2026 Southeastern Residency Conference

Title: Comparison of Ketamine Monotherapy versus Ketamine and Propofol for Procedural Sedation in the Pediatric Emergency Department and the Impact on Time to Discharge 
 
Authors: Francesco Mottola; Andrea Gerwin; Maggie Raker; Sarah Sterner; Morgan Padron 
Background/Purpose: Optimizing sedation for procedures in the pediatric emergency department (PED) is essential for effective pain control and timely discharge. Ketamine is commonly used as monotherapy, but its associated adverse effects may delay recovery. Combining ketamine with propofol may reduce these effects, potentially shortening time to discharge. However, whether this combination leads to faster discharge compared to ketamine alone remains unclear within current literature. The purpose of this study is to compare discharge times between ketamine monotherapy versus ketamine and propofol when used for procedural sedation in the pediatric emergency department. 
 
Methods: This study is a single-center, retrospective, chart review utilizing electronic health records of patients treated in the PED at the Children’s Hospital at Erlanger between January 1, 2023 and October 30, 2024. Patients were included if they were less than 18 years of age and received either ketamine or the combination of ketamine and propofol for procedural sedation with moderate depth sedation targets. Exclusion criteria included medically complex patients, patients with hypersensitivity to either ketamine or propofol, and patients admitted to the hospital after receiving procedural sedation in PED. The primary outcome is to evaluate whether the combination of ketamine and propofol leads to a quicker discharge time than the use of ketamine alone when used for procedural sedation in the PED. Secondary outcomes include the overall rate of adverse events, administration of pre‑sedation antiemetics, nausea, emesis, emergence reactions, and the mean sedation duration. 
 
Results: Preliminary data included a total of 220 patients with 109 in the ketamine group and 111 in the combination of ketamine and propofol group, respectively. Preliminary results indicate that the mean dose of ketamine was 1.95 mg/kg ± 0.74 in the ketamine group compared to 1.21 mg/kg ± 0.43 in the ketamine and propofol group. The average dose of propofol was 2.38 mg/kg ± 1.12 when used in combination with ketamine. In the ketamine group, the mean duration of sedation was 23.08 minutes ± 16.4 with a mean discharge time of 155.7 minutes ± 105.6 (p< 0.001) compared to a mean sedation duration of 25.33 minutes ± 8.5 in the ketamine and propofol group with an average time to discharge of 112.40 minutes ± 39.57 (p< 0.001). In the ketamine group, 74 patients (67.3%) received pre‑sedation antiemetics, compared with 59 patients (53.2%) in the combination of ketamine and propofol group (p= 0.25). Overall adverse events were reported in 33 (30%) of patients in the ketamine group compared to 10 (9.1%) in the ketamine and propofol group (p < 0.0001). The most common adverse events reported in the ketamine group were emesis (33%) and nausea (45%). In the ketamine and propofol group, the adverse events reported were nausea (70%) and emesis (10%). No emergence reactions were observed between either group. 
Conclusions: The use of ketamine and propofol for procedural sedation within the pediatric emergency department may decrease the time to discharge when compared to ketamine alone. This is likely due to the lower incidence of adverse events seen with the combination of ketamine and propofol. When used in combination, lower doses of ketamine were more likely to be used, which may contribute to the lower reported rate of adverse effects. However, patients within the ketamine group were also more likely to receive pre-sedation antiemetics when compared to the ketamine and propofol combination group, which may also impact incidence of adverse effects. 

