NICE neonatal early onset sepsis guidance: greater consistency, but more investigations, and greater length of stay

Arindam Mukherjee; Louise Davidson; Lazarus Anguvaa; Donovan Alistair Duffy; Nigel Kennea

doi:10.1136/archdischild-2014-306349

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NICE neonatal early onset sepsis guidance: greater consistency, but more investigations, and greater length of stay

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Re: Impact of the NICE early onset neonatal sepsis guideline in our neonatal unit: Length of stay and number of lumbar punctures performed are not increased.
Arindam Mukherjee
Published on: 22 March 2016
Impact of the NICE early onset neonatal sepsis guideline in our neonatal unit: Length of stay and number of lumbar punctures performed are not increased.
Jennifer Mitchell
Published on: 22 March 2016

Published on: 22 March 2016
Re: Impact of the NICE early onset neonatal sepsis guideline in our neonatal unit: Length of stay and number of lumbar punctures performed are not increased.
- Arindam Mukherjee, Dr
- Other Contributors:
  Louise Davidson, Lazarus Anguvaa, Donovan Alistair Duffy and Nigel Kennea
Mukherjee et al. were interested by the response to their paper indicating that not all units may have seen an increase in antibiotic use and length of stay following introduction of NICE guidance CG149. The important difference for our unit was the introduction of a second CRP at 18-24 hours to inform further investigations (lumbar puncture) and length of antibiotic course. It is not surprising that units that already u...
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Mukherjee et al. were interested by the response to their paper indicating that not all units may have seen an increase in antibiotic use and length of stay following introduction of NICE guidance CG149. The important difference for our unit was the introduction of a second CRP at 18-24 hours to inform further investigations (lumbar puncture) and length of antibiotic course. It is not surprising that units that already used a second CRP did not see this effect. In our unit the second CRP was frequently raised in asymptomatic infants. The NICE guidance places emphasis on the clinical evaluation of baby, but also includes in this the second CRP result. The second CRP may well lead to differences in interpretation about possible sepsis between units, particularly in infants, that have always been well and asymptomatic.
The guidance reads: 1.7.1.2 Consider performing a lumbar puncture to obtain a cerebrospinal fluid sample in a baby, who did not have a lumbar puncture at presentation, who is receiving antibiotics, if it is thought safe to do so and if the baby: *has a C-reactive protein concentration of 10 mg/litre or greater, or *has a positive blood culture, or *does not respond satisfactorily to antibiotic treatment.
In our unit the raised CRP has led to increased lumbar puncture and greater length of antibiotic courses in asymptomatic infants. We have a clear policy of careful clinical observation of 'at risk' infants, but inclusion of CRP in the assessment of asymptomatic infants may be problematic. We feel that a clearer distinction between the infants that have been always asymptomatic needs to be made, and the justification for a second CRP in this patient group is poorly studied. We believe that a more explicit statement about avoiding LP in babies that have always been asymptomatic may be helpful, or at least should be studied further in this patient group.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Impact of the NICE early onset neonatal sepsis guideline in our neonatal unit: Length of stay and number of lumbar punctures performed are not increased.
- Jennifer Mitchell, Neonatal Grid Trainee
- Other Contributors:
  Jessica Burgess-Shannon, Andrew David Powls
We were interested to read the experiences of other units 1-4 sharing their findings of increased duration of antibiotics, length of stay in hospital and lumbar punctures (LP) performed following implementation of the NICE guideline on prevention of early onset neonatal infection (EONI)5. We recently changed our practice to follow these NICE recommendations advocating observation of low risk infants to reduce antibiotic...
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We were interested to read the experiences of other units 1-4 sharing their findings of increased duration of antibiotics, length of stay in hospital and lumbar punctures (LP) performed following implementation of the NICE guideline on prevention of early onset neonatal infection (EONI)5. We recently changed our practice to follow these NICE recommendations advocating observation of low risk infants to reduce antibiotic exposure whilst commencing antibiotics in those deemed higher risk 5. We have not yet found that the change in practice has increased our infant's length of stay, antibiotic days or LPs performed.
In the two months (September/October) prior to our change of practice, 69 babies were treated with IV antibiotics, averaging 2.4 babies/day, with 33.3% requiring treatment for >24hrs. In the two months (November/December) following the new guideline implementation a total of 66 babies required antibiotics, averaging 1.7 babies/day with 21.1% requiring treatment for >24hrs. We have seen no increase in the frequency of LPs performed since the change (5 babies total September/October vs. 2 November/ December). We have seen additional testing in the form of repeat FBC, UEs, LFTs for the small number of babies continuing antibiotics >24 hours as recommended by NICE (5 in the first month following implementation). We recognise this is a small sample population but our findings do not suggest a trend towards an increase in antibiotics or invasive procedures as experienced by other centres 1-4.
We acknowledge that the wide variation in clinical practice prior to the publication of NICE EONI guidelines makes it challenging to compare findings between units and may account for the differences observed. For example, we have always investigated infants receiving antibiotics with an initial CRP/blood cultures and repeat CRP at 18-24 hours to inform the decision to cease antibiotics. Conversely, our colleagues' letters suggest the second CRP is a change in their practice and therefore may account for the increased antibiotic duration they observed 1-4.
Variation in the threshold to perform an LP may account for the differing trends in frequency between units. NICE suggests consideration of LP with a CRP >10 2. Locally we do not have a set CRP number that would prompt an LP but make this decision based upon the baby's clinical picture with acknowledgment of the CRP. In our babies that had an LP, their CRP's ranged from 24-160. In our first month post-implementation we saw 5 babies with a CRP rise (13-25) that necessitated a prolonged antibiotic course but did not have an LP as the baby was clinically well, with no signs of CNS involvement.
We have developed a monitoring chart, the Neonatal Early Warning Score (NEWs) in order to record observations for all babies at risk of EONI. In our first month we saw 51 babies on NEWs monitoring - 32 required antibiotics and 16 on NEWs monitoring only. Despite initial concerns of increased workload for postnatal staff these charts have embedded into practice with the majority of infants (78%) appropriately commenced on the chart for the required time period and we hope this will improve with further familiarity and education. We acknowledge that our experiences are early but we will continue to practice the new guideline following an audit that has identified no significant issues or clinical concerns. Further audit will be undertaken in due course, combined with other units in our MCN who are shortly integrating the new guideline into their practice.
References
1) Naydeva-Grigorova T, Manzoor A, Ahmed M. Arch Dis Child Fetal Neonatal Ed 2015; 100:F93-F94.
2) Mukherjee A, Davidson L, Anguvaa L et al. NICE neonatal early onset sepsis guidance: greater consistency, but more investigations, and greater length of stay. Arch Dis Child Fetal and Neonatal Ed. Published online first: 25 Jul 2014 doi:10.1136/archdischild-2014-306349
3) Mukherjee A, Ramalingaiah B, Kennea N et al. Letter: Management of neonatal early onset sepsis (CG149): compliance of neonatal units in the UK with NICE recommendations. Arch Dis Child Fetal Neonatal Ed. Published Online First: 19 December 2014 doi:10.1136/archdischild-2014-307776
4) Mukherjee A, Davidson L, Anguvaa L et al. Short research report: NICE neonatal early onset sepsis guidance: greater consistency, but more investigations and greater length of stay. Arch Dis Child Fetal Neonatal Ed. Published Online First: 25 July 2014 doi:10.1136/archdischild-2014- 306349
5) http://www.nice.org.uk/guidance/CG149 (accessed 19 Jan 2015)
Conflict of Interest:
None declared
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Conflict of Interest:
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