Neonatal Early-Onset Sepsis: Revised Evaluation Guidelines Save Money

BOSTON – Implementation of a revised algorithm for the identification of early-onset sepsis in newborn infants significantly improves resource allocation and decreases overall health care costs, a study has shown.

To gauge the efficiency of the updated algorithm, which is based on the 2010 Centers for Disease Control and Prevention guidelines for the prevention of perinatal group B streptococcal (GBS) disease, Dr. Sagori Mukhopadhyay of Children’s Hospital, Boston, and colleagues conducted a retrospective time-series analysis to compare the frequency of early-onset sepsis (EOS) evaluations during two 5-month time periods – one in 2009, when the 2002 iteration of the guidelines were followed, and one in 2011, when the 2010 guidelines were followed – measuring differences in resource utilization and costs.

"We performed a retrospective economic evaluation to determine the cost difference between periods, using individual patient data, a third-party payer perspective, and a cost-minimization approach," she reported at the annual meeting of the Pediatric Academic Societies.

"We determined the costs associated with the early-onset sepsis evaluation, including laboratory, medication, and physician fees, and time spent in evaluation, specifically nursing costs," Dr. Mukhopadhyay said.

During the periods of study, 6,504 infants were born at or beyond 36 weeks’ gestation, including 662 who were evaluated for EOS. The overall incidence of EOS was 0.62/1,000 infants.

Importantly, "the frequency of evaluation for inadequate intrapartum antibiotic prophylaxis decreased significantly from 33/1,000 in 2009 to 3/1,000 in 2011," she said, with the remaining evaluations during both time periods conducted primarily because of maternal intrapartum fever. The reduction in evaluations for inadequate intrapartum prophylaxis translated into a significant reduction in overall costs associated with EOS evaluation, from $27,883.06 in 2009 to $2,434.64 in 2011. The findings may help hospitals transition to the revised recommendations in terms of anticipated staffing needs and resource allocation, she said.

Although the incidence of perinatal early-onset GBS has decreased since the CDC issued the first iteration of its prevention guidelines in 1996, GBS remained the leading cause of early-onset neonatal sepsis in 2010, prompting the revision of the 2002 guidelines.

Under the revised algorithm, all newborns with signs of sepsis should undergo a full diagnostic evaluation, including a blood culture, a complete blood count with white blood cell differential and platelet count, a chest radiograph in the presence of any abnormal respiratory signs, and a lumbar puncture if the newborn is stable enough to tolerate the procedure and sepsis is suspected. Further, the algorithm provides for the administration of antibiotics active against GBS, including intravenous ampicillin, and other organisms that could cause sepsis, such as Escherichia coli, pending the results of the evaluation.

Additional components of the algorithm include:

• A limited evaluation (consisting of blood culture and CBC) and antibiotic treatment – pending culture results – in well-appearing newborns whose mothers had suspected chorioamnionitis.

• Routine clinical care for well-appearing infants whose mothers had no chorioamnionitis and no indication for GBS prophylaxis.

• A minimum 48 hours of observation but no routine diagnostic testing in well-appearing infants of any gestational age whose mother received adequate intrapartum GBS prophylaxis consisting of at least 4 hours of intravenous penicillin, ampicillin, or cefazolin prior to delivery.

• Observation in well-appearing infants at least 37 weeks’ gestational age whose mothers had an indication for GBS prophylaxis but who received inadequate or no prophylaxis and in whom the duration of membrane rupture prior to delivery was less than 18 hours.

• Limited evaluation as above and a minimum of 48 hours of observation in well-appearing infants less than 37 weeks’ gestation born to mothers with an indication for prophylaxis who received inadequate or no prophylaxis and in whom the duration of membrane rupture prior to delivery was more than 18 hours.

Dr. Mukhopadhyay reported having no relevant financial disclosures.

BOSTON – Implementation of a revised algorithm for the identification of early-onset sepsis in newborn infants significantly improves resource allocation and decreases overall health care costs, a study has shown.

To gauge the efficiency of the updated algorithm, which is based on the 2010 Centers for Disease Control and Prevention guidelines for the prevention of perinatal group B streptococcal (GBS) disease, Dr. Sagori Mukhopadhyay of Children’s Hospital, Boston, and colleagues conducted a retrospective time-series analysis to compare the frequency of early-onset sepsis (EOS) evaluations during two 5-month time periods – one in 2009, when the 2002 iteration of the guidelines were followed, and one in 2011, when the 2010 guidelines were followed – measuring differences in resource utilization and costs.

"We performed a retrospective economic evaluation to determine the cost difference between periods, using individual patient data, a third-party payer perspective, and a cost-minimization approach," she reported at the annual meeting of the Pediatric Academic Societies.

"We determined the costs associated with the early-onset sepsis evaluation, including laboratory, medication, and physician fees, and time spent in evaluation, specifically nursing costs," Dr. Mukhopadhyay said.

During the periods of study, 6,504 infants were born at or beyond 36 weeks’ gestation, including 662 who were evaluated for EOS. The overall incidence of EOS was 0.62/1,000 infants.

Importantly, "the frequency of evaluation for inadequate intrapartum antibiotic prophylaxis decreased significantly from 33/1,000 in 2009 to 3/1,000 in 2011," she said, with the remaining evaluations during both time periods conducted primarily because of maternal intrapartum fever. The reduction in evaluations for inadequate intrapartum prophylaxis translated into a significant reduction in overall costs associated with EOS evaluation, from $27,883.06 in 2009 to $2,434.64 in 2011. The findings may help hospitals transition to the revised recommendations in terms of anticipated staffing needs and resource allocation, she said.