Background: Staphylococcal scalded skin syndrome (SSSS) is a serious toxin-mediated dermatologic condition that primarily affects young children and is an important cause of pediatric hospitalization. This syndrome is caused by exfoliative toxins produced by Staphylococcus aureus, resulting in diffuse erythema, skin fragility, and superficial blistering with subsequent desquamation. Current management focuses on eradication of the toxin-producing organism with systemic antistaphylococcal antibiotics in conjunction with supportive care. Beta-lactam antibiotics with activity against methicillin-susceptible S. aureus, such as nafcillin, are considered first-line therapy. Clindamycin is frequently used as adjunctive therapy due to its ability to inhibit bacterial protein synthesis and suppress toxin production. However, the addition of clindamycin for antitoxin use in SSSS has remained controversial with conflicting findings in primary literature of whether it should be added to mainstay treatment. This study evaluates the association between adjunctive clindamycin use in combination with nafcillin and length of stay (LOS) in pediatric patients with SSSS at our institution. Methods: A single-center, institutional review committee (IRC)–approved retrospective analysis was conducted at Huntsville Hospital for Women and Children to evaluate nafcillin monotherapy compared to the combination of nafcillin and clindamycin in relation to LOS of patients admitted between January 1, 2019 and August 31, 2025. Pediatric patients ages one month to 18 years that received at least one dose of nafcillin and with an ICD-10 code L00 for SSSS were included in the analysis. Patients with alternate diagnoses, concomitant infections requiring broader-spectrum antibiotics, or transferred out of the facility due to needing a higher level of care were excluded. The primary outcome was hospital LOS between the two groups. Secondary outcomes included the utilization of adjunctive and supportive medications during hospitalization, specifically the use of scheduled pain medications, scheduled antipruritic medications, as-needed (PRN) pain medications, and PRN antipruritic medications. Continuous variables were summarized using means with standard deviations and medians with interquartile ranges (IQR). Categorical variables were reported as percentages. Analysis for statistical significance was computed using RStudio ®.Results: Eighty-five patients were included in the evaluation of the primary and secondary endpoints. 18 patients were treated with nafcillin monotherapy and 67 were treated with the combination of nafcillin and clindamycin. Mean LOS was 3.89 ± 1.78 days in the nafcillin group and 3.70 ± 1.66 days in the combination group, corresponding to a mean difference of −0.19 days (95% CI −1.10 to 0.69; p = 0.78). Median LOS was 3.5 days (IQR 3.0–4.8) for nafcillin monotherapy and 4.0 days (IQR 3.0–4.0) for combination therapy (Hodges–Lehmann shift 0 days; 95% CI −1 to 1; p = 0.78). No secondary outcomes were statistically significant after adjustment for multiple comparisons. Local microbiologic data demonstrated low clindamycin resistance among MSSA isolates (10%) and overall low prevalence of MRSA isolates (7.4%).Conclusion: The combination of nafcillin and clindamycin use was not associated with a statistically significant reduction in hospital LOS among pediatric patients with SSSS. These findings align with prior literature suggesting limited impact of clindamycin on hospitalization duration1, 2. Additionally, no statistically significant differences were observed in the secondary outcomes evaluating the utilization of scheduled or as-needed medications. Routine adjunctive clindamycin use for LOS reduction in pediatric SSSS is not supported by this data and should be considered within the context of institutional susceptibility patterns and antimicrobial stewardship principles.

