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GUIDELINE REVIEW
1
Neonatal Unit, Birmingham
Women’s Hospital,
Birminghamm, UK
2
Department of Paediatrics,
University of Cambridge,
Addenbrooke’s Hospital,
Cambridge, UK
Correspondence to
Dr Emma Caffrey Osvald,
Neonatal Unit, Birmingham
Women’s Hospital, Mindelsohn
Way, Birmingham B15 2TG, UK;
ecosvald@doctors.org.uk
Received 11 August 2013
Revised 10 November 2013
Accepted 15 November 2013
Published Online First
13 December 2013
To cite: Caffrey Osvald E,
Prentice P. Arch Dis Child
Educ Pract Ed 2014;99:
98–100.
98
NICE clinical guideline: antibiotics
for the prevention and treatment of
early-onset neonatal infection
Emma Caffrey Osvald,1 Philippa Prentice2
INFORMATION ABOUT CURRENT
GUIDELINE
Early-onset neonatal infection, defined as
infection within 72 h of birth, is a signifi-
cant cause of mortality and morbidity,1
where Group B streptococcus (GBS) is most
frequently responsible.1 2 The National
Institute for Health and Clinical Excellence
(NICE) guideline: ‘Antibiotics for
early-onset neonatal infection: antibiotics
for the prevention and treatment of
early-onset neonatal infection’1 was pub-
lished in August 2012. It aims to help iden-
tify those neonates at risk of infection, to
promote prompt treatment for neonates
with suspected infection and to minimise
antibiotic exposure to those babies who do
not have early-onset neonatal infection. The
guideline was developed by the National
Collaborating Centre for Women’s and
Children’s Health.
PREVIOUS GUIDELINE
There are no previous detailed national
guidelines on the management of
early-onset neonatal sepsis. The Royal
College of Obstetricians and Gynaecologists
published a guideline in 2003 (updated
2012) focusing on prevention of GBS,
which included some aspects of the man-
agement of early-onset neonatal sepsis.2
KEY ISSUES THE GUIDELINE
RECOMMENDS
For mothers
▸ Offering intrapartum antibiotics to any
woman who has had a previous baby with
invasive GBS infection or who has GBS col-
onisation, bacteriuria or infection during
the pregnancy.
▸ Considering intrapartum antibiotics for any
term pregnancy with rupture of membranes
lasting more than 18 h or in preterm preg-
nancy with prelabour rupture of membranes.
Caffrey Osvald E, et al. Arch Dis Child Educ Pract Ed 2014;99:98–100. doi:10.1136/archdischild-2013-304629
For recognising the septic neonate
▸ Identifying risk factors for early sepsis and
assessing for clinical indicators suggestive
of a septic baby. Those strongly suggestive
of sepsis are defined ‘red flags’ (box 1).
▸ Identifying clinical indicators and risk
factors classified as ‘non-red flag’. These
include: maternal GBS colonisation, bac-
teriuria or infection in the current preg-
nancy, prelabour rupture of membranes, as
well as feed intolerance, jaundice in the
baby within 24 h of birth and signs of
respiratory distress.
Box 1 Red flags
▸ Parenteral antibiotics given to the
mother for confirmed or suspected
invasive bacterial infection
▸ Suspected or confirmed infection in
another baby where there is a multiple
pregnancy
▸ Respiratory distress starting more than
4 h after birth
▸ Seizures
▸ Need for mechanical ventilation in a
term baby
▸ Signs of shock.
For management of suspected neonatal sepsis
▸ Commencing antibiotic treatment in the
neonate if one ‘red flag’ or more than one
‘non-red flag’ risk factor or clinical indica-
tor is present.
▸ Taking blood cultures and C-reactive
protein (CRP) before starting antibiotics
(see table 1).
▸ Doing a lumbar puncture (LP) if there is
strong suspicion of sepsis or clinical signs
of meningitis.
▸ Using benzylpenicillin and gentamicin as first-
line antibiotics.
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Guideline review

