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Villanueva-Bueno C, Montecatine-Alonso E, Jiménez-Parrilla F, González-López M, Manrique-Rodríguez S, Moreno-Ramos F, Cañete-Ramírez C, Dolz E, García-Robles A, Caro-Teller JM, Moral-Pumarega MT, Bergon-Sendin E, Gómez-Trevecedo Calvo MT, Gallego-Fernández C, del Vayo-Benito CÁ, Mejías-Trueba M, Gil-Navarro MV. Antimicrobial Defined Daily Dose in Neonatal Population: Validation in the Clinical Practice. Antibiotics (Basel) 2023; 12:antibiotics12030602. [PMID: 36978469 PMCID: PMC10044623 DOI: 10.3390/antibiotics12030602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/21/2023] [Accepted: 03/09/2023] [Indexed: 03/19/2023] Open
Abstract
Background: Currently, there is no validated method for estimating antimicrobial consumption in the neonatal population, as it exists for adults using Defined Daily Doses (DDD). In neonatology, although there are different methods, each one with advantages and disadvantages, there is no unified criterion for use. The aim of this study is to validate the neonatal DDD designed as a new standardised form of antimicrobial consumption over this population. Methods: The validation of the neonatal DDD, Phase II of the research project, was carried out through a descriptive observational study. Periodic cut-offs were performed to collect antimicrobial prescriptions of neonates admitted to the neonatology and intensive care units of nine Spanish hospitals. The data collected included demographic variables (gestational age, postnatal age, weight and sex), antimicrobial dose, frequency and route of administration. The selection of the optimal DDD value takes into account power value, magnitude obtained from the differences in the DDD, statistical significance obtained by the Wilcoxon test and degree of agreement in the stipulated doses. Results: Set of 904 prescriptions were collected and finally 860 were analysed based on the established criteria. The antimicrobials were mostly prescribed in the intensive care unit (63.1%). 32 different antimicrobials were collected, and intravenous administration was the most commonly used route. Neonatal DDD were defined for 11 different antimicrobials. A potency > 80% was obtained in 7 antibiotics. The 57.1% of the selected DDD correspond to phase I and 21.4% from phase II. Conclusion: DDD validation has been achieved for the majority of intravenously administered antimicrobials used in clinical practice in the neonatal population. This will make it possible to have an indicator that will be used globally to estimate the consumption of antimicrobials in this population, thus confirming its usefulness and applicability.
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Affiliation(s)
- Cristina Villanueva-Bueno
- Department of Pharmacy, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañon, 28007 Madrid, Spain
- Correspondence:
| | | | | | - María González-López
- Department of Neonatology, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Silvia Manrique-Rodríguez
- Department of Pharmacy, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañon, 28007 Madrid, Spain
| | | | - Carme Cañete-Ramírez
- Department of Pharmacy, Hospital Universitario Vall d’Hebron, 08035 Barcelona, Spain
| | - Elisenda Dolz
- Department of Pharmacy, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Las Palmas de Gran Canarias, Spain
| | - Ana García-Robles
- Division of Pharmacy, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - José Manuel Caro-Teller
- Department of Pharmacy, Hospital Universitario 12 de Octubre, Research Institute 12 de Octubre i+12, 28041 Madrid, Spain
| | | | - Elena Bergon-Sendin
- Department of Neonatology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
| | | | | | | | - Marta Mejías-Trueba
- Department of Pharmacy, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain (M.M.-T.)
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, 41013 Seville, Spain
| | - María Victoria Gil-Navarro
- Department of Pharmacy, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain (M.M.-T.)
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital, CSIC, University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, 28029 Madrid, Spain
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2
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Baltogianni M, Giapros V, Kosmeri C. Antibiotic Resistance and Biofilm Infections in the NICUs and Methods to Combat It. Antibiotics (Basel) 2023; 12:antibiotics12020352. [PMID: 36830264 PMCID: PMC9951928 DOI: 10.3390/antibiotics12020352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Neonatal sepsis is an important cause of neonatal morbidity and mortality. A significant proportion of bacteria causing neonatal sepsis is resistant to multiple antibiotics, not only to the usual empirical first-line regimens, but also to second- and third-line antibiotics in many neonatal intensive care units (NICUs). NICUs have unique antimicrobial stewardship goals. Apart from antimicrobial resistance, NICUs have to deal with another problem, namely biofilm infections, since neonates often have central and peripheral lines, tracheal tubes and other foreign bodies for a prolonged duration. The aim of this review is to describe traditional and novel ways to fight antibiotic-resistant bacteria and biofilm infections in NICUs. The topics discussed will include prevention and control of the spread of infection in NICUs, as well as the wise use of antimicrobial therapy and ways to fight biofilm infections.
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Affiliation(s)
- Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
- Correspondence: ; Tel.: +30-26-5100-7546
| | - Chrysoula Kosmeri
- Department of Pediatrics, University Hospital of Ioannina, 45500 Ioannina, Greece
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3
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Nephrotoxic medications and associated acute kidney injury in hospitalized neonates. J Nephrol 2022; 35:1679-1687. [PMID: 35167057 DOI: 10.1007/s40620-022-01264-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Hospitalized neonates are often treated with nephrotoxic medications, a known risk factor for acute kidney injury (AKI). Nephrotoxic medications and AKI, especially in periviable neonates, could be detrimental to nephrogenesis. Our objectives were to evaluate the prevalence of neonatal treatment with nephrotoxic medications and its relationship with AKI in in the first 28 days of life, and to delineate the associated demographics and diagnoses. STUDY DESIGN Multicenter retrospective analysis using the national Pediatric Hospital Information System database, including 49 pediatric hospitals. Neonates admitted within the first two postnatal days were included. Treatment with 37 nephrotoxic medications across demographics and clinical variables, and relationship with AKI were evaluated. AKI was determined by using the International Classification of Diseases codes. RESULTS Of 192,229 neonates, 74% were treated with at least one nephrotoxic medication. Incidence of AKI was significantly higher in the treated group (aRR 3.68 [95% CI: 2.85, 4.75]). The aRRs of treatment were increased in infants born < 32-week, and < 2000 g. Nephrotoxic medications were prescribed to 90-95% of neonates born ≤ 28-week gestational age. Most treatments (95-98%) occurred in the first 3 days. Intravascular aminoglycosides were the most frequent type; 28% of neonates were treated for ≥ 4 calendar days. Most common diagnoses were infections (25%) and patent ductus arteriosus (20%). CONCLUSIONS Neonatal treatment with nephrotoxic medications is common, especially among the smallest, most immature preterm neonates and demonstrates a need for initiatives to reduce neonatal exposure to these agents, when feasible. Across all gestational age categories, the prevalence of AKI is higher in the neonates treated with nephrotoxic drugs. The long-term effects of treatment with nephrotoxic medications and subsequent AKI on nephrogenesis and nephron endowment will need to be evaluated.
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4
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Villanueva-Bueno C, Montecatine-Alonso E, Jiménez-Parrilla F, Fernández-Llamazares CM, Manrique-Rodríguez S, Zamora-Flores E, Dolz E, Fernández-Polo A, Catillo-Salinas F, Comuñas J, Gallego-Fernández C, González-López M, Gómez-Trevecedo Calvo MT, Gázquez-Pérez R, Álvarez Del Vayo-Benito C, Gil-Navarro MV. Antimicrobial defined daily dose in neonatal population. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2022; 40:59-65. [PMID: 35120651 DOI: 10.1016/j.eimce.2021.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/11/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Antimicrobial defined daily dose (DDD), a standardized metric to assess antimicrobial consumption in adult population, has limitations hampering its use in neonatal patients. This study proposes an alternative DDD design applicable for neonates. METHODS Neonates (<1 month-old) from 6 Spanish hospitals during a 12-months period were included. Weight and weeks gestational age of each neonate were the variables collected. DDD (g) for each antimicrobial was calculated by multiplying the obtained weight times the recommended dose (mg/kg) of the antimicrobial for the most common infectious indication selected by the Delphi method. RESULTS A total of 4820 neonates were included. Mean age was 36.72 weeks of gestational age and Mean weight was 2.687kg. Standardized DDD (intravenous; oral route) for representative antimicrobials were: Amoxicillin (0.08; 0.08), amoxicillin-clavulanic acid (0.27; 0.08), ampicillin (0.27; x), cloxacillin (0.13; 0.13), penicillin G sodium (0.12), cefazolin (0.13), cefuroxime (0.27; x), cefotaxime (0.27), ceftazidime (0.27), ceftriaxone (0.13), cefepime (0.27) piperacillin-tazobactam (0.54), aztreonam (0.24), azithromycin (0.03; 0.03), clindamycin (0.04; 0.04), amikacin (0.04), gentamicin (0.01), metronidazole (0.04; 0.08), ciprofloxacin (0.04; 0.05), levofloxacin (x;x), fluconazole (0.02; 0.02), itraconazole (0.01; 0.01), fosfomycin (0.27). Restricted antimicrobials: meropenem (0.11), teicoplanin (0.02), vancomycin (0.08; 0.11), linezolid (0.08; 0.08), daptomycin (x), amphotericin B liposomal (0.01). CONCLUSIONS A useful method for antimicrobial DDD measurement in neonatology has been designed to monitor antimicrobial consumption in hospital settings. It should be validated in further studies and thereby included in the design for neonatal antimicrobial stewardship programs in the future.
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Affiliation(s)
- Cristina Villanueva-Bueno
- Department of Pharmacy, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - Elena Montecatine-Alonso
- Department of Pharmacy, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Cecilia M Fernández-Llamazares
- Department of Pharmacy, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Research Network on Maternal and Child Health and Development II (Red SAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Silvia Manrique-Rodríguez
- Department of Pharmacy, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Research Network on Maternal and Child Health and Development II (Red SAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Elena Zamora-Flores
- Neonatology Division, Department of Pediatrics, Gregorio Marañon Biomedical Research Institute, Gregorio Marañon University Hospital, Complutense University, Madrid, Spain
| | - Elisenda Dolz
- Department of Pharmacy, Complejo hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canarias, Spain
| | - Aurora Fernández-Polo
- Department of Pharmacy, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, PROA-NEN Project, Barcelona, Spain
| | | | - Juanjo Comuñas
- Department of Neonatology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | | | - Rocío Gázquez-Pérez
- Department of Pharmacy, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain
| | | | - Maria-Victoria Gil-Navarro
- Department of Pharmacy, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Ting JY, Autmizguine J, Dunn MS, Choudhury J, Blackburn J, Gupta-Bhatnagar S, Assen K, Emberley J, Khan S, Leung J, Lin GJ, Lu-Cleary D, Morin F, Richter LL, Viel-Thériault I, Roberts A, Lee KS, Skarsgard ED, Robinson J, Shah PS. Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective. Front Pediatr 2022; 10:894005. [PMID: 35874568 PMCID: PMC9304938 DOI: 10.3389/fped.2022.894005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.
