Antimicrobial Stewardship Program in a Pediatric Intensive Care Unit

The Impact of an Antimicrobial Stewardship Program on Days of Therapy in the Pediatric Center: An Interrupted Time-Series Analysis of a 19-Year Study

BACKGROUND

We aimed to analyze the effects of an antimicrobial stewardship program (ASP) on the proportion of antimicrobial-resistant pathogens in bacteremia, antimicrobial use, and mortality in pediatric patients.

METHODS

A retrospective single-center study was performed on pediatric inpatients under 19 years old who received systemic antimicrobial treatment from 2001 to 2019. A pediatric infectious disease attending physician started ASP in January 2008. The study period was divided into the pre-intervention (2001-2008) and the post-intervention (2009-2019) periods. The amount of antimicrobial use was defined as days of therapy per 1,000 patient-days, and the differences were compared using delta slope (= changes in slopes) between the two study periods by an interrupted time-series analysis. The proportion of resistant pathogens and the 30-day overall mortality rate were analyzed by the χ².

RESULTS

The proportion of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae bacteremia increased from 17% (39 of 235) in the pre-intervention period to 35% (189 of 533) in the post-intervention period (P < 0.001). The total amount of antimicrobial use significantly decreased after the introduction of ASP (delta slope value = -16.5; 95% confidence interval [CI], -30.6 to -2.3; P = 0.049). The 30-day overall mortality rate in patients with bacteremia did not increase, being 10% (55 of 564) in the pre-intervention and 10% (94 of 941) in the post-intervention period (P = 0.881).

CONCLUSION

The introduction of ASP for pediatric patients reduced the delta slope of the total antimicrobial use without increasing the mortality rate despite an increased incidence of ESBL-producing gram-negative bacteremia.

Antibiotic use in pediatric acute care hospitals: an analysis of antibiotic consumption data from Germany, 2013-2020

BACKGROUND

Antimicrobial stewardship (AMS) programs are effective tools for improving antibiotic prescription quality. Their implementation requires the regular surveillance of antibiotic consumption at the patient and institutional level. Our study captured and analyzed antibiotic consumption density (ACD) for hospitalized pediatric patients.

METHOD

We collected antibacterial drug consumption data for 2020 from hospital pharmacies at 113 pediatric departments of acute care hospitals in Germany. ACD was calculated as defined daily dose (DDD, WHO/ATC Index 2019) per 100 patient days (pd). In addition, we analyzed the trends in antibiotic use during 2013-2020.

RESULTS

In 2020, median ACD across all participating hospitals was 26.7 DDD/100 pd, (range: 10.1-79.2 DDD/100 pd). It was higher at university vs. non-university hospitals (38.6 vs. 25.2 DDD/100 pd, p < 0.0001). The highest use densities were seen on oncology wards and intensive care units at university hospitals (67.3 vs. 38.4 DDD/100 pd). During 2013-2020, overall ACD declined (- 10%) and cephalosporin prescriptions also decreased (- 36%). In 2020, cephalosporins nevertheless remained the most commonly dispensed class of antibiotics. Interhospital variability in cephalosporin/penicillin ratio was substantial. Antibiotics belonging to WHO AWaRe "Watch" and "Reserve" categories, including broad-spectrum penicillins (+ 31%), linezolid (+ 121%), and glycopeptides (+ 43%), increased over time.

CONCLUSION

Significant heterogeneity in ACD and prescription of different antibiotic classes as well as high prescription rates for cephalosporins and an increased use of reserve antibiotics indicate improvable antibiotic prescribing quality. AMS programs should urgently prioritize these issues to reduce antimicrobial resistance.

Antimicrobial Stewardship Programs in PICU Settings: A Systematic Review

OBJECTIVES

Development of antimicrobial stewardship programs (ASPs) is strategy for prevention and management of emergence of antimicrobial-resistant organisms. In this study, we systematically reviewed the literature on antimicrobial stewardship interventions in PICUs and analyzed approaches, structure, implementation, and outcomes of the ASPs.

DATA SOURCES

PubMed and Scopus databases were systematically searched for studies published from January 1, 2007, to December 31, 2020, reporting interventions on judicious use of antimicrobials in PICUs (last search performed February 28, 2021).

DATA SELECTION

Studies that evaluated an intervention in a PICU setting or both in PICU and other settings and reported separate results for PICU were eligible for full-text review. Studies that had implemented stewardship in the entire hospital, including the PICU, but without presenting dedicated PICU data were excluded from the analysis.

