Clinical and economic impacts of a modified-observational screening approach to well-appearing infants born to mothers with chorioamnionitis.

OBJECTIVE: Term infants born to mothers with chorioamnionitis are at risk for early-onset sepsis (EOS). We aimed to measure the impact of changing from a categorical to a modified-observational EOS screening approach on NICU admission, antibiotic utilization, and hospitalization costs. STUDY DESIGN: Single-center retrospective pre-post cohort study of full-term infants born to mothers with chorioamnionitis. Primary outcomes included NICU admission, antibiotic utilization, and hospitalization costs. Outcomes were adjusted for demographic variables. Budget-impact analysis was performed using bootstrapping with replication. RESULTS: 380 term infants were included (197 categorical; 183 modified-observational). There was a significant decrease in NICU admission and antibiotic utilization (p < 0.05) in the modified-observational cohort but no significant difference in per-patient total hospitalization costs. Budget-impact analysis suggested a high probability of cost savings. CONCLUSION: A modified-observational approach to evaluating term infants of mothers with chorioamnionitis can reduce NICU admission and unnecessary antibiotic therapy, and may lead to cost-savings.

Early onset sepsis calculator implementation is associated with reduced healthcare utilization and financial costs in late preterm and term newborns.

The neonatal early onset sepsis (EOS) calculator is a novel tool for antibiotic stewardship in newborns, associated with a reduction of empiric antibiotic treatment for suspected EOS. We studied if implementation of the EOS calculator results in less healthcare utilization and lower financial costs of suspected EOS. For this, we compared two single-year cohorts of hospitalizations within 3 days after birth in a Dutch nonacademic teaching hospital, before and after implementation of the EOS calculator. All admitted newborns born at or after 35 weeks of gestation were eligible for inclusion. We analyzed data from 881 newborns pre-implementation and 827 newborns post-implementation. We found significant reductions in EOS-related laboratory tests performed and antibiotic days, associated with implementation of the EOS calculator. Mean length of hospital stay was shorter, and EOS-related financial costs were lower after implementation among term, but not among preterm newborns.Conclusion: In addition to the well-known positive impact on antibiotic stewardship, implementation of the EOS calculator is also clearly associated with reductions in healthcare utilization related to suspected EOS in late preterm and term newborns and with a reduction in associated financial costs among those born term.What is Known:• The early-onset sepsis (EOS) calculator is a novel tool for antibiotic stewardship in newborns, associated with a reduction in empiric antibiotic treatment for suspected EOS.What is New:• In newborns at risk for EOS, EOS calculator implementation is associated with a significant reduction in laboratory investigations related to suspected EOS and significantly shorter stay in those born term.• EOS calculator implementation in term newborns is associated with a mean reduction of €207 in costs for EOS-related care per admitted newborn.

Early onset sepsis calculator-based management of newborns exposed to maternal intrapartum fever: a cost benefit analysis.

OBJECTIVE: To determine potential net monetary benefit of an early onset sepsis calculator-based approach for management of neonates exposed to maternal intrapartum fever, compared to existing guidelines. STUDY DESIGN: We performed a cost-benefit analysis comparing two management approaches for newborns >34 weeks gestational age exposed to maternal intrapartum fever. Probabilities of sepsis and meningitis, consequences of infection and antibiotic use, direct medical costs, and indirect costs for long-term disability and mortality were considered. RESULTS: A calculator-based approach resulted in a net monetary benefit of $3998 per infant with a 60% likelihood of net benefit in probabilistic sensitivity analysis. Our model predicted a 67% decrease in antibiotic use in the calculator arm. The absolute difference for all adverse clinical outcomes between approaches was ≤0.6%. CONCLUSIONS: Compared to existing guidelines, a calculator-based approach for newborns exposed to maternal intrapartum fever yields a robust net monetary benefit, largely by preventing unnecessary antibiotic treatment.

Cost-effectiveness analysis of maternal immunisation against group B Streptococcus (GBS) disease: A modelling study.

BACKGROUND: There is a considerable global burden of invasive group B streptococcal (GBS) disease. Vaccines are being developed for use in pregnant women to offer protection to neonates. OBJECTIVE: To estimate the potential impact and cost-effectiveness of maternal immunisation against neonatal and maternal invasive GBS disease in the UK. METHODS: We developed a decision-tree model encompassing GBS-related events in infants and mothers, following a birth cohort with a time horizon equivalent to average life expectancy (81 years). We parameterised the model using contemporary data from disease surveillance and outcomes in GBS survivors. Costs were taken from NHS sources and research studies. Maternal immunisation in combination with risk-based intrapartum antibiotic prophylaxis (IAP) was compared to the current standard practice of risk-based IAP alone from an NHS and Personal Social Services (health-provider) perspective. We estimated the cases averted and cost per QALY gained through vaccination. One-way sensitivity analysis, scenario analysis and probabilistic sensitivity analysis were performed. RESULTS: An effective maternal immunisation programme could substantially reduce the burden of GBS disease. The deterministic analysis estimated the threshold cost-effective price for a GBS vaccine to be £54 per dose at £20,000/QALY (£71 per dose at £30,000/QALY). Results were most sensitive to assumptions on disease incidence, sequelae rate and vaccine efficacy. Probabilistic analysis showed 90.66% of iterations fell under the £30,000 threshold at a vaccine price of £55. Inclusion of modest prevention of stillbirths and/or, preterm births, carer health impacts, maternal GBS deaths and 1.5% discounting improved cost-effectiveness compared to the base case. Lowering vaccine strain coverage made the vaccine less cost-effective. A key limitation is that the properties of the final GBS vaccine are unknown. CONCLUSIONS: Maternal GBS immunisation is expected to be cost-effective, even at a relatively high vaccine price.

