Neonatal antimicrobial stewardship efforts are needed to identify premature infants at the lowest risk for early-onset sepsis to avoid treatment that is not indicated and is potentially harmful, according to a new study published in JAMA Pediatrics.

Antibiotic use is common in premature infants, although exposure to these agents in the absence of culture-confirmed infection has been associated with increased mortality and morbidity. Stewardship efforts have started to focus on neonatal settings, and a detailed understanding of how these agents are used may help in optimizing their use. In this study, early antibiotic use was examined among very low birth weight (VLBW) infants across hospitals in the United States.

A retrospective cohort study was conducted, drawing data from a comprehensive administrative database of inpatient treatment from 297 nationwide institutions. A total of 42,618 VLBW infants were identified, of whom 40,364 (94.7%) survived for at least 1 day, including 14,923 extremely low birth weight infants (n=12,947; 86.8% of whom survived for at least 1 day).

Rate of initiation of empirical early antibiotic therapy remained essentially unchanged from 2009 to 2015.

A small but significant decrease in the rate of prolonged antibiotic duration was observed for VLBW (P =.02), but not extremely low birth weight, infants (P =.22). The annual risk difference in the proportion of VLBW infants receiving prolonged antibiotic therapy ranged from −0.94% (95% CI, −1.65% to −0.23%) to −1.08% (95% CI, −2.00% to −0.16%).

For extremely low birth weight infants, it ranged from −0.72% (95% CI, −1.83% to 0.39%) to −0.75% (95% CI, −1.96% to 0.46%).

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“Although VLBW 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,” say the authors.


Flannery DD, Ross RK, Mukhopadhyay SM, et al. Temporal trends and center variation in early antibiotic use among premature infants. JAMA Network Open. 2018;1(1):e180164. doi: 10.1001/jamanetworkopen.2018.0164