Figure 1.
Entry of an antibiotic order into the computerized system produced this screen, prompting the initiation of the CRP protocol. The protocol included automated orders for a blood culture, CRP, and WBC with differential at admission, followed by a repeat CRP and WBC with differential 48
Figure 2.
Screenshot decision support to stop antibiotics.
The CRP protocol's recommendation on antibiotic use was based on repeat CRP and WBC results drawn 48 hours following initial evaluation. In cases with two consecutively negative CRP results (CRP <10 mg/L), this discontinuation screen appeared, allowing the provider to choose to stop antibiotics. If the provider chose to continue antibiotics despite negative CRP results, they were prompted to provide reasoning for doing so. No complete white blood count (CBC) data is depicted in this screenshot, because a “test” patient had to be generated to produce this figure.
Table 1.
Patient demographics by CRP-protocol compliance status.1
Table 2.
Reasons stated by clinical providers in the clinical decision support (CDS) module for continued antibiotic therapy despite negative serial CRP values.
Figure 3.
Cumulative distribution function (CDF) plot of t48 CRP values in infants with continued antibiotics for elevated CRP value (s).
The blue line depicts the distribution of CRP values among 126 infants in which antibiotics were continued because of elevated t0 and/or t48 CRP results; 44.5% had t48 CRP values 10–20 mg/L and 34.4% had values >20 mg/L.
Table 3.
Ampicillin usage by CRP-protocol compliance status.1
Table 4.
Outcomes (%) by CRP-protocol compliance status.1
Figure 4.
Flow diagram detailing analysis of serial CRP values and ANCs in blood culture positive neonates.
Of 517 patients available for analysis during the study period, 384 fit the inclusion/exclusion criteria. Among these eligible patients, we analyzed 362 independent cases of positive blood cultures with available ANC and serial CRP data. These cases were stratified according to initial (t0) CRP status, serial (t48) CRP status, organism class (CONS vs. non-CONS), and finally by ANC status at initial (t0) evaluation. Only cases deemed to be confirmed positive blood cultures were included in this stratification scheme.
Table 5.
Organisms isolated from positive blood cultures in patients with confirmed infections and CRP <10 mg/L (N = 66) or >10 mg/L (N = 109) at initial evaluation.1
Table 6.
Organisms isolated from positive blood cultures in patients with confirmed infections (N = 38) and CRP persistently <10 mg/L.
Table 7.
Number of cases (N) with confirmed positive blood cultures and low WBC indices with positive (>10 mg/L) CRP values versus negative (<10 mg/L) serial CRP results.1