Antibiotic stewardship in the context of management of early onset neonatal sepsis-an evolving paradigm shift

Table 3 Comparison of early-onset sepsis management strategies

Feature	Categorical risk-based approach (e.g., NICE/CDC)	Sepsis risk calculator	Serial physical examination
Population	Term and late preterm infants (≥ 34 weeks)	Term and late preterm infants (≥ 34 weeks)	Term and late preterm infants (≥ 34 weeks)
Management logic	Static risk factor–based (maternal and perinatal factors)	Multivariate, individualised risk estimation using Bayesian model (maternal + infant clinical status)	Dynamic, repeated clinical assessments over time (evolving clinical signs)
Approach to treatment	Low threshold for investigation and empirical antibiotics based on risk factors	Risk-stratified approach guiding observation, investigation, or antibiotics	Antibiotics reserved for infants with evolving or persistent clinical signs
Antibiotic use	Higher antibiotic exposure; risk of overtreatment	Reduced antibiotic use (commonly 30%-50% reduction)	Reduced antibiotic use (50% reduction demonstrated in observational studies)
Safety data	High sensitivity; widely accepted safety profile	Observational studies show no increase in missed EOS, morbidity, or mortality; lower sensitivity vs categorical approaches reported	Large observational studies show reduced antibiotic use without increase in adverse outcomes
Strengths	Simple, reproducible, widely implemented; aligns with institutional risk tolerance	Individualised risk assessment; supports antibiotic stewardship; widely adopted	Patient-centred; avoids unnecessary treatment; detects evolving illness
Limitations	Poor specificity; high rates of unnecessary antibiotic use	Lower sensitivity in some studies; potential delay in treatment; derived from United States populations; relies on accurate input data	Resource-intensive; requires frequent assessments, experienced clinicians, and robust systems; inter-observer variability
Implementation considerations	Easy to apply across settings; minimal training required	Requires calculator access, local incidence calibration, and audit	Requires adequate staffing, workflow support, escalation systems, and consistent documentation
Generalisability	Widely applicable across different healthcare settings	May require adaptation for different populations and EOS incidence	More feasible in well-resourced settings with adequate staffing and monitoring capacity

EOS: Early onset neonatal sepsis; NICE: National Institute for Health and Care Excellence; CDC: Centers for Disease Control and Prevention.