Pediatrics>General Pediatrics

Are Antibiotics Necessary in All Newborns?

— Of those at low risk for sepsis, 80% received antibiotics, one study found

by Lei Lei Wu, Staff Writer, MedPage Today January 17, 2022

Are Antibiotics Necessary in All Newborns? | MedPage Today

A photo of a newborn baby in an incubator

Antibiotics were administered to most newborns, even those with low risk for early-onset sepsis (EOS), according to a retrospective cohort study.

Among over 1,000 newborns at low risk for developing EOS, 80.4% were given antibiotics, in comparison with 91% of over 6,300 newborns who were not considered low risk (P<0.001), reported Dustin Flannery, DO, MSCE, of the Children’s Hospital of Philadelphia, and colleagues.

Additionally, the duration of antibiotic administration was not significantly different between those born with and those born without low-risk delivery characteristics (adjusted difference 0.6 hours, 95% CI -3.8 to 5.1), they noted in Pediatrics.

« Delivery characteristics may help providers predict which infants are at lowest risk of EOS and assist in determining whether empiric antibiotic therapy is indicated, » they wrote.

Antibiotic use in premature and very-low-birth-weight infants is associated with necrotizing enterocolitis, a disease in which bacteria invade the intestinal tissue.

On the other hand, EOS — while uncommon — can be deadly, especially for preterm infants, with one study finding a mortality rate of nearly 30%.

« Sepsis remains one of the most feared occurrences in any neonatal setting, » wrote Ivana Culic, MD, of Beth Israel Deaconess Medical Center in Boston, and Amy O’Connell, MD, PhD, of Boston Children’s Hospital, in an accompanying editorial.

« Practitioners who have experienced a neonate becoming ill with sepsis have good reason to be cautious; neonatal sepsis can evolve rapidly and can be fatal even after initiation of appropriate antibiosis. »

previous study by Flannery and colleagues found that antibiotic use in very-low-birth-weight and extremely-low-birth-weight infants who were considered low risk for early-onset infection could be reduced without adverse effects.

But methods to assess infection risk in neonates must be refined, the study authors noted. Currently, there are algorithms to predict EOS risk in term infants.

However, studies of preterm infants looking at low-risk delivery criteria typically do not include moderately preterm or late preterm infants.

This study evaluated 7,549 infants of all gestational ages with blood cultures drawn in one of two perinatal units in Philadelphia.

Median gestational age was 37 weeks, median birth weight was 2,859 grams, and 43.9% were girls.

Forty-one infants developed EOS. In this group, median gestational age was 35 weeks, median birth weight was 2,415 grams, and 68% were girls. None were considered low-risk deliveries.

Flannery and colleagues characterized a delivery as low risk if it met all the following criteria:

  • Birth by Cesarean section
  • Rupture of amniotic membranes at delivery
  • Absence of labor or attempts to induce labor
  • Absence of suspected or confirmed maternal intra-amniotic infection
  • Absence of acute unexplained non-reassuring fetal status

Two infants with EOS met most of the criteria, with the exception of absence of acute unexplained non-reassuring fetal status. Sixteen cases were due to Escherichia coli, and 16 were due to group B Streptococcus.

However, a single set of criteria should not be applied to infants of all gestational ages, Culic and O’Connell cautioned.

« As clinicians, we all acknowledge that the risks and outcomes of sepsis are different for the population of extremely premature infants compared with the term infants, » they noted.

While applying the EOS risk calculator may decrease antibiotic use in term infants, « applying the same risk assessment tool in preterm infants would undoubtedly increase the use of antibiotics because their initial clinical signs and symptoms (temperature instability, need for respiratory support, and need for inotropic support) are likely to be present, » they wrote.

Flannery and colleagues acknowledged that more refined risk assessment strategies for EOS have been implemented since their study, which took place from 2009 to 2014.

author['full_name']Lei Lei Wu is a staff writer for Medpage Today. She is based in New Jersey. Follow 


Flannery reported research funding from the Agency for Healthcare Research and Quality from two contracts with the CDC, and from the Children’s Hospital of Philadelphia. Co-authors reported research funding from the NIH and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Culic and O’Connell reported no financial disclosures.

Primary Source – Pediatrics

Source Reference: Flannery DD, et al « Delivery characteristics and the risk of early-onset neonatal sepsis » Pediatrics 2022; DOI: 10.1542/peds.2021-052900.

Secondary Source – Pediatrics

Source Reference: Culic I, O’Connell AE « Identifying neonates at lowest risk for sepsis » Pediatrics 2022; DOI: 10.1542/peds.2021-054221.