Kaiser Permanente Sepsis Risk Calculator

DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment

Based on https://neonatalsepsiscalculator.kaiserpermanente.org

This guideline should be used in conjunction with:

Infection in the first 72 hours of life guideline and NICE NG195 Neonatal infection: antibiotics for prevention and treatment updated April 2021

INTRODUCTION

The Kaiser Permanente Sepsis Risk Calculator (KP-SRC) is an online calculator used to determine which well babies meeting the NICE criteria for treatment for possible early onset neonatal infection should receive antibiotics

Inclusion criteria

Babies who meet the criteria for antibiotic treatment as defined by NICE (See Infection in the first 72 hours of life guideline) and:
- ≥34 weeks’ gestation and
- aged ≤12 hr and
- clinically well

Exclusions

Follow Infection in the first 72 hours of life guideline if:
- antibiotics not recommended by NICE or
- baby clinically unwell or
- baby <34 weeks’ gestation or
- baby aged >12 hr or
- confirmed Group B streptococcal (GBS) sepsis or neonatal death in a previous pregnancy and mother has not received adequate intrapartum prophylaxis (see Group B streptococcal colonisation of mother guideline) or
- co-twin meets criteria for antibiotics

If baby clinically unwell, treat with antibiotics within 1 hr and follow Infection in the first 72 hours of life guideline

APPLICATION OF THE KP-SRC

If KP-SRC not available follow Infection in the first 72 hours of life guideline

Identification of babies (see Flowchart: Application of KP-SRC for a baby who meets the criteria for antibiotics)

If baby meets NICE criteria for antibiotics midwife/nursery nurse to alert neonatal team immediately
Neonatal team to assess baby and determine baby’s status as well/equivocal/clinical illness using Table 1

Table 1

Clinical examination	Description
Well appearing	No persistent physiological abnormalities
Equivocal	Any one of the following persisting ≥4 hr after birth^* Tachycardia (HR ≥160 bpm) Tachypnoea (RR ≥60) Temperature <36.5°C or ≥38°C Respiratory distress (grunting, nasal flaring or chest recessions) not requiring supplemental oxygen ≥2 of the following lasting ≥2 hr ^† Tachycardia (HR ≥160 bpm) Tachypnoea (RR ≥60) Temperature <36.5°C or ≥38°C Respiratory distress (grunting, nasal flaring or chest recessions) not requiring supplemental oxygen * Abnormalities can be intermittent † If any observations abnormal for 2 consecutive hours – arrange middle grade review and consider commencing antibiotics
Clinical illness	Persistent need for CPAP/HFNC/mechanical ventilation (outside of the delivery room) Haemodynamic instability requiring fluid bolus or inotropes Neonatal encephalopathy/perinatal depression seizure Apgar score <5 at 5 min Need for supplemental oxygen ≥2 hr to maintain SpO₂ >90% Any other symptoms of serious illness – clinician determined Following should also be classified as clinical illness equivocal state persisting >2 hr onset of symptoms at >4 hr after an asymptomatic period

Application of sepsis risk score

Access the sepsis risk calculator via maternity BadgerNet – early onset sepsis calculator or via https://neonatalsepsiscalculator.kaiserpermanente.org
Enter 2/1000 live births as incidence of early-onset sepsis (EOS)
Calculate sepsis risk score to determine individual baby’s risk for EOS and follow recommendations for management based on KP-SRC
Note the following West Midlands modification of KP-SRC:
- if KP-SRC recommends blood culture: treat baby with antibiotics until culture results available and follow Infection in the first 72 hours of life guideline
- if KP-SRC recommends observations for 24 hr: observe baby for ≥36 hr
SRC can be re-applied based on baby’s clinical status at any time up to aged 12 hr
If KP-SRC accessed via web, then print copy of EOS risk score calculated by KP-SRC, attach patient label to print out, file in baby’s notes or scan/upload screenshot to the maternity EPR
- this is not required if KP-SRC accessed via BadgerNet. Further guidance given in Table 2

Table 2

Calculator input	Value to be entered	Notes
Incidence of early-onset sepsis	2/1000 live births	Based on local incidence
Gestational age (GA)	GA in weeks and days	Weeks range: 34–43 Days range: 0–6
Highest maternal intrapartum temperature (°C)	Units °Celsius Use highest intrapartum maternal temperature including up to 1 hr following delivery	Use whole number or number with single decimal place e.g.: 37, 37.1, 37.0 NOTE: If postpartum temperature within 1 hr of birth is ≥0.5°C above intrapartum temperature, midwives to document and inform neonatal team
ROM (hours)	Use entire duration of rupture of membranes to delivery, not just pre-labour duration	Round value to single decimal place, e.g. enter ROM 4 hr 30 min as 4.5 hr, 4 hr 55 min as 5.0 hr
GBS	Enter maternal GBS screening result in current pregnancy if available. If not known enter 'unknown'
Type of intrapartum antibiotics	'GBS-specific antibiotics' are defined ONLY as penicillin G, ampicillin is an acceptable alternative. Penicillin-allergic women with no history of anaphylaxis, angioedema, respiratory distress, or urticaria after administration of penicillin or a cephalosporin should receive cefuroxime should apply only to mothers who are GBS positive or GBS unknown
and	If erythromycin, clindamycin or vancomycin ALONE are given for GBS prophylaxis, choose the option 'No antibiotics or any antibiotics given <2 hr prior to delivery' 'Broad-spectrum antibiotics (BSAB)' defined as ≥2 antibiotics given in combination when concern for the mother developing chorioamnionitis
Interval from first dose to birth	'Timing' of administration of 'GBS-specific antibiotics' or 'BSAB administration' = interval between first dose of penicillin G or second antibiotic in the combination to the time of birth e.g.: cefuroxime at 2:00 pm, metronidazole at 3:30 pm, birth at 4:30 pm, so 2^nd antibiotic given 1 hr before delivery. Choose 'No antibiotics or any antibiotics given <2 hours prior to delivery' If mother given BOTH GBS-specific antibiotics and BSAB – of the 4 possible options, select the category with the longest duration of treatment e.g.: penicillin G at 8:00 pm and 12:00 pm for GBS positive, then develops fever to 38.3°C at 2:00 pm so cefuroxime given at 3:00 pm. Penicillin G given at 4:00 pm, birth at 4:30 pm. GBS-specific antibiotics were given >4 hr before delivery, but BSAB were given only 1.5 hr before delivery. Choose 'GBS specific antibiotics given >2 hours prior to birth'

OBSERVATIONS

All babies on whom KP-SRC has been applied should have regular observations as shown in table below

Table 3

Clinical status	Observation schedule
Well appearing	Routine observations at aged 1 hr and aged 2 hr, then 2-hrly until aged 12 hr, then 4-hrly until aged 36 hr (despite KP-SRC recommending only 24 hr in some)
Equivocal	Hourly until all observations in normal range for 2 consecutive measurements. Then follow guidance for well appearing baby If any 2 consecutive measurements abnormal or equivocal request middle grade assessment and review need for antibiotics
Unwell	Admit to NICU and observation as directed by clinician

SUBSEQUENT MANAGEMENT

If baby appears unwell at any time or in equivocal state for >2 hr, treat baby with antibiotics following Infection in first 72 hours of life guideline

DISCHARGE

All babies on KP-SRC observation pathway to be observed for ≥36 hr in hospital and re-examined by neonatal team before discharge to confirm well-being