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 2nd tier regimen (Piperacillin/Tazobactam & Amikacin; perinatal history of maternal chorioamnionitis), and was escalated to 3rd tier regimen by day 7 (Vancomycin and Meropenem) due to worsening clinical status.
7/21 infants were escalated to 2nd 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:
- Increased availability of blood culture media and support from an in-house microbiology laboratory
- Provision of adjunct biochemical studies including CRP & I/T ratio
Phase B:
- Development of de-escalation protocols
