Jim Gray Consultant Microbiologist Birmingham Children’s Hospital Birmingham Women’s Hospital

1. NICE Clinical Guideline 139: Antibiotics for early-onset neonatal infection DEVELOPING & IMPLEMENTING THE GUIDELINE: LESSONS LEARNED & OPPORTUNITIES Jim Gray Consultant Microbiologist Birmingham Children’s Hospital Birmingham Women’s Hospital

2. Overview • Background to infections in NICUs • Key points from the NICE Clinical Guideline • Applicability of the principles to other areas of clinical care • Opportunities for further research

3. NICU infections in the media • 20 January 2012 • Three babies dead after infection at Belfast hospital(Pseudomonas) • 22 November 2011 • Two babies die, three other E. coli cases in Swansea • 30 August 2010 • Superbug hit baby ward at University College Hospital: the so-called "gram-negative" bacterium contributed to the death of one baby… • 6 January 2009 • Baby dies as bug strikes hospital. A baby has died and six others are in an isolation ward after an infection struck at the neo-natal unit of a Birmingham hospital. • 25 October 2008 • E.coli probe at baby death ward: ESBL-producing: Luton • 14 February 2008 • Aspergillus infection has closed a neonatal ward at a Greater Manchester hospital. • 22 December 2006 • Babies infected in neonatal unit. Six babies on a hospital neonatal unit in Norfolk have been affected by an outbreak of PVL-producing S. aureus which is usually seen in the community. • 26 July 2006 • Board reveals baby superbug cases: four cases of MRSA were reported at the neonatal unit in Edinburgh.

4. Early antibiotic therapy saves lives! Source: Deresinski S Clin Infect Dis. 2007;45:S177-S183

5. Neonates & antibiotics: special considerations • Antibiotic-resistant bacteria can spread very readily in the NICU setting • Neonates have little or no colonisation resistance • Intensive care increases the risk of HCAI • At Birmingham Women’s Hospital 2.6% of babies are colonised with an antibiotic-resistant Gram-negative bacterium • Hygiene hypothesis: antibiotic exposure (especially broad-spectrum) in early life may increase risk of asthma and atopic dermatitis • Neonatal drug clearance is generally slower

6. Early-onset neonatal sepsis: the size of the problem • Commonest cause is Group B streptococcus • Incidence 0.5/1000 live births • 10% of newborn babies receive intravenous antibiotics

7. Overuse of antibiotics extends to other age groups Acknowledgement: Jeff Aston, Antibiotic Pharmacist, BCH

8. NICE CG149: Antibiotics for early-onset neonatal infection • Important observation: • Lack of good quality evidence • Principles that we used: • Recommend the right antibiotics • Antibiotics that are effective and safe • Cover the likely pathogens • Minimum risk of selection of antibiotic resistance • Limit overall antibiotic use by: • Limiting the number of patients prescribed antibiotics • Stopping antibiotics when infection has been excluded • Limiting the duration of antibiotic therapy for infections

9. NICE Guidance: limiting the number of patients prescribed antibiotics • Indications for antibiotic therapy: • Any ‘red flag’ for high risk of infection • Systemic antibiotic treatment given to the mother for confirmed or suspected invasive bacterial infection within 24 h of the birth • Seizures in the baby • Signs of shock in the baby • Mechanical ventilation in a term baby • Suspected or confirmed infection in a co-twin • 2 or more softer risk factors for/signs of infection • Where indicated antibiotic therapy given within 30-60 minutes

10. NICE Guidance: limiting the duration of antibiotic exposure • Criteria for discontinuing antibiotics • Normal CRP at 18-24 h • Negative blood cultures • Clinical judgement • Duration of therapy • 7 days for uncomplicated infections • Longer for meningitis

11. Implementation