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Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Autmizguine
- Division of Infectious Diseases, Department of Pediatrics, Université de Montreal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada
| | - Michael S Dunn
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montreal, Montreal, QC, Canada
| | - Shikha Gupta-Bhatnagar
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Katrin Assen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Emberley
- Division of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah Khan
- Department of Microbiology, McMaster University, Hamilton, ON, Canada
| | - Jessica Leung
- Department of Pediatrics, University of Massachusetts, Worcester, MA, United States
| | - Grace J Lin
- School of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Frances Morin
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kyong-Soon Lee
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joan Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Prakesh S Shah
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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6
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Garrido F, Allegaert K, Arribas C, Villamor E, Raffaeli G, Paniagua M, Cavallaro G. Variations in Antibiotic Use and Sepsis Management in Neonatal Intensive Care Units: A European Survey. Antibiotics (Basel) 2021; 10:antibiotics10091046. [PMID: 34572631 PMCID: PMC8469483 DOI: 10.3390/antibiotics10091046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/18/2022] Open
Abstract
Management of neonatal sepsis and the use of antimicrobials have an important impact on morbidity and mortality. However, there is no recent background on which antibiotic regimens are used in different European neonatal intensive care units (NICUs). Our study aimed to describe the use of antibiotics and other aspects of early- and late-onset sepsis (EOS and LOS, respectively) management by European NICUs. We conducted an online survey among NICUs throughout Europe to collect information about antibiotic stewardship, antibiotic regimens, and general aspects of managing neonatal infections. NICUs from up to 38 European countries responded, with 271 valid responses. Most units had written clinical guidelines for EOS (92.2%) and LOS (81.1%) management. For EOS, ampicillin, penicillin, gentamicin, and amikacin were the most commonly used antibiotics. Analysis of the combinations of EOS regimens showed that the most frequently used was ampicillin plus gentamicin (54.6%). For LOS, the most frequently used antibiotics were vancomycin (52.4%), gentamicin (33.9%), cefotaxime (28%), and meropenem (15.5%). Other aspects of the general management of sepsis have also been analyzed. The management of neonatal sepsis in European NICUs is diverse. There was high self-reported adherence to the local clinical guidelines. There was homogeneity in the combination of antibiotics in EOS but less in LOS.
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Affiliation(s)
- Felipe Garrido
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
- Correspondence: ; Tel.: +34-661214947
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Cristina Arribas
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), 6229 Maastricht, The Netherlands;
| | - Genny Raffaeli
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, NICU, 20122 Milan, Italy; (G.R.); (G.C.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Miren Paniagua
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
| | - Giacomo Cavallaro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, NICU, 20122 Milan, Italy; (G.R.); (G.C.)
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7
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Villanueva-Bueno C, Montecatine-Alonso E, Jiménez-Parrilla F, Fernández-Llamazares CM, Manrique-Rodríguez S, Zamora-Flores E, Dolz E, Fernández-Polo A, Catillo-Salinas F, Comuñas J, Gallego-Fernández C, González-López M, Gómez-Trevecedo Calvo MT, Gázquez-Pérez R, Álvarez Del Vayo-Benito C, Gil-Navarro MV. Antimicrobial defined daily dose in neonatal population. Enferm Infecc Microbiol Clin 2021; 40:S0213-005X(21)00191-9. [PMID: 34183175 DOI: 10.1016/j.eimc.2021.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/05/2021] [Accepted: 05/11/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Antimicrobial defined daily dose (DDD), a standardized metric to assess antimicrobial consumption in adult population, has limitations hampering its use in neonatal patients. This study proposes an alternative DDD design applicable for neonates. METHODS Neonates (<1 month-old) from 6 Spanish hospitals during a 12-months period were included. Weight and weeks gestational age of each neonate were the variables collected. DDD (g) for each antimicrobial was calculated by multiplying the obtained weight times the recommended dose (mg/kg) of the antimicrobial for the most common infectious indication selected by the Delphi method. RESULTS A total of 4820 neonates were included. Mean age was 36.72 weeks of gestational age and Mean weight was 2.687kg. Standardized DDD (intravenous; oral route) for representative antimicrobials were: Amoxicillin (0.08; 0.08), amoxicillin-clavulanic acid (0.27; 0.08), ampicillin (0.27; x), cloxacillin (0.13; 0.13), penicillin G sodium (0.12), cefazolin (0.13), cefuroxime (0.27; x), cefotaxime (0.27), ceftazidime (0.27), ceftriaxone (0.13), cefepime (0.27) piperacillin-tazobactam (0.54), aztreonam (0.24), azithromycin (0.03; 0.03), clindamycin (0.04; 0.04), amikacin (0.04), gentamicin (0.01), metronidazole (0.04; 0.08), ciprofloxacin (0.04; 0.05), levofloxacin (x;x), fluconazole (0.02; 0.02), itraconazole (0.01; 0.01), fosfomycin (0.27). Restricted antimicrobials: meropenem (0.11), teicoplanin (0.02), vancomycin (0.08; 0.11), linezolid (0.08; 0.08), daptomycin (x), amphotericin B liposomal (0.01). CONCLUSIONS A useful method for antimicrobial DDD measurement in neonatology has been designed to monitor antimicrobial consumption in hospital settings. It should be validated in further studies and thereby included in the design for neonatal antimicrobial stewardship programs in the future.
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Affiliation(s)
- Cristina Villanueva-Bueno
- Department of Pharmacy, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - Elena Montecatine-Alonso
- Department of Pharmacy, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Cecilia M Fernández-Llamazares
- Department of Pharmacy, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Research Network on Maternal and Child Health and Development II (Red SAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Silvia Manrique-Rodríguez
- Department of Pharmacy, Hospital Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Research Network on Maternal and Child Health and Development II (Red SAMID II), Spanish Health Institute Carlos III, Madrid, Spain
| | - Elena Zamora-Flores
- Neonatology Division, Department of Pediatrics, Gregorio Marañon Biomedical Research Institute, Gregorio Marañon University Hospital, Complutense University, Madrid, Spain
| | - Elisenda Dolz
- Department of Pharmacy, Complejo hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canarias, Spain
| | - Aurora Fernández-Polo
- Department of Pharmacy, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, PROA-NEN Project, Barcelona, Spain
| | | | - Juanjo Comuñas
- Department of Neonatology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | | | - Rocío Gázquez-Pérez
- Department of Pharmacy, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain
| | | | - Maria-Victoria Gil-Navarro
- Department of Pharmacy, Institute of Biomedicine of Seville (IBIS), Hospital Universitario Virgen del Rocío, Sevilla, Spain
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8
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Garcia TM, van Roest M, Vermeulen JLM, Meisner S, Smit WL, Silva J, Koelink PJ, Koster J, Faller WJ, Wildenberg ME, van Elburg RM, Muncan V, Renes IB. Early Life Antibiotics Influence In Vivo and In Vitro Mouse Intestinal Epithelium Maturation and Functioning. Cell Mol Gastroenterol Hepatol 2021; 12:943-981. [PMID: 34102314 PMCID: PMC8346670 DOI: 10.1016/j.jcmgh.2021.05.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS The use of antibiotics (ABs) is a common practice during the first months of life. ABs can perturb the intestinal microbiota, indirectly influencing the intestinal epithelial cells (IECs), but can also directly affect IECs independent of the microbiota. Previous studies have focused mostly on the impact of AB treatment during adulthood. However, the difference between the adult and neonatal intestine warrants careful investigation of AB effects in early life. METHODS Neonatal mice were treated with a combination of amoxicillin, vancomycin, and metronidazole from postnatal day 10 to 20. Intestinal permeability and whole-intestine gene and protein expression were analyzed. IECs were sorted by a fluorescence-activated cell sorter and their genome-wide gene expression was analyzed. Mouse fetal intestinal organoids were treated with the same AB combination and their gene and protein expression and metabolic capacity were determined. RESULTS We found that in vivo treatment of neonatal mice led to decreased intestinal permeability and a reduced number of specialized vacuolated cells, characteristic of the neonatal period and necessary for absorption of milk macromolecules. In addition, the expression of genes typically present in the neonatal intestinal epithelium was lower, whereas the adult gene expression signature was higher. Moreover, we found altered epithelial defense and transepithelial-sensing capacity. In vitro treatment of intestinal fetal organoids with AB showed that part of the consequences observed in vivo is a result of the direct action of the ABs on IECs. Lastly, ABs reduced the metabolic capacity of intestinal fetal organoids. CONCLUSIONS Our results show that early life AB treatment induces direct and indirect effects on IECs, influencing their maturation and functioning.
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Affiliation(s)
- Tânia Martins Garcia
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Manon van Roest
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Jacqueline L M Vermeulen
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Sander Meisner
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Wouter L Smit
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joana Silva
- Department of Oncogenomics, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Pim J Koelink
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Jan Koster
- Department of Oncogenomics, Amsterdam, the Netherlands
| | - William J Faller
- Department of Oncogenomics, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Manon E Wildenberg
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Ruurd M van Elburg
- Department of Pediatrics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Vanesa Muncan
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands.
| | - Ingrid B Renes
- Department of Pediatrics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Danone Nutricia Research, Utrecht, the Netherlands
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9
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Abstract
Antibiotics are extensively and inconsistently prescribed in neonatal ICUs, and usage does not correlate with rates of culture positive sepsis. There is mounting data describing the short and long-term adverse effects associated with antibiotic overuse in neonates, including the increased burden of multi-drug resistant organisms. Currently there is considerable variation in antibiotic prescribing practice among neonatologists. Applying the practice of antibiotic stewardship in the NICU is crucial for standardizing antibiotic use and improving outcomes in this population. Several approaches have been proposed to identify neonatal sepsis, with the hope of reducing antibiotic utilization. These strategies all have their limitations, and often include laboratory testing and treatment of well-appearing, non-septic, infants. A conservative "watch and wait" algorithm is suggested as an alternative method for when to initiate antibiotics. This observational approach relies on availability of trained personnel able to examine infants at specified intervals, without delaying antibiotics, should signs of sepsis arise.
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Affiliation(s)
- Noa Fleiss
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas A Hooven
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Richard A Polin
- Department of Pediatrics, Columbia University School of Medicine, New York City, NY, USA.
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10
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Clements MN, Russell N, Bielicki JA, Ellis S, Gastine S, Hsia Y, Standing JF, Walker AS, Sharland M. Global antibiotic dosing strategies in hospitalised children: Characterising variation and implications for harmonisation of international guidelines. PLoS One 2021; 16:e0252223. [PMID: 34043696 PMCID: PMC8159011 DOI: 10.1371/journal.pone.0252223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/11/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Paediatric global antibiotic guidelines are inconsistent, most likely due to the limited pharmacokinetic and efficacy data in this population. We investigated factors underlying variation in antibiotic dosing using data from five global point prevalence surveys. METHODS & FINDINGS Data from 3,367 doses of the 16 most frequent intravenous antibiotics administered to children 1 month-12 years across 23 countries were analysed. For each antibiotic, we identified standard doses given as either weight-based doses (in mg/kg/day) or fixed daily doses (in mg/day), and investigated the pattern of dosing using each strategy. Factors underlying observed variation in weight-based doses were investigated using linear mixed effects models. Weight-based dosing (in mg/kg/day) clustered around a small number of peaks, and all antibiotics had 1-3 standard weight-based doses used in 5%-48% of doses. Dosing strategy was more often weight-based than fixed daily dosing for all antibiotics apart from teicoplanin, which had approximately equal proportions of dosing attributable to each strategy. No strong consistent patterns emerged to explain the historical variation in actual weight-based doses used apart from higher dosing seen in central nervous system infections, and lower in skin and soft tissue infections compared to lower respiratory tract infections. Higher dosing was noted in the Americas compared to the European region. CONCLUSIONS Antibiotic dosing in children clusters around a small number of doses, although variation remains. There is a clear opportunity for the clinical, scientific and public health communities to consolidate behind a consistent set of global antibiotic dosing guidelines to harmonise current practice and prioritise future research.
