Use of Kaiser sepsis calculator for well appearing newborns

1. Use of Early-Onset Sepsis (EOS) Calculator
for
Maternal Chorioamnionitis:
Nursing Edition
Lisa Scheid, MD
Neonatal-Perinatal Medicine

2. Objectives
• Review current practice
• Discuss EOS calculator data
• Outline new practice & workflow changes

3. Current Practice
• For ALL babies born to mothers with chorioamnionitis:
• Blood culture, CBC
• At least 48 hours of ampicillin and gentamicin
• Separation from mother in NICU for at least 6 hours
observation
• Does NOT take into account symptomatology (asymptomatic vs.
symptomatic)

4. Current Practice
• Unintended consequences:
• needle sticks
• antibiotic exposure
• delayed breastfeeding and maternal bonding
• additional hospital costs to parents
• additional NICU beds/nurse staffing

5. CURENT PRACTICE
PROPOSED PRACTICE
CHANGE
No difference for
asymptomatic and
symptoms babies if
maternal chorio
Work up ONLY if
symptomatic
Current Treatment Strategies
From AAP Committee of
Fetus and Newborn (2019)
Created before routine use
of antepartum antibiotics
Current Practice

6. CURENT PRACTICE
No difference for
asymptomatic and
symptoms babies if
maternal chorio
Work up ONLY if
symptomatic
Current Treatment Strategies
From AAP Committee of
Fetus and Newborn (2019)

7. CURENT PRACTICE
No difference for
asymptomatic and
symptoms babies if
maternal chorio
Work up ONLY if
symptomatic
Current Treatment Strategies
From AAP Committee of
Fetus and Newborn (2019)
*New Practice*

8. Current NICU Trends
(C) Symptoms only
4% (B)
EOS Calculator
93%
(A) All Chorio
2%
Other
1%
*Of 141 responses

9. • 14 hospitals in CA (Kaiser-Permanente) & MA, data from 1993-2007
• Nested case-control study: neonates >/= 34 wks
• Case: culture+ (blood or CSF) bacterial infection <72 hours of age
• Controls: random, frequency-matched 3:1 based on year and birth
hospital
• Cases: 350 out of 608,014 live births (0.05%, 0.5/1000)
• Statistical model using objective maternal data available at time of
delivery to give post-test probability of EOS (“Kaiser sepsis score”)

10. Real World Application of EOS Calculator
with Material Chorioamnionitis
• Level IV, 82 beds, 1200 NICU admissions/yr, 4000 deliveries/yr
• Assessed ALL babies 35+ wks with maternal chorio (n=312)
• 14% symptomatic, 12.8% became symptomatic, 73% never
symptomatic
• Rate of sepsis evaluations: 100% ➔ mean 27% in year after
implementation with continued downward trend

11. Real World Application of EOS Calculator
with Material Chorioamnionitis
• Retrospective study using EOS calculator
• Assessed WELL-APPEARING term newborns with
maternal chorio from 2009-2016 (n=362)
• Would have reduced blood cultures: 100% ➔ 13.8%
• Would have reduced antibiotics use: 100% ➔ 2.5%
• 1/362: +blood culture

12. Real World Application of EOS Calculator
with Material Chorioamnionitis
• 4000 deliveries/yr
• Rate of NICU admission:
100% ➔ 8%
• Rate of laboratory eval:
100% ➔ 11%
• Rate of antibiotics use:
100% ➔ 8%
• Rate of exclusive
breastfeeding: 10% ➔ 58%
Prospective Study

13. What we need to know at time of delivery:
• Gestational Age
• Highest maternal temperature
• # of hours of rupture of membranes
• Maternal GBS status
• Maternal antibiotic use (which
antibiotics, and number of doses)
*To be entered by NICU staff who attend delivery

14. ONLY THIS GROUP!

15. Possible Calculator Results
EOS Risk after Clinical
Exam
Risk per
1000/births
Clinical Recommendation Vitals
Well Appearing 0.39 No culture, no antibiotics Routine Vitals
Well Appearing 0.92 No culture, no antibiotics
Vitals every 4 hours for
24 hours
Well Appearing 2.20 Blood culture
Vitals every 4 hours for
24 hours

16. Possible Calculator Results
EOS Risk after Clinical
Exam
Risk per
1000/births
Clinical Recommendation Vitals
Well Appearing 0.39 No culture, no antibiotics Routine Vitals
Well Appearing 0.92 No culture, no antibiotics
Vitals every 4 hours for
24 hours
Well Appearing 2.20 Blood culture
Vitals every 4 hours for
24 hours

17. Possible Calculator Results
EOS Risk after Clinical
Exam
Risk per
1000/births
Clinical Recommendation Vitals
Well Appearing 0.39 No culture, no antibiotics Routine Vitals
Well Appearing 0.92 No culture, no antibiotics
Vitals every 4 hours for
24 hours
Well Appearing 2.20 Blood culture
Vitals every 4 hours for
24 hours

18. Possible Calculator Results
EOS Risk after Clinical
Exam
Risk per
1000/births
Clinical Recommendation Vitals
Well Appearing 0.39 No culture, no antibiotics Routine Vitals
Well Appearing 0.92 No culture, no antibiotics
Vitals every 4 hours for
24 hours
Well Appearing 2.20 Blood culture
Vitals every 4 hours for
24 hours

22. Process Changes for Nursing

23. Process Changes for Nursing

24. Process Changes for Nursing

25. Process Changes for Nursing

26. BE ON THE LOOKOUT FOR
CHANGE IN CLINICAL STATUS!!!

27. Practice Changes Summary
• Use of EOS Calculator in setting of maternal chorioamnionitis for
WELL APPEARING neonates
• No automatic NICU admission and sepsis work up
• Babies will room with mother
• For some babies, need nursing help with increased vital sign checks,
increased communication with Pediatricians and NICU providers
• If maternal chorioamnitiotis present, no discharge before 48 hours
even if just under observation
• Remember: Under current protocol babies would be in hospital
on antibiotics for 48 hours, and a few babies with new protocol
will have blood cultures obtained without antibiotics.

28. Thank you for your collaboration!

29. Questions/Feedback?