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Is early-onset sepsis risk calculator safe for the management of neonates born to mothers with chorioamnionitis?

Journal of Perinatology volume 38, pages 769–770 (2018)Cite this article

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The study by Money et al. addressed an important issue on the management of well-appearing term neonates born to mothers with chorioamnionitis [1]. They evaluated if the implementation of a protocol based on a neonatal early-onset sepsis (EOS) calculator developed by Kaiser Permanente would safely reduce antibiotic use in well-appearing term infants born to mothers with chorioamnionitis. They reported a reduction in antibiotics use from 99.7 to 2.5% if the EOS risk calculator was used in their cohort of 362 asymptomatic neonates exposed to chorioamnionitis. However, we question if this reduction in antibiotics use would be safe. The safe reduction is decreasing the use of antibiotics without missing a case of EOS. In this cohort, the EOS calculator failed to identify the only neonate with positive blood culture (BC) and recommended observation only, without BC and empiric antibiotics. The antibiotics use could have been reduced by 100% in their cohort with a similar safety profile by using the strategy of observing asymptomatic neonates born to mothers with chorioamniotis as suggested by the expert panel at the NICHD consensus meeting [2].

The EOS calculator is designed to estimate the risk of EOS in all neonates born at ≥34 weeks of gestation [3]. Its use was not validated for the subset of neonates exposed to chorioamnionitis. Experts have raised the concern for missing or delaying antibiotic use by using the EOS risk calculator [4]. In a related study, the EOS calculator failed to identify both infants with culture proven EOS sepsis in the cohort of 2094 neonates born at ≥34 weeks of gestation [5]. In a more recent report from the authors of the EOS calculator, during the period of EOS calculator use, the calculator failed to identify and recommend empiric antibiotic in 50% (6 out of 12) of infants at birth who later had positive BC [3]. Five infants developed symptoms later during the birth hospitalization that prompted evaluation and antibiotic therapy. The sixth infant with positive BC was never symptomatic. Lastly, in addition to concerns about the performance of the calculator, the implementation of the EOS calculator may not be feasible in every center. It requires manpower, training and resources, and an increase in provider workload with the potential for medical errors resulting from a miscalculation of EOS risk.

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References

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  1. Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA

    Zubair H. Aghai

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Correspondence to Zubair H. Aghai.

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Aghai, Z.H. Is early-onset sepsis risk calculator safe for the management of neonates born to mothers with chorioamnionitis?. J Perinatol 38, 769–770 (2018). https://doi.org/10.1038/s41372-018-0069-z

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