<p><strong>OBJECTIVE: </strong>To determine antibiotic utilization for NICU infants, as compared to non-NICU infants, in the first 3 years after birth hospital discharge.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective observational study using data from Medicaid Analytic Extract including 667 541 newborns discharged from 2007-2011. Associations between NICU admission and antibiotic prescription were assessed using regression models, adjusting for confounders, and stratified by gestational age and birth weight.</p>

<p><strong>RESULTS: </strong>596 999 infants (89.4%) received ≥1 antibiotic, with a median of 4 prescriptions per 3 person-years (IQR 2-8). Prescribed antibiotics and associated indication were similar between groups. Compared to non-NICU infants (N = 586 227), NICU infants (N = 81 314) received more antibiotic prescriptions (adjusted incidence rate ratio 1.08, 95% confidence interval [CI] (1.08,1.08)). Similar results were observed in all NICU subgroups.</p>

<p><strong>CONCLUSIONS: </strong>Antibiotic utilization in early childhood was higher among infants discharged from NICUs compared to non-NICU infants.</p>

<p><strong>OBJECTIVE: </strong>To determine the time to positivity (TTP) of blood cultures among infants with late-onset bacteraemia and predictors of TTP &gt;36 hours.</p>

<p><strong>DESIGN: </strong>Retrospective cohort study.</p>

<p><strong>SETTING: </strong>16 birth centres in two healthcare systems.</p>

<p><strong>PATIENTS: </strong>Infants with positive blood cultures obtained &gt;72 hours after birth.</p>

<p><strong>OUTCOME: </strong>The main outcome was TTP, defined as the time interval from specimen collection to when a neonatal provider was notified of culture growth. TTP analysis was restricted to the first positive culture per infant. Patient-specific and infection-specific factors were analysed for association with TTP &gt;36 hours.</p>

<p><strong>RESULTS: </strong>Of 10 235 blood cultures obtained from 3808 infants, 1082 (10.6%) were positive. Restricting to bacterial pathogens and the first positive culture, the median TTP (25th-75th percentile) for 428 cultures was 23.5 hours (18.4-29.9); 364 (85.0%) resulted in 36 hours. Excluding coagulase-negative staphylococci (CoNS), 275 of 294 (93.5%) cultures were flagged positive by 36 hours. In a multivariable model, CoNS isolation and antibiotic pretreatment were significantly associated with increased odds of TTP &gt;36 hours. Projecting a 36-hour empiric duration at one site and assuming that all negative evaluations were associated with an empiric course of antibiotics, we estimated that 1164 doses of antibiotics would be avoided in 629 infants over 10 years, while delaying a subsequent antibiotic dose in 13 infants with bacteraemia.</p>

<p><strong>CONCLUSIONS: </strong>Empiric antibiotic administration in late-onset infection evaluations (not targeting CoNS) can be stopped at 36 hours. Longer durations (48 hours) should be considered when there is pretreatment or antibiotic therapy is directed at CoNS.</p>

<p>Group B Streptococcus (GBS) remains the most common cause of neonatal early-onset sepsis among term infants and a major cause of late-onset sepsis among both term and preterm infants. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists published separate but aligned guidelines in 2019 and 2020 for the prevention and management of perinatal GBS disease. Together, these replace prior consensus guidelines provided by the Centers for Disease Control and Prevention. Maternal intrapartum antibiotic prophylaxis based on antenatal screening for GBS colonization remains the primary recommended approach to prevent perinatal GBS disease, though the optimal window for screening is changed to 36 0/7 to 37 6/7 weeks of gestation rather than beginning at 35 0/7 weeks' gestation. Penicillin, ampicillin, or cefazolin are recommended for prophylaxis, with clindamycin and vancomycin reserved for cases of significant maternal penicillin allergy. Pregnant women with a history of penicillin allergy are now recommended to undergo skin testing, because confirmation of or delabeling from a penicillin allergy can provide both short- and long-term health benefits. Aligned with the American Academy of Pediatrics recommendations for evaluating newborns for all causes of early-onset sepsis, separate consideration should be given to infants born at less than 35 weeks' and more than or equal to 35 weeks' gestation when performing GBS risk assessment. Empiric antibiotics are recommended for infants at high risk for GBS early-onset disease. Although intrapartum antibiotic prophylaxis is effective in preventing GBS early-onset disease, currently there is no approach for the prevention of GBS late-onset disease.</p>

<p>&nbsp;</p>

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Multiple strategies are used to identify newborn infants at high risk of culture-confirmed early-onset sepsis (EOS). Delivery characteristics have been used to identify preterm infants at lowest risk of infection to guide initiation of empirical antibiotics. Our objectives were to identify term and preterm infants at lowest risk of EOS using delivery characteristics and to determine antibiotic use among them.</p>