Title: The Impact of Inhaled Antibiotic Use in Critically Ill Neonatal and Pediatric Populations
Authors: Madeline DiCenso, Andrea Gerwin, Renee Hughes, Paige Klingborg
Background/Purpose: Pediatric and neonatal patients with chronic lung disease or tracheostomies face an elevated risk of pulmonary bacterial infections due to impaired airway clearance and chronic colonization. Prophylactic inhaled antibiotic (iAbx) use is described in cystic fibrosis (CF) patients but is minimally explored in tracheostomized and critically ill children without CF. Retrospective data suggests benefits to prophylactic iAbx therapy, including reduced rates of re-hospitalization and systemic antibiotic use with minimal associated side effects. However, published guidelines directing use do not currently exist. This study will describe our institution’s use of iAbx in critically ill pediatric and neonatal patients, evaluate optimal dosing strategies, and analyze potential improvements in clinical outcomes.
Methods: This was a single center, retrospective, observational chart review conducted using electronic health records from patients admitted to the neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) at Children’s Hospital at Erlanger between July 1, 2022, and July 1, 2025. Patients were included if they received iAbx during admission. Patients who did not receive iAbx or with Cystic Fibrosis were excluded. The primary outcome of the study was to describe the usage patterns of iAbx in the NICU and PICU. The secondary outcomes were to evaluate potential benefits of continuous or cycled use of iAbx and to analyze how use of inhaled antibiotics may impact clinical and functional outcomes, such as respiratory status, and days of systemic antibiotics. Due to the young age of our study population, we evaluated days of systemic antibiotics compared to days of life (DoL). Safety outcomes included resistance patterns, and hearing screen results.
Results: Preliminary results on utilization patterns indicate that mean age at initiation of therapy was 29.71 months (1–204-month range). Tobramycin was nebulized at a dose of 300 mg twice daily with the most common duration therapy of 28 days. Before iAbx therapy was initiated, patients had fewer average systemic abx days per DoL (1:14.07) compared to an increased ratio (1:9.54) after iAbx. Fraction of inhaled oxygen (FiO2) requirements were higher in the 14 days prior to iAbx initiation (average 36.7%) compared to the 14 days following iAbx initiation (average 29.7%). Data regarding the safety profile of inhaled antibiotic therapy is still in process.
Conclusions: The use of iAbx in critically ill pediatric patients at Children’s Hospital at Erlanger closely matches regimens presented in other primary literature. There may be an improvement in respiratory status represented by improved ventilator settings associated with use of inhaled antibiotic therapy. Although systemic antibiotic days normalized for DoL increased after therapy initiation, interpretation is limited by varied initiation times, with post‑treatment data constrained by the study’s fixed endpoint. Data regarding safety of inhaled antibiotic therapy and resistance patterns amongst the trial population is ongoing.

Background: Children with sickle cell disease (SCD) are at increased risk for serious bacterial infections due to functional asplenia. Fever in this population is considered a medical emergency requiring rapid evaluation and empiric antibiotics. Guidelines recommend prompt antibiotic administration, while the literature specifically supports delivery within 60 minutes of emergency department (ED) arrival. However, achieving this target is often hindered by ED crowding and limited bed availability. To address this, the Children’s Hospital of Georgia (CHOG) pediatric ED implemented a nurse-driven sickle cell fever triage protocol. This study aims to evaluate whether protocol implementation improved the proportion of patients receiving antibiotics within 60 minutes. 

Methods: This is a single-center, retrospective study conducted in the CHOG pediatric ED evaluating a nurse-first sickle cell fever triage protocol with reiteration on May 21, 2025, which allowed triage nurses to obtain IV access, labs, cultures, and notify a provider prior to room assignment. Patients 0–17 years with sickle cell disease who presented to the ED with fever (≥38°C) from November 2, 2024 to October 31, 2025 were included. Encounters with missing key time points or adult ED admissions were excluded. The primary outcome was the proportion of patients receiving antibiotics within 60 minutes of ED arrival. Secondary outcomes included frequency of protocol use and time from arrival to provider evaluation. Outcomes were compared between pre- and post-implementation periods using descriptive statistics, chi-square tests, and t-tests, as appropriate.  

Results: A total of 52 patients were included in this IRB-approved study, with 31 in the pre-protocol group and 21 in the post-protocol group. Antibiotics were administered within 60 minutes of ED arrival in 3 patients (9.7%) in the pre-protocol group and 2 patients (9.5%) in the post-protocol group (p = 0.9853). The sickle cell with fever triage protocol was utilized in 1 (3.23%) of pre-protocol encounters compared with 4 (19.05%) of post-protocol encounters (p = 0.0576). The mean time from ED arrival to provider evaluation significantly decreased from 55 minutes in the pre-protocol period to 23 minutes in the post-protocol period (p = 0.0031). 

