EMPIRICAL ANTIBIOTIC AND NEC

Cotten CM, Taylor S, Stoll B, et al. for the NICHD Neonatal Research Network. Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for ELBW infants. Pediatrics 2009;123:58-66. [Full text] [PDF]

Objectives. Our objectives were to identify factors associated with the duration of the first antibiotic course initiated in the first 3 postnatal days and to assess associations between the duration of the initial antibiotic course and subsequent necrotizing enterocolitis or death in ELBW infants with sterile initial postnatal culture results.

Methods. We conducted a retrospective cohort analysis of ELBW infants admitted to tertiary centers in 1998–2001. We defined initial empirical antibiotic treatment duration as continuous days of antibiotic therapy started in the first 3 postnatal days with sterile culture results. We used descriptive statistics to characterize center practice, bivariate analyses to identify factors associated with prolonged empirical antibiotic therapy (³5 days), and multivariate analyses to evaluate associations between therapy duration, prolonged empirical therapy, and subsequent necrotizing enterocolitis or death.

Results. Of 5693 ELBW infants admitted to 19 centers, 4039 (71%) survived >5 days, received initial empirical antibiotic treatment, and had sterile initial culture results through the first 3 postnatal days. The median therapy duration was 5 days (range: 1–36 days); 2147 infants (53%) received prolonged empirical therapy (center range: 27%–85%). Infants who received prolonged therapy were less mature, had lower Apgar scores, and were more likely to be black. In multivariate analyses adjusted for these factors and center, prolonged therapy was associated with increased odds of necrotizing enterocolitis or death and of death.

Conclusion. Prolonged initial empirical antibiotic therapy may be associated with increased risk of necrotizing enterocolitis or death and should be used with caution.

Comments. Obviously, most neonatologists use antibiotics in ELBW infants during the first few days of life. This study reminds us that we may have a false sense of security when we expose these patients to these drugs. Every therapy should have a proper indication; if infection seems to be unlikely after 2-3 days, continuing antibiotics indiscriminately appears to be unwise. TMB