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Antibiotic treatment and monitoring for suspected meningitis in newborn babies in a neonatal unit

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Antibiotics for early-onset neonatal infection HAI

About

What is covered

This pathway covers antibiotics for the prevention and treatment of early-onset neonatal infection.
Early-onset neonatal bacterial infection (infection with onset within 72 hours of birth) is a significant cause of mortality and morbidity in newborn babies. Parent organisations and the scientific literature report that there can be unnecessary delays in recognising and treating sick babies. In addition, concern about the possibility of early-onset neonatal infection is common. This concern is an important influence on the care given to pregnant women and newborn babies. There is wide variation in how risk of infection is managed in healthy babies. The approach taken by the NHS needs to:
  • prioritise the treatment of sick babies
  • minimise the impact of management pathways on healthy women and babies
  • use antibiotics wisely to avoid the development of resistance to antibiotics.
These drivers have not always been addressed consistently in the NHS, and the antibiotics for early-onset neonatal infection guideline was commissioned to ensure they would be addressed in future.
Five key principles underpin the recommendations in this guideline.
  • Unless it is dangerous, families should be offered choice. The guideline includes recommendations to support families in making choices through provision of information and, where appropriate, reassurance.
  • Intrapartum antibiotic prophylaxis should be administered in a timely manner to all eligible women who choose it.
  • Babies with suspected early-onset neonatal infection should be treated as quickly as possible.
  • Antibiotic exposure should be minimised in babies who do not have an early-onset neonatal infection.
  • An integrated system of clinical care is needed to allow full implementation of the guideline recommendations.

Updates

Updates to this pathway

29 August 2014 Minor maintenance updates.
24 June 2014 Minor maintenance updates.
6 November 2013 Minor maintenance updates.
26 February 2013 Minor maintenance updates.
4 January 2013 Minor maintenance updates.
5 September 2012 Minor maintenance updates.
24 August 2012 Podcast added.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on:

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Antibiotics for the prevention and treatment of early-onset neonatal infection

What is covered

This pathway covers antibiotics for the prevention and treatment of early-onset neonatal infection.
Early-onset neonatal bacterial infection (infection with onset within 72 hours of birth) is a significant cause of mortality and morbidity in newborn babies. Parent organisations and the scientific literature report that there can be unnecessary delays in recognising and treating sick babies. In addition, concern about the possibility of early-onset neonatal infection is common. This concern is an important influence on the care given to pregnant women and newborn babies. There is wide variation in how risk of infection is managed in healthy babies. The approach taken by the NHS needs to:
  • prioritise the treatment of sick babies
  • minimise the impact of management pathways on healthy women and babies
  • use antibiotics wisely to avoid the development of resistance to antibiotics.
These drivers have not always been addressed consistently in the NHS, and the antibiotics for early-onset neonatal infection guideline was commissioned to ensure they would be addressed in future.
Five key principles underpin the recommendations in this guideline.
  • Unless it is dangerous, families should be offered choice. The guideline includes recommendations to support families in making choices through provision of information and, where appropriate, reassurance.
  • Intrapartum antibiotic prophylaxis should be administered in a timely manner to all eligible women who choose it.
  • Babies with suspected early-onset neonatal infection should be treated as quickly as possible.
  • Antibiotic exposure should be minimised in babies who do not have an early-onset neonatal infection.
  • An integrated system of clinical care is needed to allow full implementation of the guideline recommendations.

Updates

Updates to this pathway

29 August 2014 Minor maintenance updates.
24 June 2014 Minor maintenance updates.
6 November 2013 Minor maintenance updates.
26 February 2013 Minor maintenance updates.
4 January 2013 Minor maintenance updates.
5 September 2012 Minor maintenance updates.
24 August 2012 Podcast added.

Sources

The NICE guidance that was used to create the pathway.
Antibiotics for early-onset neonatal infection. NICE clinical guideline CG149 (2012)

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on:

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Risk factors for early-onset neonatal infection, including red flags

Risk factor
Red flag
Invasive group B streptococcal infection in a previous baby
Maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
Prelabour rupture of membranes
Preterm birth following spontaneous labour (before 37 weeks' gestation)
Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth
Intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis
Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis]
Yes
Suspected or confirmed infection in another baby in the case of a multiple pregnancy
Yes

Clinical indicators of possible early-onset neonatal infection (observations and events in the baby), including red flags

Clinical indicator
Red flag
Altered behaviour or responsiveness
Altered muscle tone (for example, floppiness)
Feeding difficulties (for example, feed refusal)
Feed intolerance, including vomiting, excessive gastric aspirates and abdominal distension
Abnormal heart rate (bradycardia or tachycardia)
Signs of respiratory distress
Respiratory distress starting more than 4 hours after birth
Yes
Hypoxia (for example, central cyanosis or reduced oxygen saturation level)
Jaundice within 24 hours of birth
Apnoea
Signs of neonatal encephalopathy
Seizures
Yes
Need for cardio–pulmonary resuscitation
Need for mechanical ventilation in a preterm baby
Need for mechanical ventilation in a term baby
Yes
Persistent fetal circulation (persistent pulmonary hypertension)
Temperature abnormality (lower than 36°C or higher than 38°C) unexplained by environmental factors
Signs of shock
Yes
Unexplained excessive bleeding, thrombocytopenia, or abnormal coagulation (International Normalised Ratio greater than 2.0)
Oliguria persisting beyond 24 hours after birth
Altered glucose homeostasis (hypoglycaemia or hyperglycaemia)
Metabolic acidosis (base deficit of 10 mmol/litre or greater)
Local signs of infection (for example, affecting the skin or eye)

Glossary

The level of gentamicin in the baby's bloodstream shortly after administration. The blood sample is usually taken about 1 hour after giving the drug. High peak concentrations of gentamicin are necessary to kill bacteria.
A process of measuring the concentration of a drug in the bloodstream, to avoid excessive levels that might be associated with adverse effects or to ensure adequate levels for therapeutic effect.
The level of gentamicin in the baby's bloodstream shortly before a further dose is given. High trough gentamicin concentrations may be associated with an increased risk of adverse effects.

Paths in this pathway

Pathway created: August 2012 Last updated: August 2014

© NICE 2014

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