Impact of an Antimicrobial Stewardship Program on Antibiotic Use at a Nonfreestanding Children's Hospital

Paediatric Common Infections Pathways: improving antimicrobial stewardship and promoting ambulation for children presenting with common infections to hospitals in the UK and Ireland

Paediatric common infection pathways have been developed in collaboration between the BSAC and national paediatric groups, addressing the management of cellulitis, lymphadenitis/lymph node abscess, pneumonia/pleural empyema, pyelonephritis, tonsillitis/peritonsillar abscess, otitis media/mastoiditis, pre-septal/post-septal (orbital) cellulitis, and meningitis. Guidance for the management of a child presenting with a petechial/purpuric rash and the infant under 3 months of age with fever is also provided. The aim of these pathways is to support the delivery of high-quality infection management in children presenting to a hospital. The pathways focus on diagnostic approaches, including the recognition of red flags suggesting complex or severe infection requiring urgent intervention, approaches to antimicrobial stewardship (AMS) principles and guidance on safe and timely ambulation aligned with good practice of outpatient parenteral antimicrobial therapy (OPAT).

Pediatric Antimicrobial Stewardship Programs: Current Perspectives

With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Background

Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally.

Methods

MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data.

Results

Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides.

Conclusions

Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Scope of Antibiotic Stewardship Programs in Pediatrics

This review of pediatric antibiotic stewardship programs (ASPs) summarized the antibiotic prescribing interventions and their impact on antibiotic use and antimicrobial resistance. We reviewed studies of pediatric ASP, including the search terms "antimicrobial stewardship," "antibiotic stewardship," "children," and "pediatric." The articles' selection and review were performed independently by 2 investigators, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Twenty-one studies were included, from the past 15 years, increasing after the 2007 IDSA (Infectious Diseases Society of America) guidelines for ASP with a large variability of the programs, and the virtual exclusive focus on inpatient settings (90%): 16 formalized ASP and 5 non-ASP actions. A reduction in antibiotic prescribing in ASP has been demonstrated in the studies reporting pediatric ASP, but only one ASP showed a significant impact on antimicrobial resistance. However, the impact on antibiotic consumption in pediatrics demonstrated the important contribution of these strategies to improve antibiotic use in children, without complications or negative issues.

Pediatric Antimicrobial Stewardship: State of the Art

PURPOSE OF REVIEW

We aim to systematically review the literature on the effectiveness of pediatric antimicrobial stewardship programs (ASPs) and antimicrobial stewardship (AS) strategies in the United States (US) inpatient setting. Furthermore, we review current gaps and challenges for unique pediatric populations and those in ambulatory settings.

RECENT FINDINGS

Misuse and overuse of antimicrobials have been identified as key factors for antimicrobial resistance (AR). Multiple professional organizations support the implementation of hospital-based ASPs to decrease antimicrobial consumption, improve patient outcomes, and reduce healthcare costs. There is limited data on the effectiveness of inpatient pediatric ASPs and AS strategies in unique populations. Furthermore, there is a paucity of evidence on ASPs in ambulatory settings. This review contributes to the growing body of evidence that supports the use of pediatric ASPs to optimize antimicrobial therapy in the inpatient setting as well as in unique patient populations and ambulatory settings. Active stewardship is critical and antimicrobial consumption is a key outcome metric for programs.

Implementation and Impact of an Antimicrobial Stewardship Program at a Non-freestanding Children's Hospital

OBJECTIVES

Pediatric Antimicrobial Stewardship Programs (ASP) have been associated with improvements in antibiotic utilization and patient outcomes; however, ASP studies originating from non-freestanding children's hospitals are lacking. In this study, we present the implementation and impact of a multidisciplinary ASP that employs a collaborative physician and pharmacist driven thrice-weekly prospective audit-with-feedback approach at a non-freestanding children's hospital.

METHODS

Implementation was assessed via descriptive design. Pediatric inpatients maintained on predefined targeted antibiotics of interest for 48 to 72 hours preceding ASP review were eligible for inclusion. Outcomes evaluated included ASP recommendation and provider acceptance rates (overall and by antibiotic and provider specialty). Impact was examined using an interrupted time series design (with a preimplementation period of August 1, 2013, to July 31, 2014 and postimplementation period of December 1, 2014 to May 31, 2016). Eligibility included all targeted antibiotic usage among pediatric inpatients, with a control group comprising those who received antibiotics requiring preauthorization. Outcomes analyzed included days of antibiotic therapy per 1000 patient days (DOT/1000 PD) and 30-day hospital readmission rates over time.

RESULTS

Postimplementation, 882 antibiotic reviews were performed on 637 patients, with 327 recommendations generated. Reviews of patients maintained on vancomycin and clindamycin, and of those under care of intensivist and hospitalist physicians, were most likely to prompt recommendations. A mean targeted antibiotic usage decrease of 24.8 DOT/1000 PD (95% confidence interval, -62 to 14) was observed postimplementation, with no change in 30-day readmissions (0.64% during both periods).

CONCLUSIONS

ASP implementation at a non-freestanding children's hospital was feasible and allowed for identification of areas for targeted quality improvement, while demonstrating modest antibiotic use reduction without adversely impacting patient care.