DATA EXTRACTION

The strategy of intervention, structure of ASP team, implementation, and outcomes were assessed with a checklist tool for all studies included in the analysis. Risk of bias was assessed with the Cochrane Risk-of-Bias in Nonrandomized studies of Interventions tool.

DATA SYNTHESIS

Thirteen articles were found: 11 that applied ASP in PICUs, and two at hospital level. All PICU-dedicated ASPs applied a multimodal intervention combining strategies simultaneously; audit with feedback (6/11) and facility-specific clinical practice guidelines (7/11) were the most common strategies. A multidisciplinary team was formulated in all ASPs except for three biomarker-based interventions. Six of 11 studies included techniques to enhance behavior change and one implemented a behavior-based intervention. Antibiotic consumption was evaluated in all ASPs, cost in three of 11, antibiotic resistance in one of 11, length of hospitalization in six of 11, and mortality in eight of 11. All hospital-wide ASPs used audit with feedback in addition to facility-specific clinical practice guidelines and assessed antimicrobial consumption, expenditures, length of stay, and mortality.

CONCLUSIONS

The prevalence of ASPs in PICUs is limited, and few programs follow all of the currently available recommendations.

Antimicrobial Stewardship Improvement in Pediatric Intensive Care Units in Spain-What Have We Learned?

Antibiotic misuse in pediatric intensive care units (PICUs) can lead to increased antimicrobial resistance, antibiotic-triggered side effects, hospital costs, and mortality. We performed a multicenter, prospective study, analyzing critically ill pediatric patients (≥1 month to ≤18 years) admitted to 26 Spanish PICUs over a 3-month period each year (1 April−30 June) from 2014−2019. To make comparisons and evaluate the influence of AMS programs on antibiotic use in PICUs, the analysis was divided into two periods: 2014−2016 and 2017−2019 (once 84% of the units had incorporated an AMS program). A total of 11,260 pediatric patients were included. Total antibiotic prescriptions numbered 15,448 and, overall, 8354 patients (74.2%) received at least one antibiotic. Comparing the two periods, an increase was detected in the number of days without antibiotics in patients who received them divided by the number of days in PICUs, for community-acquired infections (p < 0.001) and healthcare-associated infections (HAIs) acquired in PICUs (p < 0.001). Antibiotics were empirical in 7720 infections (85.6%), with an increase in appropriate antibiotic indications during the second period (p < 0.001). The main indication for antibiotic adjustment was de-escalation, increasing in the second period (p = 0.045). Despite the high rate of antibiotic use in PICUs, our results showed a significant increase in appropriate antibiotic use and adjustment following the implementation of AMS programs.

Improving Vancomycin Stewardship in Critically Ill Children

BACKGROUND AND OBJECTIVES

Inappropriate vancomycin use is common in children's hospitals. We report a quality improvement (QI) intervention to reduce vancomycin use in our tertiary care PICU.

METHODS

We retrospectively quantified the prevalence of infections caused by organisms requiring vancomycin therapy, including methicillin-resistant Staphylococcus aureus (MRSA), among patients with suspected bacterial infections. Guided by these data, we performed 3 QI interventions over a 3-year period, including (1) stakeholder education, (2) generation of a consensus-based guideline for empiric vancomycin use, and (3) implementation of this guideline through clinical decision support. Vancomycin use in days of therapy (DOT) per 1000 patient days was measured by using statistical process control charts. Balancing measures included frequency of bacteremia due to an organism requiring vancomycin not covered with empiric therapy, 30-day mortality, and cardiovascular, respiratory, and renal organ dysfunction.

RESULTS

Among 1276 episodes of suspected bacterial infection, a total of 19 cases of bacteremia (1.5%) due to organisms requiring vancomycin therapy were identified, including 6 MRSA bacteremias (0.5%). During the 3-year QI project, overall vancomycin DOT per 1000 patient days in the PICU decreased from a baseline mean of 182 DOT per 1000 patient days to 109 DOT per 1000 patient days (a 40% reduction). All balancing measures were unchanged, and all cases of MRSA bacteremia were treated empirically with vancomycin.

CONCLUSION

Our interventions reduced overall vancomycin use in the PICU without evidence of harm. Provider education and consensus building surrounding indications for empiric vancomycin use were key strategies.