Conclusions: This study found no significant difference in the proportion of patients receiving antibiotics within 60 minutes of ED arrival between the pre- and post-protocol groups at a single institution. There was a significantly faster time to provider evaluation in the post-protocol group, suggesting improved early recognition and prioritization of this high-risk population. While protocol utilization increased in the post-implementation period, it remained relatively low, highlighting the need for further workflow optimization, staff education, and system-level support to enhance adherence. Future efforts should focus on identifying barriers to timely antibiotic administration, particularly challenges with obtaining IV access in this population, and improving consistent protocol activation to better align care with national guidelines and ultimately improve outcomes for children with sickle cell disease presenting with fever. 

Contact: [email protected]

Background:
Approximately 10% of patients report a penicillin allergy; however, fewer than 1% of the population have an IgE-mediated allergy. Penicillin allergy evaluation involves obtaining a detailed history of the reported reaction and may include diagnostic testing such as skin testing and/or an oral penicillin challenge. When appropriate, this process can result in the removal of the allergy label from a patient's medical record, a process known as allergy de-labeling. This practice has been well studied and is considered safe among the general population. Given its safety and effectiveness, the American College of Obstetricians and Gynecologists (ACOG) encourage penicillin allergy evaluation for any patient with a documented penicillin allergy; however, despite these recommendations, this patient population is less likely to undergo evaluation for allergy de-labeling.  
 
Antimicrobial use in pregnancy is common, particularly for managing Group B Streptococcus (GBS), cesarean section prophylaxis, and infectious complications such as chorioamnionitis. ACOG guidelines recommend beta-lactam antimicrobials, including ampicillin and cefazolin, as first-line agents for prophylaxis and treatment during the peripartum period. However, patients labeled as penicillin-allergic are often prescribed second-line, broad-spectrum antimicrobials instead. Wellstar MCG Health (WMCGH) implemented a new penicillin allergy screening assessment process for obstetrics and gynecology patients in September 2025. The purpose of this study is to expand upon existing literature by evaluating the outcomes of this new assessment.  

Methods:
This is a single center, retrospective, chart review study evaluating the outcomes of a newly implemented penicillin allergy screening assessment in obstetrics and gynecology patients. All patients 18 years or older who were seen at pre-specified WMCGH women’s clinic locations with a documented penicillin allergy were eligible for enrollment. Patients were excluded if they did not have established care with WMCGH prior to admission and if they were admitted for a non-related OB/GYN encounter. The primary outcome was the difference in the incidence of guideline recommended first-line antimicrobials received for GBS, chorioamnionitis, and surgical prophylaxis. Secondary outcomes included hospital length of stay, incidence of de-labeled penicillin allergy, rate of postpartum and surgical site infections, total days of antimicrobial use, 30-day hospital re-admission, and antimicrobial cost savings.  

Results:
A total of 140 patients were included with 97 patients in the pre-implementation group and 43 patients in the post-implementation group. For the primary outcome, 20% of patients in the pre-implementation group received first-line antimicrobials compared to 43% in the post implementation group (p = 0.106). Implementation of penicillin allergy screening was associated with a 29% relative risk reduction in patients receiving non-first line antimicrobial therapy. There was no difference in hospital length of stay between the two groups, and 30-day hospital re-admission was 10% vs. 5% in the pre- and post-implementation groups respectively. The rate of postpartum and surgical site infections was similar between pre- and post-implementation groups (4% vs 5%, p = 0.891) in addition to the total days of antimicrobial use (0.3 vs 0.2 days, p = 0.460). A total of 3 patients (7%) were de-labeled based on penicillin allergy assessment. The pre-implementation group demonstrated higher overall drug cost utilization, largely driven by more costly antimicrobial agents ordered. This difference may become more pronounced with a larger sample size, suggesting potential for meaningful cost savings at scale.

Conclusion:
Patients in the post-implementation group received guideline-recommended first-line antimicrobials more often than those in the pre-implementation group; however, this study was underpowered to detect statistical significance. Patients in the post-implementation group that were appropriately identified and screened were able to be successfully de-labeled. Most de-labeling occurred through an allergy/immunology referral consult and oral amoxicillin challenge. Further studies with larger sample sizes are warranted to better evaluate the impact of this intervention.  

