OBJECTIVE: To define a quantitative stratification algorithm for the risk of early-onset sepsis (EOS) in newborns ≥ 34 weeks' gestation.

METHODS: We conducted a retrospective nested case-control study that used split validation. Data collected on each infant included sepsis risk at birth based on objective maternal factors, demographics, specific clinical milestones, and vital signs during the first 24 hours after birth. Using a combination of recursive partitioning and logistic regression, we developed a risk classification scheme for EOS on the derivation dataset. This scheme was then applied to the validation dataset.

RESULTS: Using a base population of 608,014 live births ≥ 34 weeks' gestation at 14 hospitals between 1993 and 2007, we identified all 350 EOS cases <72 hours of age and frequency matched them by hospital and year of birth to 1063 controls. Using maternal and neonatal data, we defined a risk stratification scheme that divided the neonatal population into 3 groups: treat empirically (4.1% of all live births, 60.8% of all EOS cases, sepsis incidence of 8.4/1000 live births), observe and evaluate (11.1% of births, 23.4% of cases, 1.2/1000), and continued observation (84.8% of births, 15.7% of cases, incidence 0.11/1000).

CONCLUSIONS: It is possible to combine objective maternal data with evolving objective neonatal clinical findings to define more efficient strategies for the evaluation and treatment of EOS in term and late preterm infants. Judicious application of our scheme could result in decreased antibiotic treatment in 80,000 to 240,000 US newborns each year.

<p><strong>Importance: </strong>Racial and ethnic minorities receive lower-quality health care than white non-Hispanic individuals in the United States. Where minority infants receive care and the role that may play in the quality of care received is unclear.</p>

<p><strong>Objective: </strong>To determine the extent of segregation and inequality of care of very low-birth-weight and very preterm infants across neonatal intensive care units (NICUs) in the United States.</p>

<p><strong>Design, Setting, and Participants: </strong>This cohort study of 743 NICUs in the Vermont Oxford Network included 117 982 black, Hispanic, Asian, and white infants born at 401 g to 1500 g or 22 to 29 weeks' gestation from January 2014 to December 2016. Analysis began January 2018.</p>

<p><strong>Main Outcomes and Measures: </strong>The NICU segregation index and NICU inequality index were calculated at the hospital level as the Gini coefficients associated with the Lorenz curves for black, Hispanic, and Asian infants compared with white infants, with NICUs ranked by proportion of white infants for the NICU segregation index and by composite Baby-MONITOR (Measure of Neonatal Intensive Care Outcomes Research) score for the NICU inequality index.</p>

<p><strong>Results: </strong>Infants (36 359 black [31%], 21 808 Hispanic [18%], 5920 Asian [5%], and 53 895 white [46%]) were segregated among the 743 NICUs by race and ethnicity (NICU segregation index: black: 0.50 [95% CI, 0.46-0.53], Hispanic: 0.58 [95% CI, 0.54-0.61], and Asian: 0.45 [95% CI, 0.40-0.50]). Compared with white infants, black infants were concentrated at NICUs with lower-quality scores, and Hispanic and Asian infants were concentrated at NICUs with higher-quality scores (NICU inequality index: black: 0.07 [95% CI, 0.02-0.13], Hispanic: -0.10 [95% CI, -0.17 to -0.04], and Asian: -0.26 [95% CI, -0.32 to -0.19]). There was marked variation among the census regions in weighted mean NICU quality scores (range: -0.69 to 0.85). Region of residence explained the observed inequality for Hispanic infants but not for black or Asian infants.</p>

<p><strong>Conclusions and Relevance: </strong>Black, Hispanic, and Asian infants were segregated across NICUs, reflecting the racial segregation of minority populations in the United States. There were large differences between geographic regions in NICU quality. After accounting for these differences, compared with white infants, Asian infants received care at higher-quality NICUs and black infants, at lower-quality NICUs. Explaining these patterns will require understanding the effects of sociodemographic factors and public policies on hospital quality, access, and choice for minority women and their infants.</p>

<p><strong>OBJECTIVE: </strong>To develop a quantitative model to estimate the probability of neonatal early-onset bacterial infection on the basis of maternal intrapartum risk factors.</p>

<p><strong>METHODS: </strong>This was a nested case-control study of infants born at ≥34 weeks' gestation at 14 California and Massachusetts hospitals from 1993 to 2007. Case-subjects had culture-confirmed bacterial infection at &lt;72 hours; controls were randomly selected, frequency-matched 3:1 according to year and birth hospital. We performed multivariate analyses and split validation to define a predictive model based only on information available in the immediate perinatal period.</p>