Impact and quality of antimicrobial use in a referral pediatric intensive care unit

INTRODUCTION

We aimed to describe antimicrobial use (AU) and quality of prescriptions (QP) in a 28-bed medical-surgical PICU of a European referral children's hospital during 2019.

METHODS

AU data were expressed as days-of-therapy (DOT) over 100 days-present (DP) and as length-of-treatment (LOT). QP was based on monthly cross-sectional point-prevalence surveys. Length-of-stay (LOS), readmission rates (RR), and mortality rates (MR) were also collected.

RESULTS

PICU AU accounted for 13.5% of the global hospital AU; the median PICU density of AU was 1.4 (IQR 1.3-1.5) times higher than that of the rest of the hospital areas. Antibacterials represented 88.5% of the overall AU, cefazolin and amoxicillin-clavulanate being the most used drugs. A high QP rate was observed (149/168 optimal, 88.9%), with room for improvement in prophylactic regimens and de-escalation of broad-spectrum regimens. LOT, LOS, RR, and MR remained stable.

CONCLUSIONS

PICU AU represented a major portion of the global hospital AU. Despite high QP rates, prophylactic and broad-spectrum antibiotic regimens were optimizable.

Handshake stewardship reduces carbapenem prescription in a pediatric critical care setting

BACKGROUND

Intensive care unit (ICU) settings typically have a high-volume prescription of carbapenems. Antimicrobial stewardship programs (ASPs) aim to promote appropriate antibiotic use. Handshake stewardship (HS) is adapted from ASPs but focuses on direct feedback to physicians who prescribed antibiotics regarding the appropriateness of antibiotic prescription. This study aimed to evaluate the impact and acceptability of HS on carbapenem consumption in pediatric critical care settings.

METHODS

This study was conducted over 18 months spanning pre-and post-implementation of HS. Carbapenem prescriptions were automatically discontinued during the pre-implementation period after 72 h if no indications existed. During the post-implementation, HS was performed by direct feedback to ICU physicians regarding the appropriateness of carbapenem prescriptions within 24 h. The primary outcome was the carbapenem consumption rate, defined as days of therapy (DOT)/1,000 patient-ICU days. Secondary outcomes were the acceptability of HS, length of critical care stay (LOCS), 30-day infection-related mortality rate, and the rate of carbapenem-resistant Enterobacteriaceae (CRE).

RESULTS

There were 212 carbapenem prescriptions (163 patients) and 174 carbapenem prescriptions (110 patients) in the pre-and post-implementation periods, respectively. Carbapenem consumption decreased significantly from 667 to 369 DOT/1,000 patient-ICU days, with a median difference of 292 DOT/1,000 patient-ICU days (P < 0.001; 95% confidence interval: 175-408) after HS implementation. The acceptability of the HS was 95.4%. The LOCS, 30-day infection-related mortality, and CRE rate were not significantly different between pre-and post-implementation periods.

CONCLUSIONS

Handshake stewardship significantly reduced carbapenem prescription in critically ill pediatric patients without negatively affecting patient outcomes.

Application of Multiplex Polymerase Chain Reaction for Pathogen Identification and Antibiotic Use in Children With Respiratory Infections in a PICU

OBJECTIVES

To compare the pathogen identification rate and use of antibiotics before and after the implementation of multiplex polymerase chain reaction testing in children with respiratory infections in a PICU.

DESIGN

Single-center, pre-post study.

SETTING

PICU of Osaka Women's and Children's Hospital, Osaka, Japan.

PATIENTS

Consecutive children with respiratory infections who were admitted to the PICU between December 2017 and November 2018 (premultiplex polymerase chain reaction period) and between March 2019 and February 2020 (postmultiplex polymerase chain reaction period).

INTERVENTIONS

Conventional rapid antigen tests and bacterial culture tests were performed throughout the study period. Multiplex polymerase chain reaction testing using the FilmArray respiratory panel (BioFire Diagnostics, Salt Lake City, UT) was conducted to detect 17 viruses and three bacterial pathogens. During the postmultiplex polymerase chain reaction period, we did not recommend prescribing antibiotics for stable children, depending on the virus species and laboratory test results.

