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thank you for the invitation to talk
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about use and abuse of antibiotics in
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neonatology sure
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so why should we care about antibiotics
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in ethology so as we heard no question
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about we have a benefit for the
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individual so if you have an infection
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and we treat the infection as we heard
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from Chris of pure antibiotics is
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life-saving we have as well a benefit on
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the community level so the benefit is we
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can prevent the spread of some of the
00:00:40
infections and as we know things decayed
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there is the risk for the community
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regarding antibiotic resistance so what
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is not so well known but it's coming up
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more and more in the last ten years is
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there is aware as well a cost on the
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individual baby that you're treating
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these antibiotics we have the collateral
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damage they are doing on the microbiota
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and I like to give 23 minutes on this
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microbiome because it's very fascinating
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if you reading about the microbiome i
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probably will change how we are doing
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medicine in the next 10-20 years so we
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see usually the microbiome as we as
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humans are here and they are some
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bacteria on the skin in the gut and
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they're living with us and the reality
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is probably the other way around so we
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are living with a community of bacterias
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because the bacterial cells are ten
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times more than our human cells and in
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the genes the factories even around 100
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so what happens if you are start with
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antibiotic so we start an antibiotic and
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the diversity of our bacterial community
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is going down this depends on what kind
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of antibiotic we are giving and this
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depends on how long we are antibiotics
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kidding
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then after end of treatment there is a
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slowly recovery and that diversity is
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coming back so we may say as a clinician
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at the bedside that's fine we have a
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problem for a few days or weeks perhaps
00:02:26
there is a diarrhea but in the end all
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is fine
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unfortunately we are not ologist so we
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are treating our patients in the
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variable memorable time so if you look
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this is a mouse model where they looked
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on the colonization and there is a
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impact on the colonization on the immune
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system so if you have no colonization of
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or if you have a colonization very late
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after sometime mouth disease for weeks
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we have no idea about this time window
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in humans or if you have a conversation
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with a low diversity then this my eyes
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had a high eg level and they had a trend
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to anaphylaxis more this bacteria in the
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gut
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they interact with our stem cells and
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they interact how the Prophet
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proliferation of these stem cells
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happens so if you are giving antibiotic
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then we are intervening in this process
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and this maybe is one of the
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explanations why giving antibiotics
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early in life may have an impact on the
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health later in life even more Christian
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can't mention that in the morning we
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know that the microbiome of the modern
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and demand the question if the model is
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treated with antibiotics are not has an
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impact on the microbiome on the new Nate
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and as well for the house later in life
00:04:02
so in summary looking on that on the
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literature
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these are the diseases that are
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currently are associated with antibiotic
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treatments early in life we already have
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seen this slide by Chris of period with
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the antibiotic use and the increased
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mortality and chronic lung disease
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is and drop disease and of course there
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is the questions are baby just thicker
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but I think in the end we have to ask
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the question and we have to consider
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that perhaps the antibiotic itself is
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one factor that may be a problem for
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mortality and morbidity among and this
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infants so to conclude I think everyone
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who is prescribing antibiotics should
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care about the costs and the benefit of
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antibiotics so what we are doing in our
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Nick use with antibiotics are we doing
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the same know so this is a study from
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California they looked in about more
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than 100 leak use and they found the 40
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fall variation in antibiotic days 40
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fall that's that's huge
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so there are some units they have very
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minimal days and antibiotics and there
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are other probably more or less one
