empiric antibiotics and an evaluation with blood culture in almost all infants born to mothers with chorioamnionitis.

Utility of Early-Onset Sepsis Risk Calculator for Neonates Born to Mothers with Chorioamnionitis.

OBJECTIVES: To evaluate the performance of the early-onset sepsis (EOS) risk calculator in a cohort of neonates born to mothers with clinical chorioamnionitis, and to compare the diagnostic utility of the EOS calculator, clinical signs, and laboratory evaluations for correctly identifying EOS in this cohort. STUDY DESIGN: This was a retrospective study of neonates born at ≥35 weeks of gestation to mothers with chorioamnionitis. The risk and management categories for all neonates were calculated using the EOS calculator, and these results were analyzed and compared with laboratory data and clinical signs. RESULTS: Of the 1159 neonates born to mothers with chorioamnionitis, 5 (0.43%) had culture-proven EOS. Data for calculation of EOS risk were available for 896 neonates, including the 5 neonates with culture-proven EOS. The management recommendation based on the calculator was no empiric antibiotic treatment for 67% of the neonates, including 2 of the 5 with EOS. All neonates with culture-proven EOS had abnormal complete blood counts and C-reactive protein levels at 6-12 hours. Three of the 5 neonates with EOS had clinical signs of sepsis. CONCLUSIONS: The risk of EOS in neonates born to mothers with chorioamnionitis is low. The use of an EOS calculator may reduce the use of empiric antibiotics in chorioamnionitis-exposed neonates, but in our cohort, some neonates with culture-confirmed EOS would have been missed. A larger study is needed to evaluate whether limiting antibiotics to chorioamnionitis-exposed neonates with clinical and/or laboratory signs of infection can safely decrease antibiotic use.

Assessment of temporal variations in adherence to NRP using video recording in the delivery room.

INTRODUCTION: Video recording and video evaluation tools have been successfully used to evaluate neonatal resuscitation performance. The objective of our study was to evaluate differences in Neonatal Resuscitation Program (NRP) adherence at time of birth between three temporal resuscitative periods using scored video recordings. METHODS: This is a retrospective review of in-situ resuscitation video recordings from a level 3 perinatal center between 2017 and 2018. The modified Neonatal Resuscitation Assessment (mNRA) scoring tool was used as a surrogate marker to assess NRP adherence during daytime, evening, and nighttime hours. RESULTS: A total of 260 resuscitations, of which 258 were births via Cesarean section, were assessed. mNRA composite scores were 86.2% during daytime hours, 87% during evening hours, and 86.6% during nighttime hours. There were no significant differences in mNRA composite scores between any of the three time periods. Differences remained statistically similar after controlling for complexity of resuscitations with administration of positive pressure ventilation (PPV), intubation, or chest compressions. CONCLUSION: Overall adherence to NRP, as measured by composite mNRA scores as a surrogate marker, was high across all three daily resuscitative periods without significant differences between daytime, evening, and nighttime hours.

Do extremely preterm infants need retinopathy of prematurity screening earlier than 31 weeks postmenstrual age?

OBJECTIVE: To evaluate the utility of screening all extremely preterm infants for retinopathy of prematurity (ROP) at 4 weeks chronologic age, which is earlier than recommended by the 2018 AAP guidelines. STUDY DESIGN: Retrospective analysis of infants <27 weeks gestation from two tertiary NICUs between 2006 and 2018 who survived until first eye examination. RESULTS: 550 infants (gestational age 25.1 ± 1.2 weeks and birth weight 758 ± 323 g) had 1310 examinations performed by 32 weeks postmenstrual age (PMA), and 676 (51.6%) of these were prior to 31 weeks PMA. No examinations in infants prior to 31 weeks PMA met the criteria for laser therapy. Of 87/550 infants (15.8%) who required laser therapy, none did so prior to 32 weeks PMA. CONCLUSIONS: No infants born <27 weeks gestation were found to have severe ROP prior to 31 weeks PMA, supporting the most recent AAP recommendation of initiating ROP screening at 31 weeks PMA for extremely preterm infants.