MEASUREMENTS AND MAIN RESULTS

Ninety-six and 85 children were enrolled during the pre- and postmultiplex polymerase chain reaction periods, respectively. Rapid antigen tests identified pathogens in 22% of the children (n = 21) during the premultiplex polymerase chain reaction period, whereas rapid antigen tests and/or multiplex polymerase chain reaction testing identified pathogens in 67% of the children (n = 57) during the postmultiplex polymerase chain reaction period (p < 0.001). The most commonly identified pathogen using multiplex polymerase chain reaction testing was human rhino/enterovirus. Bacterial pathogens were identified in 50% of the children (n = 48) and 60% of the children (n = 51) during the pre- and postmultiplex polymerase chain reaction periods (p = 0.18). There were no differences in antibiotic use (84% vs 75%; p = 0.14), broad-spectrum antibiotic use (33% vs 34%; p = 0.91), or the duration of antibiotic use within 14 days of admission (6.0 vs 7.0 d; p = 0.45) between the pre- and postmultiplex polymerase chain reaction periods.

CONCLUSIONS

Although the pathogen identification rate, especially for viral pathogens, increased using multiplex polymerase chain reaction testing, antibiotic use did not reduce in children with respiratory infections in the PICU. Definitive identification of bacterial pathogens and implementation of evidence-based antimicrobial stewardship programs employing multiplex polymerase chain reaction testing are warranted.

Challenges of Antibiotic Stewardship in the Pediatric and Neonatal Intensive Care Units

The goals of antimicrobial stewardship programs (ASPs) are to optimize antimicrobial prescribing habits in order to improve patient outcomes, reduce antimicrobial resistance, and reduce hospital costs. Multiple society-endorsed guidelines and government policies reinforce the importance of ASP implementation. Effective antimicrobial stewardship can impact unique patients, hospitals, and societal antibiotic-resistance burden. The role and subsequent success of these programs has largely been reported in the adult population. Pediatric and neonatal intensive care units present unique challenges for traditional antimicrobial stewardship approaches. The purpose of this review article is to explore the challenges of appropriate antibiotic use in the pediatric and neonatal intensive care units and to summarize strategies ASPs can use to overcome these challenges. These problems include non-specific disease presentations, limited evidence for definitive treatment durations in many pediatric infections, fewer pediatric-trained infectious disease physicians, and applicability of intensive laboratory obtainment, collection, and interpretation. Additionally, many ASP implementation studies evaluating the efficacy of ASPs exclude the PICU and NICU. Areas of focus for pediatric ASPs should likely include appropriate antibiotic initiation, appropriate antibiotic duration, and appropriate antibiotic de-escalation.

Impact and quality of antimicrobial use in a referral pediatric intensive care unit

INTRODUCTION

We aimed to describe antimicrobial use (AU) and quality of prescriptions (QP) in a 28-bed medical-surgical PICU of a European referral children's hospital during 2019.

METHODS

AU data were expressed as days-of-therapy (DOT) over 100 days-present (DP) and as length-of-treatment (LOT). QP was based on monthly cross-sectional point-prevalence surveys. Length-of-stay (LOS), readmission rates (RR), and mortality rates (MR) were also collected.

RESULTS

PICU AU accounted for 13.5% of the global hospital AU; the median PICU density of AU was 1.4 (IQR 1.3-1.5) times higher than that of the rest of the hospital areas. Antibacterials represented 88.5% of the overall AU, cefazolin and amoxicillin-clavulanate being the most used drugs. A high QP rate was observed (149/168 optimal, 88.9%), with room for improvement in prophylactic regimens and de-escalation of broad-spectrum regimens. LOT, LOS, RR, and MR remained stable.

CONCLUSIONS

PICU AU represented a major portion of the global hospital AU. Despite high QP rates, prophylactic and broad-spectrum antibiotic regimens were optimizable.

Sustainability of Handshake Stewardship: Extending a Hand Is Effective Years Later

BACKGROUND

Children's Hospital Colorado created a unique method of antimicrobial stewardship, called handshake stewardship, that effectively decreased hospital anti-infective use and costs in its pilot year (2013). Handshake stewardship is distinguished by: (1) the lack of prior authorization; (2) a review of all prescribed anti-infectives; (3) a shared review by the physician and the pharmacist; and (4) a daily, rounding-based, in-person approach to supporting providers. We sought to reevaluate the outcomes of the program after 5 years of experience, totaling 8 years of data.

