September 27, 2019
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Neonatal early-onset sepsis calculator reduces use of empirical antibiotics

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Photo of Niek Achten
Niek B. Achten

Use of a clinical risk stratification tool called the neonatal early-onset sepsis, or EOS, calculator was associated with a substantial reduction in the use of empirical antibiotics for suspected EOS, according to findings from a systematic review and meta-analysis published in JAMA Pediatrics.

“The EOS calculator paradigm uses a multivariate prediction tool to estimate the risk of early onset sepsis and assign a recommendation on whether to start or withhold empiric antibiotics,” Niek B. Achten, MD, from the department of pediatrics at Tergooi Hospital in the Netherlands, told Infectious Diseases in Children. “Individual risk estimation may become increasingly important in facilitating informed and safe reduction of empirical antibiotics, improving antibiotic stewardship.”

According to the researchers, the neonatal EOS calculator — developed during research conducted in 2014 — “is based on a predictive risk model developed using a nested case-control design in a cohort of 608,014 newborns 34 weeks’ gestational age or older born at 14 hospitals in the United States.” It estimates risk based on five objective maternal risk factors and four clinical neonatal risks factors, and then stratifies newborns into three levels of risk with a corresponding recommendation for management, the researchers wrote.

To determine the association between management of neonatal EOS based on guidance from the EOS calculator — compared with conventional management strategies — and reduction in antibiotic therapy for newborns, Achten and colleagues included 13 relevant studies in their review. The studies analyzed a total of 175,752 newborns. All 13 found a substantially lower relative risk for empirical antibiotic therapy, with a range of 3% to 60%, favoring the EOS calculator, they wrote. The meta-analysis revealed a relative risk for antibiotic use of 56% (95% CI, 53%-59%) in before-and-after studies that included newborns regardless of exposure to chorioamnionitis — a risk factor associated with stronger reductions compared with studies not limited to chorioamnionitis.

Although evidence on safety was limited, they reported comparable proportions of missed cases of EOS between management guided by the EOS calculator (28%) and conventional management strategies (29%), with a pooled OR of 0.96 (95% CI, 0.26-3.52).

“Depending on setting and strategies used, the EOS calculator can also serve as a safety net by flagging at-risk newborns overseen by conventional management strategies, which are more categorical in their recommendation for treatment,” the researchers wrote. “Altogether, although evidence of the safety of management guided by the EOS calculator is limited, it shows no indication of inferiority compared with conventional management strategies thus far.”

In a related editorial, Karen M. Puopolo, MD, PhD, chief of the section of newborn pediatrics at Pennsylvania Hospital, and Gabriel J. Escobar, MD, a research scientist at the Kaiser Permanente Northern California Division of Research, both co-authors on the 2014 study, provided an overview of the tool.

“The neonatal EOS calculator provides risk estimates for individual infants and requires that neonatal clinicians decide what clinical actions should be taken at different levels of risk, understanding the number needed to treat associated with such decisions,” they wrote. “In the end, the calculator models require that we accept and manage the certainty of uncertainty.” by Joe Gramigna

Disclosures: Achten, Escobar and Puopolo report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.