467 - Early Outcomes of Antibiotic Stewardship in Infants Undergoing Fetal Myelomeningocele Repair

Publication Number: 2455.467

Nicole Welke, University of Minnesota Masonic Children's Hospital, Saint Paul, MN, United States; Amy Linabery, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, United States; Stephanie A. Eyerly-Webb, Midwest Fetal Care Center, North Oaks, MN, United States; Amanda J. Nickel, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, United States; Kyle Halvorson, Children's Minnesota, Bloomington, MN, United States; William Pomputius, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, United States; Mary Ullman, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, United States; Elizabeth Nisius, Children's Hospitals and Clinics of Minnesota - St. Paul, Minneapolis, MN, United States; Andrea Lampland, Children's Hospitals and Clinics of Minnesota - St. Paul, St. Paul, MN, United States

Background: Antibiotics are used to prevent central nervous system infections before postnatal surgical repair for myelomeningocele (MMC); however, there is a paucity of literature describing appropriate antibiotic use in neonates who underwent fetal MMC repair (fMMC) and no established standard of care.

Objective: We developed an institutional antibiotic protocol for neonates post-fMMC and describe neonatal intensive care unit (NICU) antibiotic administration and infection rates before and after implementation.

Design/Methods: A clinical antibiotic protocol was developed in collaboration with experts in neonatology, pediatric neurosurgery, and pediatric infectious disease and implemented on 5/20/2024. Beta-2-transferrin (β2T) testing was utilized to detect cerebrospinal fluid (CSF) at the surgical site to aid in infectious risk stratification. To evaluate protocol adherence and antibiotic usage, electronic health record data were abstracted for all fMMC neonates born 4/25/2016-5/19/2025 who were admitted to our NICU and discharged from our NICU by 5/19/2025. Antibiotic dosing, duration, and treatment indications (sepsis rule out, surgical procedure, and wound prophylaxis), and culture positivity were compared across the pre- and post-protocol periods. Protocol adherence metrics were also recorded. Standard descriptive statistics were used to compare antibiotic usage characteristics in the pre- and post-protocol implementation periods.

Results: In this preliminary examination, 15 patients were treated after and 88 were treated before protocol implementation. The protocol was partially or fully followed for 10/15 (67%) neonates, with 100% adherence to initial antibiotic selection and duration. Compliance varied beyond these first steps. β2T testing had the poorest adherence. Just 1 qualifying neonate (7%) was tested, and results were received after surgical site revision.
The post-protocol group had greater rates of wound dehiscence (86% vs 49%, p=0.01), but had a lower mean number of antibiotic days (7.7 days vs 20.1 days, p< 0.0001). There were no observed differences in number of antibiotic courses or culture-positive infections.

Conclusion(s): Preliminary results suggest limited real-world utility of β2T testing and the need to further engage providers to promote protocol uptake. We saw improvement in protocol adoption over time, as the non-adherences occurred with the first 5 patients born following the change. This initial dataset was underpowered to confirm reductions in antibiotic use, but demonstrated feasibility. We continue to accrue patients to evaluate the long-term clinical impact in our fMMC patients.

Summary measures of NICU antibiotic administration by protocol era
Data is reported as n (%) and mean ± SD. P-values were generated utilizing two sample t-tests for means and Fisher's exact tests for categorical variables.