Keith BarringtonToo much antibiotics, part 1. https://neonatalresearch.org/2024/10/25/too-much-antibiotics-part-1/
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Stefan Johansson, MD PhD@keithbarrington great post! There is indeed a movement towards a restrictive approach to antibiotics here in Sweden , I would say it is like ”watchful waiting”. I.e. risk factors only is not sufficient , symptoms or clinical findings also needs to be present for initiation of antibiotics. I wished we had more detailed guidelines about this, as of now this is a bit like ”more art than science” :)
@stefanjohansson It would be great to have better information about how the Swedish centres are doing this. If you put some risk factors into the Kaiser calculator it suggests cultures and antibiotics even if the infant is well. The Swedish approach seems not to do this, and has reduced antibiotic exposure, but it is difficult to transfer to other places without more detail.
@keithbarrington I wished there was a clear answer… risk factors + symtoms + gut feeling are weighed together :)
As you write in your part2-post, a lot of infants given 5d of antibiotics without a clear indication. Traditionally, CRP-elevation is often used as an argument for ab’s… I recently lectured for colleagues about CRP as a diagn marker (cited your CRaP posts!) but I think no-one got enlightened!
I will try to get Johan Gyllensvärd to this thread, he is the expert!
As you write in your part2-post, a lot of infants given 5d of antibiotics without a clear indication. Traditionally, CRP-elevation is often used as an argument for ab’s… I recently lectured for colleagues about CRP as a diagn marker (cited your CRaP posts!) but I think no-one got enlightened!
I will try to get Johan Gyllensvärd to this thread, he is the expert!
@keithbarrington At the #99nicuMeetup we had a great lecture by René Kornelisse from NL about antibiotics use, it is the 2nd video in the playlist shared here: https://99nicu.org/meetup2024/
His take home message was really that blood cultures are reliable and treating suspected sepsis (high CRP but neg culture) is debatable…
Jesper Padkær Petersen@stefanjohansson @keithbarrington from where do we know that blood cultures are the golden standard? As I understand it all evidence on their sensitivity and specifity is bench research.
@padkaer @keithbarrington This overview paper by Klingenberg, Kornelisse et al (from 2018 but still) walks through the question in some detail.
As we cannot know the blood culture results when we initiate antibiotic treatment, that decision still needs to be based on risk factors, symtoms and lab tests (blood counts etc).
IMHO, the tricky Q is when/how to discontinue antibiotics when the blood culture does not come back positive after 24-48 hours.
Culture-Negative Early-Onset Neonatal Sepsis — At the Crossroad Between Efficient Sepsis Care and Antimicrobial Stewardship
Sepsis is a leading cause of mortality and morbidity in neonates. Presenting clinical symptoms are unspecific. Sensitivity and positive predictive value of biomarkers at onset of symptoms are suboptimal. Clinical suspicion therefore frequently leads ...
@stefanjohansson @keithbarrington excellent paper, know it.
And as I remember it the blood culture studies it quotes are all bench?
And as I remember it the blood culture studies it quotes are all bench?
@padkaer @keithbarrington yes, they are done in vitro.
@stefanjohansson @keithbarrington I think that the main challenge in our aproach to neonatal infections is lack of a working defintion/golden standard. Most labwork values including CRP are obviously flawed. Bloodcultures are frequently stated as “golden standard”, but IMHO we know neither their sensitivity nor specificity for clinicaly important infections. Even if we knew these, PPV & NPV would likely vary significantly between settings. 1/2
@stefanjohansson @keithbarrington As we adress this critical issue, I suggest it’s important, that we don’t miss opportunities to randomise and create the much needed evidence. 2/2