1. Neonatal Sepsis

2. Neonatal Sepsis Goals We will not discuss…
Definition, clinical presentation, or specific management strategies of septic infants (Abx, CV support, ventilation, etc. special cases such as CLABSI, VAP, etc)
What we will review: identification strategies for the neonate considered to be AT SUFFICIENT RISK for sepsis
We will examine recent changes in recommendations based on newer data and innovative approach to real-time decision making

3. Neonatal Sepsis Goals
Examine highlights of the evolution of studies and reappraisal between 2010 and 2016
Touch on about ten published literature reviews and recommendation statements from the CDC and AAP Committee on Fetus and Newborn
Understand how this evolution is changing clinical practice

4. Definitions EOS: Early Onset Sepsis < 7 DOL Chorio Exposed Infants
Antibiotic Exposed Infants

5. Is it Neonatal Sepsis? A Case
While on rounds one morning …
An artillery firing exercise is under way at a shooting range in Yeoncheon County South Korea

6. Diminishing EOS Incidence Incidence is the rate of new (or newly diagnosed) cases of the disease. It is generally reported as the number of new cases occurring within a period of time (e.g., per month, per year).

7. Diminishing EOS Incidence Incidence is the rate of new (or newly diagnosed) cases of the disease. It is generally reported as the number of new cases occurring within a period of time (e.g., per month, per year).

8. 2000s: Overtreating and Overexposure to Abx

9. 2000s: Risks of Unnecessary Abx

10. 2011: Previous Recommendations

11. 2011: Then
Footnotes!! * * *

12. 2011: Fine Print

13. 2011: Chorio Suspected Now superseded by Prevalence-driven KP calculator*

14. 2011: Adequate GBS IAP

15. 2011: GBS Px Indicated * *

16. 2011: Inadequate GBS IAP Now superseded by Prevalence-driven KP calculator*

17. 2011

18. 2011

19. 2011

20. 2011

21. 2011

22. 2011: GA

23. 2011: Maternal Temp

24. 2011: ROM

25. 2011 Componenets

26. 2011 Maternal Predictors

27. 2011 Maternal Predictors

29. 2012 AAP Statement

30. 2012 AAP Clinical Report

31. 2012 AAP Clinical Report

32. 2012 AAP Clinical Report

33. 2012 AAP Clinical Report

34. 2012: Skepticism Arises!

35. 2014: Skepticism Arises!

36. 2014: Reprise of 2011 Paper

37. 2014

38. 2014

39. 2014 Clinical Signs in Newborns

40. 2014 Study Cohort

41. 2014 NNT

42. 2014 NNT based on sepsis risk

43. 2014 Reappraisal of Guidelines

44. 2014 Reappraisal of Guidelines

45. 2014 Chorio Reappraisal

46. 2014 Chorio Reappraisal

47. 2014 Chorio Reappraisal

48. 2014 New Recommendations

49. 2014 New Recommendations

50. 2014 New Recommendations

51. 2014 New Recommendations

52. 2014 New Recommendations

53. 2016, May

54. 2016: Clinical Presentation

55. Now

56. Is it Neonatal Sepsis? Another Case
Oh yes, the rest of the first story …..

57. Is it Neonatal Sepsis? Another Case
One afternoon:
Scheduled LTCS at 37+0 b/c of previous classical T-incision; no labor, no fetal or maternal distress; “at risk for uterine rupture”
O2 requirement after del room CPAP
0 - 2 HOL: O2 requirement 30%, very sporadic grunting, comfortable WOB, weaned to 25% first 2 HOL
2-3 HOL; develops persistent grunting; CXR c/w RDS; nl glc; CBG shows only a mild resp acidosis, in fact a small base excess; CPAP started
Maternal Hx: GBS neg, ROM at time of delivery, no maternal fever or chorio concerns whatsoever
Is there a point which justifies starting Abx after BC +/- CBC?

58. Discussion Who is using the calculator on a regular basis now?
Who remains skeptical, and if so, why?
What further refinements need to be incorporated in this model of care?

59. Conclusion: Review of EOS Risk Appraisal and Evaluation Strategies
We have seen that a substantial reduction of EOS incidence stimulated a reappraisal of previous guidelines in light of:
Concerns for Abx overtreatment
Antibiotic stewardship
We have witnessed the adoption of KPSRC to aid real time decisions regarding EOS risk based on readily available EMR data
Preterm infants < 35+0 who are “chorio exposed” or have maternal risk factors and/or are symptomatic remain evaluated and treated as before

60. 1943 local time, sunset 1956