International Variations in the Use of Antimicrobials and Management of Sepsis: A Survey of 382 Neonatal Units in 12 Countries.

Abstract

Introduction: Antimicrobial exposure is nearly universal among very preterm infants, yet evidence to guide optimal treatment duration and sepsis management remains limited. Unnecessary prolonged antimicrobial use may contribute to adverse outcomes and antimicrobial resistance. We aimed to characterize international practices in the management of culture-proven infections in infants born <29 weeks' gestation.

Methods: This cross-sectional study surveyed neonatal intensive care units (NICUs) across 12 networks within the International Network for Evaluating Outcomes of Neonates. A pre-piloted online questionnaire captured unit-level practices regarding treatment duration for culture-proven infections, antifungal prophylaxis, blood culture collection, and central line management. Responses were analyzed descriptively at the network and unit levels.

Results: Of 608 eligible NICUs in this study, 382 (62.8%) responded. A 7-day treatment duration was most commonly reported for Gram-positive sepsis (45.2% of NICUs), whereas 14 days was most commonly reported for Gram-negative sepsis (44.4%). Treatment durations were longer for concurrent meningitis: 57% of units reported 14 days for Gram-positive meningitis and 69.2% reported 21 days for Gram-negative meningitis. Antifungal prophylaxis was reported by 62.1% of units. Most NICUs (79.7%) routinely obtained blood cultures from a single sterile site. Overall, 75.7% of units reported central line removal for Gram-negative sepsis and 57.3% for Gram-positive sepsis.

Conclusion: Reported antimicrobial duration and sepsis management practices for very preterm infants varied across neonatal units and international networks. These findings underscore persistent uncertainty and the urgent need for high-quality evidence to inform standardized, evidence-based antimicrobial stewardship in this vulnerable population.