Is MPV a Predictive Marker for Neonatal Sepsis? A Pilot Study.

Neonatal sepsis (NS) continues to be a diagnostic challenge and a prime cause of mortality. Forage for a lucid, cost-effective yet highly sensitive and specific marker in diagnosing this entity is an incessant task. This study aimed to evaluate the predictive value of mean platelet volume (MPV) in diagnosing NS. Neonates diagnosed with sepsis from January 2016 to March 2016 were included in the study. The subjects were stratified into the following: (i) culture-proven sepsis (group I); (ii) culture-negative clinical sepsis (group II); and (iii) control group (group III). Several hematologic markers such as hemoglobin, total leukocyte count, platelet count, MPV, plateletcrit, platelet distribution width, immature-to-mature neutrophil ratio, toxic change, serum urea, bilirubin, and C-reactive protein were analyzed. The results were compared among the groups, and their efficacy in diagnosing NS was appraised. The study involved 210 neonates, of which, groups I, II, and III constituted 64, 75, and 71 cases, respectively. The mean MPV among groups I, II, and III was 9.56, 8.86, and 8.58 fL, respectively (P<0.05). Strikingly higher values of platelet count, immature-to-mature neutrophil ratio, MPV, plateletcrit, and C-reactive protein were found in group I in contrast to those in groups II and III (P<0.05). The baseline MPV of patients with culture-proven sepsis was comparatively higher than controls and was found to be statistically significant. Hence, MPV can be a simple, economical, and specific predictor of NS.

Race, Income and Insurance Status Affect Neonatal Sepsis Mortality and Healthcare Resource Utilization.

BACKGROUND: Socioeconomic disparities negatively impact neonatal health. The influence of sociodemographic disparities on neonatal sepsis is understudied. We examined the association of insurance payer status, income, race and gender on neonatal sepsis mortality and healthcare resource utilization. METHODS: We used the Kid's Inpatient Database, a nationwide population-based survey from 2006, 2009 and 2012. Neonates diagnosed with sepsis were included in the study. Multivariable logistic regression (mortality) and multivariable linear regression (length of stay and total hospital costs) were constructed to determine the association of patient and hospital characteristics. RESULTS: Our study cohort included a weighted sample of 160,677 septic neonates. Several sociodemographic disparities significantly increased mortality. Self-pay patients had increased mortality (odds ratio 3.26 [95% confidence interval: 2.60-4.08]), decreased length of stay (-2.49 ± 0.31 days, P < 0.0001) and total cost (-$5015.50 ± 783.15, P < 0.0001) compared with privately insured neonates. Additionally, low household income increased odds of death compared with the most affluent households (odds ratio 1.19 [95% confidence interval: 1.05-1.35]). Moreover, Black neonates had significantly decreased length of stay (-0.86 ± 0.25, P = 0.0005) compared with White neonates. CONCLUSIONS: This study identified specific socioeconomic disparities that increased odds of death and increased healthcare resource utilization. Moreover, this study provides specific societal targets to address to reduce neonatal sepsis mortality in the United States.

Cost Analysis of Fluconazole Prophylaxis for Prevention of Neonatal Invasive Candidiasis.

BACKGROUND: Fluconazole prophylaxis (FP) in premature infants is well studied and has been shown to decrease invasive candidiasis (ICs). IC in neonates has significant financial costs; determining the cost-benefit of FP may provide additional justification for targeting high-risk neonates. We aimed to determine the IC rate in premature infants at which FP is cost-beneficial. METHODS: A decision tree cost-analysis model using cost of FP related to costs associated with IC was used. We searched PubMed for all papers that used intravenous FP and reported rates of IC in very low birth weight neonates. Average IC rates in those who received FP (2.0%; range, 0-6.1%) and in those who did not receive FP (9.2%; range, 0-20.5%) were used. Incremental hospital costs because of IC and for FP were retrieved from the literature. Sensitivity analysis was performed to determine the incremental cost of FP across the range of published IC rates. RESULTS: The average cost per patient attributed to IC in patients receiving FP was $785 versus $2617 in those not receiving FP. Sensitivity analysis demonstrates the rate of IC would need to be <2.8% for FP to lose its cost-benefit. In Monte Carlo simulation, targeting infants <1000 g would lead to $50,304,333 in cost savings per year in the United States. CONCLUSIONS: FP provides a cost-advantage across most IC rates seen in the youngest premature infants. Using a rate of 2.8% for their individual high-risk neonatal intensive care unit patients, providers can determine if FP is cost-beneficial in determining for whom to provide IC prophylaxis.