Serial physical examinations, a simple and reliable tool for managing neonates at risk for early-onset sepsis

Abstract

Aim: To investigate whether serial physical examinations (SPEs) are a safe tool for managing neonates at risk for early-onset sepsis (EOS).

Methods: This is a retrospective cohort study of neonates (≥ 34 wks' gestation) delivered in three high-volume level IIIbirthing centres in Emilia-Romagna (Italy) during a 4-mo period (from September 1 to December 31, 2015). Neonates at risk for EOS were managed according to the SPEs strategy, these were carried out in turn by bedside nursing staff and physicians. A standardized form detailing general wellbeing, skin colour and vital signs was filled in and signed at standard intervals (at age 3, 6, 12, 18, 36 and 48 h) in neonates at risk for EOS. Three independent reviewers reviewed all charts of neonates and abstracted data (gestational age, mode of delivery, group B streptococcus status, risk factors for EOS, duration of intrapartum antibiotic prophylaxis, postpartum evaluations, therapies and outcome). Rates of sepsis workups, empirical antibiotics and outcome of neonates at-risk (or not) for EOS were evaluated.

Results: There were 2092 live births and 1 culture-proven EOS (Haemophilus i) (incidence rates of 0.48/1000 live births). Most newborns with signs of illness (51 out of 101, that is 50.5%), and most of those who received postpartum antibiotics (17 out of 29, that is 58.6%) were not at risk for EOS. Compared to neonates at risk, neonates not at risk for EOS were less likely to have signs of illness (51 out of 1442 vs 40 out of 650, P = 0.009) or have a sepsis workup (25 out of 1442 vs 28 out of 650, P < 0.001). However, they were not less likely to receive empirical antibiotics (17 out of 1442 vs 12 out of 650, P = 0.3). Thirty-two neonates were exposed to intrapartum fever or chorioamnionitis: 62.5% (n = 20) had a sepsis workup and 21.9% (n = 7) were given empirical antibiotics. Among 216 neonates managed through the SPEs strategy, only 5.6% (n = 12) had subsequently a sepsis workup and only 1.9% (n = 4) were given empirical antibiotics. All neonates managed through SPEs had a normal outcome. Among 2092 neonates, only 1.6% (n = 34) received antibiotics; 1.4% (n = 29) were ill and 0.2% (n = 5) were asymptomatic (they were treated because of risk factors for EOS).

Conclusion: The SPEs strategy reduces unnecessary laboratory evaluations and antibiotics, and apparently does not worsen the outcome of neonates at-risk or neonates with mild, equivocal, transient symptoms.

Keywords: Group B streptococcus; Intrapartum antibiotic prophylaxis; Newborn; Prevention; Sepsis.

Figure 1

The neonatal management approach for neonates at risk for early-onset sepsis. Full evaluation includes blood culture and complete blood count, C-reactive protein, chest X ray and lumbar puncture. GBS: Group B streptococcus; IAP: Intrapartum antibiotic prophylaxis; RFs: Risk factors.

Figure 2

Neonates at risk or not at risk for early-onset sepsis: Signs of illness, sepsis workup and empirical antibiotics. Neonates delivered via a planned caesarean section are included among NARNs. ARNs: Neonates born to GBS-positive mothers or with risk factors; NARNs: Neonates born to GBS-negative mothers without risk factors; SPE: Serial physical examinations; WAARNs: Well-appearing at-risk neonates; GBS: Group B streptococcus.