Antibiotics, lifesaver or threat premature infants?

Antibiotics are sometimes all that stand between life and death for a baby in neonatal intensive care.

But antibiotics also contribute to life-threatening problems for preemies and other sick infants and to broad concerns about their overuse and the toll of drug-resistant bugs that find ways around our medical arsenal.

New research out of California shows wide discrepancy in how often and for how long hospitals there are administering antibiotics to babies, and the study’s lead author said it clearly points to risky overuse in some places.

There’s no reason to expect that what was found in California would be any different in other states, said Dr. Joseph Schulman, who works for the state and led the study. Schulman’s team was able to analyze antibiotic use in 127 neonatal intensive-care units because of a recent state law that requires hospitals to report the data.

He looked at antibiotic use in 2013 and found a 40-fold variation, from 2.4 percent to 97.1 percent of patient days. The average was 24.5 percent. (Patient days are measured by counting the total number of days spent in the hospital by all infants. In other words, three babies who spent 10 days each would account for 30 patient days.)

Schulman’s team found no evidence that high rates of antibiotic use corresponded to higher rates of proven infections, so it wasn’t as simple as the sickest babies being clustered at certain hospitals and driving up antibiotic use.

The study, which appears online today in the journal Pediatrics, included 52,061 infants who spent 746,051 days in intensive care and is the largest of its kind.

Infants exposed to antibiotics have higher rates of necrotizing enterocolitis, which is a serious intestinal condition often found in preemies, and an increased risk of death. Early antibiotic use also has been linked to obesity and asthma later in life.

Antibiotic-resistant infections sicken more than 2 million people and kill at least 23,000 each year in the United States. The authors of a commentary piece in the same issue of Pediatrics point out that 58,000 infants born in India in 2013 died of antibiotic-resistant infections.

“There is fertile ground for the United States to also experience such a disaster,” wrote Drs. Roger Soll of the University of Vermont and William Edwards of Dartmouth College.

Although it wasn’t surprising to see variation in practices among the neonatologists at different hospitals, such a wide difference was concerning, Schulman said.

Antibiotic use is not a simple decision for doctors.

Babies “can’t talk to you about how they feel, they usually don’t mount a fever,” said Dr. Edward Shepherd, chief of neonatology at Nationwide Children’s Hospital.

Doctors try to determine whether a baby is set up for infection because of circumstances, including maternal infection. They observe the child for signs of decline and watch for high or low white-blood-cell counts and low blood pressure.

And when it seems as if it would be better to err on the side of caution and give a baby the medications, doctors send blood to the lab for cultures that can confirm an infection. Tests take a couple of days and aren’t always accurate, though, complicating matters.

Schulman said recent studies focusing on safely lowering the threshold for starting and ending antibiotic use in some babies — and more studies like those in the future — should help physicians avoid overprescribing.

Dr. Dennis Cunningham, an infectious-disease expert at Children’s, said he’s not surprised to hear about wide differences in prescribing practices in an area with so much room for individual approaches. Those who learned at the elbow of doctors who preached restraint are more likely to apply restraint, and vice versa, he said.

Shepherd said he did not have data on antibiotic use at Children’s comparable to what is now available in California. But the hospital has been striving for judicious use of the medications and has an antibiotic stewardship program led by an infectious-disease specialist, he said.

Doctors are placing particular emphasis on avoiding broad-spectrum, last-resort infection fighters such as vancomycin when they aren’t necessary.

Most babies treated for infection are given antibiotics based on suspicion, not proof, of infection, Schulman said.

If blood cultures come back negative, neonatologists at Children’s often will stop an antibiotic at 48 hours, once the lab has had time to watch for evidence of infection, Shepherd said.

“Antibiotics are a truly double-edge sword,” he said. “Hopefully, this (study) will result in more people paying attention to how many antibiotics they’re using.”

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