METHODS

We retrospectively measured anti-infective (antibiotic, antiviral, antifungal) use hospital-wide by unit and by drug for an 8-year period spanning October 2010 to October 2018. Aggregated monthly use was measured in days of therapy per thousand patient days (DOT/1000 PD). The percentage of children admitted ever receiving an anti-infective was also measured, as well as severity-adjusted mortality, readmissions, and lengths of stay.

RESULTS

Hospital-wide mean anti-infective use significantly decreased, from 891 (95% confidence interval [CI] 859-923) in the pre-implementation phase to 655 (95% CI 637-694) DOT/1000 PD in post-implementation Year 5; in a segmented regression time series analysis, this was a rate of -2.6 DOT/1000 PD (95% CI -4.8 to -0.4). This is largely attributable to decreased antibacterial use, from 704 (95% CI 686-722) to 544 (95% CI 525 -562) DOT/1000 PD. The percentage of children ever receiving an anti-infective during admission likewise declined, from 65% to 52% (95% CI 49-54). There were no detrimental effects on severity adjusted mortality, readmissions, or lengths of stay.

CONCLUSIONS

The handshake method is an effective and sustainable approach to stewardship.

Profile of Antimicrobial Use in the Pediatric Population of a University Hospital Centre, 2015/16 to 2018/19

BACKGROUND

Antimicrobial stewardship is a standard practice in health facilities to reduce both the misuse of antimicrobials and the risk of resistance.

OBJECTIVE

To determine the profile of antimicrobial use in the pediatric population of a university hospital centre from 2015/16 to 2018/19.

METHODS

In this retrospective, descriptive, cross-sectional study, the pharmacy information system was used to determine the number of days of therapy (DOTs) and the defined daily dose (DDD) per 1000 patient-days (PDs) for each antimicrobial and for specified care units in each year of the study period. For each measure, the ratio of 2018/19 to 2015/16 values was also calculated (and expressed as a proportion); where the value of this proportion was ≤ 0.8 or ≥ 1.2 (indicating a substantial change over the study period), an explanatory rating was assigned by consensus.

RESULTS

Over the study period, 94 antimicrobial agents were available at the study hospital: 70 antibiotics (including antiparasitics and antituberculosis drugs), 14 antivirals, and 10 antifungals. The total number of DOTs per 1000 PDs declined from 904 in 2015/16 to 867 in 2018/19. The 5 most commonly used antimicrobials over the years, expressed as minimum/maximum DOTs per 1000 PDs, were piperacillin-tazobactam (78/105), trimethoprim-sulfamethoxazole (74/84), ampicillin (51/69), vancomycin (53/68), and cefotaxime (55/58). In the same period, the care units with the most antimicrobial use (expressed as minimum/maximum DOTs per 1000 PDs) were hematology-oncology (2529/2723), pediatrics (1006/1408), and pediatric intensive care (1328/1717).

CONCLUSIONS

This study showed generally stable consumption of antimicrobials from 2015/16 to 2018/19 in a Canadian mother-and-child university hospital centre. Although consumption was also stable within drug groups (antibiotics, antivirals, and antifungals), there were important changes over time for some individual drugs. Several factors may explain these variations, including disruptions in supply, changes in practice, and changes in the prevalence of infections. Surveillance of antimicrobial use is an essential component of an antimicrobial stewardship program.

Physician experiences implementing antimicrobial stewardship rounds in pediatric hospital medicine: An exploratory, qualitative study

Objectives:

An antimicrobial stewardship intervention was implemented for pediatric medicine units using an in-person rounds-based approach to provide stewardship recommendations and education from an antimicrobial stewardship physician and antimicrobial stewardship pharmacist.

Design, Setting, Participants, and Methods:

In this exploratory qualitative study, purposeful sampling was used to recruit participants for individual interviews at a tertiary- and quaternary-care referral center. Pediatricians and residents who attended ≥1 stewardship round were included. A semistructured interview guide was created focusing on perceptions of antimicrobial stewardship, personal experiences at stewardship rounds, and perceived impacts on patient care. Using a constant comparative analysis approach, codes were developed and collapsed into themes.

Results:

Overall, 8 pediatricians and 10 residents completed interviews. Qualitative analysis yielded 3 themes: insights into clinical reasoning, opportunity for growth and learning, and establishing and exploring professional relationships. The handshake-rounds approach encouraged participants to critically evaluate antimicrobial choices and to engage in discussion with the antimicrobial stewardship team. Participants felt validated at stewardship rounds and gained confidence prescribing antimicrobials. Face-to-face interaction reduced reluctance for some participants to consult infectious disease (ID) service; however, others worried that physicians may avoid ID consultation because of stewardship rounds.

