Quality improvement: enhancing antibiotic stewardship for suspected early onset neonatal infection by refining use of the Kaiser Permanente screening tool and using a CRP threshold of 20 mg/L

Objectives and background The UK incidence of early onset neonatal infection (EONI) is 0.7 per 1000 live births and is associated with significant morbidity and mortality. However, because of the difficulty distinguishing infection from non-specific clinical signs, many neonates are unnecessarily treated with antibiotics. In Southampton, 13% live births were treated for suspected EONI in 2018. To reduce unnecessary antibiotics, the Kaiser Permanente Neonatal Infection Calculator (KPNIC) was introduced in September 2018 but had additional safety measures and needed refinement. In 2021, the National Institute for Health and Care Excellence Neonatal Infection Guideline removed the recommended C-reactive protein (CRP) threshold of 10 mg/L after which Southampton increased its local CRP threshold to 20 mg/L. The objective was to reduce both antibiotic initiation and duration in infants with low suspicion of infection. Method This quality improvement project comprised five Plan-Do-Study-Act cycles implementing and adapting KPNIC, supported by multidisciplinary education of the midwifery and neonatal team. Data on infants receiving antibiotics within 72 hours of life were extracted from the electronic patient record and blood cultures. Safety monitoring assessed 14-day readmissions. Analysis was by Excel and visualised with run charts. Results Antibiotic initiation fell from 13% to 6.6% live births. Cefotaxime care days decreased from 1089 in 2019 to 270 in 2024, (reduction of 819 days). No infants were readmitted with infection after antibiotic cessation using CRP of 20 mg/L. Conclusion Reducing unnecessary antibiotics by using KPNIC and a CRP threshold of 20 improved patient outcomes and hospital efficiency. The novel use of CRP 20 in this project provides guidance to clinicians regarding what might be a safe CRP threshold in the context of suspected EONI. University Hospital Southampton now meets British Association of Perinatal Medicine and National Health Service resolution transitional care standards. An implementation toolkit supports wider adoption.