[email protected]

Background/Purpose: Neonatal sepsis remains a leading cause of neonatal mortality in the United States despite advances in intrapartum screening and antibiotic administration. Late onset sepsis (LOS) is defined as suspected or confirmed sepsis at greater than seventy-two hours of life. Patient presentation is often nonspecific, creating a low threshold for empiric treatment, which may lead to unnecessary antimicrobial administration and increased development of resistant organisms. Previously, there was not a standardized workflow for treating LOS in our neonatal intensive care unit (NICU) and special care nursery (SCN). This led to variations in practices and created an opportunity for care optimization. A pharmacy-driven order set for empiric therapies in the treatment of LOS was implemented at our institution, composed of screening suggestions and empiric antibiotic recommendations based on specified patient risk factors. This review evaluated the appropriate use of this new order set and how effectively LOS is managed by evaluating appropriate antimicrobial selection and culture collection.
 
Methodology: This was a multi-center, IRB-reviewed determined exempt, retrospective cohort review conducted at the Moses Cone Memorial Hospital NICU and Alamance Regional Medical Center SCN in Greensboro and Burlington, NC, respectively. On November 1, 2024, a pharmacy-driven order set for empiric neonatal LOS treatment went live at both sites. For this evaluation, patients were included if they were admitted to either site and received antimicrobial agent(s) for the treatment of LOS. Patients were excluded if they received antimicrobial(s) for another known indication or if they received antimicrobial agent(s) but were not admitted to one of the study locations. Patients were then divided into a pre-group from December 1, 2023 through October 31, 2024 and a post-group from December 1, 2024 through October 31, 2025. The primary outcome was the composite of positive cultures covered by empiric antibiotics and adequate coverage of “culture negative” sepsis with empiric antimicrobials based on patient risk factors and suspected infection source. Secondary outcomes included number of instances in which 2 initial blood cultures were obtained, percentage of patients with positive blood cultures who had repeat blood cultures obtained, average days of therapy, use of the late onset sepsis order set, and whether appropriate doses of antimicrobials were utilized.  
 
Results: 89 instances of LOS in 60 patients were included in the study. There were 51 instances of LOS included in the pre-order set group, and 38 instances included in the post-order set group. The primary composite outcome of positive cultures covered by empiric antibiotics and adequate coverage for culture negative sepsis was 71% in the post-order set group and 66.7% in the pre-order set group (p=0.659). In the post-order set group, providers were more likely to obtain a set of two blood cultures (instances with 2 initial blood cultures obtained 5.9% vs 57.9%, p<0.001). The pharmacy-driven order set was utilized in 55.3% of instances in the post-order set group. Other secondary outcomes were similar between groups.
 
Conclusions: The implementation of a pharmacy-driven order set at our institution resulted in a clinically significant increase in empiric coverage of culture negative sepsis and significant trend in increase in number of initial blood cultures collected. There was not a significant difference in the percentage of positive cultures covered by empiric antibiotics. Common reasons that empiric therapy did not cover culture negative sepsis included lack of anaerobic coverage in suspected infections of intraabdominal sources and lack of MRSA coverage in patients with MRSA risk factors. Potential limitations to this evaluation include limited sample-size, single-institution review, and variability of provider preference. Future directions include assessing barriers to utilization of the LOS order set and implementation of strategies to increase utilization.

