Using a simple point-prevalence survey to define appropriate antibiotic prescribing in hospitalised children across the UK

Point prevalence surveys of antibiotic prescribing in children at a tertiary hospital in a resource constraint, low-income sub-Saharan African country-the impact of an antimicrobial stewardship program

BACKGROUND

Resistance to multiple antibiotics by several pathogens has been widely described in children and has become a global health emergency. This is due to increased use by parents, caregivers, and healthcare providers. This study aims to describe the prevalence rates of antibiotic prescribing, ascertain the impact of antimicrobial stewardship programs, and target improving the quality of antibiotic prescribing in the paediatric population over time in a hospital.

METHOD

A point prevalence survey of antibiotic use was performed yearly for 4 years to monitor trends in antibiotic prescribing. Data from all patients admitted before 8 a.m. on the day of the PPS were included. A web-based application designed by the University of Antwerp was used for data entry, validation, and analysis ( http://www.global-pps.com ).

RESULTS

A total of 260 children, including 90 (34.6%) neonates and 170 (65.4%) older children, were admitted during the four surveys. Overall, 179 (68.8%) patients received at least one antibiotic. In neonates, the prevalence of antibiotic use increased from 78.9 to 89.5% but decreased from 100 to 58.8% in older children. There was a reduction in the use of antibiotics for prophylaxis from 45.7 to 24.6%. The most frequently prescribed antibiotic groups were third generation cephalosporins and aminoglycosides. The most common indications for antibiotic prescription were sepsis in neonates and central nervous system infection in older children. The documentation of reason in notes increased from 33 to 100%, while the stop-review date also increased from 19.4 to 70%.

CONCLUSION

The indicators for appropriate antibiotic prescription improved over time with the introduction of antibiotic stewardship program in the department.

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 resistance control activities at a tertiary hospital in a low-resource setting: an example of Queen Elizabeth Central Hospital in Malawi

Background

Addressing AMR has been most problematic in low- and middle-income countries, which lack infrastructure, diagnostic capacity, and robust data management systems, among other factors. The implementation of locally-led efforts in a low-income country to develop sustainability and build capacity for AMR control within the existing infrastructure has not been well documented.

Methods

We detail current AMR control initiatives at Queen Elizabeth Central Hospital, a tertiary referral government hospital in Malawi with limited resources, and present the activities accomplished to date, lessons learned, and challenges ahead.

Results

The key areas of AMR control initiatives that the group focused on included laboratory diagnostics and surveillance, antimicrobial stewardship, infection prevention and control, pharmacy, leadership, education, and funding.

Discussion

The hospital AMR Control Working Group increased awareness, built capacity, and implemented activities around AMR control throughout the hospital, in spite of the resource limitations in this setting. Our results are based on the substantial leadership provided by the working group and committed stakeholders who have taken ownership of this process.

Conclusion

Limited resources pose a challenge to the implementation of AMR control activities in low- and middle-income countries. Leadership is central to implementation. Future efforts will need to transition the initiative from an almost fully personal commitment to one with wider engagement to ensure sustainability.

Quality indicators for appropriate antibiotic prescribing in urinary tract infections in children

BACKGROUND

The aim of this study was to define a set of urinary tract infections (UTIs)-specific quality indicators for appropriate prescribing in children and evaluate clinical practices in a district general hospital in Greece.

METHODS

The UTIs-specific quality indicators were informed by a review of the existing literature. Quality indicators were selected to describe the overall antibiotics use, prescribing patterns and UTIs clinical management regarding treatment and prophylaxis in a cohort of children admitted with a UTI. Microbiological, clinical and prescribing data about dosing, duration and route of administration were collected from the patients' electronic health records.

RESULTS

Twelve quality indicators were adapted or developed for prescribing in childhood UTIs. A broad variety of antibiotics were prescribed for UTIs, with a drug utilization (DU) 90% rate of 6 and 9 different antibiotics for febrile and afebrile UTIs, respectively. Despite the low incidence of multi-drug resistant UTIs in the study period (9/261, 3.4%), broad-spectrum antibiotics were prescribed in 33.5% (164/490) of prescriptions. A total of 62.8% (164/261) of patients were started on empiric combined therapies, while opportunities to de-escalate were missed in 37.8% (62/164) of them. One quarter (67/261, 25.7%) of patients did not fulfil the criteria for receiving treatment, while nearly half of those prescribed prophylaxis (82/175, 46.9%) could have avoided having a prophylaxis prescription.

CONCLUSIONS

Our study identified substantial gaps for improvement in antimicrobial prescribing for UTIs in children. The application of the proposed quality indicators could help to limit unnecessary antibiotics use in children with UTI.