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Affiliation(s)
| | - Neal Russell
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s University, London, United Kingdom
| | - Julia A. Bielicki
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s University, London, United Kingdom
| | - Sally Ellis
- Global Antibiotic Research & Development Partnership, Geneva, Switzerland
| | - Silke Gastine
- Infection, Immunity and Inflammation, Institute of Child Health, University College London, London, United Kingdom
| | - Yingfen Hsia
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s University, London, United Kingdom
| | - Joseph F. Standing
- Infection, Immunity and Inflammation, Institute of Child Health, University College London, London, United Kingdom
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s University, London, United Kingdom
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11
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Singh P, Steurer MA, Cantey JB, Wattier RL. Hospital-level Antibiotic Use and Complexity of Care Among Neonates. J Pediatric Infect Dis Soc 2020; 9:656-663. [PMID: 31879765 PMCID: PMC7974016 DOI: 10.1093/jpids/piz091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 12/05/2019] [Indexed: 11/13/2022]
Abstract
BACKGROUND Despite increasing neonatal antibiotic stewardship efforts, understanding of interhospital variation in neonatal antibiotic use is limited. METHODS A retrospective cohort study was conducted among primarily academically affiliated hospitals participating in the Vizient Clinical Database/Resource Manager. Neonatal discharges were identified by admission age <1 month, excluding nonviable neonates and normal newborns. Hospitals with ≥100 neonatal discharges and complete data for January-December 2016 were included. Antibiotic use was measured in days of therapy per 1000 patient-days (DOT/1000 pd). A composite measure of neonatal care complexity (NCC; low, medium, high) was based on the volume of very low-birth-weight neonates and neonates undergoing surgical procedures, cardiac surgery, or extracorporeal membranous oxygenation. RESULTS The 118 included hospitals represented 184 716 neonatal discharges; 22 hospitals with low NCC, 56 with medium NCC, and 40 with high NCC. Mean antibiotic DOT/1000 pd was 363 (standard deviation [SD], 94) in high NCC hospitals, 243 (SD, 88) in medium NCC hospitals, and 184 (SD, 122) in low NCC hospitals. Increasing NCC was associated with higher antibiotic use, with an incidence rate ratio (IRR) of 1.95 (95% confidence interval [CI], 1.55 to 2.47) for high vs low NCC and IRR 1.31 (95% CI, 1.05 to 1.64) for medium vs low NCC. Increasing case mix index was associated with higher antibiotic use (IRR 1.86 per unit increase; 95% CI, 1.50 to 2.31). CONCLUSIONS Aggregate antibiotic use among hospitalized neonates varies based on care complexity. Substantial variation despite stratification by complexity suggests incomplete risk adjustment and/or avoidable variation in care.
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Affiliation(s)
- Prachi Singh
- Department of Infectious Diseases, University of California San Francisco Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Martina A Steurer
- Department of Epidemiology and Biostatistics, Pediatrics and the California Preterm Birth Initiative, University of California San Francisco, San Francisco, California, USA
| | - Joseph B Cantey
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, Texas, USA
| | - Rachel L Wattier
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
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12
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Abstract
Preterm infants are susceptible to infections that can rapidly progress to disastrous outcomes. Antibiotics are lifesaving, but their prolonged and inappropriate use are associated with adverse outcomes. In this review, we discuss the current status of antimicrobial use in the preterm neonatal population, and the challenges in determining the initiation, duration, and choice of antibiotics. Finally, we review the clinical studies on the potential consequences of prolonged antimicrobial exposure in prematurely born infants.
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13
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Drug Utilisation and Off-Label Use on a German Neonatal Intensive Care Unit: A Retrospective Cohort Study and 10-Year Comparison. PHARMACY 2020; 8:pharmacy8030173. [PMID: 32957455 PMCID: PMC7559028 DOI: 10.3390/pharmacy8030173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/17/2022] Open
Abstract
Pharmacotherapy of neonates is complex and marked to a large extent of off-label use. The implementation of the Paediatric Regulation (2007) gave hope for a change in the safety and efficacy for drugs used in neonatal intensive care units (NICU). This study investigates drug utilisation patterns and off-label use in a German neonatal intensive care unit (NICU) in 2014. A 12-months retrospective, observational cohort study was performed at the NICU of the University Children's Hospital Erlangen, Germany. Licensing status was determined using the Summary of Product Characteristics (SmPC). Results are compared with a similar study conducted 10 years earlier. The study included 204 patients (57.8% male) (2004: 183) and 2274 drug prescriptions were recorded (2004: 1978). The drugs that were mostly prescribed were drugs for the nervous system (2004: 22.6%; 2014: 26.9%) and anti-infectives for systemic use (2004: 26.0%; 2014: 24.9%);34.3% (2004) and 39.2% (2014) of all prescriptions were off-label;62.7% of all patients received at least one off-label or unlicensed drug (2004: 70%). For 13 drugs, the licensing status changed either from off-label to label (n = 9) or vice versa (n = 4). Overall, there was no significant change neither in terms of the drugs used nor regarding their licensing status. Further studies are needed to validate these findings in a European context.
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14
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Araujo da Silva AR, Marques A, Di Biase C, Faitanin M, Murni I, Dramowski A, Hübner J, Zingg W. Effectiveness of antimicrobial stewardship programmes in neonatology: a systematic review. Arch Dis Child 2020; 105:563-568. [PMID: 32156697 DOI: 10.1136/archdischild-2019-318026] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/18/2019] [Accepted: 02/07/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Antimicrobial stewardship programmes (ASPs) are recommended to improve antibiotic use in healthcare and reduce antimicrobial resistance (AMR). Our aim was to investigate the effectiveness of ASPs in reducing antibiotic consumption, use of broad-spectrum/restricted antibiotics, antibiotic resistance and healthcare-associated infections (HAIs) in neonates. METHODS We searched PUBMED, SCIELO, EMBASE and the Cochrane Database (January 2000-April 2019) to identify studies on the effectiveness of ASPs in neonatal wards and/or neonatal intensive care units (NICUs). Outcomes were as follows: reduction of antibiotic consumption overall and of broad-spectrum/target antibiotics, inappropriate antibiotic use, antibiotic resistance and HAIs. ASPs conducted in settings other than acute care hospitals, for children older than 1 month, and ASPs addressing antifungal and antiviral agents, were excluded. RESULTS The initial search identified 53 173 titles and abstracts; following the application of filters and inclusion criteria, a total of six publications were included in the final analysis. All studies, of which one was multi-centre study, were published after 2010. Five studies were conducted exclusively in NICUs. Four articles applied multimodal interventions. Reduction of antibiotic consumption overall and/or inappropriate antibiotic use were reported by four articles; reduction of broad-spectrum/targeted antibiotics were reported by four studies; No article evaluated the impact of ASPs on AMR or the incidence of HAI in neonates. CONCLUSION ASPs can be effectively applied in neonatal settings. Limiting the use of broad-spectrum antibiotics and shorting the duration of antibiotic treatment are the most promising approaches. The impact of ASPs on AMR and HAI needs to be evaluated in long-term studies.
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Affiliation(s)
| | - Amanda Marques
- Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
| | - Clara Di Biase
- Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
| | - Monique Faitanin
- Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
| | - Indah Murni
- Gadjah Mada University, Yogyakarta, Daerah Istimewa Yogyakart, Indonesia
| | | | - Johannes Hübner
- University Children's Hospital at Dr. von Haunersches Kinderspital, LMU Munich, Munich, Germany
| | - Walter Zingg
- Geneva University Hospitals, Geneva, Switzerland
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15
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McMullan B, Cooper C, Spotswood N, James R, Jones C, Konecny P, Blyth C, Karen T. Antibiotic prescribing in neonatal sepsis: an Australian nationwide survey. BMJ Paediatr Open 2020; 4:e000643. [PMID: 32232180 PMCID: PMC7101048 DOI: 10.1136/bmjpo-2020-000643] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/24/2020] [Accepted: 02/27/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate quality and variation in antibiotic prescribing for neonatal sepsis. DESIGN We analysed prescribing in hospitalised neonates using the National Antimicrobial Prescribing Survey in Australian neonates from 1 January 2014 to 31 December 2018. SETTING Data from antibiotic point prevalence surveys performed in hospitals, ranging from rural hospitals to tertiary paediatric and maternity hospitals within Australia. PATIENTS Admitted neonates <28 days of age from participating hospitals. MAIN OUTCOME MEASURES Variation and appropriateness in prescribing for neonatal sepsis and variation in dosing for gentamicin and benzylpenicillin across hospitals. RESULTS A total of 415 prescriptions among 214 neonates from 39 different hospitals were included. The majority of prescriptions (342, 82.4%) were for neonates <7 days of age. The most commonly prescribed antibiotics were gentamicin and benzylpenicillin, with 323 (77.8%) prescriptions. Dosing variability was substantial, with doses ranging from 2 to 8 mg/kg for gentamicin (median 5 mg/kg, IQR 4-5) and from 45 to 72 mg/kg for benzylpenicillin (median 60 mg/kg, IQR 50-60), although only 13 (3.2%) and 19 (4.6%) prescriptions were locally assessed as inappropriate or non-compliant with guidelines, respectively. At time of audit, 22% of antibiotics had been given for more than 48 hours and 9% more than 72 hours, although microbiologically confirmed infection was documented in only nine (4.2%) neonates. CONCLUSIONS Prescribing for neonatal sepsis was dominated by use of benzylpenicillin and gentamicin with substantial variation in dosing. A small minority had culture-confirmed infection. Efforts to standardise antibiotic dosing and duration for suspected neonatal sepsis are recommended.
