Neonatal infection: antibiotics for prevention and treatment

Safety: no confirmed late sepsis, adverse events or deaths.

Shorter hospital stays: eligible babies were able to complete antibiotic treatment at home, reducing unnecessary time in hospital.

Family experience: parents valued getting home sooner and being together as a family.

Parent confidence: families found oral antibiotics easy to give to their babies.

Staff experience: staff reported that the NOAH pathway was practical to implement once guidance, training and reassurance were in place.

Reduced treatment burden: fewer cannulation attempts because babies spent less time on intravenous antibiotics; they also had reduced exposure to gentamicin as a result of the switch to oral antibiotics.

System benefits: reduced demand for neonatal beds, which reduced the demand for staff and lowered costs.

Environmental impact: reduced hospital stays may have contributed to a smaller carbon footprint.

Choice of oral antibiotic: One important evolution in the projects was in the choice of oral antibiotic. The NOAH project and the project across Kent, Surrey and Sussex both originally used oral co-amoxiclav, in line with the RAIN trial. Following multidisciplinary review with microbiology, infectious diseases and pharmacy colleagues, the NOAH project switched to oral amoxicillin. The key reasons for this change were the discovery of a dosing discrepancy with co-amoxiclav, the spectrum of likely pathogens in early-onset neonatal infection and antimicrobial stewardship principles around avoiding unnecessarily broad-spectrum treatment. The project at St George's Hospital used amoxicillin from the beginning.

Clinicians have embraced the change: The neonatal intravenous-to-oral antibiotic switch pathways have been rapidly adopted and well received at every implementing site. Even the most cautious clinicians have embraced the change.

Sharing the evidence and need for champions: Delivering clinical training that included a review of the evidence underpinning the safety of oral switch helped inspire confidence in the change. Appointing champions to monitor implementation was key while the change became embedded in clinical practice, allowing for early detection and improvement of any issues identified.

Need for strong leadership: Strong local leadership was critical at every site. Having a named project lead with the drive and authority to move things forward made a significant difference. Senior neonatal doctors were the key stakeholders and having a consultant body willing to embrace change supported smooth implementation.