We had been working on ways to reduce the use of antibiotics in the neonatal ICU for a long time when I took the decision to attempt it with the next baby under our care.
The baby was premature, born in 28th week of pregnancy. She was 730 grams, her lungs were not fully developed. She needed ventilator support and intravenous nutrition. Generally, in such babies we start antibiotics as a defensive medicine as they may have a co-existing infection.
If we go by statistics, 15 percent of babies who weigh less than 1500 grams may acquire some form of infection during their hospital stay and need antibiotics. But ideally, these babies don't need antibiotics till there is an evidence of an infection.
In order to treat this baby without antibiotics, we needed to build a robust infection control system. I appointed two dedicated nurses to look after this baby, they were not allowed to touch any other baby in the neonatal ICU. We replaced all re-usable with disposables--bed sheet, syringes, canula, etc. We placed a strict hand-washing protocols-- we sanitised our hands each time we touched the babies or something else.
I increased my rounds to ICU from two a day to four. For four days, everything went as planned.
I was very nervous. I came back home for lunch but my mind was in the ICU. I wanted to rest a bit but sleep eluded me. Being a paediatrician and a father, I knew how devastating losing a child could be for parents
But on the 5th day, her blood count and platelet fell. It could be because of number of reasons, including infection. Pulmonary, blood stream and urinary tract infections are common in such babies. And these babies are so delicate that we have to respond fast.
It was a critical moment.
As her CRP (c-reactive protein) test was normal, we decided to wait till blood culture report confirmed infection.
I was very nervous. I came back home for lunch but my mind was in the ICU. I wanted to rest a bit but sleep eluded me. Being a paediatrician and a father, I knew how devastating losing a child could be for parents. The memories of a case flashed through my mind.
Around a year back, I had this baby in my ICU. Till evening, he was stable. I took my evening round and thereafter went home. At night, I called up the ICU in-charge to check on all the babies. Everything was alright.
But my phone rang at 3 in the morning. It was my nursing-in-charge on the other side, she told me that the baby looked sick. I rushed to the hospital. The baby had blood infection which had spread to his other organs as well. We tried our best but we couldn't save the baby.
His mother was inconsolable. I felt terrible.
It is difficult to put in words what a neonatologist feels like when an infant dies. It is traumatic, devastating to see little lifeless body of a baby that was a bundle of joy for his /her parents.
Our is a profession where we often encounter human tragedy and we all have to develop our own defence mechanisms to deal with it. But it is not always easy—particular when you lose infants under your care. Those little eyes closing forever before they could open properly, those little hands and flailing legs going immobile is a trauma difficult to tackle. The cries and grief of her mother haunted me for a long time.
Now, the thought of losing the baby I had decided to treat without antibiotics almost paralysed me. I asked myself if I was doing the right thing, or I am being adventurous. I had to weigh the risk against benefits. But I knew that use of antibiotics when not needed have many harmful effects on the baby. I knew that we are losing the battle against resistant bugs and again decided to suppress my temptation to start antibiotics.
I could barely sleep and would call the ICU several times every night to know how the baby was doing.
Fifteen days passed and the baby sailed through all ups and downs. I felt confident when she was stable. But every little fluctuation in her parameters meant that I again fought a bitter battle with myself.
I often asked myself: should I change course?
But every time I thought of life- long benefits of not using antibiotics and decided to stay the course I had chosen.
She stayed with us for 63 days before I finally signed her discharge papers. Her parents has named her Mannat and she comes to me for her routine check-ups. She will turn 2 the coming September. She doesn't know but she is an inspiration for me. She infuses a new confidence in me--confidence to not use antibiotics when not needed.
She taught me to have faith in laboratory findings, she taught me to follow set protocols, she taught me to use antibiotics rationally.
The writer is head of the department, neonatology, Fortis Hospital, Mohali