Sensitivity of the Kaiser Permanente early-onset sepsis calculator: A ... - The Lancet

Kuzniewicz et al. (2017)California, USAProspective
single-centre cohort2010 – 2015Baseline period: 95,543 babies
Calculator period:
56,261 babies
≥35 weeks gestationEpoch 1: 24 cases of EOS
4 missed by calculator.
Epoch 2: 15 cases of EOS
2 missed by the calculator, plus 4 additional possible mises
Epoch 3: 12 cases of EOS
2 missed by calculator as confirmed following d/w Dr Kuzniewicz
Antibiotic use reduced from 5.0% to 2.6%lowDhudasia et al. (2018)Philadelphia, USA
'retrospective'
single-centre cohortEpoch 1:
March 2014-May 2015
Epoch 2:
July 2015 - October 2016Epoch 1: 5692 babies
Epoch 2: 6090 babies
≥36 weeks gestation
4 cases of EOS: 1 × GBS, 3 × E. coli
maximum 3 misses, minimum 1 miss
Case 1 E. coli - maternal temp 38.8C, on parenteral antibiotics, initial risk score: 1.54, after examination: 7.66 - could have been a delay in treatment, depending on how old baby was when symptoms developed F = possible miss
Case 2 GBS – score at birth 0.3. Tachypnoeic at 36hours which is a NICE red flag for antibiotics, therefore – miss.
Case 4 E. coli - unclear if mother was treated for chorioamnionitis – maternal temp 39C. Score at birth: 3.41 but was 'well'; score after examination: 1.40 = possible miss
note the authors used different thresholds: we used the thresholds in Kuzniewicz 2017 for consistencyAntibiotic use reduced from 6.3% to 3.7%
lowStrunk et al. (2018)Subiaco, Western Australia
Prospective, single-centre cohortEpoch1:
Oct 2014 - January 2015
Epoch 2:
July -December 2016Epoch1: 1731 babies
Epoch 2: 2502 babies
≥35 weeks gestation
2 cases of EOS
1 case in each epoch, both were clinically unwell requiring admission to the neonatal unit.
The calculator recommended empirical treatment in both cases, therefore, no missed casesAntibiotic use reduced from 12.0% to 7.6%
lowGoel et al.
(2019)Wales, UKProspective cohort
(EOS calculator results not acted upon – NICE guidelines followed)
February–April 20183593 babies
≥34 weeks gestation
7 positive blood cultures, 2 contaminants (Staph. aureus and alpha-haemolytic streptococci)
5 cases of EOS
3 × cases picked up by both NICE and calculator
2 × missed by both, therefore no misses compared to NICEAntibiotic use would have been reduced from 16% to 4.3%,
74% relative reductionlowArora et al.
(2019)Illinois, USAProspective, single-centre cohortAugust 2016 –September 2017
276 babies
≥34 weeks gestation
admitted to neonatal unit1 case of EOS
Treated with empirical antibiotics according to calculator recommendations, therefore no missesAntibiotic use
reduced from
70.3% to 49.6%
lowStipelman et al. (2019)Utah, USASingle centre, prospective quality improvement programmeJune 2014 – December 201711,924 babies admitted to a newborn nursery
unclear gestation
187 infants were excluded because their treatment was decided by NICU clinicians who had not received the quality improvement training.
3 cases of EOS, 1 × GBS, 1 × Enterococcus faecalis, 1 × E. coli
2 misses:
Case 1: GBS
score at birth: 0.09; well: 0.04, equivocal: 0.43, ill: 1.83
Treated because became clinically ill at 6 h. This is a miss –it fits NICE criteria for treatment based on clinical indicators but scored <3.
Case 2: Enterococcus faecalis
score at birth: 0.25;
Maternal chorioamnionitis and prolonged rupture of membranes. Would most likely have been treated from birth using NICE guidelines.Antibiotic use
reduced from
7% to 1%
lowShakib et al. (2015)Utah, USA
Single centre, retrospective record review2006 −2013698 babies
≥34 weeks gestation
born to mothers with chorioamnionitis6 positive blood cultures, 5 contaminants (4x CoNS, 1 × micrococcus)
1 case of EOS: GBS
No misses - EOS risk score for the GBS case was 7.85 per 1000Antibiotic use would have been reduced to 12%Low-moderate
Money et al. (2017)Staten Island, NY, USA
Single centre, retrospective record review2009 – 2016362
babies
"term" babies, unwell babies excluded
born to mothers with chorioamnionitis3 positive blood cultures, 2 contaminants (1 × CoNS, 1 × Actinomyces odontolyticus)
1 case of EOS: Enterococcus
Enterococcus: highest maternal temp 38.1 °C, 20 h ROM, chorioamnionitis exposed.
EOS risk score was 0.77/1000 = 1 × missAntibiotic use would have been reduced from 99.7% to 2.5%Low-moderate
Carola et al. (2018)Philadelphia, USA
Single centre, retrospective record review2006 – 2017896 babies
≥35 weeks gestation
born to mothers with chorioamnionitis
5 cases of EOS
1 × GBS, 1 × E. coli, 3 × 'other' Streptococci
minimum 1 miss, maximum 3.
E. coli: at birth score: 2.39, after examination: 0.98, therefore miss
GBS: at birth score: 4.02, after examination: 1.65, possible miss, depending which score was used
Strep. sanguinis: at birth score 2.03, after examination 41.34, possible miss, depending which score was usedAntibiotic use would have been reduced to 23.5%Low-moderate
Sharma et al.
(2019)Minneapolis, USASingle-centre prospective cohort studyPre implementation January - December 2015
post implementation:
April 2016 - March 2018epoch 1: 109 babies
epoch 2: 180 babies
≥36 weeks gestation
born to mothers with chorioamnionitis
1 case of EOS
Treated with empirical antibiotics according to calculator recommendations, therefore no missesAntibiotic use reduced from 40% to 23%lowJoshi et al.
(2019)Stanford, USASingle centre, retrospective record/chart review, as part of a separate quality improvement project2015–2017339 babies
≥34 weeks' gestation
born to mothers with chorioamnionitis
1 case of EOS: GBS
Highest maternal temp 38.3 °C, known maternal GBS carriage but untreated, chorioamnionitis exposed. EOS score at birth was 0.93 per 1000, therefore= 1 × miss
Antibiotic use reduced by 12.3% to 5.1%, but this was not achieved by using the calculatorLow-moderate

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