<p><strong>METHODS: </strong>This was a retrospective cohort study of term and preterm infants born January 1, 2009 to December 31, 2014, with blood culture with or without cerebrospinal fluid culture obtained ≤72 hours after birth. Criteria for determining low EOS risk included: cesarean delivery, without labor or membrane rupture before delivery, and no antepartum concern for intraamniotic infection or nonreassuring fetal status. We determined the association between these characteristics, incidence of EOS, and antibiotic duration among infants without EOS.</p>

<p><strong>RESULTS: </strong>Among 53 575 births, 7549 infants (14.1%) were evaluated and 41 (0.5%) of those evaluated had EOS. Low-risk delivery characteristics were present for 1121 (14.8%) evaluated infants, and none had EOS. Whereas antibiotics were initiated in a lower proportion of these infants (80.4% vs 91.0%, P &lt; .001), duration of antibiotics administered to infants born with and without low-risk characteristics was not different (adjusted difference 0.6 hours, 95% CI [-3.8, 5.1]).</p>

<p><strong>CONCLUSIONS: </strong>Risk of EOS among infants with low-risk delivery characteristics is extremely low. Despite this, a substantial proportion of these infants are administered antibiotics. Delivery characteristics should inform empirical antibiotic management decisions among infants born at all gestational ages.</p>

<p><strong>BACKGROUND: </strong>In September 2017, the American Academy of Pediatrics issued guidance recommending hepatitis B vaccine be administered to well newborns with birth weight ≥2000 g within 24 hours after birth. At that time, ∼85% of well newborns were vaccinated before discharge at our center; however, only 35% were vaccinated within 24 hours after birth. Our aim was to vaccinate 70% of eligible newborns within 24 hours after birth by June 2018 while maintaining the overall rate of vaccination.</p>

<p><strong>METHODS: </strong>A multidisciplinary improvement team analyzed existing vaccine administration processes in the well-newborn nursery. From October 2017 to January 2018, changes were made to activation of vaccine orders and to obtaining and documenting the consent processes. Vaccine administration was bundled with routine care given ≤24 hours after birth, and parent scripting was changed from offering vaccine as an option to stating it as a recommendation. From November 2016 to June 2019, we determined the overall rate and timing of vaccination using statistical process control methods.</p>

<p><strong>RESULTS: </strong>Among 10 887 eligible infants, the proportion administered hepatitis B vaccine ≤24 hours after birth increased from 35.5% to 78.8% after process changes with special-cause variation on process control charts. Proportion of infants receiving vaccine any time before discharge also increased from 86.5% to 92.3%.</p>

<p><strong>CONCLUSIONS: </strong>Specific process changes allowed our birth center to comply with the recommended timing for hepatitis B vaccination of ≤24 hours after birth among eligible newborns.</p>

<p><strong>OBJECTIVE: </strong>To determine the difference in rate of weight gain from birth to 5 years based on exposure to maternal group B streptococcal (GBS) intrapartum antibiotic prophylaxis (IAP).</p>

<p><strong>DESIGN: </strong>Retrospective cohort study of 13 804 infants.</p>

<p><strong>SETTING: </strong>Two perinatal centres and a primary paediatric care network in Philadelphia.</p>

<p><strong>PARTICIPANTS: </strong>Term infants born 2007-2012, followed longitudinally from birth to 5 years of age.</p>

<p><strong>EXPOSURES: </strong>GBS IAP defined as penicillin, ampicillin, cefazolin, clindamycin or vancomycin administered ≥4 hours prior to delivery to the mother. Reference infants were defined as born to mothers without (vaginal delivery) or with other (caesarean delivery) intrapartum antibiotic exposure.</p>

<p><strong>OUTCOMES: </strong>Difference in rate of weight change from birth to 5 years was assessed using longitudinal rate regression. Analysis was a priori stratified by delivery mode and adjusted for relevant covariates.</p>

<p><strong>RESULTS: </strong>GBS IAP was administered to mothers of 2444/13 804 (17.7%) children. GBS IAP-exposed children had a significantly elevated rate of weight gain in the first 5 years among vaginally-born (adjusted rate difference 1.44% (95% CI 0.3% to 2.6%)) and caesarean-born (3.52% (95% CI 1.9% to 5.2%)) children. At 5 years, the rate differences equated to an additional 0.24 kg among vaginally-born children and 0.60 kg among caesarean-born children.</p>

<p><strong>CONCLUSION: </strong>GBS-specific IAP was associated with a modest increase in rate of early childhood weight gain. GBS IAP is an effective intervention to prevent perinatal GBS disease-associated morbidity and mortality. However, these findings highlight the need to better understand effects of intrapartum antibiotic exposure on childhood growth and support efforts to develop alternate prevention strategies.</p>

<p><strong>OBJECTIVES: </strong>To determine if maternal intrapartum group B (GBS) antibiotic prophylaxis is associated with increased risk of childhood asthma, eczema, food allergy, or allergic rhinitis.</p>

