Daily Sepsis Research Analysis

UNLABELLED: Neonatal hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH) can alter the immune system and may present symptoms similar to sepsis. This has led to widespread use of empirical antibiotics, despite limited evidence that support the need for universal empirical treatment. We aimed to evaluate the incidence of culture-proven sepsis and current antibiotic use patterns in neonates undergoing TH. We conducted a multicenter retrospective study including term and near-term neonates with HIE treated with TH in two European NICUs with different antibiotic strategies: one with universal empirical antibiotics (Italy, n = 228) and one with selective use (Belgium, n = 74). We collected data on blood culture results, antibiotic exposure, inflammatory biomarkers (CRP, PCT, leukocytes), and clinical outcomes. Of 302 newborns (276 term and 26 late preterm) who underwent TH, 278 (92%) received antibiotics at birth, with varying regimens for a median of 6 days. Blood cultures were performed in 228 Italian babies and in 72/74 Belgian infants (300 in total, equal to 99.3%), revealing only 2 cases of culture-confirmed early-onset sepsis (0.6%). In Belgium, all cultures from eight infants with clinical suspicion of sepsis were negative, resulting in a Number Needed to Treat (NNT) of 111 to prevent one confirmed infection. Late-onset sepsis occurred in four of 302 patients (1.3%). Biomarkers (CRP, PCT, leukocytes) fluctuated during cooling and rewarming but were not predictive of EOS.

CONCLUSION: The incidence of confirmed early-onset sepsis in neonates with HIE undergoing TH was very low, despite extensive empirical antibiotic use. These findings question the necessity for routine universal empiric antibiotics and advocate for a selective risk-based approach based on clinical assessment. Careful monitoring and prudent antibiotic use are crucial to reduce unnecessary exposure and its potential harms in this vulnerable population.

WHAT IS KNOWN: • Distinguishing the symptoms of HIE from those of EOS at birth or shortly thereafter is very complex, as they are often similar and can mimic one another. • Most newborns receiving hypothermic treatment are treated with empirical antibiotics in the suspicion of sepsis, even though the incidence of early-onset sepsis in the European healthcare context is very low. WHAT IS NEW: • Our multicentric study found a remarkably low incidence of confirmed EOS in newborns undergoing TH, irrespective of the antibiotic strategy used in each single center. • We provide data that can support a restriction on the use of empirical antibiotic therapy in neonates undergoing therapeutic hypothermia, also considering the bacterial resistance that the imprudent use of antibiotics is turning into a global emergency.

BACKGROUND: The spread of antibiotic resistance makes it necessary to implement Antimicrobial Stewardship (AMS) Programs; the aim of this study is to evaluate the impact of an AMS program in the management of urinary tract infection (UTI) in emergency setting. METHODS: A prospective multicentre study was conducted enrolling all adult patients admitted to one of the 8 emergency departments participating in the study with a diagnosis of UTI from February 2023 to July 2024. Only one of the eight centers received a persuasive AMS program. The primary outcome evaluated was the prevalence of empirical antimicrobial prescription belonging to Access class according to WHO classification in AMS and non-AMS ED; secondary outcomes included the prevalence of etiologial diagnosis, the clinical response and seven-day and 30-day mortality rates. RESULTS: During the study period, 657 patients were enrolled, 135 in the AMS and 522 in the non-AMS group, with a median age of 71 years (IQR 58-79). Patients in the AMS group had a more severe disease with a higher rate of sepsis or septic shock at admission (p < 0.001). In the AMS group, the percentage of patients with a microbiological diagnosis was higher (67% vs 43.1% p < 0.001); regarding empirical antibiotic therapy, drugs of the Access class were more frequently prescribed as empirical treatment in the AMS group (48.3 vs 37%, p = 0.04). No statistically significant differences were observed in terms of 7- and 30-day mortality and 7-day clinical response between the 2 groups, despite the higher severity of patients in the AMS group. CONCLUSIONS: In the centre where an AMS program was conducted, an increase in the number of positive urine cultures (67% vs 43.1%) has been observed, and a higher rate of prescriptions for Access class antibiotics. Further prospective data are needed to evaluate the impact of AMS intervention on antimicrobial prescribing in emergency setting.

OBJECTIVE: Hospital settings may influence outcomes and resource utilization in end-stage kidney disease (ESKD) patients receiving peritoneal dialysis (PD). However, data on PD outcomes across hospital settings remain limited. This study aims to evaluate characteristics, in-hospital treatments, complications, and healthcare costs for PD patients in urban teaching, urban non-teaching, and rural hospitals across the United States. METHODS: We conducted a cohort study using the National Inpatient Sample database in the United States from 2003 to 2018. Multivariable logistic and linear regression models were employed to compare in-hospital treatment outcomes, mortality, and healthcare costs across hospital settings, adjusting for demographics, comorbidities, and hospital characteristics. RESULTS: A total of 99,528 hospitalized ESKD patients receiving PD were included. Among these patients, 60,833 (61%) were in urban teaching hospitals, 32,714 (33%) in urban non-teaching hospitals, and 5,981 (6%) were in rural hospitals. In multivariable analysis, patients in urban non-teaching hospitals had lower risk of PD catheter adjustments (OR 0.81, 95% CI 0.68-0.97), hyperkalemia (OR 0.85, 95% CI 0.76-0.95), metabolic acidosis (OR 0.69, 95% CI 0.61-0.78), volume overload (OR 0.82, 95% CI 0.71-0.95), and mortality (OR 0.76, 95% CI 0.63-0.93) but higher risk of PD peritonitis (OR 1.25, 95% CI 1.15-1.36), and sepsis (OR 1.13, 95% CI 1.03-1.24), compared with urban teaching hospitals. Meanwhile, patients in rural hospitals had a lower risk of metabolic acidosis (OR 0.84, 95% CI 0.79-0.90) and volume overload (OR 0.82, 95% CI 0.76-0.89) but higher need for hemodialysis (OR 1.12, 95% CI 1.06-1.19), and risk of PD peritonitis (OR 1.18, 95% CI 1.13-1.24). Urban non-teaching and rural care were associated with lower hospitalization length of stays by 1.5 and 0.5 days and costs by $31632 and $10376, respectively. CONCLUSION: Rural and urban non-teaching hospitals experienced fewer metabolic complications and less volume overload but faced higher rates of PD-related peritonitis compared to urban teaching hospitals. These findings highlight clinical and economic differences in PD across hospital settings in the United States and crucial strategies for personalizing PD care and optimize resources. Future research should explore system-level interventions to enhance PD delivery in diverse healthcare settings.