Evaluation and treatment of neonates with suspected late-onset sepsis:: A survey of neonatologists' practices -: art. no. e42
Evaluation and treatment of neonates with suspected late-onset sepsis:: A survey of neonatologists' practices -: art. no. e42
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DOI：
10.1542/peds.110.4.e42
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发表时间：
2002-10-01
期刊：
影响因子：
8
通讯作者：
Jarvis, WR
中科院分区：
文献类型：
--
作者：
Rubin, LG;S치nchez, PJ;Jarvis, WR
目标。确定目前新生儿重症监护病房（NICUs）疑似晚发性脓毒症婴儿的诊断和治疗实践，并确定可能受益于临床实践指南的领域。2000年6月，我们对参与儿科预防网络的儿童医院新生儿重症监护病房的新生儿科医生和感染控制专业人员进行了一项多中心调查。35家设有新生儿重症监护病房的医院的工作人员完成了调查；34名是感染控制专业人员，278名是新生儿临床医生，主要是新生儿科医生或新生儿科研究员。在这些设施中，凝固酶阴性葡萄球菌（con）是迟发性败血症婴儿中最常见的血培养分离物，占血液感染的54%。当怀疑是晚发性脓毒症时，83%的临床医生在没有中心静脉导管存在或有中心血管存在且无血液回流的情况下只进行了1次血培养。32%的人获得了1个或更多的c反应蛋白浓度测定。60%的临床医生给一个900克、3周大、疑似晚发性败血症的婴儿开了含有万古霉素的治疗方案。中心静脉导管或休克的存在增加了万古霉素的使用。耐甲氧西林金黄色葡萄球菌在新生儿重症监护病房的存在并没有增加万古霉素的使用，但万古霉素限制政策减少了万古霉素的经年性使用。单个新生儿重症监护室的临床医生倾向于有类似的经验性抗生素处方做法：在35个中心中，有29个（83%）的受访者在处方含万古霉素的经验性治疗方案方面有类似的做法，比例大于或等于75%。当获得单次血培养并生长con时，47%至85%的人完成了整个疗程的抗菌素治疗，但当两次血培养中有一次获得生长con时，完成整个疗程的应答者比例明显较低（22%-47%）。11%的应答者在怀疑脓毒症时取出了脐带导管，但不到5%的人在怀疑脓毒症时取出了非脐带中心静脉导管。大多数（大于或等于61%）患者尽管有con菌血症的记录，但仍保留了非脐带导管。对于疑似晚发性脓毒症，尤其是由con引起的脓毒症，新生儿医生的处理方法各不相同。需要采取措施防止con阳性血培养，并将con污染物与病原体区分开来。为了安全地减少万古霉素在新生儿重症监护病房的使用，应该制定、实施和评估临床实践指南。指南应包括获得血液培养前的最佳皮肤消毒和导管消毒，获得两次血液培养并使用辅助测试和信息来帮助区分污染物和病原体，以及限制经验性万古霉素的使用。
Objective. To ascertain current diagnostic and treatment practices for suspected late-onset sepsis in infants in neonatal intensive care units (NICUs) and identify areas that may benefit from clinical practice guidelines.Methods. During June 2000, we conducted a multi-center survey of neonatologists and infection control professionals regarding practices related to late-onset sepsis in NICUs at children's hospitals participating in the Pediatric Prevention Network.Results. Personnel at 35 hospitals with NICUs completed surveys; 34 were infection control professionals, and 278 were neonatology clinicians, primarily attending neonatologists or neonatology fellows. At these facilities, coagulase-negative staphylococci (CoNS) were the most frequent blood culture isolate from infants with late-onset sepsis accounting for 54% of bloodstream infections. When late-onset sepsis was suspected, 83% of clinicians drew only 1 blood culture when no central venous catheter was present or when a central vascular was present with no blood return. Thirty-two percent obtained 1 or more C-reactive protein concentration determinations. Sixty percent of clinicians prescribed a vancomycin-containing regimen for a 900 g, 3-week-old infant with suspected late-onset sepsis. The presence of a central venous catheter or shock increased empiric vancomycin use. The presence of methicillin-resistant Staphylococcus aureus in the NICU did not increase vancomycin use, but a vancomycin restriction policy decreased empiric vancomycin use. Clinicians at an individual NICU tended to have similar empiric antibiotic-prescribing practices: in 29 (83%) of 35 centers greater than or equal to75% of respondents had similar practice with regard to prescribing a vancomycin-containing regimen for empiric therapy. Forty-seven percent to 85% completed a full course of antimicrobials when a single blood culture was obtained and grew CoNS, but a significantly lower percentage of respondents (22%-47%) completed a full course when 1 of 2 blood cultures obtained grew CoNS. Eleven percent of respondents removed an umbilical catheter at the time of suspected sepsis, but fewer than 5% removed a nonumbilical central venous catheter for suspected sepsis. Most (greater than or equal to61%) retained a nonumbilical catheter despite documentation of CoNS bacteremia.Conclusions. Neonatologists varied in management of suspected late-onset sepsis, particularly that caused by CoNS. Procedures to prevent CoNS-positive blood cultures and to differentiate CoNS contaminants from pathogens are needed. For safely decreasing vancomycin use in NICUs, clinical practice guidelines should be developed, implemented, and evaluated. The guidelines should include optimal skin antisepsis and catheter disinfection before obtaining blood for culture, obtaining 2 blood cultures and using adjunctive tests and information to help differentiate contaminants from pathogens, and restriction on empiric vancomycin use.