<p><strong>RESULTS: </strong>We identified 350 case-subjects from a cohort of 608,014 live births. Highest intrapartum maternal temperature revealed a linear relationship with risk of infection below 100.5°F, above which the risk rose rapidly. Duration of rupture of membranes revealed a steadily increasing relationship with infection risk. Increased risk was associated with both late-preterm and postterm delivery. Risk associated with maternal group B Streptococcus colonization is diminished in the era of group B Streptococcus prophylaxis. Any form of intrapartum antibiotic given &gt;4 hours before delivery was associated with decreased risk. Our model showed good discrimination and calibration (c statistic = 0.800 and Hosmer-Lemeshow P = .142 in the entire data set).</p>

<p><strong>CONCLUSIONS: </strong>A predictive model based on information available in the immediate perinatal period performs better than algorithms based on risk-factor threshold values. This model establishes a prior probability for newborn sepsis, which could be combined with neonatal physical examination and laboratory values to establish a posterior probability to guide treatment decisions.</p>

<p><strong>BACKGROUND: </strong>The absolute neutrophil count and the immature/total neutrophil ratio (I/T) provide information about the risk of early onset sepsis in newborns. However, it is not clear how to combine their potentially overlapping information into a single likelihood ratio.</p>

<p><strong>METHODS: </strong>We obtained electronic records of blood cultures and of complete blood counts with manual differentials drawn &lt;1 hour apart on 66,846 infants ≥ 34 weeks gestation and &lt;72 hours of age born at Kaiser Permanente Northern California and Brigham and Women's Hospitals. We hypothesized that dividing the immature neutrophil count (I) by the total neutrophil count (T) squared (I/T) would provide a useful summary of the risk of infection. We evaluated the ability of the I/T to discriminate newborns with pathogenic bacteremia from other newborns tested using the area under the receiver operating characteristic curve (c).</p>

<p><strong>RESULTS: </strong>Discrimination of the I/T (c = 0.79; 95% confidence interval: 0.76-0.82) was similar to that of logistic models with indicator variables for each of 24 combinations of the absolute neutrophil count and the proportion of immature neutrophils (c = 0.80, 95% confidence interval: 0.77-0.83). Discrimination of the I/T improved with age, from 0.70 at &lt;1 hour to 0.87 at ≥ 4 hours. However, 60% of I/T had likelihood ratios of 0.44-1.3, thus only minimally altering the pretest odds of disease.</p>

<p><strong>CONCLUSIONS: </strong>Calculating the I/T could enhance prediction of early onset sepsis, but the complete blood counts will remain helpful mainly when done at &gt;4 hours of age and when the pretest probability of infection is close to the treatment threshold.</p>

<p><strong>BACKGROUND: </strong>A complete blood count (CBC) with white blood cell differential is commonly ordered to evaluate newborns at risk for sepsis.</p>

<p><strong>OBJECTIVES: </strong>To quantify how well components of the CBC predict sepsis in the first 72 hours after birth.</p>

<p><strong>METHODS: </strong>For this retrospective cross-sectional study we identified 67 623 term and late-preterm (≥ 34 weeks gestation) newborns from 12 northern California Kaiser hospitals and 1 Boston, Massachusetts hospital who had a CBC and blood culture within 1 hour of each other at &lt;72 hours of age. We compared CBC results among newborns whose blood cultures were and were not positive and quantified discrimination by using receiver operating characteristic curves and likelihood ratios.</p>

<p><strong>RESULTS: </strong>Blood cultures of 245 infants (3.6 of 1000 tested newborns) were positive. Mean white blood cell (WBC) counts and mean absolute neutrophil counts (ANCs) were lower, and mean proportions of immature neutrophils were higher in newborns with infection; platelet counts did not differ. Discrimination improved with age in the first few hours, especially for WBC counts and ANCs (eg, the area under the receiver operating characteristic curve for WBC counts was 0.52 at &lt;1 hour and 0.87 at ≥ 4 hours). Both WBC counts and ANCs were most informative when very low (eg, the likelihood ratio for ANC &lt; 1000 was 115 at ≥ 4 hours). No test was very sensitive; the lowest likelihood ratio (for WBC count ≥ 20 000 at ≥ 4 hours) was 0.16.</p>

<p><strong>CONCLUSION: </strong>Optimal interpretation of the CBC requires using interval likelihood ratios for the newborn's age in hours.</p>