#393 - [Journal Club] - 📌 Replacing Sepsis Screens with Serial Physical Exams: Is It Safe?

In this episode of The Incubator Podcast, Ben and Daphna review a pivotal population-based study from Norway examining a new approach to Early-Onset Sepsis (EOS). The hosts discuss whether serial physical examinations can safely replace routine antibiotic prophylaxis in at-risk term and late-preterm infants. With antibiotic exposure often far exceeding sepsis incidence, this study offers compelling data for a "less is more" strategy. Tune in as Ben and Daphna explore the safety, efficacy, and bedside implications of substituting automatic treatment with structured clinical monitoring—and what this means for reducing unnecessary interventions in the NICU.

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Serial physical examination to reduce unnecessary antibiotic exposure in newborn infants: a population-based study. Vatne A, Eriksen BHH, Bergqvist F, Fagerli I, Guthe HJT, Iversen KV, Ud Din FS, van der Weijde J, Kvaløy JT, Rettedal S.Arch Dis Child Fetal Neonatal Ed. 2025 Nov 19:fetalneonatal-2025-329639. doi: 10.1136/archdischild-2025-329639. Online ahead of print.PMID: 41260908

Transcript

Ben Courchia MD (00:00.974) Hello everybody, welcome back to the Incubator Podcast. We’re back today for another episode of Journal Club. Daphna, good morning. How are you?

Daphna Yasova Barbeau MD (00:07.631) I’m good, and I just found this Incubator pen on my desk. This one is our favorite. Is that in the store? I’m not meaning to pitch the store this often, but I really love this pen. Do we need more of these pens?

Ben Courchia MD (00:14.474) No, that’s not in the store.

Ben Courchia MD (00:20.376) This pen is really good. That’s a pen that we gave out at Delphi last year. It’s a good pen. Mine is probably here.

Daphna Yasova Barbeau MD (00:24.567) Maybe we’ll give them out at Delphi this year.

Ben Courchia MD (00:30.05) We have a plan to give more pens at Delphi this year.

Daphna Yasova Barbeau MD (00:35.885) And maybe if you find us at some other conferences.

Ben Courchia MD (00:39.2) Yeah, if you find us at other conferences—ah, there is mine. There you go.

Daphna Yasova Barbeau MD (00:46.372) Yeah. There it is.

Daphna Yasova Barbeau MD (00:52.151) And you’re a pen guy, okay? So when I say I really like a pen, people might be like, "Daphna likes all the pens."

Ben Courchia MD (00:57.23) No, no. We have pencils. We have Incubator-branded pencils. We have Incubator-branded Sharpies. And we tend to give those out at conferences. So if you find us at the next conference... I mean, right now, if you come to the next conference, it’s Delphi. I believe after that, we’ll be at Cool Topics. Is it right immediately the next one? So we usually give them out. I made a mistake last time I was at Cool Topics. I put out too much of the swag, and then before I could even finish setting up the booth, they were all gone. Very amateurish on my part.

Daphna Yasova Barbeau MD (01:22.775) Amateur.

Ben Courchia MD (01:26.318) Anyway, and it was funny because I was there with Michael, our sound engineer, and he was like, "I hope you were not hoping to sell those because they’re gone." I was like, "No, we were giving them out." But yeah, I didn’t think that we were going to get raided. So that was funny. All right. We’re here for another episode of Journal Club, and I have a very interesting paper kind of following in your footsteps from yesterday.

Daphna Yasova Barbeau MD (01:34.735) We were giving them out, just thought they would last longer.

Ben Courchia MD (01:54.542) It’s a paper I found in the Archives of Disease in Childhood - Fetal and Neonatal Edition. It’s coming out of Norway. The first author is Anlaug Vatne. It’s called "Serial Physical Examination to Reduce Unnecessary Antibiotic Exposure in Newborn Infants: A Population Study." The introduction talks a little bit about what we said yesterday. So the initial clinical signs of neonatal early-onset sepsis (defined as sepsis within the first three days of life) are often subtle. If they’re not subtle, you don’t need our help. You don’t need us for that. And they can mimic other neonatal conditions, such as delayed or prolonged cardiopulmonary transition. We don’t really have good lab tests that can help us with high sensitivity, high specificity. Again, we were talking about CRP yesterday, and we don’t really have the tests that we need.

These diagnostic challenges are addressed in the 2018 American Academy of Pediatrics Guidelines and in the Swiss Network’s recommendation, with the latter suggesting the use of serial physical examination for enhanced clinical observation or continuous monitoring every hour in the NICU to identify infants with suspected early-onset sepsis. Other approaches include risk stratification using sepsis risk calculators or algorithms based on the presence or absence of maternal risk factors. The clinical implementation of these different approaches has resulted in contemporary antibiotic exposure in term infants (defined as those born at a gestational age of 37 weeks or greater) and late preterm infants (34 weeks to 36 and 6/7) in high-income countries ranging between 1.2% to 12%.