Evaluation of RSV hospitalizations in high-risk infants who received nirsevimab vs. palivizumab 
Authors: Allison Lopez, Courtney Campbell, Erica Gray, Katelyn Gibson 

Background 
Respiratory syncytial virus (RSV) is a common acute respiratory infection that can cause mild cold-like symptoms in most infants, but some high-risk infants, such as those born prematurely or with chronic lung or congenital heart disease, can develop severe disease requiring hospitalization. Prophylaxis is the most effective way to prevent severe RSV infection. Palivizumab and nirsevimab are monoclonal antibodies that provide passive immunity by preventing RSV from entering healthy cells. Palivizumab requires monthly dosing during RSV season, while nirsevimab is given as a single dose for the entire season. Our institution recently switched from palivizumab to nirsevimab following updated ACIP, CDC, and AAP guidance. There is established data supporting palivizumab use in high-risk infants, but limited evidence exists for nirsevimab in this population. This study aims to compare RSV-related hospitalizations in high-risk infants receiving nirsevimab versus palivizumab to inform RSV prophylaxis use at our institution. 

Methods 
This is a single-center retrospective chart review of high-risk infants who received palivizumab or nirsevimab for RSV prophylaxis during the 2022-2023 or 2024-2025 season, respectively. High-risk infants include those born prematurely and those with chronic lung disease or significant congenital heart disease. Infants were included if they met institutional criteria for RSV prophylaxis and received at least one dose of nirsevimab or palivizumab. The primary outcome was the number of hospitalizations with confirmed RSV infection. Secondary outcomes included risk factors for severe RSV, number and timing of prophylactic doses, timing of hospitalization relative to dosing, and the number of confirmed RSV cases in Georgia. The purpose of this study was to evaluate whether a single dose of nirsevimab is sufficient for high-risk infants throughout the RSV season through comparison of hospitalization rates between infants receiving palivizumab versus nirsevimab. 

Results 
A total of 146 patients were included in this study, with 82 patients receiving nirsevimab and 64 patients receiving palivizumab. The patients in the two groups were similar regarding baseline characteristics, and the majority of patients were African American. Of the patients included, four were hospitalized with confirmed RSV infection. Three of these patients had received nirsevimab and one had received palivizumab. There was no significant difference seen in the primary outcome comparing hospitalizations in the nirsevimab group and the palivizumab group (P = 0.63). 

Conclusions 
This single-center retrospective chart review demonstrates that the use of nirsevimab for RSV prophylaxis does not increase the risk of hospitalization in high-risk infants compared to palivizumab. No statistically significant difference was seen between nirsevimab and palivizumab in terms of RSV-related hospitalizations. The results of this study support continued utilization of nirsevimab for RSV prophylaxis in high-risk infants. 

Contact: [email protected] 

Title: Impact of Ciprofloxacin/Dexamethasone Utilization in Pediatric Tracheostomy Patients
Authors: Rachel Dickey, Andrea Gerwin, Stephanie Conrad
Background/Purpose: Ciprofloxacin/dexamethasone (cip/dex) is a combination antibiotic and corticosteroid that is available in a topical otic formulation. Current approved indications include the treatment of acute otitis externa and post-tympanostomy tube otorrhea. Cip/dex has been used off-label for reducing granulation tissue formation in pediatric tracheostomy patients by pediatric otolaryngologists for many years despite limited supporting data, mostly anecdotal. With long term use of cip/dex, there is theoretical concern for development of resistance to fluoroquinolone (FQ) antibiotics, such as ciprofloxacin and levofloxacin, the only enteral antibiotic formulations with effective broad-spectrum gram-negative coverage. The purpose of this review is to examine the influence of FQ exposure on antimicrobial resistance in our pediatric tracheostomy patients.
Methods: This study is a single center, retrospective review conducted using electronic health records of patients followed by Children’s Hospital at Erlanger between January 1, 2018 and December 31, 2025. Included patients had a tracheostomy and microbiological data available in the EHR. Patients were excluded if they received cip/dex drops via alternative route, were lost to follow up, or had care transferred to another institution. Patients were divided into groups based on history of FQ resistant or sensitive organisms. The primary outcome will evaluate total topical and systemic FQ exposure in patients who received cip/dex drops. Secondary outcomes will include number of respiratory cultures and rate of hospitalizations. Standardization of reported outcomes was achieved by normalizing cip/dex exposure, FQ exposure days, and days of hospitalization to patient tracheostomy days.
Results: Preliminary results include 16 patients in the FQ-sensitive cohort and 15 patients in the FQ-resistant cohort. Mean days of cip/dex per tracheostomy day were 0.06 (0-0.34) in FQ-sensitive group as compared to 0.05 (0-0.27) in the FQ-resistant group. The mean days of hospitalization per tracheostomy day were 0.76 (0.06-2.96) in the FQ-sensitive group as compared to 0.75 (0.01-8.42) in the FQ-resistant group. Approximately 56 % of the FQ sensitive group were male as compared to 60% of the FQ resistant group. Mean age (months) at tracheostomy was 8.73 (0.9-23.37) and 8.18 (1.70-29.70) in sensitive group and resistant group, respectively. The average number of cultures in the sensitive group and resistant group were 9.9 (2-34) and 10.9 (6-20).
Conclusions: There is a paucity of data on the impact of cip/dex drops on bacterial resistance patterns. The FQ-resistant cohort had more cultures than the FQ-sensitive patients. Patients with FQ-resistance had similar hospitalization days per tracheostomy days and tracheostomy duration when compared to the FQ-sensitive cohort. Both cohorts had similar ratios of systemic FQs and topical cip/dex exposure.

