Antibiotics in neonatal bacterial infections

[Khaque]

Dear Colleagues,

Most of us on suspicion of neonatal blood stream bacterial infection initiate antibiotic therapy and stop it if the blood cultures are negative and the baby is well (usually 48 hours), but what there does not seem to be a consensus is as to how long antibiotic therapy should be continued in culture proven blood stream infection (not meningitis or osteomyelitis) or culture negative but clinically suspected or surrogate marker supported blood stream infection. In our survey of 210 neonatal units in UK some years ago the range varied from 5 to 21 days!

What I would like to know from colleagues is;

1. How long do you give antibiotics in culture proven bacterial blood stream infection (no meningitis or osteomyelitis)?

2. How long do you give antibiotics in culture negative but clinically suspected or surrogate marker supported blood stream infection?

3. Do you use any laboratory markers to determine the duration of antibiotic therapy? If yes ,what markers do you rely on most?

Grateful for your views

Khalid

Professor Khalid N. Haque

FRCP(Lond), FRCP(Edin), FRCP(Ire),

FRCPCH, FPAMS(Pak), FAAP, FICP, MBA,

DCH(Lond), DTM&H(Liv)

Professor of Neonatal Medicine

[Stefan Johansson]

Our responses:

Q1. Usually 10 (-14) days, depending on what bacteria that grows in the culture.

Q2. Usually 7 (-10) days, depending on the "certainty" of the culture-neg infection*

Q3. We use CRP as a guidance, but generally stick to the courses above

*In the very common situation with a relatively well term infant and slightly elevated CRP (-50) at presentation (which then decrease to normal), we generally use a three day course. That is the time it takes to get a negative response from the microbiology department.

[Khaque]

My question Stefan really is how did you come to the decision to use 10 or 7 days in the firat place? Dogma!, Textbooks transmitting the same message from one edition to another! or through evidence?

Khalid Haque

[Stefan Johansson]

You caught me. Dogma it is!

[JACK]

I think there are more factors playing in deciding the course of antibiotics.

The obvious ones are the presence/absence of meningitis and arthritis.

Once these two are not present then the next big factor I think is .....

............cost/resources.

When resources are unlimited I think we mostly opt for 10-14 days course. On the other hand when we have pressure that the patient has a difficult financial situation we may go for a 7-10 day course.

It may sound ethically unfair to have two different stratification but that is the best we can do in an unjust world.

Also we opt to give longer courses for babies who were sicker at presentation or those that had complications secondary to their infection. We feel that those who were sicker and also with more complications may have a more virulent organism or weaker immune system necessitating a longer course.

Of course I am shooting from the hip, with no references here.

[Stefan Johansson]

My question Stefan really is how did you come to the decision to use 10 or 7 days in the firat place? Dogma!, Textbooks transmitting the same message from one edition to another! or through evidence?

Khalid Haque

You caught me. Dogma it is!

Just one more comment - we have national guidelines regarding antibiotic treatment incl length of therapy. But I suspect the documentation for length of therapy is meager, i.e. we do what we are used to do.

I also recall our (within-the-unit) controversy regarding aminoglycoside dosing(once- or twice-daily in full term infants). The literature does not really give good evidence that one regime is superior to the other. At that time I thought the general scientific guidance for ab therapy was rather weak.

[hehady]

Q1. Two weeks for BSI; longer courses for meningitis and arthritis

Q2. 10 days

Q3. We use CRP as a guidance, we rarely look at clearance of bacteria from follow up blood cultures.

[Khaque]

As suspected most of us are creatures of habit and do what either we have been taught or what is in textbooks. I am surprised at the dogmatic statements of the number of days they give antibiotics for but provide NO evidence for their practice. I do not buy the cost argument it seems un ethical and would urge none of us to decide the duration of antibiotic therapy that way.

Khalid Haque

[Khaque]

Should have quoted this earlier;

“ Beware of those who have found the truth, follow those who seek it.”

Hijikata 13th Century

[JACK]

... I do not buy the cost argument ...

Khalid Haque

I agree with you totally that it sounds unethical and politically incorrect.

But we have some patients whose parents have no insurance cover and are extremely poor and the baby was not very sick at presentation, then we do opt for a shorter course. I am not speaking in favor of this but sharing the ground realities.

May be the situation is different in the place where you practice...may be the state takes care of all medical bills or maybe all are insured. However the world is not flat. We have to accommodate even those who cannot afford two square meals a day. Neonatology is not exclusive science meant only for the rich....we may have to bend a little rules to accommodate all - even the underprivileged. I have worked in some really poor places in the world and have seen that even in resource restricted places with a little bit of planning and management, good neonatal outcomes are possible.

However the condition of the baby should be the most important deciding factor.

We always check for clearance of bacteria from Blood Stream. We also prolong the course of antibiotics when we notice that clearance is taking longer even when the correct antibiotics are being given(as per the sensitivity reports.)

We do not use CRP either for diagnosing or following progress. It is culture result and/or clinical picture.

An active crying baby who sucks well, whose blood counts are normal, whose blood cultures are negative, who is maintaining vitals and having a normal systemic examination tells me all that I need to know and I would not complicate my life by asking for a CRP.

I do agree that the rules for antibiotic therapy are not clear and that we often ape our teachers and seniors. But till something clearer is found out I am still sticking with the 10-14 day course.