So just for comparison, yesterday we were talking about babies with HIE who give us a lot more anxiety. We were talking about numbers like 92% yesterday. But for your run-of-the-mill admission with a little bit of TTN and some of these things, we’re talking about 1.2% to 12%. And they’re making the point that we made yesterday, which is where I got this sort of epiphany. The exposure is disproportionately high compared to the incidence. Culture-positive early-onset sepsis ranges from 0.3 to 0.73 cases per 1,000 liveborn term and late preterm infants.

Ben Courchia MD (04:16.462) So this study comes in this particular context. Building on previous findings, serial physical examination was previously tested and shown to be safe, including in late preterm infants, supporting the inclusion of infants born at about 34 weeks or greater. And within the framework of a quality improvement project, the aim of the study was to evaluate whether serial physical exams could reduce antibiotic exposures for these infants. So did they do it? Did they jeopardize the lives of babies?

Study setting: This is conducted in six hospitals across all four Norwegian health trusts. And that covers about 25% of the birth cohort in Norway. This was a multicenter population-based interventional study evaluating the effect of this new approach, serial physical examination in the NICU for all inborn infants with a gestational age of 34 weeks or greater who were suspected to be at risk of early-onset sepsis. All live-born infants were included, including all infants who received antibiotics for suspected early-onset sepsis in their respective geographical areas. Infants at risk of early-onset sepsis were defined as infants who had mild or transient clinical signs of possible sepsis, infants born to mothers who had clinical chorioamnionitis, or infants with a sibling who had GBS sepsis. Infants who received antibiotics prophylactically as part of the national protocol for therapeutic hypothermia were excluded, kind of like the patients we were talking about yesterday, as well as infants with congenital heart disease or neurological malformations in need of surgery.

So what does that mean that they did this serial physical exam? Infants appearing well at birth remained with their mothers in the nursery. Infants with clinical signs were promptly admitted to the NICU. These infants were exposed to chorioamnionitis or had siblings with a history of GBS sepsis and were admitted within the first two hours of life.

Ben Courchia MD (06:21.902) All infants in the nursery were monitored according to standard practice, screening vital signs, oxygen saturation at two to four hours of age. Further assessments were performed in infants at risk of infection, infants with an initial screening, or who developed clinical signs of sepsis or infection during their stay. Infants identified as being at risk were admitted to the NICU for structured serial physical exams and vital signs hourly for the first 48 hours. Full sets of vitals were obtained every hour except blood pressure, which was obtained only when cap refill time exceeded three seconds. Continuous pulse ox was used. Skin-to-skin was encouraged, and parents were welcomed to accompany their newborn in the NICU.

Antibiotics were administered without delay if clinical signs indicated severe sepsis or shock, if the clinical condition deteriorated despite corrective action, or if vital signs did not improve over time. The decision to initiate antibiotics was made by the team in agreement with the consultant neonatologist or pediatric consultant. So the baseline period extended from 2018 to 2019, post-implementation 2020 to 2021. And IV antibiotics was basically IV antibiotics for early-onset sepsis. Culture-negative sepsis was defined using the International Classification of Diseases 10 (ICD-10) and the Norwegian Pediatric Association looking at clinical signs of infection, C-reactive protein levels, duration of antibiotics, exclusion of other stuff, et cetera.

OK, so did this pan out? A total of 54,713 live-born infants with a gestational age of 34 weeks or greater were included. Of these, 27,385 infants were born during the baseline period and 27,328 during the post-implementation period. Looking at antibiotic exposure: after the implementation of serial physical exams, the percentage of infants receiving antibiotics was reduced by 50%.

Ben Courchia MD (08:34.254) Antibiotic exposure decreased from 1.8% (with a 95% confidence interval going from 1.6 to 2) to 0.9%. When comparing baseline with the post-implementation period, antibiotic exposure decreased from 1.7% to 0.9%. The number of infants receiving prophylactic antibiotics remained unchanged, with 22 infants in 2018, 24 in 2019, 26 in 2020, and 25 in 2021, with a p-value of 0.9. The percentage of infants receiving antibiotics for any reason, including prophylactic and empirical, was 1.9%, 1.8%, et cetera.

So the point they’re trying to make here is that it’s not like their entire system shifted. The kids who were supposed to receive prophylactic antibiotics, kind of like the babies with HIE, they continue to get it. There was not a big shift in their approach. This basically hints at the fact that the reduction by 50% in early-onset antibiotic exposure was most likely due to their intervention.

And then the follow-up question is: did they have more early-onset sepsis? The incidence of culture-positive early-onset sepsis was 0.4 per 1,000 live-born infants. And there was a decrease in culture-negative early-onset sepsis observed—I don't have the exact data, but it was statistically significant. Neonatal intensive care unit admission rates and time to antibiotic administration remained unchanged. There were no infection-related deaths, and no readmissions for infection within 14 days.