Background/Purpose: Early-onset sepsis (EOS) is a systemic infection occurring within the first week of life and remains a major contributor to neonatal morbidity and mortality. Clinical manifestations of EOS are often nonspecific. Empiric broad‑spectrum antibiotics are frequently initiated in suspected infection based on maternal or neonatal risk factors. Literature supports discontinuation of empiric antibiotic therapy if blood cultures remain negative at 36 – 48 hours. Despite support for discontinuation, providers often continue antibiotics due to concerns of missed infection or presumed clinical improvement due to initiation of therapy. Prolonged antibiotic exposure in neonates is associated with adverse outcomes including disruption of gut microbiome, necrotizing enterocolitis, and development of antimicrobial resistance. This study aimed to evaluate the prevalence of prolonged empiric antibiotic therapy for culture‑negative EOS.

Methodology: This was a multi-centered, retrospective chart review which evaluate neonates delivered within the Northeast Georgia Health System and admitted to the NICU between January 1, 2023, and December 31, 2024. Patients were included if blood cultures were obtained within the first 72 hours of life, and at least one dose of ampicillin plus gentamicin was administered. Patients with positive blood cultures within the first 72 hours were excluded, as well as any patient that was discharged and readmitted within the first 72 hours of life. The primary objective was to evaluate the prevalence of prolonged empiric antibiotic therapy (> 48 hours) despite negative cultures. The secondary objective was to evaluate the prevalence of treatment failure, defined as discontinuation and reinitiation of any antibiotic within the first 14 days of life.

Results: A total of 125 neonates met inclusion criteria. Of these, 94 neonates (75%) received standard empiric therapy, and 31 neonates (25%) received prolonged empiric therapy despite negative blood cultures. Baseline characteristics were similar between groups, with no statistically significant differences observed for gestational age, birth weight, gender, or mode of delivery. The mean total days antibiotic exposure was 3 days in the standard group compared to 7 days in the prolonged group (P < 0.001). Treatment failure occurred in 9 of 94 neonates (10%) in the standard group and 3 of 31 neonates (10%) in the prolonged group, with no significant difference between groups (P = 0.613).

Conclusions: Of the 125 neonates included in this retrospective chart review, (25%) received empiric antibiotics beyond the consensus recommended 36 to 48 hour rule‑out period despite negative cultures. Prolonged empiric therapy did not reduce treatment failure when compared to the standard group. There was a clinically significant increase in antibiotic exposure in the prolonged group. Further studies are needed to evaluate the long-term effects of empiric treatment for early onset sepsis. These findings also highlight opportunities for antimicrobial stewardship initiatives aimed at reinforcing evidence-based, consensus recommended use of empiric antibiotics.