Use of broad-spectrum antibiotics in children diagnosed with multisystem inflammatory syndrome temporarily associated with SARS-CoV-2 infection in Poland: the MOIS-CoR study

OBJECTIVES

Multisystem inflammatory syndrome in children (MIS-C) is the result of an immune response triggered by a previous exposure to SARS-CoV-2. The clinical presentation of MIS-C overlaps with other life-threatening bacterial infections, in which antimicrobials are the mainstay therapy. The aim of study was to describe the use of antibiotics in children with MIS-C in Poland.

METHODS

The analysis of 345 children reported from 42 Polish cities to the national MultiOrgan Inflammatory Syndromes COVID-19 Related Study (MOIS-CoR Study) from June 2020 to April 2021.

RESULTS

At least one antibiotic was used in 310 (90%) children, mainly third-generation cephalosporin (251/310). Broad-spectrum antibiotics were used in 258 (75%) children and 224 (87%) received this treatment for more than 3 days. Concentrations of serum procalcitonin >2 µg/l and the presence of lower respiratory symptoms were associated with increased odds of receiving any antibiotic.

CONCLUSION

Although bacterial infections in patients with MIS-C are uncommon, we show that MIS-C poses a challenge to clinicians who are faced with the decision to start, continue, or stop antimicrobial therapy. Antibiotic stewardship in patients with MIS-C should be improved to ensure that likely pathogens are treated and that antimicrobials are stopped when bacterial infections are excluded and the diagnosis of MIS-C is made.

Diagnostic and treatment dilemmas in well children with petechial rash in the emergency department

This article presents a discussion based on a case study of an eight-month-old boy with petechial rash who presented at the emergency department (ED). Blood tests were obtained and intravenous antibiotics were administered. The patient was admitted to the children's ward and was discharged the next day. It was suspected that the rash was caused by a non-specific viral illness. Non-blanching rashes, such as petechial rash, in well children often lead to diagnostic and treatment dilemmas in the ED. Clinicians fear missing the diagnosis of invasive meningococcal disease, which results in blood tests, cannulation and early administration of antibiotics. Non-blanching rashes have many potential causes and extensive tests and antibiotic treatment may not always be necessary and have the potential to cause harm. A tailored approach to investigate, treat and discharge well children with petechial rash from the ED is advocated.

Antimicrobial Use in Pediatric Oncology and Hematology: Protocol for a Multicenter Point-Prevalence Study With Qualitative Expert Panel Assessment

Background

Because infections are a major driver of morbidity and mortality in children with hematologic or oncologic diseases, antimicrobials are frequently prescribed in pediatric oncology practice. However, excess or inappropriate use of antimicrobials is directly linked to the emergence of antimicrobial resistance. Although point-prevalence studies have examined the extent of antimicrobial use, a comprehensive qualitative evaluation of individual antimicrobial prescriptions remains lacking.

Objective

The aim of this study is to identify appropriate versus inappropriate antimicrobial use among pediatric cancer patients in a point-prevalence study, followed by an expert panel adjudication process and a subsequent report of these findings to participating centers. This study also aims to improve the quality of patient care by informing centers about discrepancies between internal standards of care and national guidelines.

Methods

Our point-prevalence study is performed at pediatric cancer centers in Germany and Austria. All patients under 18 years old who are hospitalized at the time of the study are included. As a supplement to the point-prevalence study, an expert panel is qualitatively assessing each of the antimicrobial prescriptions at the participating centers to review local guidelines and compare them with national guidelines.

Results

As of December 2021, the point-prevalence survey has been conducted at 30 sites and expert panel adjudication for qualitative assessment of each antimicrobial use is ongoing. Results of the study are expected in 2022.

Conclusions

This is the first point-prevalence study conducted among pediatric cancer centers with an integrated, multistep, qualitative approach that assesses each antimicrobial prescription. The results of this study will inform possible interventions for internal guidelines and antimicrobial stewardship programs implemented at pediatric cancer centers. In addition, local guidelines will be compared with national guidelines. Furthermore, this study will contribute to the overall integration of antimicrobial stewardship principles and initiatives in pediatric oncology and hematology, thereby improving safety and quality of care for children and adolescents with cancer and blood disorders.

International Registered Report Identifier (IRRID)

DERR1-10.2196/35774

Antibiotic Use in Children Before, During and After Hospitalization

Purpose

To investigate ambulatory antibiotic use in children during 1 year before and 1 year after in‐hospital antibiotic exposure compared to children from the general population that had not received antibiotics in‐hospital.

