Antimicrobial defined daily dose adjusted by weight: a proposal for antibiotic consumption measurement in children

Proposed macroscopic quality indicators of antimicrobial stewardship in primary care: An observational study

OBJECTIVE

The objective of this study was to evaluate the ability of two macroscopic quality indicators to guide antibiotic stewardship strategies.

METHODS

Setting: Bourgogne-Franche-Comté region (eight departments). Antibiotic reimbursement data, expressed in defined daily doses, were used to calculate two macroscopic quality indicators from 2015 to 2020. Urinary tract infection indicator: (fosfomycin + nitrofurantoin + pivmecillinam) / (ciprofloxacin + ofloxacin + norfloxacin) calculated in women aged 15 to 64. Indicator for ear, nose, throat and respiratory tract infections: (amoxicillin/ (amoxicillin-clavulanate + oral 3GC) calculated in children under 15 years of age.

RESULTS

In 2020, global antibiotic consumption varied from 22.2 to 26.6 defined daily doses per 1000 inhabitants per day, depending on the department. The macroscopic quality indicators were lowest in the departments of Nièvre and Yonne. The scores for the urinary tract infection indicator were 0.55 and 0.74, respectively, while those for the ear, nose and throat and respiratory tract infection indicators were 1.85 and 2.12, respectively. Both scores continuously increased in all departments of the region during the survey, except in 2020 for the urinary tract infection indicator, due to a nitrofurantoin shortage.

CONCLUSION

Even in departments with low antibiotic consumption, our macroscopic quality indicators help to identify antibiotic stewardship targets for the most common community-based infections,. They are easy to calculate from quantitative data without requiring any information on diagnosis. Complementarily to other indicators, they provide messages specifically addressed to general practitioners regarding population, molecules and diagnostic elements.

Antibiotic defined daily dose in pediatrics. A single center study to proof the principle that a specific pediatric definition could be not needed

OBJECTIVES

To evaluate if a specific pediatric defined daily dose (PeDDD) can be replaced with the defined daily dose (DDD) indicated by World Health Organization (WHO).

METHODS

The 50th percentile of body weight for age of children admitted from 2016 to 2020 at Istituto Giannina Gaslini, Genoa, Italy, was used to calculate PeDDD for vancomycin at 40mg/kg and meropenem at 60mg/kg. Data obtained were then used to calculate the PeDDD number based on the amount of drugs delivered quarterly from 2012 to 2016. Subsequently the DDD number was calculated for vancomycin at 2g and meropenem at 3g. With these results two curves were generated which were then compared for parallelism and area under the curve (AUC).

RESULTS

PeDDD was found to be 2.6 times DDD for both drugs, but both curves obtained were parallel and the AUCs were identical CONCLUSIONS: DDD according to WHO definition could be adopted in pediatrics to measure antibiotic consumption and therefore no specific PeDDD could be needed.

Development of Antimicrobial Defined Daily Dose (DDD) for the Pediatric Population

Antimicrobial stewardship programs (ASPs) optimize antimicrobial use, improve patient outcomes, and reduce resistance. To assess the effectiveness of ASPs, it is necessary to have indicators that can be widely used. Defined daily dose (DDD) was designed by WHO for the adult population as a consumption indicator. However, there are no DDDs adapted to the pediatric population. The main objective of this study is to establish the most appropriate DDD values in this population. An observational, retrospective, multicenter study was conducted. Antimicrobial prescriptions were collected from pediatric wards of seven Spanish tertiary hospitals for 2 years. The DDDs obtained from the prescriptions were compared with the theoretical DDDs agreed upon in the first stage. To select the optimal DDD, the following were analyzed: power value, magnitude obtained from the differences in the DDD, statistical significance, and degree of agreement in the stipulated doses. A total of 4788 prescriptions were collected. Pediatric DDD was defined for 30 different antimicrobials. A potency >80% was obtained in 24 antibiotics. 51.2% of the selected DDD correspond to Phase I and 39.5% from Phase II. Pediatric DDD of different antimicrobials was obtained, providing an indicator that can be used globally in different hospitals to analyze the consumption and efficacy of ASPs.

Monitoring Antibiotic Consumption in Pediatrics. How Close to Reality Are Days of Therapy and Recommended Daily Dose Methods?

BACKGROUND

Hospitals are advised to monitor antibiotic use. Several approximation methods do exist to perform this task. Adult cohorts can easily be monitored using the defined daily dose method, or its German adaption recommended daily doses (RDD) method, that seems inapplicable in pediatric cohorts due to body weight variations. Guidelines recommend the days of therapy (DOT) method in pediatrics. Still, there is a need for more detailed analysis regarding the performance of both methods.

METHODS

Based on data from 4½ years of our fully computerized patient care data managing system in a combined neonatal and pediatric intensive care unit, we compare the results for DOT and RDD per 100 patient days with exact measurement of antibiotic consumption (individual daily dose per 100 patient days) as internal reference.

RESULTS

The DOT method reflected antibiotic consumption in our cohort on the level of total consumption, subgroups, and agents with almost always high accuracy (correlation with individual daily dose between 0.73 and 1.00). The RDD method showed poor correlation on the level of total consumption (r = 0.21) and fluctuating results on more detailed levels (correlation, 0.01-0.94). A detailed analysis of body weight distribution and ordered packaging sizes of single agents revealed that RDD seems to work well when only one package size of the agent was ordered in our pharmacy.

CONCLUSION

The DOT method is superior to RDD for monitoring antibiotic drug consumption in pediatric cohorts. RDD seems to work satisfactory well for selected antibiotic agents that are administered with little variation in packaging size.

