Antibiotic stewardship in NICU

ASP Fundamentals - The NICU Rulebook

Antibiotic Stewardship (ASP) involves coordinated interventions to promote optimal antibiotic use, improving patient outcomes while minimizing unintended consequences.

• Core Principles (The 4 Ds):

  • Right Drug: Based on local antibiogram & culture data.
  • Right Dose: Optimized for neonatal pharmacokinetics/pharmacodynamics.
  • Right Duration: Shortest effective course; stop at 48 hours if sepsis is ruled out.
  • De-escalation: Narrowing spectrum based on culture results.

• Goals & Importance:

  • ↓ Antimicrobial Resistance (AMR).
  • ↓ Adverse effects (e.g., necrotizing enterocolitis, invasive candidiasis).
  • Protects the neonatal gut microbiome.

⭐ Unnecessary early-life antibiotics are linked to an increased risk of atopy, obesity, and inflammatory bowel disease.

Core Strategies - The Stewardship Playbook

• Empirical Therapy Selection:
  • Base choices on local NICU antibiogram data.
  • Risk-stratify for Early-Onset (EOS) vs. Late-Onset Sepsis (LOS).
• Antibiotic Timeout:
  • Mandatory formal review at 48-72 hours post-initiation.
  • Assess necessity of continuing, stopping, or narrowing therapy.
• De-escalation:
  • Switch to a narrower-spectrum agent once culture and sensitivity results are available.
  • Reduces selective pressure for resistance.
• Biomarker Guidance:
  • Falling trends in Procalcitonin (PCT) and C-Reactive Protein (CRP) support antibiotic discontinuation.

⭐ In suspected early-onset sepsis with negative cultures and a stable infant, antibiotics can be safely discontinued at 48 hours.

Metrics & Antibiograms - Keeping Score

• Key Consumption Metrics:
  • Days of Therapy (DOT): Total days a patient is on any antibiotic.
  • Length of Therapy (LOT): Duration of a single antibiotic course.
  • Defined Daily Doses (DDD): Assumed average maintenance dose per day for a drug. Unit: DDDs per 100 or 1000 patient-days.

⭐ Days of Therapy (DOT) is the preferred metric over DDD in pediatric populations as it is not influenced by dosing adjustments.

• Local NICU Antibiogram:

  • Essential for guiding empirical therapy.
  • Must be created and updated regularly (e.g., annually) to reflect local resistance patterns.

• Stewardship Measures:

  • Process Measures: Adherence to guidelines, pre-authorization compliance.
  • Outcome Measures: ↓ Resistance rates, ↓ C. difficile infections, ↓ antibiotic costs.

• Empiric therapy for early-onset sepsis (EOS) remains Ampicillin and an aminoglycoside (Gentamicin).
• Crucially, stop antibiotics at 48-72 hours if blood cultures are negative and the baby is clinically stable.
• The IAP-NIC sepsis calculator is key for risk stratification to avoid unnecessary antibiotic use.
• Procalcitonin (PCT) is a more specific biomarker than CRP for guiding antibiotic de-escalation.
• Avoid third-generation cephalosporins as first-line empiric therapy to prevent resistance.
• Prolonged antibiotic courses are linked to increased risks of NEC, fungal sepsis, and mortality.