Next Newborn / Neonatal

Initiative
General Meeting ; March 7, 2017
 Initiative
Antibiotics Stewardship / Neonatal Sepsis
University of North Carolina Chapel Hill
Ryan Haushalter, RN
Sigal Peter-Wohl, MD
 Initiative Background

PQCNC has recognized the need for antibiotic stewardship

with ASNS but there is much more to be done
Antibiotic overuse is associated with marked alterations in the
microbiome of the GI tract in newborns
The role of the microbiome in the GI tract is becoming
increasingly recognized as critical in normal immunologic
development
Alterations in the microbiome may play a role in
Diabetes
Asthma
Autoimmune disorders
Irritable Bowel Syndrome
Obesity
Cancers (pancreatic and others)
Lynch SV and Pedersen O. The Human Intestinal Microbiome in Health and
Disease.
N Engl J Med. 2016 Dec 15;375(24):2369-2379.
 Initiative Background

The NICU population is uniquely

vulnerable to antibiotic overuse
Susceptible population
Antibiotic use is associated with
development of invasive candidiasis
Prolonged duration of empiric antibiotic
therapy in ELBW infants is associated with
increased risk of death and NEC

Sohn AH 2001, CottenCM 2006, CottenCM 2009, Alexander VN 2011,

PendersJ 2011
 Initiative Background
From: Association Between Antibiotic Use and Neonatal Mortality and Morbidities in Very Low-Birth-Weight
Infants Without Culture-Proven Sepsis or Necrotizing Enterocolitis
JAMA Pediatr. 2016;170(12):1181-1187. doi:10.1001/jamapediatrics.2016.2132
 Initiative Background

The newborn population continues to

be exposed to high rates of
antibiotics after birth.
Wide variation in antibiotic use rate
in NICUs (40-fold), independent of
proven infection burden, NEC,
surgical volume, or mortality rate.
 Initiative Background

CPQCC
database: 127
NICUs,
52061 infants,
746051 patient-
days

Schulman J. et al. Neonatal intensive care unit antibiotic use. Pediatrics. 2015;135(5):826-33.
 Initiative Background

As many as 5-10% of newborns continue to

be exposed to antibiotics per CDC
guidelines
There are other tools to consider in
determining which newborns receive such
therapy
We have a chance to partner with families
and begin educating regarding the risks of
antibiotics in the newborn nursery and
NICU
 Initiative Aim

Right antibiotic
At the right dose
At the right time
For the right duration
 Initiative Goal
Spread ASNS work to ALL well
nurseries in North Carolina
Include Kaiser calculator and other best
practices
Antibiotic Time Out
Narrow the antibiotic spectrum use
In the NICUs reduce antibiotics use
In infants without culture-proven sepsis
or NEC
Evaluate/standardize antibiotic
treatment course for perioperative
 Initiative Reach

Target patient population

Potentially all NICU patients in North
Carolina
Level II and above
All newborn infants in North Carolina
Mother baby and newborn nurseries
Target facilities
All facilities performing deliveries
All facilities with an NICU
 Initiative Impact

Antimicrobial stewardship interventions have

been proven to improve individual patient
outcomes, reduce the overall burden of antibiotic
resistance, and save healthcare dollars
ASNS currently has 40 facilities with 65% of
deliveries enrolled. Opportunity to enroll 43
additional facilities with additional 35% of state
births
Currently 60% of state NICUs enrolled in ASNS.
Opportunity to expand to include remaining 40%
 Initiative Challenges / Barriers

Non-specific signs of sepsis

Treatment for Culture-negative sepsis
Treatment for NEC
Contamination/colonization vs. infection with
coagulase-negative Staphylococci
Limited pharmacokinetics and clinical studies
of antibiotic efficacy, toxicity of antibiotics
Require sophisticated data reports (require
significant IT support)
 Acknowledgment
UNC NCCC Team UNC NBN Team
Amy Brown, PharmD Amy Brown, PharmD
Amy Clifton Ashley Wallace, FNP
Erin Dineen, RN Carl Seashore, MD
Erin Rouse, RN Chelsea Herrington, RN
Jennifer Flippin, RN Eli Tiller, MD
Jenna Roberson, RN
Melanie Dawes
Joanne Kilb, NNP
Teri Wallace, RN
Karen Hogan
Kathryn Crabtree, RN
Matt Massaro, NNP
Lara Reller NP
Nicole Kuhn, NNP
Olivia Linthavong, MD Lisa Carr, RN
Rindi Haynes, RN Marriam Azam, RN
Rani Delaney, NNP Mary Terrell, MD
Ryan Haushalter, RN Matthew Zeitler, MD
Sigal Peter-Wohl, MD Rose Meitzen, RN
Sue Meyer, NNP Shona Hang
 Supporting Materials

https://www.cdc.gov/getsmart/healthcare/
Neu, New J N Engl J Med, 2011
Patel, Seminar in perinatology, 2012
Schulman, Pediatrics 2015
Cotton, presentation at PQCNC ASNS, 2016
Patel presentation at AAP national conferance 2014
Lynch SV, N Engl J Med. 2016
Joseph Y. Ting , JAMA Pediatr. 2016;170(12):1181-1187