An assessment of factors impacting choice of antibiotics in the management of neonatal infections in a Neonatal Intensive Care Unit in a Resource-Limited Setting – a Pilot Project in Quality Improvement

Introduction: Victoria Jubilee Hospital (VJH) has the largest NICU in Jamaica. Neonatal infections is a leading cause of morbidity and mortality. Quality improvement involves evaluation of antibiotic choices so as to enhance antibiotic stewardship.

Methods: Over three weeks, demographic and clinico-pathological data were reviewed along with indications for escalation and de-escalation of regimens. With no established antibiograms available, a line listing of confirmed infections was used as a proxy of the epidemiological profile of common infections.

Results:

21 neonates aged 0-20 days were reviewed. Gestational ages were 28 - 40 weeks, with 1/3 being premature. Birthweight ranged from 790-3610 gm. 17/21 (81%) received respiratory support, with one death during the period.

Major clinic-pathological conditions included:

• Pneumonia (congenital & ventilator-associated, VAP)
• Necrotizing enterocolitis
• Persistent pulmonary hypertension
• Meconium aspiration syndrome

20/21 neonates were commenced on empiric first line antibiotics – Amoxicillin /Amoxi-clavulanic Acid and Gentamicin. One infant was commenced on 2^nd tier regimen (Piperacillin/Tazobactam & Amikacin; perinatal history of maternal chorioamnionitis), and was escalated to 3^rd tier regimen by day 7 (Vancomycin and Meropenem) due to worsening clinical status.

7/21 infants were escalated to 2^nd tier by day 7 (due to leukocytosis and worsening respiratory status; 6/7 had no positive cultures). One neonate grew Coagulase negative Staphylococcus and was treated for VAP. Although multi-drug resistant, with an in-vivo response, course was extended to 10 days' duration. There was no evidence of de-escalation of antimicrobials during the study period.

Conclusion: Antibiotic selection was primarily guided by overall epidemiological profile and clinical parameters rather microbiological results. Antibiotic de-escalation was not practiced. Stewardship strategies proposed include:

Phase A:

1. Increased availability of blood culture media and support from an in-house microbiology laboratory
2. Provision of adjunct biochemical studies including CRP & I/T ratio

Phase B:

1. Development of de-escalation protocols