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Affiliation(s)
- Brendan McMullan
- Immunology and Infectious Diseases, Sydney Children's Hospital Randwick, Sydney, New South Wales, Australia.,National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Celia Cooper
- Department of Infectious Diseases, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Naomi Spotswood
- Burnet Institute, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Rodney James
- National Centre for Antimicrobial Stewardship, Melbourne, Victoria, Australia
| | - Cheryl Jones
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Pamela Konecny
- Infectious Diseases, Immunology and Sexual Health, St George Hospital, Kogarah, Sydney, New South Wales, Australia.,St George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher Blyth
- School of Paediatrics and Child Health, University of Western Australia, Subiaco, Western Australia, Australia.,Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia.,Department of Paediatric Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Perth, Western Australia, Australia
| | - Thursky Karen
- National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Service and Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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16
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Thaulow CM, Blix HS, Eriksen BH, Ask I, Myklebust TÅ, Berild D. Using a period incidence survey to compare antibiotic use in children between a university hospital and a district hospital in a country with low antimicrobial resistance: a prospective observational study. BMJ Open 2019; 9:e027836. [PMID: 31138583 PMCID: PMC6549646 DOI: 10.1136/bmjopen-2018-027836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES To describe and compare antibiotic use in relation to indications, doses, adherence rate to guidelines and rates of broad-spectrum antibiotics (BSA) in two different paediatric departments with different academic cultures, and identify areas with room for improvement. DESIGN Prospective observational survey of antibiotic use. SETTING Paediatric departments in a university hospital (UH) and a district hospital (DH) in Norway, 2017. The registration period was 1 year at the DH and 4 months at the UH. PARTICIPANTS 201 children at the DH (mean age 3.8: SD 5.1) and 137 children at the UH (mean age 2.0: SD 5.9) were treated with systemic antibiotics by a paediatrician in the study period and included in the study. OUTCOME MEASURES Main outcome variables were prescriptions of antibiotics, treatments with antibiotics, rates of BSA, median doses and adherence rate to national guidelines. RESULTS In total, 744 prescriptions of antibiotics were given at the UH and 638 at the DH. Total adherence rate to guidelines was 75% at the UH and 69% at the DH (p=0.244). The rate of treatments involving BSA did not differ significantly between the hospitals (p=0.263). Use of BSA was related to treatment of central nervous system (CNS) infections, patients with underlying medical conditions or targeted microbiological treatment in 92% and 86% of the treatments, at the UH and DH, respectively (p=0.217). A larger proportion of the children at the DH were treated for respiratory tract infections (p<0.01) compared with the UH. Children at the UH were treated with higher doses of ampicillin and cefotaxime (p<0.05) compared with the DH. CONCLUSION Our results indicate that Norwegian paediatricians have a common understanding of main aspects in rational antibiotic use independently of working in a UH or DH. Variations in treatment of respiratory tract infections and in doses of antibiotics should be further studied.
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Affiliation(s)
| | - Hege Salvesen Blix
- Faculty of Medicine, Department of Pharmacology, University of Oslo, Oslo, Norway
- Department of Drug Statistics, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Ingvild Ask
- Pediatric Department, Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Dag Berild
- Department of Infectious Diseases, University of Oslo, Oslo, Norway
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17
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Allegaert K, Simons S, Van Den Anker J. Research on medication use in the neonatal intensive care unit. Expert Rev Clin Pharmacol 2019; 12:343-353. [PMID: 30741041 DOI: 10.1080/17512433.2019.1580569] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Research on medication use aims at assessing how much of current pharmacotherapy is rational. In neonates, this is hampered by extensive off-label drug use and limited knowledge. Areas covered: We report on medication use research and have conducted a systematic review of observational studies on medication use to provide an updated overview on characteristics, objectives, methods, and patterns in hospitalized neonates. Moreover, a review on aspects of medication use for opioids, anti-epileptics, gastric acid-related disorders and respiratory stimulants with emphasis on trends and impact of interventions is presented, illustrating how research on medication use can contribute to improved neonatal pharmacotherapy and more focused research. Medication use reports describe patterns and provide signals on irrational use, benchmarking, or can guide research priorities. Moreover, this may generate information on how neonatal health topics and their pharmacotherapy are handled over time or across regions. Expert opinion: Research on medicine utilization is relevant, since it will inform us on aspects like trends, variability, or about the impact and pattern of implementation of guidelines in neonates. Further progress necessitates to merge datasets on medication use with clinical characteristics, and perinatal drug use remains an area in need of additional research.
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Affiliation(s)
- Karel Allegaert
- a Department of Pediatrics, Division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Sinno Simons
- a Department of Pediatrics, Division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - John Van Den Anker
- c Division of Clinical Pharmacology, Department of Pediatrics , Children's National Health System , Washington , DC , USA.,d Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland.,e Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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18
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Litz JE, Goedicke-Fritz S, Härtel C, Zemlin M, Simon A. Management of early- and late-onset sepsis: results from a survey in 80 German NICUs. Infection 2019; 47:557-564. [DOI: 10.1007/s15010-018-1263-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022]
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19
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Gkentzi D, Dimitriou G. Antimicrobial Stewardship in the Neonatal Intensive Care Unit: An Update. Curr Pediatr Rev 2019; 15:47-52. [PMID: 30657041 PMCID: PMC6696821 DOI: 10.2174/1573396315666190118101953] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/08/2019] [Accepted: 01/09/2019] [Indexed: 12/19/2022]
Abstract
Neonates represent a vulnerable population for infections and neonatal sepsis is a major cause of mortality and morbidity worldwide. Therefore, antimicrobials are the most commonly prescribed drugs in the Neonatal Intensive Care Unit Setting but unfortunately are quite often used inappropriately with various short and long-term effects. The rational use of antimicrobials is of paramount importance in this population and structured antimicrobial stewardship interventions should be in place. These interventions are slightly different from those used in adults and older children due to the particularities of the neonatal medicine. The aim of this review is to provide an update in the field and identify areas for further consideration and future research.
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Affiliation(s)
- Despoina Gkentzi
- Department of Paediatrics, Patras Medical School, Patras, Greece
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20
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Reduction of Inappropriate Antimicrobial Prescriptions in a Tertiary Neonatal Intensive Care Unit After Antimicrobial Stewardship Care Bundle Implementation. Pediatr Infect Dis J 2019; 38:54-59. [PMID: 30531528 DOI: 10.1097/inf.0000000000002039] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Our objective was to evaluate the appropriateness of antibiotic prescriptions in the neonatal intensive care unit using standardized criteria and determine the effects of an antimicrobial stewardship program (ASP) on patterns of antibiotic usage. METHODS A retrospective audit of antibiotic use from July 2010 to June 2013 was conducted, focusing on prescriptions of vancomycin, cefotaxime, meropenem and linezolid for >3 calendar-days. We evaluated the appropriateness of each course of antibiotic treatment based on the Centers for Disease Control and Prevention 12-Step Guidelines to Prevent Antimicrobial Resistance (steps 4, 6 and 9). An ASP was introduced in August 2014, and the same audit criteria were applied to review antimicrobial use in the subsequent 12 months. RESULTS In the pre-ASP era, 26.3%, 12.1%, 11.4% and 0% of meropenem, cefotaxime, vancomycin and linezolid courses, respectively, were inappropriate. The most common instance of inappropriate utilization included failure to use narrow-spectrum antimicrobials when appropriate. After the introduction of ASP program, 22.2%, 7.5%, 5.4% and 0% of meropenem, cefotaxime, vancomycin and linezolid courses, respectively, were inappropriate. The numbers of inappropriate antibiotic-days/1000 days of therapy with meropenem, cefotaxime and vancomycin changed from 1.89 to 1.96 [rate ratio (RR), 1.04 (0.70-1.52)], 3.56 to 1.73 [RR, 0.49 (0.33-0.71)] and 2.70 to 1.01 [RR, 0.37 (0.22-0.60)], respectively. In subgroup analysis, very low birth weight infants (birth weight, <1500 g) showed no improvement in the rates of inappropriate antibiotic prescriptions. CONCLUSIONS In this study, we found that ASP initiatives can be applied in neonatal populations to reduce inappropriate antimicrobial prescriptions, though a different approach may be needed among very low birth weight infants.
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21
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Flint RB, van Beek F, Andriessen P, Zimmermann LJ, Liem KD, Reiss IKM, de Groot R, Tibboel D, Burger DM, Simons SHP. Large differences in neonatal drug use between NICUs are common practice: time for consensus? Br J Clin Pharmacol 2018; 84:1313-1323. [PMID: 29624207 PMCID: PMC5980600 DOI: 10.1111/bcp.13563] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/24/2018] [Accepted: 02/11/2018] [Indexed: 01/27/2023] Open
Abstract
Aims Evidence for drug use in newborns is sparse, which may cause large differences in drug prescriptions. We aimed to investigate the differences between neonatal intensive care units (NICUs) in the Netherlands in currently prescribed drugs. Methods This multicentre study included neonates admitted during 12 months to four different NICUs. Drugs were classified in accordance with the Anatomical Therapeutic Chemical (ATC) classification system and assessed for on/off‐label status in relation to neonatal age. The treatment protocols for four common indications for drug use were compared: pain, intubation, convulsions and hypotension. Results A total of 1491 neonates (GA range 23+6–42+2 weeks) were included with a total of 32 182 patient days, 181 different drugs and 10 895 prescriptions of which 23% was off‐label in relation to neonatal age. Overall, anti‐infective drugs were most frequently used with a total of 3161 prescriptions, of which 4% was off‐label in relation to neonatal age. Nervous system drugs included 2500 prescriptions of which 31% was off‐label in relation to neonatal age. Nervous system drugs, blood and blood forming organs, and cardiovascular drugs showed the largest differences between NICUs with ranges of 919–2278, 554–1465, and 238–952 total prescriptions per 1000 patients per ATC class, respectively. Conclusions We showed that drug use varies widely in neonatal clinical practice. The drug classes with the highest proportion of off‐label drugs in relation to neonatal age showed the largest differences between NICUs, i.e. cardiovascular and nervous system drugs. Drug research in neonates should receive high priority to guarantee safe and appropriate medicines and optimal treatment.
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Affiliation(s)
- Robert B Flint
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pharmacy and Radboud Institute of Health Sciences (RIHS), Radboudumc, Nijmegen, The Netherlands.,Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Floor van Beek
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Peter Andriessen
- Department of Pediatrics, Division of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Luc J Zimmermann
- Department of Pediatrics, Maastricht University Medical Center, School of Oncology and Developmental Biology, School of Mental Health and Neuroscience, Maastricht, The Netherlands
| | - Kian D Liem
- Department of Pediatrics, Division of Neonatology, Radboudumc, Nijmegen, Nijmegen, The Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ronald de Groot
- Laboratory of Pediatric Infectious Diseases, Department of Pediatrics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Department of Pediatrics, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - David M Burger
- Department of Pharmacy and Radboud Institute of Health Sciences (RIHS), Radboudumc, Nijmegen, The Netherlands
| | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
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Liem TBY, Slob EMA, Termote JUM, Wolfs TFW, Egberts ACG, Rademaker CMA. Comparison of antibiotic dosing recommendations for neonatal sepsis from established reference sources. Int J Clin Pharm 2018; 40:436-443. [PMID: 29340851 PMCID: PMC5918525 DOI: 10.1007/s11096-018-0589-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/04/2018] [Indexed: 11/28/2022]
Abstract
Background Incorrect dosing is the most frequent prescribing error in neonatology, with antibiotics being the most frequently prescribed medicines. Computer physician order entry and clinical decision support systems can create consistency contributing to a reduction of medication errors. Although evidence-based dosing recommendations should be included in such systems, the evidence is not always available and subsequently, dosing recommendations mentioned in guidelines and textbooks are often based on expert opinion. Objective To compare dosage recommendations for antibiotics in neonates with sepsis provided by eight commonly used and well-established international reference sources. Setting An expert team from our Dutch tertiary care neonatal intensive care unit selected eight well-established international reference sources. Method Daily doses of the seven most frequently used antibiotics in the treatment of neonatal sepsis, classified by categories for birth weight and gestational age, were identified from eight well-respected reference sources in neonatology/pediatric infectious diseases. Main outcome measure Standardized average daily dosage. Results A substantial variation in dosage recommendations of antibiotics for neonatal sepsis between the reference sources was shown. Dosage recommendations of ampicillin, ceftazidime, meropenem and vancomycin varied more than recommendations for benzylpenicillin, cefotaxime and gentamicin. One reference source showed a larger variation in dosage recommendations in comparison to the average recommended daily dosage, compared to the other reference sources. Conclusion Antibiotic dosage recommendations for neonates with sepsis can be derived from important reference sources and guidelines. Further exploration to overcome variation in dosage recommendations is necessary to obtain standardized dosage regimens.