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hundred percent of the days where
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antibiotic days this was independent of
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proven infection or neck and it was as
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well independent of mortality do we know
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what antibiotics we are using or are we
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in agreement this is a study from the
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Netherlands they looked about ten eq's
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and as you can see every color is
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another antibiotic class and the picture
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is is very cold and at least in the
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Netherlands they are not in agreement
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but they are giving on their knee cues
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how is the situation in Switzerland we
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don't know really
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we have in the mls data one I came
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asking are we giving our tree term
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infant below 32 weeks antibiotics for
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five days or more without positive
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culture and looking on this in 2015 when
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the state are true then we have about
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three units they are giving more or less
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never antibiotics for five days and more
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and there are other units are giving
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more to third or to have their babies
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below 32
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weeks antibiotics for five days or more
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with negative culture of course we have
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to consider that perhaps they have a
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different system of culture perhaps
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there is a difference in sepsis related
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mortality this has to be looked at but i
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think it's remarkable and we can
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conclude there is a high variability of
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antibiotic use in our news so for what
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are we using our antibiotics i think
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that's similar slides that piece of
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clear showed about eighty-nine percent
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in this study diseases various study
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from the united states were used for
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rule out sepsis of culture negative
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situations like culture- sepsis
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pneumonia so what is about the number
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needed to treat with antibiotics to have
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a proven infection so i looked in the
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literature and they found several
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publication wrong from the group from
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eric from Luzon they looked on late
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preterm babies 222 had an antibiotic
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therapy three out of them have the
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sepsis so it gives the number of to
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treat from 74 in Norway this is the only
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published population-based study that I
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know regarding antibiotic use in turn
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babies they had about 4,000 babies
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treated with antibiotics and this was
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the lowest number that i found in the
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number needed to treat us 44 to have one
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proven infection new pins is our
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procalcitonin study so far not published
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hopefully soon so we had 1740 babies in
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Switzerland in the netherlands in Prague
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and Canada and we had a number needed to
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treat of 64 and then you go now to the
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united states that our publication which
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number needed to treat from 154 or if
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you look on a special situation special
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risk situation like Cory immunities
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there was the number needed to treat of
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138 now of course we can say well but
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it's very dangerous to have sexy so we
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have to treat very much babies to to
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have known
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mortality so what about the mortality so
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it goes on there are none in the new pin
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study we had nonsense related mortality
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in Norway there was one baby dying on a
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GPS sepsis and in the USA and even by
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chorioamnionitis there was a very low
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number so in the USA for example you
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have to treat more than 11,000 babies to
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have one baby will die on sepsis of
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course we don't want to have that babies
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but at least we have to think about are
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these numbers reasonable so i think we
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can conclude regarding the start of
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therapy we have a high number needed to
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treat for proven infection in term at
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least interment late preterm babies
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what about the duration of antibiotic
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therapy again the study from Norway
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looking on how long do they treated
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their babies for culture prove
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insecticide-treated eight days for
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culture- sepsis they had a mean six days
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for rule out sepsis four days so that
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gives an overall duration of antibiotic
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therapy for the whole group of four
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point eight days
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this is a study from the US just babies
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with culture negative situations are
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with rule out sepsis and they had a mean
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duration of 5.3 days in this situation
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the range indifferently cues was between
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3.2 and 8.6 days
00:10:23
this is a publication of 2016 and not
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from to talk two thousand it was also
