Problem
Chorioamnionitis (CA) refers to the inflammation, often of infective origin, that affects the placenta, fetal membranes and amniotic fluid and complicates up to 3.9% of deliveries.1 CA is a significant risk factor for early-onset neonatal sepsis.2 3
The Centers for Disease Control and Prevention (CDC) and the Committee on Fetus and Newborns (COFN) recommended empiric antibiotic treatment for all infants born to mothers with CA.4
Al Wakra Hospital (AWH) is a level-2 hospital under the Hamad Medical Corporation, Qatar, catering to 5000–6000 deliveries every year, and our neonatal intensive care unit (NICU) admits 1100–1300 neonates annually.
An audit conducted in our NICU in 2019 showed that the rate of suspected CA among mothers delivering at AWH increased from 1% in 2016 to 2.8% in 2019. In parallel, the proportion of CA-exposed neonates admitted to our NICU increased from 9.3% of admissions in 2016 to 11.5% in 2019. Based on the CDC/COFN recommendation, all these babies received intravenous antibiotics for a minimum of 48 hours, although up to 75% were well-appearing term babies. Among all term neonates admitted to our NICU during 2019, 42% received first-line antibiotics.
Our team reviewed the background data and explored the current evidence for managing neonates exposed to CA. The updated American Academy of Pediatrics (AAP) guideline5 recommended the use of the early-onset sepsis calculator (EOSCAL) as a reliable and safe option for risk stratification and management of neonates at risk for EOS.
We decided to use the EOSCAL to reduce antibiotic use among well-appearing term neonates exposed to suspected maternal CA in our unit.
The starting aim of our project was to reduce antibiotic use among term (37 weeks or more) well-appearing neonates exposed to CA to <50% by 31 July 2020. We adopted the Institute of Healthcare Improvement (IHI) model of improvement for this project. The IHI model has been extensively used by different healthcare organisations worldwide, including ours, and is a proven model for accelerating improvement.6