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Affiliation(s)
- T B Y Liem
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands.
| | - E M A Slob
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
| | - J U M Termote
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Centre, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
| | - T F W Wolfs
- Department of Pediatrics, Infectious Diseases and Immunology, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
| | - A C G Egberts
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
| | - C M A Rademaker
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
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23
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Goerens A, Lehnick D, Büttcher M, Daetwyler K, Fontana M, Genet P, Lurà M, Morgillo D, Pilgrim S, Schwendener-Scholl K, Regamey N, Neuhaus TJ, Stocker M. Neonatal Ventilator Associated Pneumonia: A Quality Improvement Initiative Focusing on Antimicrobial Stewardship. Front Pediatr 2018; 6:262. [PMID: 30320046 PMCID: PMC6165906 DOI: 10.3389/fped.2018.00262] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/03/2018] [Indexed: 12/24/2022] Open
Abstract
Background and Aims: Neonatal ventilator associated pneumonia (VAP) is a common nosocomial infection and a frequent reason for empirical antibiotic therapy in NICUs. Nonetheless, there is no international consensus regarding diagnostic criteria and management. In a first step, we analyzed the used diagnostic criteria, risk factors and therapeutic management of neonatal VAP by a literature review. In a second step, we aimed to compare suspected vs. confirmed neonatal VAP episodes in our unit according to different published criteria and to analyze interrater-reliability of chest x-rays. Additionally, we aimed to evaluate the development of VAP incidence and antibiotic use after implementation of multifaceted quality improvement changes regarding antimicrobial stewardship and infection control (VAP-prevention-bundle, early-extubation policy, antimicrobial stewardship rounds). Methods: Neonates until 44 weeks of gestation with suspected VAP, hospitalized at our level-III NICU in Lucerne from September 2014 to December 2017 were enrolled. VAP episodes were analyzed according to 4 diagnostic frameworks. Agreement regarding chest x-ray interpretation done by 10 senior physicians was assessed. Annual incidence of suspected and confirmed neonatal VAP episodes and antibiotic days were calculated and compared for the years 2015, 2016, and 2017. Results: 17 studies were identified in our literature review. Overall, CDC-guidelines or similar criteria, requesting radiographic changes as main criteria, are mostly used. Comparison of suspected vs. confirmed neonatal VAP episodes showed a great variance (20.4 vs. 4.5/1,000 ventilator-days). The interrater-reliability of x-ray interpretation was poor (intra-class correlation 0.25). Implemented changes resulted in a gradual decline in annual VAP incidence and antibiotic days from 2015 compared with 2017 (28.8 vs. 7.4 suspected episodes/1,000 ventilator-days, 5.5 vs. 0 confirmed episodes/1,000 ventilator-days and 211 vs. 34.7 antibiotic days/1,000 ventilation-days, respectively). Conclusion: The incidence of suspected VAP and concomitant antibiotic use is much higher than for confirmed VAP, therefore inclusion of suspected episodes should be considered for accurate evaluation. There is a high diagnostic inconsistency and a low reliability of interpretation of chest x-rays regarding VAP. Implementation of combined antimicrobial stewardship and infection control measures may lead to an effective decrease in VAP incidence and antibiotic use.
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Affiliation(s)
- Anouk Goerens
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Dirk Lehnick
- Clinical Trial Unit, University of Lucerne, Lucerne, Switzerland
| | - Michael Büttcher
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Infectious Diseases Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Karin Daetwyler
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Matteo Fontana
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Petra Genet
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Marco Lurà
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric Pulmonology Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Davide Morgillo
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Sina Pilgrim
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Katharina Schwendener-Scholl
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Nicolas Regamey
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric Pulmonology Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Thomas J Neuhaus
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Martin Stocker
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
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24
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Steinmann KE, Lehnick D, Buettcher M, Schwendener-Scholl K, Daetwyler K, Fontana M, Morgillo D, Ganassi K, O'Neill K, Genet P, Burth S, Savoia P, Terheggen U, Berger C, Stocker M. Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature Review. Front Pediatr 2018; 6:294. [PMID: 30370263 PMCID: PMC6194187 DOI: 10.3389/fped.2018.00294] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/20/2018] [Indexed: 12/31/2022] Open
Abstract
Background: Antimicrobial stewardship (AMS) is an important strategy of quality improvement for every hospital. Leadership is an important factor for implementation of quality improvement and AMS programs. Recent publications show successful AMS programs in children's hospitals, but successful implementation is often difficult to achieve and literature of AMS in neonatal and pediatric intensive care units (NICU/PICU) is scarce. Lack of resources and prescriber opposition are reported barriers. A leadership style focusing on empowering frontline staff to take responsibility is one approach to implement changes in health care institutions. Aim: Literature review regarding empowering leadership and AMS in health care and assessment of the impact of such a leadership style on AMS in a NICU/PICU over 3 years. Methods: Assessment of the impact of a leadership change September 1, 2015 from control-driven to an empowering leadership style on antibiotic use and hospital acquired infections. Prospective analysis and annual comparison of antibiotic use, rate of suspected and confirmed ventilator-associated pneumonia (VAP) and central-line associated blood stream infection (CLABSI) including antibiotic use overall, antibiotic therapy for culture-negative and culture-proven infections including correct initial choice and streamlining of antibiotics in the NICU/PICU of the Children's Hospital of Lucerne between January 1, 2015 and December 31, 2017. Results: Five articles were included in the literature review. All five studies concluded that an empowering leadership style may lead to a higher engagement of physicians. Three out of five studies reported improved AMS as reduced rate in hospital-acquired infections and improved prevention of MRSA infections. From 2015 to 2017, antibiotic days overall and antibiotic days for culture-negative situations (suspected infections and prophylaxis) per 1000 patient days declined significantly from 474.1 to 403.9 and from 418.2 to 309.4 days, respectively. Similar, the use of meropenem and vancomycin declined significantly. Over the 3 years, suspected and proven VAP- and CLABSI-episodes decreased with no confirmed episodes in 2017. Conclusion: An empowering leadership style which focuses on enabling frontline physicians to take direct responsibilities for their patients may be a successful strategy of antimicrobial stewardship allowing to overcome reported barriers of AMS implementation.
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Affiliation(s)
- Karin E Steinmann
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Dirk Lehnick
- Department of Health Sciences and Health Policy, Biostatistics and Methodology, University Lucerne, Lucerne, Switzerland
| | - Michael Buettcher
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Infectious Diseases Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Katharina Schwendener-Scholl
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Karin Daetwyler
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Matteo Fontana
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Davide Morgillo
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Katja Ganassi
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Kathrin O'Neill
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Petra Genet
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Susanne Burth
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Patrizia Savoia
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Ulrich Terheggen
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Christoph Berger
- Department of Infectious Diseases and Hospital Epidemiology and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Stocker
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.,Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
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25
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Carr JP, Burgner DP, Hardikar RS, Buttery JP. Empiric antibiotic regimens for neonatal sepsis in Australian and New Zealand neonatal intensive care units. J Paediatr Child Health 2017; 53:680-684. [PMID: 28421643 DOI: 10.1111/jpc.13540] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 11/24/2016] [Accepted: 01/08/2017] [Indexed: 11/29/2022]
Abstract
AIM Neonatal sepsis remains an important cause of morbidity and mortality, and requires prompt empiric treatment. However, only a minority of babies who receive antibiotics for suspected sepsis have an infection. Antimicrobial exposure in infancy has important short- and long-term consequences. There is no consensus regarding empirical antimicrobial regimens. METHODS The study included a survey of empiric antimicrobial regimens in all tertiary neonatal intensive care units in Australia and New Zealand in 2013-2014. RESULTS All 27 units responded. For early-onset sepsis, all units used a combination of gentamicin with either penicillin or ampicillin. For late-onset sepsis, the frequency of units using empiric vancomycin (41%) versus empiric flucloxacillin (48%) was similar. Gestational age or the presence of a central venous catheter had little influence on using vancomycin instead of flucloxacillin. For late-onset sepsis with meningitis there was marked variation in antimicrobial combinations, with 15 different regimens described. A total of 93% used a cefotaxime-based regimen, either as monotherapy (22%) or combined with a second (22%) or third (48%) agent. For suspected necrotising enterocolitis, 89% used an aminoglycoside, metronidazole and a penicillin. Historical outbreaks of multi-resistant organisms exerted long-term influence over regimen choice. CONCLUSIONS There was limited use of broad-spectrum agents such as carbapenems or third-generation cephalosporins. In this region with low methicillin-resistant Staphylococcus aureus prevalence, empiric vancomycin use was common, selected for activity against coagulase-negative staphylococci. Empiric vancomycin is rarely necessary because coagulase-negative staphylococci are often contaminants and sepsis is rarely fulminant, occurring almost exclusively in extremely low birthweight infants. Implementation of appropriate, local antimicrobial policies is crucial to minimise antimicrobial exposure in this vulnerable population and halt the development of antimicrobial resistance.
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Affiliation(s)
- Jeremy P Carr
- Department of Infection and Immunity, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - David P Burgner
- Department of Infection and Immunity, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Rohan S Hardikar
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jim P Buttery
- Department of Infection and Immunity, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
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26
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Ghaffary S, Entezari Maleki T, Abdollahpor J, Hamishehkar H. Measurement and Comparison of Inpatient Antibiotic Use in Five Different Hospitals in Tabriz. PHARMACEUTICAL SCIENCES 2017. [DOI: 10.15171/ps.2017.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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27
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Rosli R, Dali AF, Abd Aziz N, Abdullah AH, Ming LC, Manan MM. Drug Utilization on Neonatal Wards: A Systematic Review of Observational Studies. Front Pharmacol 2017; 8:27. [PMID: 28228724 PMCID: PMC5297412 DOI: 10.3389/fphar.2017.00027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/16/2017] [Indexed: 11/13/2022] Open
Abstract
Despite limited evidence on safety and efficacy of drug use in neonates, drugs are extensively used in this age group. However, the availability of information on drug consumption in neonates, especially inpatient neonates, is limited. This paper systematically reviews published studies on drug utilization in hospitalized neonates. A systematic literature review was carried out to identify observational studies published from inception of databases used till August 2016. Four search engines, namely Medline, CINAHL, Embase, and PubMed, were used. Publications written in English that described drug utilization in neonatal wards were selected. Assessment of the data was based on the category of the study design, the objective of study and the method used in reporting drug consumption. A total of 20 drug utilization studies were identified, 12 of which focused on all drug classes, while the other eight evaluated antimicrobials. Studies were reported in Europe (n = 7), the United States (n = 6), India (n = 5), Brazil (n = 1), and Iran (n = 1). Substantial variance with regard to study types (study design and methods), data source, and sample size were found among the selected studies. Of the studies included, 45% were cross-sectional or retrospective, 40% were prospective studies, and the remaining 15% were point prevalence surveys. More than 70% of the studies were descriptive studies, describing drug consumption patterns. Fifteen per cent of the descriptive studies evaluated changes in drug utilization patterns in neonates. Volume of units was the most prevalent method used for reporting all drug categories. The ATC/DDD system for reporting drug use was only seen in studies evaluating antimicrobials. The most commonly reported drugs across all studies are anti-infectives for systemic use, followed by drugs for the cardiovascular system, the nervous system and the respiratory system. Ampicillin and gentamicin were the most prescribed antimicrobials in hospitalized neonates. The present review reveals that neonates are exposed to a high number of drugs and various methods are used to report drug consumption in this age group. The best measure of drug consumption to quantify prevalence of drug use in neonates remains to be identified and additional research in this area is warranted.