Conclusions:

Participants found stewardship rounds to be an effective strategy for education and development of clinical reasoning skills for optimal antimicrobial prescribing—choosing wisely or choosing rightly. The effects of stewardship rounds on timing and frequency of ID consultation are interesting. Further research into important patient outcomes and consultation practices are needed locally, but our experiences may help others to reflect on the power of conversation and relationships in antimicrobial stewardship.

Antibiotic stewardship in the PICU: Impact of ward rounds led by paediatric infectious diseases specialists on antibiotic consumption

Antimicrobial stewardship programmes (ASP) are aimed at optimising antimicrobial utilization. However, only few studies have focused on paediatric intensive care units (PICU), where inappropriate antibiotic use occurs frequently. We assessed the effect and safety of a once weekly paediatric infectious disease (PID) ward round with prospective audit and feedback on antibiotic consumption in a multidisciplinary PICU. This study was conducted within 6-months periods before and after the implementation of a weekly PID-ward round. Antimicrobial management and two main recommendations per patient were discussed and documented. The primary outcome was antimicrobial utilization, measured by days of therapy (DoT) and length of therapy (LoT) per 1000 patient days (PD) for all PICU stays. Secondary outcomes included PICU mean length of stay, total mortality, infection-related mortality and cost of therapy. 1964 PD were analyzed during the pre- and 1866 PD during the post-implementation phase. Adherence to the recommendations was 79%. An 18% reduction of DoT/1000 PD was observed in the post-implementation period (p = 0.005). LoT/1000 PD decreased by 11% (p = 0.09). Meropenem and vancomycin usage were reduced by 49% (p = 0.07) and 56% (p = 0.03), respectively. We conclude, that a once weekly PID-ward round with prospective audit and feedback is safe and effective and reduces antibiotic consumption in PICUs.

Patterns of antimicrobial consumption in neonatal and pediatric intensive care units in Germany and Brazil

Antibiotic consumption (AC) is a key component of antimicrobial stewardship programs to recognize local patterns of antibiotic use. Our aim was to measure AC in neonatal units, including neonatal (NICU)/paediatric (PICU) intensive care units in different countries. We conducted a multicenter, retrospective, cohort study in three NICUs, one neonatal ward, and three PICUs with a total of 84 beds. Global and individual AC in days of therapy (DOT) and DOT per 1000 patient-days were assessed. During the study period, 2567 patients were admitted, corresponding to 4961 patient-days in neonatal units and 9243 patient-days in PICUs. Multidrug-resistant Gram-negative bacteria and methicillin-resistant Staphylococcus aureus were more frequent in Brazil than in Germany. Average AC was 386.5 and 1335.5 DOT/1000PD in German and Brazilian neonatal units, respectively. Aminopenicillins plus 3rd generation cephalosporins were the most commonly prescribed antibiotics in German neonatal units, while aminopenicillins plus aminoglycosides were the class most commonly used in Brazilian NICU. Average AC was 888.1 and 1440.7 DOT/1000PD in German and Brazilian PICUs, respectively. Antipseudomonal penicillins were most commonly used in the German PICU, and glycopeptides were the most frequently prescribed in Brazilian PICUs. Carbapenems represented 2.3-14% of total DOTs in German neonatal units and 4% in the Brazilian NICU and 13.0% in the German PICU and 6-12.2% in Brazilian PICUs. We concluded that different patterns of most commonly prescribed antibiotics were observed in neonatal units and PICUs in these two countries, probably related to different local patterns of antibiotic resistance, with a higher antibiotic consumption in Brazilian study units.

Impact of a Prospective Audit and Feedback Antimicrobial Stewardship Program in Pediatric Units in Tertiary Care Teaching Hospital in Thailand

BACKGROUND

Antimicrobial stewardship programs (ASPs) have been proven to be beneficial in reducing the use of antimicrobial agents, antibiotic resistance, and health care costs. The data supporting the utility of ASPs has come largely from adult hospital units, but few pediatric hospital units have implemented ASPs. Our objective for this study was to assess the impact of ASPs in pediatric units in tertiary care teaching hospitals.