<p><strong>METHODS: </strong>Retrospective cohort study of 14 046 children. GBS prophylaxis was defined as administration of intravenous penicillin, ampicillin, cefazolin, clindamycin, or vancomycin to the mother, ≥4 hours before delivery. Composite primary outcome was asthma, eczema, or food allergy diagnosis within 5 years of age, identified by diagnosis codes and appropriate medication prescription. Allergic rhinitis was defined by using diagnostic codes only and analyzed as a separate outcome. Analysis was a priori stratified by delivery mode and conducted by using Cox proportional hazards model adjusted for multiple confounders and covariates. Secondary analyses, restricted to children retained in cohort at 5 years' age, were conducted by using multivariate logistic regression.</p>

<p><strong>RESULTS: </strong>GBS prophylaxis was not associated with increased incidence of composite outcome among infants delivered vaginally (hazard ratio: 1.13, 95% confidence interval [CI]: 0.95-1.33) or by cesarean delivery (hazard ratio: 1.08, 95% CI: 0.88-1.32). At 5 years of age, among 10 404 children retained in the study, GBS prophylaxis was not associated with the composite outcome in vaginal (odds ratio: 1.21, 95% CI: 0.96-1.52) or cesarean delivery (odds ratio: 1.17, 95% CI: 0.88-1.56) cohorts. Outcomes of asthma, eczema, food allergy, separately, and allergic rhinitis were also not associated with GBS prophylaxis.</p>

<p><strong>CONCLUSIONS: </strong>Intrapartum GBS prophylaxis was not associated with subsequent diagnosis of asthma, eczema, food allergy, or allergic rhinitis in the first 5 years of age.</p>

<p><strong>BACKGROUND: </strong>Clinicians often express concerns about poor sensitivity of blood cultures in neonates resulting from inadequate inoculant volumes. Our objective was to determine the inoculant volume sent for neonatal sepsis evaluations and identify areas of improvement.</p>

<p><strong>METHODS: </strong>Single-center prospective observational study of infants undergoing sepsis evaluation. Blood volume was determined by clinician documentation over 21 months, and additionally by weighing culture bottles during 12 months. Adequate volume was defined as ≥1 mL total inoculant per evaluation. For first-time evaluations, local guidelines recommend sending an aerobic-anaerobic pair with 1 mL inoculant in each.</p>

<p><strong>RESULTS: </strong>There were 987 evaluations in 788 infants. Clinicians reported ≥1 mL total inoculant in 96.9% evaluations. Among 544 evaluations where bottles were weighed, 93.4% had ≥1 mL total inoculant. Very low birth weight infants undergoing evaluations &gt;7 days after birth had the highest proportion of inadequate inoculants (14.4%). Only 3/544 evaluations and 26/1011 bottles had total inoculant &lt;0.5 mL. Ninety evaluations had &lt;1 mL in both aerobic and anaerobic bottles despite a total inoculant volume that allowed inoculation of ≥1 mL in one of the bottles.</p>

<p><strong>CONCLUSIONS: </strong>Obtaining recommended inoculant volumes is feasible in majority of neonates. Measuring inoculant volumes can focus improvement efforts and improve test reliability.</p>

<p><strong>IMPACT: </strong>Clinicians express concern about the unreliability of neonatal blood cultures because of inadequate inoculant volume. We investigated over 900 evaluations and found &gt;90% of evaluations have ≥1 mL inoculant. Monitoring adequacy of blood culture technique can identify areas of improvement and may allay concerns about blood culture reliability. Current recommendations for adequate inoculant volume for blood cultures are met in a majority of neonates. Areas of improvement include preterm late-onset sepsis evaluations and distribution techniques during inoculation.</p>

<p>Group B (GBS) remains the most common cause of neonatal early-onset sepsis among term infants and a major cause of late-onset sepsis among both term and preterm infants. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists published separate but aligned guidelines in 2019 and 2020 for the prevention and management of perinatal GBS disease. Together, these replace prior consensus guidelines provided by the Centers for Disease Control and Prevention. Maternal intrapartum antibiotic prophylaxis based on antenatal screening for GBS colonization remains the primary recommended approach to prevent perinatal GBS disease, though the optimal window for screening is changed to 36 0/7 to 37 6/7 weeks of gestation rather than beginning at 35 0/7 weeks' gestation. Penicillin, ampicillin, or cefazolin are recommended for prophylaxis, with clindamycin and vancomycin reserved for cases of significant maternal penicillin allergy. Pregnant women with a history of penicillin allergy are now recommended to undergo skin testing, because confirmation of or delabeling from a penicillin allergy can provide both short- and long-term health benefits. Aligned with the American Academy of Pediatrics recommendations for evaluating newborns for all causes of early-onset sepsis, separate consideration should be given to infants born at less than 35 weeks' and more than or equal to 35 weeks' gestation when performing GBS risk assessment. Empiric antibiotics are recommended for infants at high risk for GBS early-onset disease. Although intrapartum antibiotic prophylaxis is effective in preventing GBS early-onset disease, currently there is no approach for the prevention of GBS late-onset disease.</p>