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Affiliation(s)
- Rosliana Rosli
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA Selangor, Malaysia
| | - Ahmad Fauzi Dali
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA Selangor, Malaysia
| | - Noorizan Abd Aziz
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA Selangor, Malaysia
| | - Amir Heberd Abdullah
- Department of Environmental Health, Faculty of Health Sciences, Universiti Teknologi MARA Bertam, Malaysia
| | - Long Chiau Ming
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARASelangor, Malaysia; Unit for Medication Outcomes Research and Education, Pharmacy, School of Medicine, University of TasmaniaHobart, Australia
| | - Mohamed Mansor Manan
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARASelangor, Malaysia; School of Pharmacy, KPJ Healthcare University CollegeNilai, Negeri Sembilan, Malaysia
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28
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Laine N, Hoppu K, Airaksinen M, Saxen H. Antimicrobial consumption in a tertiary children's hospital in Finland (2003-2013). Eur J Hosp Pharm 2016; 23:266-271. [PMID: 31156863 DOI: 10.1136/ejhpharm-2015-000766] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 12/21/2015] [Accepted: 01/06/2016] [Indexed: 11/03/2022] Open
Abstract
Background Numbers of resistant pathogens are constantly increasing, and prudent use of antimicrobials is of paramount importance. In order to see whether any changes in the use of antimicrobials in recent years have occurred, we decided to monitor the consumption of these drugs at a single tertiary paediatric hospital. Materials and methods This single-centre retrospective study investigated the consumption of antimicrobials in defined daily doses (DDDs according to the Anatomical Therapeutical Chemical /DDD index) in a 130-bed paediatric tertiary hospital. The data on the consumption of antimicrobials were collected from years 2003-2013 by using electronic surveillance records provided by the local pharmacy. The consumption was related to days of hospital care. Results During 2003-2013, the use of penicillins, cephalosporins and carbapenems increased by 28%, 46% and 110%, respectively. The consumption of both aminoglycosides and vancomycin decreased by 61% and 41%, respectively. Amphotericin B use clearly decreased by 39% while the use of novel azoles and echinocandins increased. Conclusions Increased use of carbapenems was the most significant finding of our study. The year-to-year consumption of antibacterials was in general relatively stable and new antibacterials were taken into use conservatively. In contrast to antibacterials, novel antifungals were rapidly adopted into use despite scarce evidence on their safety in children.
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Affiliation(s)
- Niina Laine
- Children's Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland.,Department of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
| | - Kalle Hoppu
- Poison Information Centre, Helsinki University Central Hospital, Helsinki, Finland
| | - Marja Airaksinen
- Department of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
| | - Harri Saxen
- Children's Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
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29
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Media Stories on NICU Outbreaks Lead to an Increased Prescription Rate of Third-Line Antibiotics in the Community of Neonatal Care. Infect Control Hosp Epidemiol 2016; 37:924-930. [PMID: 27143176 DOI: 10.1017/ice.2016.95] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Between 2010 and 2012, 3 outbreaks of nosocomial infections in German neonatal intensive care units (NICUs) attracted considerable public interest. Headlines on national television channels and in newspapers had important consequences for the involved institutions and a negative impact on the relationship between families and staff in many German NICUs. OBJECTIVE To determine whether NICU outbreaks reported in the media influenced provider behavior in the community of neonatal care and led to more third-line antibiotic prescribing. DESIGN Observational cohort study. METHODS To investigate secular trends, we evaluated data for very-low-birth-weight infants (VLBWIs, birth weight <1,500 g) enrolled in the German Neonatal Network (GNN) between 2009 and 2014 (N=10,253). For outbreak effects, we specifically analyzed data for VLBWIs discharged 6 months before (n=2,428) and 6 months after outbreaks (n=2,508). RESULTS The exposure of all VLBWIs to third-line antibiotics increased after outbreaks (19.4% before vs 22.5% after; P=.007). This trend particularly affected male infants (4.6% increase; P=.005) and infants with a birth weight between 1,000 and 1,499 g (3.5% increase; P=.001) In a logistic regression analysis, month of discharge as linear variable of time was associated with increased exposure to third-line antibiotics (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.009-1.014; P<.001), and discharge within the 6-month period after outbreak reports independently contributed to this long-term trend (OR, 1.14; 95% CI, 1.017-1.270; P=.024). CONCLUSIONS Media reports directly affect medical practice, eg, overuse of third-line antibiotics. Future communication and management strategies must be based on objective dialogues between the scientific community and investigative journalists. Infect Control Hosp Epidemiol 2016;37:924-930.
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30
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Abstract
Antibiotics are invaluable in the management of neonatal infections. However, overuse or misuse of antibiotics in neonates has been associated with adverse outcomes, including increased risk for future infection, necrotizing enterocolitis, and mortality. Strategies to optimize the use of antibiotics in the neonatal intensive care unit include practicing effective infection prevention, improving the diagnostic evaluation and empiric therapy for suspected infections, timely adjustment of therapy as additional information becomes available, and treating proven infections with an effective, narrow-spectrum agent for the minimum effective duration. Antibiotic stewardship programs provide support for these strategies but require the participation and input of neonatologists as stakeholders to be most effective.
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Affiliation(s)
- Joseph B Cantey
- Division of Neonatal/Perinatal Medicine, Division of Infectious Diseases, Texas A&M Health Science Center College of Medicine, Baylor Scott & White Health, Temple, TX, USA.
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31
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de Souza AS, Dos Santos DB, Rey LC, Medeiros MG, Vieira MG, Coelho HLL. Off-label use and harmful potential of drugs in a NICU in Brazil: A descriptive study. BMC Pediatr 2016; 16:13. [PMID: 26795213 PMCID: PMC4722776 DOI: 10.1186/s12887-016-0551-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 01/13/2016] [Indexed: 11/26/2022] Open
Abstract
Background Neonates admitted to neonatal intensive care units (NICU) are exposed to a wide variety of drugs, most without any data on safety and efficacy. Objective: To describe the drugs prescribed to different groups of neonates hospitalized in a NICU, and to analyze off-label use and harmful potential of drugs, in terms of the potential risks. Methods This was a six-month retrospective cohort study of drug use in a NICU, with neonates who were inpatients for a period of over 24 hours, and using prescription data from electronic medical records. Drug information found in the package leaflets, in the British National Formulary for Children 2012–2013, and in the Thomson Micromedex database were compared. Drugs and excipients considered potentially harmful were evaluated according to the literature. Results One hundred ninety-two neonates were included in the study, with a mean gestational age (GA) of 33.3 weeks (SD ± 4.3), 75.0 % were preterm, with an average of 18.8 days of hospitalization (SD ± 18.1), and a total of 3617 neonates-day. 3290 prescriptions were registered, on average 17.1 prescriptions/neonate (SD ± 17.9) and 8.8 drugs/neonate (SD ± 5.9). The number of prescriptions and drugs was higher in neonates with GA <31 weeks (p <0.05). Anti-infectives for systemic use, blood, alimentary tract and metabolism drug groups were more frequent, varying according to the GA. Neonates (99.5 %) were exposed to unlicensed drugs (UL) and off label use (OL), more frequently in GA <28 weeks (p <0.05). Most OL drugs used were indicated for newborns. 15 potentially harmful drugs were used in more than 70 % of the neonates, and most were OL; exposure to harmful excipients occurred in 91.6 % of the neonates, a percentage even higher when considering immature neonates. Conclusions Immature neonates in a Brazilian NICU are exposed to a variety of OL, UL and potentially harmful drugs and excipients.
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Affiliation(s)
- Alcidésio Sales de Souza
- Pharmacy Department, Mother and Child Hospital of Brasilia, Brasília, Federal District, Brazil. .,Doctoral Program in Development and Technological Innovation in Drugs, Federal University of Ceará, Fortaleza, Ceará, Brazil. .,Mother and Child Hospital of Brasilia, SGAS, Av. L2 Sul, Quadra608, Módulo A, Asa Sul, Brasília, CEP 70203-900, DF, Brazil.
| | - Djanilson Barbosa Dos Santos
- Postgraduate Programme in Pharmaceutical Sciences, Federal University of Ceará, Fortaleza, Ceará, Brazil.,Federal University of Recôncavo da Bahia, Santo Antônio de Jesus, Bahia, Brazil
| | - Luís Carlos Rey
- Mother and Child Health Department, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Marina Garruti Medeiros
- Postgraduate Programme in Pharmaceutical Sciences, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Marta Gonçalves Vieira
- Neonatology Department, Mother and Child Hospital of Brasilia, Brasília, Federal District, Brazil
| | - Helena Lutéscia Luna Coelho
- Doctoral Program in Development and Technological Innovation in Drugs, Federal University of Ceará, Fortaleza, Ceará, Brazil.,Postgraduate Programme in Pharmaceutical Sciences, Federal University of Ceará, Fortaleza, Ceará, Brazil
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32
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Early-onset Sepsis and Antibiotic Exposure in Term Infants: A Nationwide Population-based Study in Norway. Pediatr Infect Dis J 2016; 35:1-6. [PMID: 26368059 DOI: 10.1097/inf.0000000000000906] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sepsis is a leading cause of neonatal morbidity and mortality. Clinical suspicion may lead to overuse of antibiotics. The objective of this study was to assess the epidemiology of early-onset sepsis (EOS) and antibiotic exposure during the first week of life in Norwegian term infants. METHODS This is a nationwide population-based study from the Norwegian Neonatal Network. During the 3-year study period (2009-2011), 20 of Norway's 21 neonatal units prospectively collected data. Among 168,877 live-born (LB) term infants born during the study period, 10,175 (6.0%) infants were hospitalized in the first week of life and included in the study. RESULTS There were 91 cases of culture-confirmed EOS (0.54 per 1000 LB) and 1447 cases classified as culture-negative EOS (8.57 per 1000 LB). The majority of culture-confirmed EOS cases were caused by Gram-positives (83/91; 91%), most commonly group B streptococci (0.31 per 1000 LB). Intravenous antibiotics were administered to 3964 infants; 39% of all admissions and 2.3% of all LB term infants. Empiric therapy consisted of an aminoglycoside and either benzylpenicillin or ampicillin in 95% of the cases. The median (interquartile range) treatment duration was 8 (7-10) days for culture-confirmed EOS and 6 (5-7) days for culture-negative EOS. There was 1 EOS-attributable death (group B streptococcal EOS) during the study period. CONCLUSIONS In this registry-based study, the incidence of culture-confirmed EOS was in line with previous international reports and the mortality was very low. A large proportion of infants without infection were treated with antibiotics. Measures should be taken to spare neonates unnecessary antibiotic treatment.
