Majority of premature infants receive antibiotics without infection

Clinicians should do more to identify premature infants that are at low risk of developing sepsis to prevent unnecessary antibiotic exposure, which has been associated with increased risks of death, according to a new study.

One in 90 very-low-birth-weight infants develop sepsis, and it can kill up to 50% of the babies born between 22 and 24 weeks that develop the infection. But an analysis published Friday in JAMA Network Open found many infants receive antibiotics without evidence of an infection, which can put them at risk for a host of adverse health outcomes, including acquiring antimicrobial-resistant infections, chronic lung disease, necrotizing enterocolitis or death.

"Although very-low-birth-weight premature infants are at higher risk of early-onset infection compared with term-born infants, we found an overall rate of antibiotic initiation that was an order of magnitude higher than the actual incidence of infection," the study concluded.

The study authors analyzed more than 40,000 inpatient encounters involving premature infants at nearly 300 academic and community hospitals between January 2009 and September 2015.

More than 61% of the centers studied started antibiotic therapy for more than three-quarters of infants who weighed less than 3.3 pounds at birth.

At least 30% of antibiotics prescribed in the United States are unnecessary, according to the Centers for Disease Control and Prevention.

But physicians didn't change their prescribing patterns from January 2009 through September 2015 despite increased hospital efforts to improve antibiotic stewardship, according to the study. Providers administered antibiotics to 78% of very-low-birth-weight infants within 3 days of birth and 87% of infants with extremely low birth weight, defined as being under 2.2 pounds. More than a quarter of very-low-birth-weight infants and more than one-third of extremely-low-birth-weight infants were exposed to antibiotics for more than five days, which is considered prolonged.

In an accompanying editorial, Dr. Matthew Bizzarro, medical director of the Neonatal Intensive Care Unit at Yale University School of Medicine, wrote that the analysis' findings and other studies seem to show clinicians aren't identifying and treating premature infants at high risk for developing sepsis accurately.

"It is therefore the responsibility of individuals who prescribe antibiotics to premature infants to ensure, to the best of their ability that treatment is only administered to those who need it," Bizzarro wrote.

Study author Dr. Dustin Flannery, a Perinatal-Neonatal Medicine fellow at The Children's Hospital of Philadelphia, said there is little guidance on early antibiotic use in premature infants. He said more research is needed to "refine the approach" to early onset sepsis risk assessment in premature babies.

Many clinicians preemptively administer antibiotics to premature infants as a means of staving off infections such as sepsis, pneumonia; infection of the fluid that surrounds the brain, meningitis, skin and urinary tract infections because they have underdeveloped immune systems that make them susceptible to a number of pathogens.

But questions have been raised about whether that practice may do more harm than good. A 2016 study published in the journal Nature Microbiology found evidence of antimicrobial-resistant bacteria residing in the gut of premature infants that has raised calls for shorter courses of antibiotic treatment and limiting the number of antibiotics given to premature infants.

In 2001, 8% of the 4.6 million infant stays nationwide were for pre-term birth or low birth weight, according to a 2017 study published in the journal Pediatrics. The costs associated with admissions totaled $5.8 billion, representing 47% of the costs for all infant hospitalizations and 27% for all pediatric stays.