Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and.
Palo Alto Medical Foundation, Palo Alto, California.
Pediatrics. 2018 Apr;141(4). doi: 10.1542/peds.2017-2056.
The risk of early-onset sepsis is low in well-appearing late-preterm and term infants even in the setting of chorioamnionitis. The empirical antibiotic strategies for chorioamnionitis-exposed infants that are recommended by national guidelines result in antibiotic exposure for numerous well-appearing, uninfected infants. We aimed to reduce unnecessary antibiotic use in chorioamnionitis-exposed infants through the implementation of a treatment approach that focused on clinical presentation to determine the need for antibiotics.
Within a quality-improvement framework, a new treatment approach was implemented in March 2015. Well-appearing late-preterm and term infants who were exposed to chorioamnionitis were clinically monitored for at least 24 hours in a level II nursery; those who remained well appearing received no laboratory testing or antibiotics and were transferred to the level I nursery or discharged from the hospital. Newborns who became symptomatic were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, culture results, and clinical outcomes were collected.
Among 277 well-appearing, chorioamnionitis-exposed infants, 32 (11.6%) received antibiotics during the first 15 months of the quality-improvement initiative. No cases of culture result-positive early-onset sepsis occurred. No infant required intubation or inotropic support. Only 48 of 277 (17%) patients had sepsis laboratory testing. The implementation of the new approach was associated with a 55% reduction (95% confidence interval 40%-65%) in antibiotic exposure across all infants ≥34 weeks' gestation born at our hospital.
A management approach using clinical presentation to determine the need for antibiotics in chorioamnionitis-exposed infants was successful in reducing antibiotic exposure and was not associated with any clinically relevant delays in care or adverse outcomes.
即使在绒毛膜羊膜炎的情况下，外观良好的晚期早产儿和足月儿发生早发性败血症的风险也很低。国家指南推荐的针对绒毛膜羊膜炎暴露婴儿的经验性抗生素策略导致许多外观良好、未感染的婴儿接受抗生素治疗。我们旨在通过实施一种关注临床表现以确定是否需要抗生素的治疗方法，减少绒毛膜羊膜炎暴露婴儿的不必要抗生素使用。
在质量改进框架内，于 2015 年 3 月实施了一种新的治疗方法。在二级婴儿室中对外观良好的绒毛膜羊膜炎暴露的晚期早产儿和足月儿进行至少 24 小时的临床监测；那些继续表现良好的婴儿不接受任何实验室检查或抗生素治疗，并转移到一级婴儿室或出院。出现症状的新生儿进一步进行评估和/或用抗生素治疗。收集抗生素使用、实验室检查、培养结果和临床结果。
在 277 名外观良好的绒毛膜羊膜炎暴露婴儿中，在质量改进倡议的前 15 个月，有 32 名（11.6%）婴儿接受了抗生素治疗。没有发生培养结果阳性的早发性败血症病例。没有婴儿需要插管或使用正性肌力支持。只有 277 名（17%）患者中的 48 名进行了败血症实验室检查。新方法的实施与所有在我院出生的≥34 周妊娠的婴儿的抗生素暴露减少了 55%（95%置信区间为 40%-65%）相关。
使用临床表现来确定绒毛膜羊膜炎暴露婴儿是否需要抗生素的管理方法成功地减少了抗生素暴露，并且与任何临床相关的治疗延迟或不良结果无关。