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Australia-wide Point Prevalence Survey of Antimicrobial Prescribing in Neonatal Units: How Much and How Good? Pediatr Infect Dis J 2015; 34:e185-90. [PMID: 25961896 DOI: 10.1097/inf.0000000000000719] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is increasing recognition of the threat to neonatal patients from antibiotic resistance. There are limited data on antimicrobial prescribing practices for hospitalized neonates. We aimed to describe antimicrobial use in hospitalized Australian neonatal patients, and to determine its appropriateness. METHODS Multicentre single-day hospital-wide point prevalence survey in 2012, in conjunction with the Antimicrobial Resistance and Prescribing in European Children study. The appropriateness of antimicrobial prescriptions was also assessed. All patients admitted at 8 am on the survey day, in 6 neonatal units in tertiary children's hospitals across 5 states, were included in an analysis of the quantity and quality of all antimicrobial prescriptions. RESULTS The point prevalence survey included 6 neonatal units and 236 patients. Of 109 patients (46%) receiving at least 1 antimicrobial, 66 (61%) were being treated for infection, with sepsis the most common indication. There were 216 antimicrobial prescriptions, 134 (62%) for treatment of infection and 82 (38%) for prophylaxis, mostly oral nystatin. Only 15 prescriptions were for targeted as opposed to empirical treatment. Penicillin and gentamicin were the most commonly prescribed antibiotics, with vancomycin third most common. Half of all treated patients were receiving combination antimicrobial therapy. There was marked variation in vancomycin and gentamicin dosing. Overall, few prescriptions (4%) were deemed inappropriate. CONCLUSION This is the first Australia-wide point prevalence survey of neonatal antimicrobial prescribing in tertiary children's hospitals. The findings highlight positive practices and potential targets for quality improvement.
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Serum creatinine concentration in very-low-birth-weight infants from birth to 34-36 wk postmenstrual age. Pediatr Res 2015; 77:696-702. [PMID: 25675426 PMCID: PMC4407015 DOI: 10.1038/pr.2015.25] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 10/27/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Serum creatinine (s[Cr]) reference ranges for very-low-birth-weight (VLBW) infants must account for physiologic changes in the first months of life. METHODS We retrospectively identified a sample of 218 appropriate-for-gestational age (GA) VLBW infants without risk factors for renal impairment, and classified into one of three GA groups: 25-27, 28-29, and 30-33 wk. We observed three phases of s[Cr] change (initial, decline, and equilibrium), whose characteristics varied by GA group. We used mixed-effects regression models to estimate mean and upper 95th prediction interval of s[Cr] for each GA group from birth to 34-36 wk post menstrual age (PMA). RESULTS In phase I, s[Cr] increased after birth, then returned slowly to baseline. The duration of phase I and the magnitude of s[Cr] rise decreased with increasing GA. In phase II, s[Cr] declined abruptly at a rate that increased with GA. A gradual transition to phase III, a steady-state equilibrium with similar s[Cr] among GA groups, began at approximately 34-36 wk PMA. We constructed GA group-specific nomograms depicting s[Cr] behaviour across the three phases. CONCLUSION The reference ranges derived from a sample of infants without risk factors for renal impairment provide a context for quantitative interpretation of s[Cr] trends in VLBW infants.
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Nitsch-Osuch A, Kurpas D, Kuchar E, Zycińska K, Zielonka T, Wardyn K. Antibiotic consumption pattern in the neonatal special care unit before and after implementation of the hospital's antibiotic policy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 835:45-51. [PMID: 25252896 DOI: 10.1007/5584_2014_32] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Current and detailed knowledge of antibiotic use is essential in order to implement strategies for reducing the overuse of antibiotics. The objective of our study was to determine the effectiveness of the implementation of the hospital antibiotic policy (HAP) by assessing antibiotic consumption in the Special Neonatal Care Unit (SNCU) in Warsaw, Poland, before and after this intervention. Antibiotic use was calculated in daily defined doses (DDDs) per 100 patient-days and DDDs per 100 admissions. The antibiotics were ranked by volume of DDDs and the number of antibiotics, which accounted for 90 % and 100 % of the total volume, respectively: DU90% and DU100% (where DU stands for drug use). Total antibiotic consumption increased slightly after the introduction of the HAP: the total DDDS was 707.87 and 753.12 in 2011 and 2012, while the number of DDDs/100 admissions was 352.17 and 369.12 in 2011 and 2012, respectively. After the introduction of the HAP, an increase in ampicillin and aminoglycoside use was observed, along with a reduction in the DU100% and DU90% rates (15 vs. 9 and 4 vs. 3, respectively). The introduction of the HAP resulted in changes in antibiotic consumption patterns, but the general antibiotic consumption density remained the same.
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Affiliation(s)
- A Nitsch-Osuch
- Department of Family Medicine, Warsaw Medical University, 1A Banacha St., Block F, 02-097, Warsaw, Poland,
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Lean WL, Kamlin CO, Garland SM, Jacobs SE. Stable rates of neonatal sepsis in a tertiary neonatal unit. J Paediatr Child Health 2015; 51:294-9. [PMID: 25123527 DOI: 10.1111/jpc.12715] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2014] [Indexed: 11/28/2022]
Abstract
AIMS To describe the rate of early- and late-onset sepsis in neonates admitted to the neonatal intensive care unit at the Royal Women's Hospital and to compare the rate of late-onset sepsis (LOS) with a published (2008) cohort from the same unit. The secondary aim was to examine clinicians' compliance with antibiotic guidelines. METHODS Infants born <32 weeks' gestation or <1500 g admitted between 1 July 2011 and 31 December 2011 were included. Strict definitions of sepsis and compliance with antibiotic guidelines were applied. RESULTS One hundred and seventy-two infants met the inclusion criteria, with 152 having blood culture evaluations for early-onset sepsis (EOS) and 58 having 109 evaluations for LOS. Definite EOS occurred in 1.3% with Escherichia coli isolated. The rate of definite LOS in 2011 of 22% was not significantly different than the 27% in 2008, with coagulase-negative staphylococcus the main isolate. Antibiotic continuation beyond 72 h in infants with negative blood cultures was the main reason for non-compliance with antibiotic guidelines. CONCLUSIONS The rate of EOS is comparable with published reports and the rate of LOS has remained stable over a 3-year period. Discontinuation of antibiotics with negative septic markers and blood cultures at 48-72 h is encouraged.
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Affiliation(s)
- Wei Ling Lean
- Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia
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Abstract
There are unique challenges to antimicrobial stewardship in neonatal intensive care units (NICUs). Diagnosis of infection is difficult as neonates can have nonspecific signs and symptoms. Between and within NICUs, significant variation exists in the treatment duration of suspected sepsis and pneumonia. Development of multidisciplinary teams and meaningful metrics are essential for sustainable antibiotic stewardship. Potential stewardship interventions include optimizing culturing techniques, guiding empiric therapy by NICU-specific antibiograms, using ancillary laboratory tests, and promptly discontinuing therapy once infection is no longer suspected. Use of large neonatal databases can be used to benchmark antibiotic use and conduct comparative effectiveness research.
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Affiliation(s)
- Joseph B Cantey
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Division of Neonatal/Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Sameer J Patel
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 20, Chicago, Illinois 60611-2605, USA
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Fortin É, Fontela PS, Manges AR, Platt RW, Buckeridge DL, Quach C. Measuring antimicrobial use in hospitalized patients: a systematic review of available measures applicable to paediatrics. J Antimicrob Chemother 2014; 69:1447-56. [DOI: 10.1093/jac/dku003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Salehifar E, Nasehi M, Eslami G, Sahraei S, Alizadeh Navaei R. Determination of antibiotics consumption in buali-sina pediatric hospital, sari 2010-2011. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2014; 13:995-1001. [PMID: 25276201 PMCID: PMC4177661 DOI: pmid/25276201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The increasing prevalence of antibiotic-resistant bacteria is a major health-care problem worldwide. WHO recommends DID (daily defined dose per 100 Inhabitant per day) as a standard tool for measurement of antibiotic consumption. Since there was not any information regarding the antibiotics usage pattern in the north of Iran, the aim of this study was determine this in our centre. This cross-sectional study was performed in Buali Sina hospital. Using the health information system (HIS) database, records of patients hospitalized during 22 Sep 2010 - 21 Sep 2011. Data of different wards including Neonatal, NICU, PICU, Pediatrics and Pediatric surgery were separately extracted and analyzed. Drug consumption data were expressed as DID. SPSS 16 software was used for statistical analysis. Independent samples t-test was used to compare the quantitative variables. A total of 4619 in-patients records during 1 year of study including 2494 patients in fall and winter and 2125 patients in spring and summer were evaluated. The most hospitalized patients were in Pediatric ward (43.9 %). The highest DID value were obtained for ceftriaxone (21.7), ampicillin (6.05) and vancomycin (4.7), while the lowest value was for gentamicin (0.01). In both cold and warm seasons, Ceftriaxone was the most frequent prescribed antibiotic. The rate of antibiotics consumption especially Ceftriaxone in our setting was significantly higher than the other centers. Strategies for more justified administration of antibiotics especially broad -spectrum ones are necessary.
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Affiliation(s)
- Ebrahim Salehifar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Thalassemia Research Center, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Mohammadmehdi Nasehi
- Department of Pediatrics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
- Corresponding author: E-mail:
| | - Gohar Eslami
- Department of Clinical Pharmacy, Faculty of Pharmacy, Thalassemia Research Center, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Sima Sahraei
- Department of Pharmaceutical Care, Buali Sina Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Reza Alizadeh Navaei
- Clinical Research Development Center, Buali Sina Hospital, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
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Brett A, Bielicki J, Newland JG, Rodrigues F, Schaad UB, Sharland M. Neonatal and pediatric antimicrobial stewardship programs in Europe-defining the research agenda. Pediatr Infect Dis J 2013; 32:e456-65. [PMID: 23958812 DOI: 10.1097/inf.0b013e31829f0460] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The relationship between suboptimal use of antimicrobials and antimicrobial resistance has become increasingly clear. Despite significant international effort aimed at reducing inappropriate antimicrobial prescribing in hospitals, antimicrobial resistance remains a major public health threat. Antimicrobial Stewardship Programs (ASPs) comprise a series of measures aimed at optimizing the use of antimicrobials, while improving the quality of patient care and promoting cost-effectiveness. This discussion article aims to summarize some of the approaches that have been used in neonatal and pediatric ASPs, with a particular focus on the European healthcare setting. Current evidence demonstrates neonatal and pediatric ASPs to be safe, practical to implement, generally cost-effective and possibly associated with a reduction in antimicrobial resistance rates. This review identified that, despite the recognized need for additional evidence and information on implementation, published data on pediatric ASPs derives mainly from the United States, with very few published reports on formal ASPs in European children's hospitals. Consequently, the optimal method of implementation remains unknown within a European setting. Future research needs to include novel study designs on how best to introduce ASPs, monitoring of clinically relevant outcomes and cost-effectiveness with improved measurement of the impact on antimicrobial resistance.