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obvious the sneak us with a higher
00:10:31
number of new bond started on
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antibiotics have a significantly longer
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course so it's not true that any cues
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that started early could say well we
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start early but we finish early so we
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have a short course at least in this
00:10:45
study this was not true
00:10:47
another study i'm looking on duration
00:10:50
found as well about fifty percent had a
00:10:53
treatment in culture negative situation
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for 325 days interesting here to see
00:10:58
babies treated for more or equal five
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days in sixty-two percent the reason was
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a memoria
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I think it's very difficult to diagnose
00:11:08
of ammonia in tree terminator babies I
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don't know how they have done it
00:11:12
of course there is nothing mentioned in
00:11:14
this publication so i think we can
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conclude that the duration of antibiotic
00:11:21
therapy for suspected infection for
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culture- infection is probably often
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prolonged so okay now having this these
00:11:31
facts the question is so what is there
00:11:33
anything what what we can do can be make
00:11:37
it better
00:11:38
I come back to the study from lausanne
00:11:41
the study was primary not focused on
00:11:45
duration of antibiotic therapy but they
00:11:47
look that is a laboratory measurement
00:11:51
really helpful regarding the decision to
00:11:54
start antibiotic therapy so they had two
00:11:57
cohorts in the first cohort they had
00:11:59
just the national guidelines and for the
00:12:02
second cohort they made a special policy
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how to treat baby and how to do it and
00:12:09
the interestingly point here is looking
00:12:12
on the data they had the duration
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without the protocol of 77.5 hours and
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in the second period with the protocol
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the local they came down to 64.2 hours
00:12:24
comparing these results to Norway in the
00:12:27
normal publication they mentioned that
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they didn't have any guidelines
00:12:32
regarding antibiotic therapy
00:12:35
remember we had four point eight days in
00:12:38
the USA in this huge population we had
00:12:41
five point three trays days in the new
00:12:43
pin study we had a protocol as well for
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the standard group and our duration of
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antibiotic therapy for the whole group
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in the standard group was very similar
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to the daytime lows on 65 hours we have
00:12:59
to mention this publication because
00:13:01
guidelines and protocols may have
00:13:04
another words affect and perhaps it's
00:13:06
not what we wanted to do so this study
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is about the nice guidelines in the UK
00:13:11
probably as you know the nice guidelines
00:13:14
requested or asked to do a CRP with 18
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hours after
00:13:19
starting antibiotics and they hoped bcrp
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it is possible to shorten the duration
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for antibiotic therapy to come down with
00:13:27
lumbar punctures and what happened was
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exactly the contrary so the duration of
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antibiotic therapy was prolonged stay in
00:13:35
the hospital was prolonged and the
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number of long departure longer punches
00:13:38
went up so protocols and guidelines i
00:13:43
think may have a benefit now of course i
00:13:48
have to say something about the PCT p
00:13:53
city is just one out of many biomarkers
00:13:55
and I think one of the important thing
00:13:58
if you're looking on a biomarker we have
00:13:59
to know what are the normal values for
00:14:03
these biomarkers after birth because
00:14:06
probably as well the CRP has some
00:14:09
physiological increase after birth and
00:14:11
not they below
00:14:13
54 below 10 and this is true as well for
00:14:16
the PCT very can see here this is what
00:14:18
we used this increased in the first
00:14:23
three days flag we have a protocol so we
00:14:27
try to say okay rather any risk factors
00:14:30
yes or no whether any clinical symptoms
00:14:32
better some conventional laboratory
00:14:35
findings like a local site opinion or a
00:14:38
CRP above 10 and then we categorize them
00:14:41
and say okay if you have just one point
00:14:43
there is a low-risk we still we had a
00:14:45
medium risk or if you had all three of
00:14:48
them a high-risk and then we have the
00:14:51
culture positive infections and we tried
00:14:54
in the low and the medium risk to do a
00:14:56
PCT guidance trying to shorten
00:14:59
antibiotic therapy and we came down in
00:15:02
the itt analysis to 55 hours and the
00:15:05
per-protocol analyst analysis to 51
00:15:08
hours i think this shows that is
00:15:11
possible to shorten antibiotic therapy
00:15:13
and quite sure it is possible with other
00:15:15
biomarkers I don't think that this is
00:15:18
now a specific PCT thing that is that
00:15:22
you can do this with other biomarkers
00:15:24
and I think the biomarkers just to help
00:15:28
so if you are able to have a short
00:15:30
duration of antibiotic
00:15:32
therapy without any biomarkers that's
00:15:34
fine then probably you don't need them
00:15:36
but if you have doctors who are not able
00:15:39
to make this decision then a biomarker
00:15:42
may help to do it so biomarker guidance
00:15:45
may help to shorten antibiotic therapy
00:15:47
as the last point antibiotic stewardship
00:15:52
as you know this is a big word there is
00:15:55
a recent publication lancet infectious
00:15:57
disease i think this was a NICU in Texas
00:16:01
and they were able with an intervention
00:16:04
to come down on the antibiotic use on
00:16:07
their NICU looking at where was it
00:16:11
possible to come down
00:16:13
it was a total amount of antibiotics and
00:16:15
as you can see here it was especially
00:16:17
possible in the suspected early-onset
00:16:20
senses so the use on this nique you of
00:16:24
antibiotics was focused on early onset
00:16:26
sepsis number two again trustees ammonia
00:16:31
and as you can see the suspected lay
00:16:33
down to Texas and the culture proven
00:16:35
infection they were just a small part of
00:16:38
their antibiotic use and antibiotic
00:16:41
stewardship is if you hear that all of
00:16:44
our thinking about all you need quite a
00:16:46
lot of resources you need the infectious
00:16:48
disease specialist unit isn't that so
00:16:50
the question is it possible to do it not
00:16:53
reason is lower resources so these are
00:16:56
the data from Lucerne end of 2015 and we
00:17:01
had the impression we are using too much
00:17:02
of antibiotics we are we we are using
00:17:05
too much of recognizing of meropenem so
00:17:08
we said let's try to come down on this
00:17:11
and antibiotics so it was possible to
00:17:14
come down reality from seventeen percent
00:17:17
regarding antibiotic days and just
00:17:20
possible in our units to come down mr.
00:17:23
maximizing and American by around fifty
00:17:26
percent and the mortality at least was
00:17:29
not increasing so I think this shows it
00:17:32
is possible of course it really depends
00:17:35
where you are if you are using your
00:17:37
antibiotics very carefully and very rare
00:17:42
than trouble be this is not possible at
00:17:44
least in our situation
00:17:45
it was possible so antibiotic server
00:17:48
surveillance and stewardship i think in
00:17:52
any form is mandatory for any NICU so my
00:17:57
take-home message in the end is really
00:18:00
this I think when you're prescribe
00:18:03
antibiotics we really have to think
00:18:05
about and they're the mindset that we
00:18:08
probably many of us have you have a baby
00:18:11
and you think well should I start with
00:18:14
antibiotics
00:18:15
there is some risk but the risk is not
00:18:17
that high
00:18:18
perhaps the baby has a little bit of
00:18:20
technique but that's it and then the
00:18:22
mine that all let's give some
00:18:24
antibiotics then we are safe i think
00:18:27
this is probably not true because
00:18:28
probably there is a cost on the
00:18:30
individual health regarding the damage
00:18:33
of the microbiota thank you for your
00:18:36
attention

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Conference program

