Antimicrobials for neonates: evaluation and prescribing practices in Australian neonatal units

While antimicrobials are frequently prescribed in neonatal units, the way in which these prescriptions start, change and cease has had limited evaluation. This study aimed to provide a detailed description of infection evaluation and treatment practices in Australian neonatal healthcare facilities. A cross-sectional study of infection evaluations and antimicrobial prescriptions was conducted in three Australian neonatal units. All neonatal inpatients were audited across two five-day data capture periods per unit, with extended data collection for any neonate evaluated or treated for suspected or confirmed infection. This included determination of the reason(s) for commencing antimicrobials, the nature and duration of treatment, evaluation of whether infection had occurred, and identification of alternative diagnoses to infection. The study captured 401 patient episodes for 388 patients (1256 patient days). Eighty-three evaluations for potential infection were identified, of which 70 (84%) had a course of antimicrobials prescribed. The antimicrobial use rate was 119 antimicrobial days per 1000 patient days. For 12/70 (17%) antimicrobial courses, a bacterial, fungal or viral infection was detected. Twelve groups of reasons were identified for starting antimicrobial therapy, and neonates with higher care complexity more frequently received antimicrobials. Neonates were evaluated for infection both within neonatal units and prior to arriving in neonatal units. Antimicrobial choice change occurred in 33/70 courses (47%). Antimicrobials with a moderate or high potential for antimicrobial resistance (AMR) were prescribed in 30/70 courses (43%), with a practice pattern of adding these agents mid-course. For courses where there was no microbiologically confirmed infection, 42% had an identifiable alternative diagnosis. Antimicrobials are prescribed to neonates in varied hospital care contexts, for heterogenous indications, and most often without subsequent microbiological confirmation of infection. Antimicrobials with a propensity for AMR development are commonly prescribed. Renewed and expanded efforts to optimize neonatal antimicrobial prescribing practices are needed.