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Affiliation(s)
- Ana Brett
- From the *Infectious Diseases Unit and Emergency Service, Hospital Pediátrico, Centro, Hospitalar e Universitário de Coimbra, Coimbra, Portugal; †Paediatric Infectious Diseases Research Group, St George's University London, London, United Kingdom; ‡Division of Pediatric Infectious Diseases, Children's Mercy Hospital and Clinics, University of Missouri-Kansas City, MO; and §Paediatric Infectious Diseases Division, University Children's Hospital, Basel, Switzerland
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The antibiotic resistance and prescribing in European Children project: a neonatal and pediatric antimicrobial web-based point prevalence survey in 73 hospitals worldwide. Pediatr Infect Dis J 2013; 32:e242-53. [PMID: 23838740 DOI: 10.1097/inf.0b013e318286c612] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The neonatal and pediatric antimicrobial point prevalence survey (PPS) of the Antibiotic Resistance and Prescribing in European Children project (http://www.arpecproject.eu/) aims to standardize a method for surveillance of antimicrobial use in children and neonates admitted to the hospital within Europe. This article describes the audit criteria used and reports overall country-specific proportions of antimicrobial use. An analytical review presents methodologies on antimicrobial use. METHODS A 1-day PPS on antimicrobial use in hospitalized children was organized in September 2011, using a previously validated and standardized method. The survey included all inpatient pediatric and neonatal beds and identified all children receiving an antimicrobial treatment on the day of survey. Mandatory data were age, gender, (birth) weight, underlying diagnosis, antimicrobial agent, dose and indication for treatment. Data were entered through a web-based system for data-entry and reporting, based on the WebPPS program developed for the European Surveillance of Antimicrobial Consumption project. RESULTS There were 2760 and 1565 pediatric versus 1154 and 589 neonatal inpatients reported among 50 European (n = 14 countries) and 23 non-European hospitals (n = 9 countries), respectively. Overall, antibiotic pediatric and neonatal use was significantly higher in non-European (43.8%; 95% confidence interval [CI]: 41.3-46.3% and 39.4%; 95% CI: 35.5-43.4%) compared with that in European hospitals (35.4; 95% CI: 33.6-37.2% and 21.8%; 95% CI: 19.4-24.2%). Proportions of antibiotic use were highest in hematology/oncology wards (61.3%; 95% CI: 56.2-66.4%) and pediatric intensive care units (55.8%; 95% CI: 50.3-61.3%). CONCLUSIONS An Antibiotic Resistance and Prescribing in European Children standardized web-based method for a 1-day PPS was successfully developed and conducted in 73 hospitals worldwide. It offers a simple, feasible and sustainable way of data collection that can be used globally.
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Irwin A, Sharland M. Measuring antibiotic prescribing in hospitalised children in resource-poor countries: a systematic review. J Paediatr Child Health 2013; 49:185-92. [PMID: 21679337 DOI: 10.1111/j.1440-1754.2011.02126.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Antibiotic resistance represents a significant threat to global health. Widespread exposure to antibiotics drives the development of antibiotic resistance. Little is known about the exposure to antibiotics of hospitalised children, particularly in resource-poor countries where the burden of infectious disease is highest. The review sought to identify original research quantifying antibiotic use in hospitalised children in resource countries. The methods used were: A systematic search of the MEDLINE, CINAHL, EMBASE, LILACS and African Index Medicus databases. Eighteen papers were identified and the methodology varied considerably. Only seven used a recognised defined daily dose (DDD) methodology. The studies reveal a high exposure of hospitalised children to antibiotics. With the exception of data from China, the studies were limited by their design. Limited evidence of the variation in drug, dose and total exposure to antibiotic use in hospitalised children in resource-poor countries exists. An international network of surveillance of both antimicrobial prescribing and resistance using a simple standardised methodology in this context remains an important goal. A simplified paediatric version of the adult DDD methodology is required to allow international comparison between populations.
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Affiliation(s)
- Adam Irwin
- Institute of Child Health, Alder Hey Children's Hospital NHS Foundation Trust, Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
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Newland JG, Banerjee R, Gerber JS, Hersh AL, Steinke L, Weissman SJ. Antimicrobial Stewardship in Pediatric Care: Strategies and Future Directions. Pharmacotherapy 2012; 32:735-43. [DOI: 10.1002/j.1875-9114.2012.01155.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jason G. Newland
- Section of Infectious Diseases; Department of Pediatrics; University of Missouri-Kansas City; Children's Mercy Hospitals & Clinics; Kansas City; Missouri
| | - Ritu Banerjee
- Division of Pediatric Infectious Diseases; Department of Pediatrics and Adolescent Medicine; Mayo Clinic College of Medicine; Mayo Children's Hospital; Rochester; Minnesota
| | - Jeffrey S. Gerber
- Division of Infectious Diseases; Department of Pediatrics; University of Pennsylvania School of Medicine; Children's Hospital of Philadelphia; Philadelphia; Pennsylvania
| | - Adam L. Hersh
- Division of Infectious Diseases; Department of Pediatrics; University of Utah; Primary Children's Medical Center; Salt Lake City; Utah
| | - Leah Steinke
- Department of Pharmacy; Children's Hospital of Michigan; Detroit Medical Center; Detroit; Michigan
| | - Scott J. Weissman
- Division of Infectious Diseases; Department of Pediatrics; University of Washington Medical Center; Seattle Children's Hospital; Seattle; Washington
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Porta A, Hsia Y, Doerholt K, Spyridis N, Bielicki J, Menson E, Tsolia M, Esposito S, Wong ICK, Sharland M. Comparing neonatal and paediatric antibiotic prescribing between hospitals: a new algorithm to help international benchmarking. J Antimicrob Chemother 2012; 67:1278-86. [PMID: 22378680 DOI: 10.1093/jac/dks021] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The WHO anatomical therapeutic chemical (ATC)/defined daily dose (DDD) methodology is a standardized method of comparing antimicrobial use. The ATC/DDD is defined as the average maintenance daily dose of a drug used in a 70 kg adult, ignoring the considerable differences in body weight of neonates and children. The aim of this study was to develop a new standardized way of comparing rates of antimicrobial prescribing between European children's hospitals. METHODS This pilot study at four European children's hospitals (in the UK, Greece and Italy) collected data including demographics, antibiotic use, dosing and indication in children and neonates over a 14 day period. RESULTS A total of 1217 antibiotic prescriptions were issued with 47 different antibiotics used. Approximately half of all children and a third of all neonates received antibiotics, with wide variation between centres in the type and dose of antibiotic used. We propose a new pragmatic three-step algorithm. The first step includes a simple comparison of the proportion of hospitalized children on antibiotics by weight bands and the number of antimicrobials that account for 90% of total DDD drug usage (DU90%). The second step is a comparison of the dosing used (mg/kg/day). The third step is to compare overall drug exposure using DDD/100 bed days for standardized weight bands between centres. CONCLUSIONS This novel method has the potential to be a useful tool to provide antibiotic use comparator data and requires validation in a large prospective point prevalence study.
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Affiliation(s)
- Alessandro Porta
- Department of Maternal and Paediatric Sciences, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Benko R, Matuz M, Peto Z, Bogár L, Viola R, Doró P, Soós G, Hajdú E. Variations and determinants of antibiotic consumption in Hungarian adult intensive care units. Pharmacoepidemiol Drug Saf 2011; 21:104-9. [PMID: 21796720 DOI: 10.1002/pds.2192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/18/2011] [Accepted: 05/25/2011] [Indexed: 01/18/2023]
Abstract
PURPOSE The aim of this work was to study the use of systemic antibacterials and its possible determinants in Hungarian intensive care units (ICUs). METHODS Hospital pharmacy. departments provided package level dispensing data for their corresponding ICU (2006). Data were converted into defined daily doses (DDDs) and expressed as DDD per 100 patient-days and DDD per 100 admissions. Antibiotics were ranked by volume of DDDs, and the agents responsible for 90% of total use (DU90%) were noted. To explore differences and relationships between antibiotic use and antibiotic policy elements/ICU characteristics, the analysis of variances or the Pearson correlation analysis was performed. RESULTS Valid data were obtained for 44 ICUs. Antibiotic use varied widely (from 27.9 to 167.8 DDD per 100 patient-days and from 104.7 to 1784.6 DDD per 100 admissions). In total, 11-34 different antibacterials per ICUs were used, of which, 5-15 were in the DU90% segment. The proportional use of parenteral agents ranged from 46.2 to 98.3%. The mean of overall antibiotic use was highest for penicillins with beta-lactamase inhibitors, followed by quinolones and third-generation cephalosporins. Of the studied factors, only the ICU category (i.e., level of care) showed significant association with total antibacterial use. CONCLUSIONS The striking differences in total antibiotic use and the extensive use of the oral agents in some ICUs may indicate room for improvement. As none of the antibiotic policy elements were accompanied by lower antibiotic use in the pooled analysis, it suggests that--beside the ICU category--other unrevealed factors determine antibiotic use.
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Affiliation(s)
- Ria Benko
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary.
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Liem TBY, Heerdink ER, Egberts ACG, Rademaker CMA. Quantifying antibiotic use in paediatrics: a proposal for neonatal DDDs. Eur J Clin Microbiol Infect Dis 2010; 29:1301-3. [PMID: 20556467 PMCID: PMC2937144 DOI: 10.1007/s10096-010-0990-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 05/29/2010] [Indexed: 11/30/2022]
Abstract
The defined daily dose (DDD) as defined by the World Health Organization (WHO) has been the most frequently used unit of measurement to measure antibiotic use. However, measuring antibiotic use in paediatrics is a problem as the WHO DDD methodology is not applicable in children (aged >1 month) due to the large variation in body weight within this population. Based on the narrow range of body weights in the neonatal population, we therefore aimed to develop a set of neonatal DDDs for antibiotics. Eight well-respected (inter)national sources for dosage recommendations of antibiotics in children and neonates were consulted for the assumed maintenance dose of the ten most frequently used antibiotics in neonatal intensive care units in its main indication for neonates. A set of neonatal DDDs for ten commonly used antibiotics in neonates based on an assumed neonatal weight of 2 kg was proposed. Primarily in children DDDs are not applicable to quantify antibiotic use since there is large variation in body weight. In the neonatal population, however, based on its narrow range of body weights and when access to patient level data is not available, neonatal DDDs can be used as a unit of measurement.
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Affiliation(s)
- T B Y Liem
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, Room Ke.03.136.0, 3584 EA Utrecht, The Netherlands.
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