Table 1 Initial investigations for suspected sepsis What should I start doing for all neonates?
▸ Give antibiotics within 1 h of deciding to treat.
Blood culture Always
▸ Prescribe benzylpenicillin at dosage of 25 mg/kg twice
C-reactive protein Always, repeat after 18–24 h daily and increase to three times daily if clinically
Skin swabs Not indicated concerned.
Urine MC&S Not indicated ▸ Prescribe gentamicin at a starting dosage of 5 mg/kg 36
hourly.
Swab of conjunctival Indicated if discharge is purulent to test for
▸ Consider LP in a baby with a CRP ≥10 mg/L.
discharge chlamydia and gonococcus
▸ Send swabs that detect chlamydia and gonococcus if
Lumbar puncture If CRP >10 mg/L, blood culture positive, clinical purulent conjunctivitis is present.
suspicion of sepsis/meningitis or no clinical
improvement
MC&S, microscopy, culture and sensitivites. What can I continue to do as before?
▸ Allow parents and carers to make informed decisions
▸ Being mindful that different antibiotic regimes are recom- about their children’s care.
mended for specific infections, for example in meningitis ▸ Consider monitoring baby’s vital signs and clinical con-
or umbilical infection. Adhere to your local guidelines dition for at least 12 h if only one risk factor or one clin-
and refer to relevant NICE guidelines. ical indicator for sepsis is present.
▸ Rechecking CRP after 18–24 h after commencing antibiotics. ▸ Achieve trough gentamicin concentration of <2 mg/L.
▸ Consider stopping antibiotics after 36 h if the blood
culture is negative, CRP remains low and the neonate is What should I do differently?
clinically stable. ▸ Consider stopping antibiotics at 36 h if blood cultures
▸ Treating for a minimum 7-day course of intravenous are negative, the baby is clinically well, the suspicion of
antibiotics is suggested where there is a strong suspicion infection was low and the CRP trend is reassuring.
of sepsis or a positive blood culture. However, this may ▸ Consider completing the course of intravenous antibio-
vary depending on the pathogen and the clinical status tics in non-hospital setting for babies who are well.
of the baby. When in doubt adhere to local policy and
microbiology advice. UNRESOLVED CONTROVERSIES
The clinical and cost effectiveness of maternal ante-
natal GBS screening and subsequent treatment in
UNDERLYING EVIDENCE BASE/METHODOLOGY labour of those identified as GBS positive is unclear. It
This, like all NICE recommendations, is based on sys- is also unknown whether there is benefit in treating
tematic reviews of research evidence. Where no sub- all women in preterm labour with prophylactic anti-
stantive clinical research evidence was found the biotics, including those with intact membranes. More
recommendation is based on other evidence-based information is needed to distil which specific risk
guidelines or the collective experience of the factors, symptoms and signs are most indicative of
Guideline Development Group (see box 2). early-onset neonatal sepsis. Additionally more evi-
dence is needed to provide us with a cost-effective
WHAT DO I NEED TO KNOW
What should I stop doing?
▸ Routinely taking urine microscopy, culture and sensiti-
Clinical bottom line
vites (MC&S) or skin swab MC&S as part of initial
investigations. This NICE guideline provides evidence-based best practice
▸ Routinely commencing antibiotics in well babies with advice for management of early-onset neonatal infection
only one ‘non-red flag’ clinical indicator or risk factor. which can be serious and fatal.
▸ Consider whether intrapartum antibiotics are indicated
and should be offered to the labouring woman.
Box 2 Resources ▸ Antibiotics are recommended in the neonate if one
red flag risk factor or clinical indicator is present.
http://guidance.nice.org.uk/CG149 ▸ Commence intravenous antibiotics within 1 h of decid-
Link to NICE guideline and full guideline ing to treat.
http://guidance.nice.org.uk/CG149/PublicInfo/pdf/English ▸ Choose benzylpenicillin and gentamicin as first-line
English link to public information on antibiotics for antibiotics.
early-onset neonatal infection ▸ Minimise antibiotic exposure to the neonate by
http://www.nice.org.uk/newsroom/podcasts/index.jsp? stopping antibiotics at 36 h if blood cultures are nega-
pid=44 tive, CRP and clinical suspicion of sepsis remains low.
Antibiotics for early-onset neonatal infection podcast with ▸ Keep families informed and to allow them to be part
Dr Mark Turner of the decisions made about their child.

Caffrey Osvald E, et al. Arch Dis Child Educ Pract Ed 2014;99:98–100. doi:10.1136/archdischild-2013-304629 99
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Guideline review

laboratory investigation to exclude early-onset sepsis. REFERENCES

Finally, the duration of the antibiotic course also often
remains unclear.
Contributors This article was written by ECO with input from PP.
Competing interests None.
Provenance and peer review Commissioned; externally peer
reviewed.
1 National Institute for Health and Clinical Excellence:
Antibiotics for early-onset neonatal infection. CG149. London:
National Institute for Health and Clinical Excellence, 2012.
2 Royal College of Obstetricians and Gynaecologists: The
Prevention of Early-onset Neonatal Group B Streptococcal
Disease. Green-top Guideline No 36. Royal College of
Obstetricians and Gynaecologists, 2012.

