Risk Perception and Decision Making about Early-Onset Sepsis among Neonatologists: A National Survey

Abstract

Objective Many newborns are investigated and empirically treated for suspected early-onset sepsis (EOS). This study aimed to describe neonatologists' self-identified risk thresholds for investigating and treating EOS and assess the consistency of these thresholds with clinical decisions.

Study Design Voluntary online survey, available in two randomized versions, sent to neonatologists from 20 centers of the Brazilian Network on Neonatal Research. The surveys included questions about thresholds for investigating and treating EOS and presented four clinical scenarios with varying calculated risks. In survey version A, only the scenarios were presented, and participants were asked if they would order a blood test or start antibiotics. Survey version B presented the same scenarios and the risk of sepsis. Clinical decisions were compared between survey versions using chi-square tests and agreement between thresholds and clinical decisions were investigated using Kappa coefficients.

Results In total, 293 surveys were completed (145 survey version A and 148 survey version B). The median risk thresholds for blood test and antibiotic treatment were 1:100 and 1:25, respectively. In the high-risk scenario, there was no difference in the proportion choosing antibiotic therapy between the groups. In the moderate-risk scenarios, both tests and antibiotics were chosen more frequently when the calculated risks were included (survey version B). In the low-risk scenario, there was no difference between survey versions. There was poor agreement between the self-described thresholds and clinical decisions.

Conclusion Neonatologists overestimate the risk of EOS and underestimate their risk thresholds. Knowledge of calculated risk may increase laboratory investigation and antibiotic use in infants at moderate risk for EOS.

Key Points

• Neonatologists overestimate the risk of EOS.

• There is wide variation in diagnostic/treatment thresholds for EOS.

• Clinical decision on EOS is not consistent with risk thresholds.

• Knowledge of risk may increase investigation and treatment of EOS.

Keywords

neonatal sepsis - surveys - laboratory investigation - treatment

Publikationsverlauf

Eingereicht: 20. Mai 2020

Angenommen: 02. November 2020

Artikel online veröffentlicht:
20. Dezember 2020

• References

• 1 Jefferies AL. Management of term infants at increased risk for early-onset bacterial sepsis. Paediatr Child Health 2017; 22 (04) 223-228
• 2 Singh T, Barnes EH, Isaacs D. Australian Study Group for Neonatal Infections. Early-onset neonatal infections in Australia and New Zealand, 2002-2012. Arch Dis Child Fetal Neonatal Ed 2019; 104 (03) F248-F252
• 3 Puopolo KM, Benitz WE, Zaoutis TE. COMMITTEE ON FETUS AND NEWBORN, COMMITTEE ON INFECTIOUS DISEASES. Management of neonates born at ≥35 0/7 weeks' gestation with suspected or proven early-onset bacterial sepsis. Pediatrics 2018; 142 (06) e20182894
• 4 Gong CL, Dasgupta-Tsinikas S, Zangwill KM, Bolaris M, Hay JW. Early onset sepsis calculator-based management of newborns exposed to maternal intrapartum fever: a cost benefit analysis. J Perinatol 2019; 39 (04) 571-580
• 5 Klingenberg C, Kornelisse RF, Buonocore G, Maier RF, Stocker M. Culture-negative early-onset neonatal sepsis - at the crossroad between efficient sepsis care and antimicrobial stewardship. Front Pediatr 2018; 6: 285
• 6 Verani JR, McGee L, Schrag SJ. Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep 2010; 59 (RR-10): 1-36
• 7 Bedford Russell AR, Kumar R. Early onset neonatal sepsis: diagnostic dilemmas and practical management. Arch Dis Child Fetal Neonatal Ed 2015; 100 (04) F350-F354
• 8 Puopolo KM, Lynfield R, Cummings JJ. et al. Committee on Fetus and Newborn, Committee on Infectious Diseases. Management of infants at risk for group B streptococcal disease. Pediatrics 2019; 144 (02) e20191881
• 9 Good PI, Hooven TA. Evaluating newborns at risk for early-onset sepsis. Pediatr Clin North Am 2019; 66 (02) 321-331
• 10 Swift L, Miles S, Price GM, Shepstone L, Leinster SJ. Do doctors need statistics? Doctors' use of and attitudes to probability and statistics. Stat Med 2009; 28 (15) 1969-1981
• 11 Escobar GJ, Puopolo KM, Wi S. et al. Stratification of risk of early-onset sepsis in newborns ≥ 34 weeks' gestation. Pediatrics 2014; 133 (01) 30-36
• 12 Kuzniewicz MW, Walsh EM, Li S, Fischer A, Escobar GJ. Development and implementation of an early-onset sepsis calculator to guide antibiotic management in late preterm and term neonates. Jt Comm J Qual Patient Saf 2016; 42 (05) 232-239
• 13 Helmbrecht AR, Marfurt S, Chaaban H. Systematic review of the effectiveness of the neonatal early-onset sepsis calculator. J Perinat Neonatal Nurs 2019; 33 (01) 82-88
• 14 Money N, Newman J, Demissie S, Roth P, Blau J. Anti-microbial stewardship: antibiotic use in well-appearing term neonates born to mothers with chorioamnionitis. J Perinatol 2017; 37 (12) 1304-1309
• 15 Botelho ACN, Oliveira JG, Damasco AP. et al. Streptococcus agalactiae carriage among pregnant women living in Rio de Janeiro, Brazil, over a period of eight years. PLoS One 2018; 13 (05) e0196925
• 16 Freitas FT, Romero GA. Early-onset neonatal sepsis and the implementation of group B Streptococcus prophylaxis in a Brazilian maternity hospital: a descriptive study. Braz J Infect Dis 2017; 21 (01) 92-97
• 17 Berardi A, Spada C, Reggiani MLB. et al. GBS Prevention Working Group of Emilia-Romagna. Group B Streptococcus early-onset disease and observation of well-appearing newborns. PLoS One 2019; 14 (03) e0212784
• 18 Benincasa BC, Silveira RC, Schlatter RP, Balbinotto Neto G, Procianoy RS. Multivariate risk and clinical signs evaluations for early-onset sepsis on late preterm and term newborns and their economic impact. Eur J Pediatr 2020; 179 (12) 1859-1865
• 19 Kuzniewicz MW, Puopolo KM, Fischer A. et al. A quantitative, risk-based approach to the management of neonatal early-onset sepsis. JAMA Pediatr 2017; 171 (04) 365-371
• 20 van Herk W, el Helou S, Janota J. et al. Variation in current management of term and late-preterm neonates at risk for early-onset sepsis: an international survey and review of guidelines. Pediatr Infect Dis J 2016; 35 (05) 494-500