Implementation of Early Onset Sepsis Calculator Safely Decreases Antibiotic Use and Laboratory Testing in Newborns Born to Mothers with Chorioamnionitis

Background: The management of newborns at risk for early-onset sepsis remains controversial, especially when they are well-appearing. Use of the Kaiser Permanente Neonatal Early-Onset Sepsis Risk Calculator has safely reduced the use of systemic antibiotics in neonates ≥ 34 weeks gestational age by weighing maternal and neonatal clinical data and assessing a newborn’s calculated risk of sepsis. Reducing the need for asymptomatic newborns exposed to systemic antibiotics has many advantages, such as avoiding separation from family, promoting early skin-to-skin and breastfeeding, reducing cost, and reducing antibiotic resistance. Our objective goal was to reduce antibiotic use in well-appearing newborns ≥ 35 weeks gestational age born to mothers with chorioamnionitis by 50% in a 12-month period. Our secondary goal was to reduce unnecessary lab testing. Methods: This study was part of a multi-site quality improvement project with data collected retrospectively via chart review in the electronic medical record. We created an EOS calculator guideline and educated a multidisciplinary care team prior to implementation of broad application of the EOS calculator. We collected data on tool compliance, antibiotic use, blood culture draws, CBC orders, and increase in clinical illness necessitating an increase in level of care. Baseline data was collected for the same variables from the 12- month period preceding implementation. NICU and well newborn hospitalists completed four quarterly plan-do-study-act cycles focusing on awareness of antibiotic usage, documentation, and re-education (Figure 1). Fisher’s exact test was used to calculate statistical significance amongst the variables. Results: There were 64 newborns ≥ 35 weeks gestation born to mothers with chorioamnionitis from the 12-month period prior to implementation of the calculator and 76 newborns during the 12-month period after implementation. With consistent use of the EOS calculator, there were statistically significant decreases in antibiotic use and unnecessary lab testing (Figure 2). Antibiotic use decreased from 82.8% to 26.3% (p value < .001) meeting our objective (Figure 1, 2). For our secondary goals, blood culture draw by 4 hours of life decreased from 87.5% to 48.7% (p value < .001) without any positive blood cultures. CBC ordering by 4 hours of life decreased from 76.9% to 19.7% (p value < .001). There was not a statistically significant increase in the number of babies requiring an increase in level of care after implementation of the EOS calculator (p value 0.6). Conclusion: Consistent use of the neonatal EOS calculator tool resulted in statistically significant decreases in antibiotic use, blood cultures, and CBC ordering without any missed diagnoses of early onset sepsis or an increase in level of care from baseline. In an academic setting, our quality improvement methodology was successful and would be replicable for expanding antibiotic stewardship to all newborns.

* Implemented newborn bedside antibiotic signage to promote antibiotic awareness. Implemented monthly pediatric resident education on EOS calculator use and documentation. ! Increased resident signage of EOS calculator algorithm at NICU resident work stations. #Implemented biannual newborn care provider reminders. Implemented mid-way resident rotation reminder of EOS calculator. +Implemented clarification of “equivocal” clinical status to all newborn care providers during periodic education reminders.

+Pre calculator data obtained over a 12 month period from 12-1-2016 thru 11-30-2017, n=64. #Post calculator data was obtained over a 12 month period form 12-1-2017 thru 11-30-2018, n=76. * p value < .001