METHODS

We conducted a retrospective chart review to compare antimicrobial use pre- and post-ASP over a 6-month period in a tertiary care hospital in which an ASP had been in use since July 2017. Meropenem, vancomycin, and colistin were selected to be monitored. ASP rounds were conducted twice a week to assess and provide feedback on antimicrobial prescriptions. Antimicrobial use was measured as days of therapy (DOTs) per 1000 patient-days and was compared pre- and post-ASP by using independent t tests.

RESULTS

Charts of children hospitalized who were in antimicrobial treatment pre-ASP (44.3%) and post-ASP (41.7%) were reviewed. The percentages of children who received selected antimicrobial agents did not differ between pre- and post-ASP. During the post-ASP period, a significant reduction in DOT with vancomycin and colistin was observed. Vancomycin use decreased from 58.5 to 40.2 DOTs per 1000 patient-days (P = .038), and colistin decreased from 36.3 to 13.8 DOTs per 1000 patient-days (P = .026). Meropenem use decreased from 126.8 to 111.2 DOTs per 1000 patient-days (P = .467). Between the 2 periods, there was no effect on length of stay and mortality.

CONCLUSIONS

ASPs can lead to a significant reduction in selected antimicrobial use in children who are hospitalized, with no effect on length of stay or mortality rate.

Antimicrobial Stewardship Interventions to Combat Antibiotic Resistance: an Update on Targeted Strategies

PURPOSE OF REVIEW

Overutilization of antimicrobials is a known contributor to the development of antimicrobial resistance, which is a threat to global health. The goal of antimicrobial stewardship programs (ASPs) is to implement targeted interventions to reduce inappropriate antimicrobial prescribing and prevent development of antimicrobial resistance. We aim to review recently published literature focused on five categories of ASP interventions that have demonstrated success in optimizing appropriate antimicrobial use, improving patient outcomes, and fighting antimicrobial resistance.

RECENT FINDINGS

In the past year, ASP interventions in the published literature have focused on minimizing duration of antimicrobial therapy for infectious syndromes, implementing novel methods for performing prospective audit and feedback, utilizing microbiology laboratory or rapid diagnostic tests to expedite diagnosis, leveraging clinical decision support and electronic medical record tools, and performing penicillin allergy assessment. While the majority of studies assessing ASP interventions do not assess changes in antimicrobial resistance, outcomes demonstrating improved appropriate antibiotic use have been used as a surrogate. Successful ASPs should seek to implement and evaluate novel interventions targeting improvement in antimicrobial prescribing. Such interventions are of critical importance to prevent further growth of antimicrobial resistance.

Clinical impact of an antimicrobial stewardship program on high-risk pediatric patients

OBJECTIVE

To evaluate the clinical impact of an antimicrobial stewardship program (ASP) on high-risk pediatric patients.

DESIGN

Retrospective cohort study.

SETTING

Free-standing pediatric hospital.

PATIENTS

This study included patients who received an ASP review between March 3, 2008, and March 2, 2017, and were considered high-risk, including patients receiving care by the neonatal intensive care (NICU), hematology/oncology (H/O), or pediatric intensive care (PICU) medical teams.

METHODS

The ASP recommendations included stopping antibiotics; modifying antibiotic type, dose, or duration; or obtaining an infectious diseases consultation. The outcomes evaluated in all high-risk patients with ASP recommendations were (1) hospital-acquired Clostridium difficile infection, (2) mortality, and (3) 30-day readmission. Subanalyses were conducted to evaluate hospital length of stay (LOS) and tracheitis treatment failure. Multivariable generalized linear models were performed to examine the relationship between ASP recommendations and each outcome after adjusting for clinical service and indication for treatment.

RESULTS

The ASP made 2,088 recommendations, and 50% of these recommendations were to stop antibiotics. Recommendation agreement occurred in 70% of these cases. Agreement with an ASP recommendation was not associated with higher odds of mortality or hospital readmission. Patients with a single ASP review and agreed upon recommendation had a shorter median LOS (10.2 days vs 13.2 days; P &lt; .05). The ASP recommendations were not associated with high rates of tracheitis treatment failure.

CONCLUSIONS

ASP recommendations do not result in worse clinical outcomes among high-risk pediatric patients. Most ASP recommendations are to stop or to narrow antimicrobial therapy. Further work is needed to enhance stewardship efforts in high-risk pediatric patients.