A comparison of Triple I classification with neonatal early-onset sepsis calculator recommendations in neonates born to mothers with clinical chorioamnionitis.

OBJECTIVE: To compare the early-onset sepsis (EOS) calculator recommendations for infants born to mothers with clinical chorioamnionitis with those made by the Triple I classification. STUDY DESIGN: Retrospective analysis of chorioamnionitis-exposed neonates ≥35 weeks. EOS risk was calculated with baseline risks of 0.5/1000 and 4/1000. Mothers were retrospectively categorized using the Triple I classification. Calculator recommendations were compared with the Triple I classification recommendations. RESULTS: We included 687 chorioamnionitis-exposed neonates. With a baseline risk of 0.5/1000, the calculator recommended no evaluation in 68.4% of infants of mothers with confirmed Triple I. With a baseline risk of 4/1000, 62.3% of infants of mothers with confirmed Triple I and 57.1% of infants born to mothers who did not meet fever criteria would have received evaluation. CONCLUSIONS: The EOS calculator with either baseline risk does not recommend evaluation in a large number of infants born to mothers with confirmed Triple I.

Hypertensive disorders during pregnancy are associated with reduced severe intraventricular hemorrhage in very-low-birth-weight infants.

OBJECTIVE: To determine differences in severe intraventricular hemorrhage (IVH) between very-low-birth-weight (≤1500 g, VLBW) infants born to mothers with and without hypertensive disorders (HD). DESIGN/METHODS: Retrospective analysis from the Optum Neonatal Database. The primary outcome of interest was severe IVH (grade 3 or 4). Secondary outcomes included other neonatal morbidities, mortality, and length of hospitalization. Outcomes were compared between VLBW infants born to mothers with and without HD. RESULTS: A total of 5456 infants met inclusion criteria. After multivariable regression analysis, risks of severe IVH and bronchopulmonary dysplasia (BPD) were lower ([OR 0.42, 95% CI 0.33-0.89, p = 0.01] and [OR 0.75, 95% CI 0.58-0.97, p = 0.03], respectively) and median length of hospitalization was decreased in the HD group (49 versus 61 days, p < 0.001). CONCLUSIONS: VLBW infants born to mothers with HD have a decreased risk of severe IVH, BPD, and a shorter duration of hospitalization.

Culture Pus, Not Blood: Decreasing Routine Laboratory Testing in Patients With Uncomplicated Skin and Soft Tissue Infections.

BACKGROUND: Blood cultures and complete blood cell counts (CBCs) are commonly used in evaluating patients with skin and soft tissue infections (SSTIs). Published data have shown that these tests may not aid in patient management. The objective of this study was to decrease the collection of blood test specimens in children with uncomplicated SSTIs. METHODS: We designed a longitudinal preintervention/postintervention study that used modifications of well-known propaganda posters. These were displayed in work stations to discourage staff from ordering routine blood cultures in children being evaluated for uncomplicated SSTIs. We studied a total of 230 otherwise healthy patients with SSTIs admitted to a freestanding children's hospital between September 1, 2013, and August 31, 2014. Data were collected in 3 groups: a 4-month baseline period, a 4-month poster display period, and a 4-month follow-up period to determine practice change persistence. Data collected included baseline clinical characteristics, the number of laboratory studies obtained, and outcomes (including length of stay). RESULTS: Patients in the 3 groups were similar in terms of clinical characteristics. Compared with baseline, posters were associated with decreased blood cultures (47%-17%; P < .001) and CBCs (53%-36%; P = .04). This effect partially persisted for results of blood cultures (27%; P = .01) and CBCs (42%, P = .17). There was no change in median length of stay. Seven-day emergency department returns increased in the poster group (0-7%; P = .02) with no clear relation to laboratory testing, but not in the follow-up group (3%; P = .15). CONCLUSIONS: A simple and creative poster campaign improved staff laboratory testing practices.