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Reducing antibiotic use on the neonatal unit by improving communication of blood culture results: a completed audit cycle
  1. M A Jardine,
  2. Y Kumar,
  3. S Kausalya,
  4. S Harigopal,
  5. J Wong,
  6. A Shivaram,
  7. T J Neal,
  8. C W Yoxall
  1. Correspondence to:
    Dr Yoxall, Liverpool Women’s Hospital, Crown Street, Liverpool L8 7SS, UK;

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It is common clinical practice to discontinue antibiotic treatment of asymptomatic babies if the blood cultures are negative at 48 hours.1–3 However, if blood culture results are only available during the normal working day, then antibiotic treatment of some babies may continue into the next working day. In our neonatal unit, blood culture results were routinely received from the microbiology laboratory via fax as a list every morning. Extra positive results would be telephoned through, if they became available, during the normal working day. Results could also be checked by the clinical staff telephoning the laboratory during “office hours”. This gave the potential for inadvertent prolongation of antibiotic courses for up to a day. In a previous study, McDonald et al4 found this to be a common occurrence. It is of concern because unnecessary antibiotic use may contribute to antibiotic pressure within the neonatal unit and may encourage the selection of drug resistant organisms.

We performed two audits into this problem within our neonatal unit. Our audit standard on each occasion was that antibiotics should be stopped at 48 hours, if blood cultures were negative, unless a decision to continue was clearly documented in the case notes. Babies with negative blood cultures were identified from the microbiology database. Each episode was classified into one of four groups: (a) antibiotics not started; (b) antibiotics stopped within 48 hours; (c) antibiotics given for more than 48 hours deliberately; (d) antibiotics given for more than 48 hours unintentionally. The results are summarised in table 1.

The first audit was conducted on 451 babies with negative blood cultures between January 1997 and December 1998. We were able to collect complete data from case notes and drug charts for 376 (83.4%) of these blood cultures. We found that the audit standard was not met in 144/376 (38.3%). The median (range) duration of antibiotic treatment for each baby was 60 (16.9–332) hours.

The blood culture analyser in use in our laboratory (BacT/Alert Microbial Detection System; Organon Teknika Corporation, Durham, North Carolina, USA) tests for bacterial growth every 10 minutes and communicates the blood culture status (positive or negative) to a computer. After our initial audit, we established a computer link between the blood culture analyser and the neonatal unit. This allows the clinical staff to check the status of any blood culture in the analyser in real time, 24 hours a day.

The second audit was performed on babies with negative blood cultures between May 2000 and August 2000. Two hundred negative blood cultures were identified. Complete data were available for 179/200 (89.5%). The audit standard was not met in only 20/179 (11.2%); p<0.001 compared with the first audit. The median (range) duration of treatment was reduced to 48 (1–182) hours (p<0.0001). There was an overall reduction of two doses of antibiotic per baby (from a mean of 8.8 to 6.8 doses per baby).

Overall, we estimated that we gave 21 684 doses of antibiotics on the neonatal unit between January 1997 and December 1998. If the computer system had been in operation during this period, we estimate that we could have reduced this by 16.2% to 18 169. We think that this magnitude of reduction in antibiotic pressure on the neonatal unit is worth achieving.

Table 1

Reduction in unintentional antibiotic use over 48 hours after introduction of real time availability of blood culture status by a computer link between the blood culture machine and our neonatal unit