JAMA Study Suggests Antibiotic Use Among Premature Infants May Be Unnecessarily High: Public Health Watch

Increased stewardship may reduce administration of drugs to low birth-weight babies designed to prevent early-onset sepsis.

We’ve all been told, at least once in our lives, that, “You’re never too young to start…”

Investing. Saving money. Exercising.

You name it. We hear that until, well, we’re too old.

Now, the results of a new study published on May 25 by the Journal of the American Medical Association (JAMA), suggests patients are never too young to be responsibly prescribed antibiotics.

Indeed, at a time when the US Centers for Disease Control and Prevention (CDC) has made antibiotic stewardship a priority—10 days before the JAMA study was published, the agency’s “Grand Rounds” program for May was entitled “Be Antibiotics Aware: Smart Use, Best Care”—researchers from the Children’s Hospital of Philadelphia and CS Mott Children’s Hospital at the University of Michigan found that among a retrospective cohort of more than 40,000 infants born prematurely (at several hundred hospitals across the United States) over a 7-year period, the vast majority received antibiotic therapy within 3 days of their birth, primarily as a means for mitigating their increased risk for early-onset sepsis.

In all, 87% of those with extremely low birth weight (defined as <1000 grams) and 78.6% of those with very low birth weight (defined as <1500 grams) received antibiotics. Many of these young patients were administered the drugs for 5 or more days.

Notably, although the authors found that antibiotic use in babies born prematurely was less than what was found in similar analyses performed in the early 2000s, they noticed little change in prescribing patterns over the 7-year period of the study (from 2009 to 2015).

“Our study found overall lower rates of both antibiotic initiation and prolonged antibiotic administration among… infants compared with prior reports, potentially reflecting increased attention to indiscriminate antimicrobial use in the premature population,” they write. “However, we found little change over the past 7 years, reflecting continued uncertainty among neonatal clinicians about the optimal application of antibiotic stewardship principles among very premature infants.”

The JAMA study also suggests that antibiotic use among infants born prematurely continues to far outpace the risk for early-onset sepsis in this population. A study published in 2016 in the journal Pediatrics, which was cited in the paper, found that incidence rates for sepsis (all-cause) were significantly less than 1 in 1000 live births, and stable over a 10-year period from 2005 through 2014.

Interestingly, the authors of the JAMA paper found that antibiotic exposure varied from center to center. For example, 69 of 113 centers started antibiotic therapy for more than 75% of very low birth-weight infants, and 56 of 66 centers started antibiotic therapy for more than 75% of extremely low birth-weight infants. Meanwhile, the proportion of infants administered prolonged antibiotics ranged from 0% to 80.4% (very low birth-weight) and 0% to 92% (extremely low birth-weight) across centers included in the analysis.

“These observations identify several issues that should be addressed to optimize antibiotic stewardship among [very low birth-weight] infants,” the authors note. “The wide site variation in administration of prolonged antibiotics likely reflects clinical uncertainty more than variation in illness severity between sites… It is, therefore, possible that clinical strategies based on such delivery characteristics and/or placental pathologic findings might provide a framework for developing approaches to decreasing empirical antibiotic use among [premature] infants. [Our] findings suggest a continued need for neonatal antibiotic stewardship efforts designed to help clinicians identify premature infants at lowest risk of [early-onset sepsis] to avoid nonindicated, and perhaps harmful, antibiotic exposure.”

In other words, patients are never too young…

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous health care-related publications. He is the former editor of Infectious Disease Special Edition.