84: Empiric Neonatal Antibiotics for Maternal Fever: CRP as a Quality Improvement Intervention

Abstract

Background: Clinically suspected chorioamnionitis (CSC) is a commonly diagnosed complication of pregnancy. The burden of this diagnosis continues to impact maternal and neonatal care. Objectives: To determine the usefulness of a single C-reactive protein (CRP) measurement in identifying when antibiotic treatment can be discontinued in asymptomatic neonates ≥35 weeks, investigated for early onset neonatal sepsis (EONS) secondary to CSC. Design/Methods: As part of a quality improvement (QI) project to keep asymptomatic babies with their mothers, a clinical care map was developed focusing on reducing the intensity and duration of monitoring, investigating and treating those born to mothers with CSC. These at-risk newborns had routine diagnostic testing at birth and were monitored at their mothers' bedside where they received empiric intravenous antibiotic therapy. Antibiotic duration was reassessed based on the 24 h clinical exam and a CRP measurement obtained between 15 h and 22 h of age. Infants who remained well with CRP values less than 10 mg/L could have their antibiotics discontinued prior to the 48 h culture results and potentially be discharged home with parental counseling. A retrospective chart review was conducted between November 1, 2011 and November 1, 2012, on infants' ≥35 weeks gestation who were evaluated for EONS secondary to CSC. Data were abstracted for both maternal and infant diagnostic evaluations and clinical signs and symptoms. Results: Of 5886 babies delivered during this period, 162 initially asymptomatic infants were investigated after birth for EONS secondary to CSC. Although none of the neonates had positive blood cultures, 10 went onto develop symptoms consistent with EONS. Despite three of the symptomatic infants having low CRP levels, all 10 received antibiotics in NICU for between 48 h to seven days. Of the remaining 152 asymptomatic infants, 125 had CRP values <10 mg/L and 113 (90%) of those neonates had <48 h of antibiotics. Forty-nine infants were discharged home before two days. The 27 asymptomatic infants with high CRP measurements remained in postpartum and were treated until the 48 h blood culture results were reported as negative. Conclusions: For asymptomatic at-risk neonates, a CRP measurement <10 mg/L between 15 h and 22 h of age supported clinical assessment and reduce both antibiotic exposure and length of hospital stay. The clinical care map optimizes the allocation of neonatal resources, supports a family centered approach to practice and is clinically safe.