Welcome Words
M. Roth-Kleiner, R. Arlettaz Mieth
10 Jan. 2017 · 9:33 a.m.
526 views
Short Reports Introduction
E. Giannoni, T. Karen, Resp. Lausanne, Zürich
10 Jan. 2017 · 9:38 a.m.
Association of Axonal Injury and Preeclampsia
Katrina Evers, Neonatology UKBB
10 Jan. 2017 · 9:39 a.m.
182 views
Q&A - Association of Axonal Injury and Preeclampsia
Katrina Evers, Neonatology UKBB
10 Jan. 2017 · 9:44 a.m.
102 views
Retinopathy of Prematurity
Roland Gerull, Bern
10 Jan. 2017 · 9:47 a.m.
154 views
Q&A - Retinopathy of Prematurity
Roland Gerull, Bern
10 Jan. 2017 · 9:54 a.m.
Parechovirus Infection: A Rare Cause of Neonatal Encephalitis (in French)
Dr Truant AS, Cheffe de clinique, Néonatologie, CHUV, Lausanne
10 Jan. 2017 · 9:59 a.m.
350 views
Q&A - Parechovirus Infection: A Rare Cause of Neonatal Encephalitis
Dr Truant AS, Cheffe de clinique, Néonatologie, CHUV, Lausanne
10 Jan. 2017 · 10:04 a.m.
234 views
112 views
Genetic Susceptibility to Neonatal Group B Streptococcal Disease
Alessandro Borghesi, Fellay lab, EPFL
10 Jan. 2017 · 10:17 a.m.
131 views
Q&A - Genetic Susceptibility to Neonatal Group B Streptococcal Disease
Alessandro Borghesi, Fellay lab, EPFL
10 Jan. 2017 · 10:25 a.m.
Psychomotor Development in Children Prenatally Exposed to Methadone
G. Grand-Guillaume-Perrenoud, Pediatrics, Children's University Hospital Geneva
10 Jan. 2017 · 10:27 a.m.
Q&A - Psychomotor Development in Children Prenatally Exposed to Methadone
G. Grand-Guillaume-Perrenoud, Pediatrics, Children's University Hospital Geneva
10 Jan. 2017 · 10:34 a.m.
Introduction to Christoph Berger's Presentation
C. Kind, R. Gerull, Resp. St.Gallen, Bern
10 Jan. 2017 · 10:37 a.m.
Vertical Infections: An Update
Christoph Berger, Zürich
10 Jan. 2017 · 10:40 a.m.
253 views
Q&A - Vertical Infections: An Update
Christoph Berger, Zürich
10 Jan. 2017 · 11:15 a.m.
Introduction to Eric Giannoni's Presentation
R. Pfister, S. Kämpfen, Resp. Geneva, Basel
10 Jan. 2017 · 11:44 a.m.
Sepsis, Antibiotics and Resistances: Where Are We?
Christoph Bührer, Berlin
10 Jan. 2017 · 2:21 p.m.
145 views
Use and Abuse of Antibiotics in Neonatology
Martin Stocker, Lucerne
10 Jan. 2017 · 2:50 p.m.
291 views
Panel Discussion : Controversies on Use of Antibiotics in Neonatology
Martin Stocker, Christoph Berger, Eric Giannoni, Christoph Bührer
10 Jan. 2017 · 3:10 p.m.
105 views
Introduction to Christoph Bührer's Presentation
Romaine Arlettaz Mieth , Neonatologist, Zürich, President of the Organizing Committee
10 Jan. 2017 · 3:47 p.m.
Evidence-Based Haemodynamic Management in Neonatal Sepsis
Christoph Bührer, Berlin
10 Jan. 2017 · 3:48 p.m.
416 views
Q&A - Evidence-Based Haemodynamic Management in Neonatal Sepsis
Christoph Bührer, Berlin
10 Jan. 2017 · 4:16 p.m.
SwissNeoDose Project
Marc Pfister, Ped Pharmacology, UKBB
10 Jan. 2017 · 4:20 p.m.
112 views
Awards (Case of the Year; Milupa; Best Poster Case Report; Best Oral Short Presentation) & Closing Comments
Matthias Roth-Kleiner, CHUV, President of the SSN
10 Jan. 2017 · 4:30 p.m.

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