The conclusions are that the implementation of serial physical examination for suspected early-onset sepsis in six Norwegian NICUs, including more than 50,000 infants born after 34 weeks, reduced antibiotic exposure in the first three days of life by 50 percent. Serial physical examination represents a safe and effective strategy to reduce unnecessary antibiotic exposure in term and late preterm infants at risk of early-onset sepsis. They say more studies are needed. I don’t know. This is pretty convincing. Maybe the answer to this solution has always been this: just better eyes on our patients. Yeah, right? How fascinating is that?

Daphna Yasova Barbeau MD (11:11.06) Spend more time at the bedside. I love that. I mean, isn’t that just the crux of medical care as we were taught? To observe and monitor and watch our patients?

Ben Courchia MD (11:20.078) It's the essence.

Ben Courchia MD (11:24.686) You now have joined the faculty teaching principles of medicine at the medical school where we teach medical students a lot of things related to physical examination. And it is, like you said, the core of our practice is assessing a patient at the bedside and making a decision.

Daphna Yasova Barbeau MD (11:42.479) That's right. Yeah, I actually love that. But it’s a reminder that how many of our administrative tasks, our EMR tasks, all this stuff is taking us away from making these decisions. And into the credit of all of our colleagues, I think if you don’t have a lot of time to assess the baby, then you feel like, "Well, better put them on antibiotics, I won’t be able to assess them." You know, I think about other units; we are always in-house. So we have that luxury of being able to reassess and assess with a trained eye multiple times a patient. It's interesting taking us back to our principles, but easier said than done in today’s modern medicine.

Ben Courchia MD (12:31.47) But you know, I’m sorry, I’m going to push back on that. When you were a resident and you were on the floors, we had this. Like there were patients that were there for serial exams. And I would remember I would go every couple of hours and do an assessment.

Daphna Yasova Barbeau MD (12:43.032) For sure. Yeah, like the kids with asthma, you were doing every hour sometimes.

Ben Courchia MD (12:49.612) Right, we would do these respiratory checks and then you would do... like patients with abdominal pain, and you would say, "Let’s just reassess." It’s how we were trained, and somehow we get to the NICU and this gets lost when it shouldn’t. And again, I think it has to do with our load, and then I’m gonna point you to the section on neonatal and perinatal medicine to look at the neonatal staffing toolkit because...

Daphna Yasova Barbeau MD (13:08.652) Whether the babies are even more critical. And that will segue nicely into my article tomorrow.

Ben Courchia MD (13:22.124) Your next paper tomorrow? Awesome. Okay, so then we’ll do that. But yeah, I mean, it’s not an excuse to say, "We’re stretched so thin." It’s like, well, then maybe that’s a problem. Because every time I have parents who ask about antibiotics—not push back, they’re like, "Okay, what are the risks of giving this antibiotic?" I go... like, it’s never fun to explain ototoxicity and nephrotoxicity, and then tell them, "But it’s okay."

Daphna Yasova Barbeau MD (13:46.52) Yeah, it’s real hard to convince them after that. And they say, "How sure are you that my baby has an infection?"

Ben Courchia MD (13:56.766) 0.3%. I was like, "Oh my god." Yeah, I think these discussions are always helpful for us as physicians because they put us back in front of the reality of the data. And it’s hard. If there’s an alternative—can you imagine if you had to get a consent and you said, "Have this medication that can potentially impair hearing, can have kidney damage, or if I check on your baby every couple of hours and everything is okay, then we can avoid it altogether." It’s not going to be a tough decision for anyone.

Daphna Yasova Barbeau MD (14:27.214) Sure, for sure. What I also am taking away is when some of our team members say, "Dr. Barbeau, why have you pulled that chair up by the baby's bedside? We don’t want you right here all the time." I can say, "Well, in this paper, they said that I could do this, sit by the bedside and watch the baby." Is that not the right takeaway?

Ben Courchia MD (14:45.268) I don’t know. I don’t know if pulling the paper is going to do much good for you. It is the right takeaway. I have to mention for the audience that the staff members in our NICU are a little bit concerned when you pull the chairs because ideas come to you. And then you sit there and you’re like, "What if we got this test?" But I think that was really...

Daphna Yasova Barbeau MD (15:03.438) No, we’ve got a good team.

Ben Courchia MD (15:13.218) That was really something, like I think people have learned to appreciate how dedicated you are. So I think this is no longer something that I hear.

Daphna Yasova Barbeau MD (15:20.654) Or at least to pay attention to the babies of which I’m sitting at their bedside.

Ben Courchia MD (15:24.63) Correct. Correct. All right, Daphna, we’re going to stop schmoozing. I’ll see you tomorrow for another episode. Bye.

Daphna Yasova Barbeau MD (15:27.373) Okay, sounds good. Bye everyone.