1. The kaiser early onset calculator
Presentation to the South West Atain group

2. background
The Kaiser early onset sepsis calculator was developed by the Kaiser Permanente health system in California
It uses a statistical algorithm to give an estimate of sepsis risk for a newborn infant extrapolated from a big data database
It goes onto give a suggested management response stratified against the risk

3. Theoretical comparison of kaiser vs NICE guidance 149
Combines continuous variables
Uses patiennts from California
Does not suggest CRP
Applicable 34week up
In first 72 hours
NICE
combines ‘binary risk factors
Uses multiple sources from different countries including UK
Relies heavily on CRP absolute and trends
All gestations
First 48 hours

4. Critical Questions Is the Kaiser generalisable to UK population
Is it applicable to population where group B strep is not undertaken
Is it organisationally or even medicolegally
Accepable not to follow NICE

5. Potential advantages of Kaiser
Published evidence from US and Australia suggests it would reduce antibiotic exposure by 30-50%
Early antibiotic exposure is associated with increase in atopy and allergy and childhood obesity
Reduce admissions and resulting costs and detrimental effects

6. Safty – ‘Missed cases’
Its not intellectually valid to think about missed cases – the tool gives an incidence of infection ie tells us how many identical cases we would have to see to identify an infection
However the safty is imperitive comparing the two tools

7. Retrospective analysis of cases with known positive culture
Truro Exeter Taunton Bath and Swansea
Over 5-8 year period
From a total birth population of
Giving incidences of per 1000
Kaiser missed NICE missed
Some cases missed by both
Our conclusion safty comparible

8. Cases missed by Kaiser
Cases who were initially normal and then developed symptoms such as fever ( often representing from home
Suggestion: screen and treat infants who were normal and then develop symptoms
Do not put patients through Kaiser more than once

9. Prospective modelling of use of kaiser tool
Prospectively apply Kaiser tool but treat as per NICE
3 month audit in Bath would have reduced antibiotic exposure by 43%
Similar exercise in Southhamton – reduced antibiotic exposure by

10. Next steps for me My trust supportive but wanted commissioner support
Support of National CRG Neil Marlow lead to letter of support fro Medical director specialist commissioning South – providing we collaborate on prospective audit
Developed a local guideline using Kaiser to start and ‘Crpology’ to stop from 36 hrs

11. Colaborative audit tool
Trigger list of risk factors to lead to use tool
Excel based tool with drop downs
Agreement that the Swansea unit will undertake an analysis after months of data

12. Units currently using Kaiser tool
Plymouth from febuary
Bath- June
Southampton - september
Other currently prospectively auditing but treating with kaiser
Some considering using kaiser for asymptomatic babies

13. Experience to date
Plymouth – reduced antibiotic exposure by 85% - saved 35 days of tc
Bath one culture positive – initially culture and obs only – grew haemophillus at 20 hrs repeat culture neg lp neg crp 47 treated for 7 days

14. Initial Audit in Bath
Kaiser recommendation to start antibiotics 26/119 (21.8%) vs NICE recommendation 67/119 (56.3%) = 34.5% reduction in antibiotic usage assuming full adherence to Kaiser guideline 
No of babies who were actually started on antibiotics 42/119 (35.3%)
We use our version of CRPology to determine when to stop antibiotics essentially culture negative, asymptomatic and crp less than 20 from 36 hrs (daily crp if above 20) ​
​No. of babies given abx
​Max CRP
​​Positive microbiology
​Antibiotic duration
​Start antibiotics (26/119)
​26/26 77
​None
​36 hrs- 7 days
​Blood culture + obs (9/119)
​6/9 (3/9 culture only)
​49
H influenzae* n=1 Staph epidermidis (contaminant) n=1
​36 hrs- 5 days (longest due to CXR changes) 
​Routine obs (84/119)
​8/84
43 
​None 
​36 hrs- 5 days 

15. Plymouth data
Compares retrospective group treated by NICE for risk factors alone prev 2 years to infants with at least 1 risk factor
Kaiser group excludes 9 infants who were deemed clinically septic and treated
I think this is where the 80% reduction comes from 100% treated in first group 16% in second group?
2 year NICE audit (438)
Kaiser (at least 1 risk factor)166
Suspected infection Treated for 5 days
136 (31%)
10 (6%)
Treated for 36 hrs
275 (63%)
9 (5%)

16. Lets see how it works