Audit Of Antibiotic Prescribing Practices For Neonatal Sepsis In New Born Unit At Kenyatta National Hospital

Abstract

BACKGROUND Neonatal sepsis is a major contributor of morbidity and mortality globally. Neonates usually present with nonspecific signs, hence requires a high index of suspicion(1). Neonates with sepsis deteriorate rapidly, leading to death, if treatment is delayed. The Ministry of Health, Kenya has published guidelines for management of neonatal sepsis in Basic Paediatric Protocols (revised in 2016), which are widely used(2). Auditing of antibiotic use is necessary as antibiotic misuse is one of the most important factor for development of antibiotic resistance (3,4). At the Kenyatta National hospital, a large national tertiary referral hospital, average 250 neonates per month are being admitted in NBU. Since the guidelines on management of neonatal sepsis were made in Kenya, antibiotic use has not been audited in NBU at KNH. Documentation of antibiotic prescribing practices will improve our knowledge, inform our ways of practices, help correct errors and allow staff training to prevent misuse and antibiotic resistance. OBJECTIVES To assess the antibiotic prescribing practices against recommended Kenyan guidelines(2) for neonatal sepsis among neonates admitted to NBU at KNH. In addition, the study described the outcome of neonates with neonatal sepsis on antibiotics within 7 days. METHODS This was a prospective audit carried out over period of three months in NBU at KNH. Informed consent was obtained from each participant enrolled in the study. Files (admission record) of neonates who met the inclusion criteria were audited after review by the doctor on call at admission. Information regarding patient’s demographic data, maternal and neonatal history (risk factors),clinical signs examined, laboratory investigations requested, diagnosis, antibiotics prescribed (choice, dosages, frequency and duration) was abstracted from files using a structured questionnaire. Review of the files was done daily for 5 days to check whether antibiotics were continued, stopped or changed to second line based on clinical condition of the neonate. Data on outcome of the neonate with neonatal sepsis were determined within 7 days or on discharge (survived/died). RESULTS Overall documentation of perinatal risk factors and clinical features present was very poor. The most commonly documented perinatal risk factors were low birth weight in 100%, prolonged rupture of membranes 51.6%, foul smelling liquor in 11.2%, chorioamnionitis in 10.2% and difficult or xii prolonged labour in 7.8%. Overall 53(16.6%) neonates had maternal risk factors present. The clinical features not documented by clinician on admission were convulsions in 252(41.05%), grunting in 128(20.85%), lower chest wall indrawing in 76(12.4%) and lethargy in 65(10.6%). The rate of investigations to confirm infection was very low. Blood cultures were done only in 13(4%) neonates on admission, while complete blood count and C reactive protein were done in 224(70%) and 198(62%) respectively. Immature to total lymphocyte count and lumbar puncture were not done in any of the neonates. Appropriate antibiotics as per the Kenyan guidelines were prescribed in 313(97.8%) of neonates on admission. Appropriate doses of penicillin and gentamicin were given in 310(96.9%) and 282(88%) respectively on admission. There was prolonged unnecessary use of antibiotics in neonates who improved clinically at 48 – 72 hours. Neonates who improved clinically at 48 hours were 148(53.62%), yet antibiotics were stopped in 8(2.9%) only. At 72 hours 168(65.12%) neonates improved clinically, but antibiotics were stopped only in 22(8.53%). Overall mortality among 320 neonates admitted was 80(25%) over 7 days. Mortality among preterm neonates (< 37 weeks gestation) was 70(21.8%). Twenty (25%) neonates died within the first 24 hours, 24 (30%) died within 24 - 48 hours, and 36 (45%) died between 48 hours - 7 days. Out of the neonates who died within 48 hours, 38(11.8%) were preterm. CONCLUSION There was poor documentation of clinical features, perinatal risk factors and condition of the neonates at the time of change of antibiotics. Appropriate antibiotics as per the Kenyan guidelines (Basic Pediatrics Protocols-2016) were given in 97.8% of neonates on admission. The rate of investigations to confirm infection was very low. Blood cultures were done only in 4% of neonates on admission and lumbar punctures were not done.The continuation of antibiotics was inappropriate. Overall mortality was high in neonates at 25% (80). Mortality among preterm neonates (< 37 weeks gestation) was 70(21.8%). Forty four (55%) died within 48 hours. RECOMMENDATIONS Proper documentation of perinatal risk factors and clinical features is advocated. Full septic screen should be done on admission to confirm infection and while changing antibiotics. We should emphasize on discontinuing empiric antibiotics as soon as the neonate is clinically stable and laboratory tests done are normal. Antibiotic stewardship should be promoted.