T. A. Boyle1, R. A. Starker1, E. A. Perez1, A. Hogan1, A. Brady1, J. Sola1, H. Neville1 1University Of Miami,Pediatric Surgery,Miami, FL, USA
Introduction: Necrotizing enterocolitis (NEC) is a common, persistent cause of morbidity and mortality in neonatal intensive care units (ICU). Even infants who recover from acute illness face the prospect of impaired neurodevelopment, cholestasis, or short bowel syndrome. Despite the relative ubiquity of NEC in the setting of neonatal ICU patients, a successful algorithm has not been found and thus treatment strategies, such as time to resume feedings, antibiotic choice and duration, vary dramatically within and between neonatal intensive care units. The aim of this study is to demonstrate the variability of antibiotic therapy regimens in NEC despite similar patient outcomes, and prepare for future study evaluating the appropriate length of antibiotic therapy and time to resume feeds for each stage of NEC.
Methods: A retrospective chart review was conducted on all NEC patients presenting at a high-volume tertiary care center from January to December 2015. Cases were identified using a query of the following ICD9 and ICD10 codes: ICD9 777.50, 777.51, 777.52, 777.53; ICD10 P77.9, P77.1, P77.2, P77.3. Each case was reviewed for patient and maternal demographics, antenatal history, symptom presentation, feeding management, antibiotic use, surgical intervention, and patient outcome. Patients included those managed both surgically and medically. The primary outcomes were time to feeds and in-hospital mortality.
Results: A total of 32 infants were diagnosed with NEC during the study period. The cohort was 63% males and 50% African American. The median gestational age was 26 weeks (IQR: 25, 31) and the median birthweight was 927 grams (696, 1566). In this cohort, 47% of the cases were classified as stage I, 22% as stage II and 31% as stage III. Every patient was treated with at least 3 days of antibiotics, and the most common regimen was 10 days of broad spectrum coverage, including anaerobic coverage. Overall, the regimens were inconsistent and correlated poorly with disease stage and outcome. The median (IQR) duration of antibiotics in each stage was 10 days (7,10) in stage 1, 10 days (7,14) in stage 2, and 14 days (10,17) in stage 3 (Figure 1). The median time to feeds was 21 days (8, 33) in stage 1, 11 days (10, 14) in stage 2, and 27 days (13, 50) in stage 3. Two patients died, one stage 1A patient, who was treated with 7 days of antibiotics, and one stage 2B patient, who was treated with 10 days of antibiotics. Neither death was directly attributable to NEC.
Conclusion: This retrospective chart review revealed broad variability in medical management of necrotizing enterocolitis with neither successful, nor poor outcomes being related to length of antibiotic treatment. Clearly, research is needed to improve and standardize clinical management of infants presenting with NEC. This is required to eliminate excess antibiotic usage, and modernizing care for this common ailment in the premature infant.