Although the incidence of perinatal early-onset GBS has decreased since the CDC issued the first iteration of its prevention guidelines in 1996, GBS remained the leading cause of early-onset neonatal sepsis in 2010, prompting the revision of the 2002 guidelines.

Under the revised algorithm, all newborns with signs of sepsis should undergo a full diagnostic evaluation, including a blood culture, a complete blood count with white blood cell differential and platelet count, a chest radiograph in the presence of any abnormal respiratory signs, and a lumbar puncture if the newborn is stable enough to tolerate the procedure and sepsis is suspected. Further, the algorithm provides for the administration of antibiotics active against GBS, including intravenous ampicillin, and other organisms that could cause sepsis, such as Escherichia coli, pending the results of the evaluation.

Additional components of the algorithm include:

• A limited evaluation (consisting of blood culture and CBC) and antibiotic treatment – pending culture results – in well-appearing newborns whose mothers had suspected chorioamnionitis.

• Routine clinical care for well-appearing infants whose mothers had no chorioamnionitis and no indication for GBS prophylaxis.

• A minimum 48 hours of observation but no routine diagnostic testing in well-appearing infants of any gestational age whose mother received adequate intrapartum GBS prophylaxis consisting of at least 4 hours of intravenous penicillin, ampicillin, or cefazolin prior to delivery.

• Observation in well-appearing infants at least 37 weeks’ gestational age whose mothers had an indication for GBS prophylaxis but who received inadequate or no prophylaxis and in whom the duration of membrane rupture prior to delivery was less than 18 hours.

• Limited evaluation as above and a minimum of 48 hours of observation in well-appearing infants less than 37 weeks’ gestation born to mothers with an indication for prophylaxis who received inadequate or no prophylaxis and in whom the duration of membrane rupture prior to delivery was more than 18 hours.

Dr. Mukhopadhyay reported having no relevant financial disclosures.

BOSTON – Implementation of a revised algorithm for the identification of early-onset sepsis in newborn infants significantly improves resource allocation and decreases overall health care costs, a study has shown.

To gauge the efficiency of the updated algorithm, which is based on the 2010 Centers for Disease Control and Prevention guidelines for the prevention of perinatal group B streptococcal (GBS) disease, Dr. Sagori Mukhopadhyay of Children’s Hospital, Boston, and colleagues conducted a retrospective time-series analysis to compare the frequency of early-onset sepsis (EOS) evaluations during two 5-month time periods – one in 2009, when the 2002 iteration of the guidelines were followed, and one in 2011, when the 2010 guidelines were followed – measuring differences in resource utilization and costs.

"We performed a retrospective economic evaluation to determine the cost difference between periods, using individual patient data, a third-party payer perspective, and a cost-minimization approach," she reported at the annual meeting of the Pediatric Academic Societies.

"We determined the costs associated with the early-onset sepsis evaluation, including laboratory, medication, and physician fees, and time spent in evaluation, specifically nursing costs," Dr. Mukhopadhyay said.

During the periods of study, 6,504 infants were born at or beyond 36 weeks’ gestation, including 662 who were evaluated for EOS. The overall incidence of EOS was 0.62/1,000 infants.

Importantly, "the frequency of evaluation for inadequate intrapartum antibiotic prophylaxis decreased significantly from 33/1,000 in 2009 to 3/1,000 in 2011," she said, with the remaining evaluations during both time periods conducted primarily because of maternal intrapartum fever. The reduction in evaluations for inadequate intrapartum prophylaxis translated into a significant reduction in overall costs associated with EOS evaluation, from $27,883.06 in 2009 to $2,434.64 in 2011. The findings may help hospitals transition to the revised recommendations in terms of anticipated staffing needs and resource allocation, she said.

Although the incidence of perinatal early-onset GBS has decreased since the CDC issued the first iteration of its prevention guidelines in 1996, GBS remained the leading cause of early-onset neonatal sepsis in 2010, prompting the revision of the 2002 guidelines.

Under the revised algorithm, all newborns with signs of sepsis should undergo a full diagnostic evaluation, including a blood culture, a complete blood count with white blood cell differential and platelet count, a chest radiograph in the presence of any abnormal respiratory signs, and a lumbar puncture if the newborn is stable enough to tolerate the procedure and sepsis is suspected. Further, the algorithm provides for the administration of antibiotics active against GBS, including intravenous ampicillin, and other organisms that could cause sepsis, such as Escherichia coli, pending the results of the evaluation.

Additional components of the algorithm include:

• A limited evaluation (consisting of blood culture and CBC) and antibiotic treatment – pending culture results – in well-appearing newborns whose mothers had suspected chorioamnionitis.

• Routine clinical care for well-appearing infants whose mothers had no chorioamnionitis and no indication for GBS prophylaxis.

• A minimum 48 hours of observation but no routine diagnostic testing in well-appearing infants of any gestational age whose mother received adequate intrapartum GBS prophylaxis consisting of at least 4 hours of intravenous penicillin, ampicillin, or cefazolin prior to delivery.

• Observation in well-appearing infants at least 37 weeks’ gestational age whose mothers had an indication for GBS prophylaxis but who received inadequate or no prophylaxis and in whom the duration of membrane rupture prior to delivery was less than 18 hours.

• Limited evaluation as above and a minimum of 48 hours of observation in well-appearing infants less than 37 weeks’ gestation born to mothers with an indication for prophylaxis who received inadequate or no prophylaxis and in whom the duration of membrane rupture prior to delivery was more than 18 hours.

Dr. Mukhopadhyay reported having no relevant financial disclosures.