Trends and Pattern of Antibiotic Use in Children in Northern Spain, Interpreting Data about Antibiotic Consumption in Pediatric Outpatients

Monitoring of antibiotic prescription and consumption behavior is crucial. The Access, Watch, and Reserve (AWaRe) classification of antibiotics has been recently introduced in order to measure and improve patterns of antibiotic use. In this study, retrospective data about systemic antibiotic consumption (expressed in defined daily dose per 1000 inhabitants per day (DID)) in pediatric outpatients in a region in northern Spain (around 100,000 children up to 14 years old) from 2005 to 2018 were analyzed and compared with antibiotic consumption in general population in Spain. The pattern of use was analyzed by the percentage of the current AWaRe categories, the Access-to-Watch index, and the amoxicillin index. Data were calculated annually and compared into two periods. Mean antibiotic consumption in pediatric outpatients was 14.0 DID (CI 95% 13.38–14.62). It remained stable throughout the study and was lower than consumption in general population in Spain, particularly from 2016. Changes in the consumption of the main active principles have led to an improvement in the three metrics of the pattern of use. It is important to have a thorough knowledge of the methodology applied in studies about antibiotic consumption. There is a lack of an optimal standardized metric for the pediatric population.

Evolution of antibiotic consumption in pediatric outpatients of Asturias, Spain (2005-2018)

INTRODUCTION

Data about consumption of antibiotics in Spain are worrisome. They are mainly prescribed in the community sector and there is a high exposure to antibiotics in the pediatric population. The aim of this study is to describe the evolution of antibiotic consumption in the pediatric population of Asturias during 2005-2018 period.

METHODS

Retrospective and descriptive study using data about consumption of antibacterial agents for systemic use (J01 group of the Anatomical Therapeutic Chemical Classification) in pediatric outpatients in Asturias between 2005 and 2018. Data, expressed as defined daily dose (DDD) per 1000 inhabitants per day (DID), in three periods were compared.

RESULTS

Mean antibiotic consumption in pediatric outpatients in Asturias (2005-2018) was 14 DID (CI95% 13.4-14.6). Consumption increased until 2009 (15.2 DID) and decreased from 2015 onwards (11.9 DID in 2018). Remarkable data along the study were: 1) increase in amoxicillin consumption (p = 0.027), that have exceeded that of amoxicillin-clavulanate since 2011; 2) steady consumption of macrolides, with an increase in azithromycin (p < 0.001) and a decrease in clarithromycin (p = 0.001); 3) reduction of cephalosporins consumption (p < 0.001); 4) increase in quinolones consumption (p = 0.002).

CONCLUSIONS

Global antibiotic consumption in pediatric outpatients in Asturias between 2005 and 2018 has experienced a constant decrease lately and an improvement in patterns of antibacterial use.

[Evolution of antibiotic consumption in pediatric outpatients of Asturias, Spain (2005-2018)]

INTRODUCTION

Data about consumption of antibiotics in Spain are worrisome. They are mainly prescribed in the community sector and there is a high exposure to antibiotics in the pediatric population. The aim of this study is to describe the evolution of antibiotic consumption in the pediatric population of Asturias during 2005-2018 period.

MATERIAL AND METHODS

Retrospective and descriptive study using data about consumption of antibacterial agents for systemic use (J01 group of the Anatomical Therapeutic Chemical Classification) in pediatric outpatients in Principado de Asturias between 2005 and 2018. Data, expressed as defined daily dose (DDD) per 1000 inhabitants per day (DID), in three periods were compared.

RESULTS

Mean antibiotic consumption in pediatric outpatients in Principado de Asturias (2005-2018) was 14 DID (CI95% 13.4-14.6). Consumption increased until 2009 (15.2 DID) and decreased from 2015 onwards (11.9 DID in 2018). Remarkable data along the study were: 1) increase in amoxicillin consumption (p=0.027), that have exceeded that of amoxicillin-clavulanate since 2011; 2) steady consumption of macrolides, with an increase in azithromycin (p<0.001) and a decrease in clarithromycin (p=0.001); 3) reduction of cephalosporins consumption (p<0.001); 4) increase in quinolones consumption (p=0.002).

CONCLUSIONS

Global antibiotic consumption in pediatric outpatients in Principado de Asturias between 2005 and 2018 has experienced a constant decrease lately and an improvement in patterns of antibacterial use.

Benefits of a Pediatric Antimicrobial Stewardship Program in Antimicrobial Use and Quality of Prescriptions in a Referral Children's Hospital

OBJECTIVES

To evaluate the results of the first 24 months of a postprescription review with feedback-based antimicrobial stewardship program in a European referral children's hospital.

STUDY DESIGN

We performed a pre-post study comparing antimicrobial use between the control (2015-2016) and the intervention periods (2017-2018) expressed in days of therapy/100 days present. Quality of prescriptions was evaluated by quarterly cross-sectional point-prevalence surveys. Length of stay, readmission rates, in-hospital mortality rates, cost of systemic antimicrobial agents, and antimicrobial resistance rates were included as complementary outcomes.

RESULTS

Total antimicrobial use and antibacterial use significantly decreased during the intervention period (P = .002 and P = .001 respectively), and total antifungal use remained stable. A significant decline in parenteral antimicrobial use was also observed (P < .001). In 8 quarterly point-prevalence surveys (938 prescriptions evaluated), the mean prevalence of use of any antimicrobial among inpatients was 39%. An increasing trend in the rate of optimal prescriptions was observed after the first point-prevalence survey (P = .0898). Nonoptimal prescriptions were more common in surgical than in medical departments, in antibacterial prescriptions with prophylactic intention, and in empirical more than in targeted treatments. No significant differences were observed in terms of mortality or readmission rates. Only minor changes in antimicrobial resistance rates were noted.

CONCLUSIONS

Our antimicrobial stewardship program safely decreased antimicrobial use and expenditure, and a trend toward improvement in quality of prescription was also observed.