Despite increasing awareness of their unintended consequences, antibiotics are on of the most-prescribed medications to neonates. Approximately 5-10% of infants in level 1 and 2 nurseries receive empiric antibiotics for suspected infection, but less than 0.1% are actually infected. This means that approximately 100-200 infants receive unnecessary antibiotics per every infected newborn. Common indications for neonatal antibiotic use include suspected sepsis, maternal group B Streptococcus colonization, exposure to chorioamnionitis or prolonged rupture of membranes, and prematurity (gestational age ≤36 weeks). Treatment for suspected – but unproven – sepsis is common and costly, and it accounts for a significant fraction of antibiotic exposure in healthy newborns. Finally, the decisions to start, continue, and stop antibiotics in well newborns are may be determined by institutional norms or provider preferences rather than objective findings.
Antibiotic stewardship programs (ASPs) can substantially reduce unnecessary antibiotic exposure but require specialist support. Single-center and cross-sectional surveys have demonstrated that antibiotic use in level 3 and 4 neonatal intensive care units (NICUs) is both excessive and variable. ASPs can effectively reduce unnecessary antibiotic use by providing an audit of prescribing practices and giving provider feedback, providing education and decision support to frontline providers, and by restricting certain antibiotics when appropriate. ASPs have been successful in a variety of settings, including adult and pediatric service lines and outpatient settings. However, data in the NICU are limited, and data in the well-baby nursery are nonexistent. The Antimicrobial Stewardship Support in South Texas (ASSIST-1) study, our pilot study of nursery telestewardship, represented the first effort to bridge this major knowledge gap. In it, we found that nursery-based ASP can safely and effectively reduce antibiotic exposure among neonates in well-baby and intermediate-care nurseries.
Many well-baby nurseries – particularly those in rural or medically underserved areas – do not have access to neonatal ASP support, representing a major health disparity. In contrast to NICUs, which are generally located in large referral centers and have an academic affiliation with a university system, well-baby nurseries are often located in critical access areas as rural, community-based private hospitals. For such hospitals, the well-baby nursery may represent most or all of the pediatric care within the facility. Not surprisingly, a recent survey of ASP programs in nurseries across the U.S. found that most level 1 and level 2 nurseries did not have ASPs, pediatric pharmacists, or pediatric infectious diseases providers on-site. Nursery providers in these medically underserved areas tend to agree with the importance of having an ASP, but list lack of access to expertise and lack of time as major barriers to implementing antibiotic stewardship in their nursery. Because medically underserved nurseries are traditionally unable to implement ASPs, babies born in these settings are at increased risk for the negative health outcomes associated with unnecessary antibiotic exposure.