From the Journals

Management of asymptomatic chorioamnionitis-exposed neonates needs revamping

Publish date: June 8, 2017

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Reworking the ‘rule out sepsis’ workup is crucial

Dr. Jan and her associates have taken steps in the right direction in altering management of asymptomatic term and near-term newborns with a maternal history of chorioamnionitis to avoid administering empirical antibiotics to all these babies, which is sorely needed as the current American Academy of Pediatrics and Centers for Disease Control and Prevention guidelines are outdated.

However, their alternative plan needs some tweaking. The positive predictive value of abnormal complete blood count or C-reactive protein results is too low to be of use in diagnosing sepsis.‍ “We believe a better approach would be to forgo routine laboratory evaluations among this population altogether and manage them using clinical signs alone.”

They said it was important to state two key caveats. “First, in the immediate postpartum period, mild respiratory distress among term or near-term newborns may be attributable to the physiologic transition, which occurs in all newborn infants. It is not necessary to draw laboratories or start antibiotics on these patients as long as their symptoms improve and resolve within the first 6 hours of life. Second, if newborns with a maternal history of chorioamnionitis are to be monitored for signs of sepsis outside the NICU setting, observations must be frequent (at least hourly for the first 6 hours of life and then every 3 hours for the next 18 hours) and performed by adequately trained medical staff. In the absence of frequent, reliable observation, there is a possibility that the early signs of sepsis will be missed and go untreated with potentially severe consequences.”

This approach, as with any other, needs additional study.

Thomas A. Hooven, MD, and Richard A. Polin, MD, pediatricians at the Columbia University, New York, discussed the study by Jan et al. in a commentary, which is summarized here (Pediatrics. 2017;140[1]:e20171155). They reported that they received no external funding and had no relevant financial disclosures.

FROM PEDIATRICS

Clinical observation and laboratory evaluation without immediate antibiotic use in asymptomatic chorioamnionitis-exposed neonates prevented neonatal intensive care unit (NICU) admission in two-thirds of these infants, Amanda I. Jan, MD, of the University of Southern California, Los Angeles, and her associates reported in a study.

Since maternal intrapartum antibiotic prophylaxis was introduced, neonatal early-onset sepsis (EOS) rates have dropped considerably, and rates remain low even in chorioamnionitis-exposed infants.‍ Despite these low risks, current American Academy of Pediatrics and Centers for Disease Control and Prevention recommendations still call for a limited laboratory evaluation and immediate empirical antibiotic therapy in all infants exposed to chorioamnionitis, often necessitating NICU admission for IV antibiotics, the researchers noted.

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A retrospective cohort study of infants and mothers who delivered between May 1, 2008, and Dec. 31, 2014, identified newborns, 35 weeks’ gestational age or greater, who were born with a maternal diagnosis of chorioamnionitis, and 240 asymptomatic newborns were admitted to the mother-infant unit. Of those, 67.5% remained well with a routine newborn course in the mother-infant unit, and 32.5% subsequently were admitted to the NICU because of abnormal laboratory data, a positive blood culture, or the onset of clinical signs of sepsis (Pediatrics. 2017;140[1]:e20162744).

Of the 78 infants admitted to the NICU and put on antibiotics, 76% were treated with antibiotics for more than 72 hours, with a median 7 days of treatment, compared with a median 2 days for nonadmitted infants (P less than .001). Only 85% of admitted infants received any breast milk, compared with 94% of infants in the mother-infant unit (P = .032), and none of the admitted infants were exclusively breastfed.

“When the overall risks of EOS are low, exposure of large numbers of well-appearing infants to even short courses of antibiotics is no longer justified,” Dr. Jan and her associates stated. “The [difference in] cost of a stay in the mother-infant unit for 2 days, compared with a NICU stay, which averaged a week, is substantial. The charge for our NICU is $12,612 per day in contrast to $5,300 per day in the mother-infant unit. The cost savings for the 162 infants who were cared for 2 days in the mother-infant unit, compared with an EOS evaluation and antibiotic therapy in the NICU, totals $2,369,088, or $359,861 per year.

“There were no deaths or morbidities identified in any infant during the study period,” they reported. No infant was readmitted to the study hospital for sepsis after discharge.

Dr. Jan and her associates recommend their alternative management of asymptomatic chorioamnionitis-exposed neonates involving lab evaluations and close clinical observation without immediate antibiotic administration in a mother-infant unit. They believe this prevents unnecessary antibiotic exposure, unnecessarily high hospitalization costs, and disruption of maternal-neonatal bonding and breastfeeding. Additional studies are needed to determine the safety of this approach.

This study received no external funding, and Dr. Jan and her associates reported no relevant financial disclosures.

cnellist@frontlinemedcom.com

Management of asymptomatic chorioamnionitis-exposed neonates needs revamping

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