Help for parents and doctors! Part 2

Children are not small adults, and teenagers are not big toddlers. The techniques of
‘Toddler Taming’ will not work on this age group. Dealing with teenagers at home and in
the middle of a busy clinic can be challenging, and again it is useful to have some expertise
to turn to. I think this book is excellent for reading and recommending.1
Children grow up, and teenagers are challenging at home and as patients. I have
used its sensible advice at home for my three children, only one of whom is still a teen-
ager, and in consultations. Gael is a psychologist and has parented teenagers, so she
speaks from her professional and personal experience. There is commonality with the
techniques of motivational interviewing, and the ‘21 Golden Rules’ impressed upon
me the responsibility of always being the ‘grown up’ in challenging encounters.
Examples are rule 1 ‘Teach by example before giving instructions’ and rule 3 ‘Listen
three times as much as you talk’. The latter can seem impossible with a shrugging
monosyllabic son, but sit on the sofa for a while when he is playing an electronic game
and conversations start. You may think this applies only at home, but as doctors we
can get to know our teenage patients very well and can start to transfer into the paren-
tal role with its associated frustrations. It is easy to become didactic and lecturing in
style, and this is known to not impress or influence adolescents. The parenting techni-
ques recommended are probably not the ones we experienced as teenagers, and my
husband and I found it hard to start with, but once negative comments are made such
as ‘you are lazy’, ‘you don’t care about anyone else’ it is hard to take them back and it
does not improve your eventual adult relationship, which should be a parent’s and
doctor’s ultimate aim. You can label the ‘act’—for example, that was a silly thing to do
—rather than labelling the person—rule 4 ‘Think before you speak’.
My son has never taken to any club activities. Having been active young sportspeople
we applied a lot of pressure on him to try new activities. Our son became more oppos-
itional and recalcitrant. Fortunately with the help of this book we stepped back and
reframed. We were trying to make him relive our teenage years, and he sensed a judging
disappointment. Now we support him in his interests such as sightseeing, eating out,
cooking and shopping. He has become much more confident and communicative with
our change in attitude. Teenage years are normal, and the child is developing self-
awareness and efficacy, which is essential; we as parents and doctors just have to learn
how to manage our frustration with not always being in charge or being right. And for
my young adults I will and have rule 21 ‘Nail(ed) the door ajar—forever!’

Deborah Shanks

Correspondence to Dr Deborah Shanks, Raigmore Hospital, Inverness IV2 4ST, UK; deborah.shanks@nhs.net
To cite Shanks D. Arch Dis Child Educ Pract Ed 2014;99:100.
Published Online First 10 April 2014
Received 4 February 2014. Accepted 20 March 2014
Arch Dis Child Educ Pract Ed 2014;99:100.
doi:10.1136/archdischild-2014-306143

▸ http://dx.doi.org/10.1136/edpract-2013-305911
REFERENCE
1 Lindenfield G. Confident teens. 208 pages. Thorsons, ISBN: 978-0007100620.

100 Caffrey Osvald E, et al. Arch Dis Child Educ Pract Ed 2014;99:98–100. doi:10.1136/archdischild-2013-304629
 Downloaded from http://ep.bmj.com/ on November 30, 2014 - Published by group.bmj.com

NICE clinical guideline: antibiotics for the

prevention and treatment of early-onset
neonatal infection
Emma Caffrey Osvald and Philippa Prentice

Arch Dis Child Educ Pract Ed 2014 99: 98-100 originally published online
December 13, 2013
doi: 10.1136/archdischild-2013-304629

Updated information and services can be found at:

http://ep.bmj.com/content/99/3/98

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Topic Articles on similar topics can be found in the following collections

Collections Guideline review (7)
Drugs: infectious diseases (94)
Pregnancy (40)
Reproductive medicine (68)
Meningitis (13)
Epidemiologic studies (81)
Infection (neurology) (22)
Urinary tract infections (11)
Urinary tract infections (11)
Urology (33)
Guidelines (31)
Mechanical ventilation (7)

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