Methods

Explorative data‐linkage cohort study from Norway of children aged 3 months to 17 years. One group had received antibiotics in‐Hospital (H+), and one group had not received antibiotics in‐hospital (H‐). The H+ group was recruited during admission in 2017. Using the Norwegian Population Registry, 10 children from the H‐ group were matched with one child from the H+ group according to county of residence, age and sex. We used the Norwegian Prescription Database to register antibiotic use 1 year before and 1 year after the month of hospitalisation.

Results

Of 187 children in the H+ group, 83 (44%) received antibiotics before hospitalisation compared to 288/1870 (15%) in the H‐ group, relative risk (RR) 2.88 (95% confidence interval 2.38–3.49). After hospitalisation, 86 (46%) received antibiotics in the H+ group compared to 311 (17%) in the H‐ group, RR 2.77 (2.30–3.33). Comorbidity‐adjusted RR was 2.30 (1.84–2.86) before and 2.25 (1.81–2.79) after hospitalisation. RR after hospitalisation was 2.55 (1.99–3.26) in children 3 months‐2 years, 4.03 (2.84–5.71) in children 3–12 years and 2.07 (1.33–3.20) in children 13–17 years.

Conclusions

Children exposed to antibiotics in‐hospital had two to three times higher risk of receiving antibiotics in ambulatory care both before and after hospitalisation. The link between in‐hospital and ambulatory antibiotic exposure should be emphasised in future antibiotic stewardship programs.

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.

Understanding doctors' emergency department antibiotic prescribing decisions in children with respiratory symptoms in the UK: a qualitative study

OBJECTIVE

Exploration of the factors that influence hospital doctors' antibiotic prescribing decisions when treating children with respiratory symptoms in UK emergency departments.

METHODS

A qualitative study using semistructured interviews based on a critical incident technique with 21 physicians of different grades and specialties that treat children in the UK. Interviews were audio-recorded then transcribed verbatim and analysed using thematic analysis.

RESULTS

Four themes were identified. These themes illustrate factors which influence clinician prescribing. The three principal themes were authorities, pressures and risk. The fourth transcending theme that ran through all themes was clinician awareness and complicity ('knowing but still doing').

CONCLUSIONS

Hospital doctors prescribe antibiotics even when they know they should not. This appears to be due to the influence of those in charge or external pressures experienced while weighing up the immediate and longer term risks but clinicians do this with full insight into their actions. These findings have implications for invested parties seeking to develop future antimicrobial stewardship programmes. It is recommended that stewardship interventions acknowledge and target these themes which may in turn facilitate behaviour change and antimicrobial prescribing practice in emergency departments.

Retrospective audit of antibiotic use in a university general pediatrics department using hospital pharmacy dispensing data

Antibiotics are among the most frequently prescribed drugs in children's hospitals, which is why regular monitoring of antibiotic use in hospitals is of great importance. This retrospective audit (60 months, January 2014 - December 2018) analyzes the antibiotic consumption at a university inpatient department of general pediatrics including neonatal and pediatric intensive care based on pharmacy dispensing data in units of grams per 100 patient days and in Defined Daily Doses per 100 patient days. The results provide potential targets for Antibiotic Stewardship interventions. Conversely, this audit elicits methodological limitations of the method of antibiotic surveillance in pediatrics recommended by the Robert Koch Institute, Berlin.

Carbapenem stewardship program in a French university children's hospital

INTRODUCTION

Carbapenems, last-resort antibiotics, are widely used as first-line treatment in patients carrying extended-spectrum beta-lactamases (ESBL) Enterobacteriaceae, including in a pediatric setting. We aimed to implement an antibiotic stewardship program (ASP) to improve the use of carbapenems.

METHODS

We implemented an ASP at the Bordeaux Children's University Hospital with 6-month audits on prescribing practice before and after an intervention (revision of antibiotic treatment protocols, a half-day educational session with feedback of the first study period). The number of carbapenem prescriptions was analyzed and two criteria were used to assess conformity of the indication for carbapenem prescription and conformity of the reassessment. A logistic regression was used to assess the overall compliance of carbapenem prescriptions over the two periods adjusted for ESBL carriage.

RESULTS

A total of 57 patients were included with 37 carbapenem prescriptions before the intervention and 23 after. Overall carbapenem consumption decreased from 0.54 prescriptions per 100 admissions to 0.32 (p = 0.06). Conformity increased during the study for indication (46-87%, p = 0.004) and for reassessment (48-78%, p = 0.04) and was significantly associated with the second study period, after adjustment for ESBL carriage.

CONCLUSION

Our intervention contributed to a significant improvement in the compliance to indications for carbapenem indication and in the reassessment of the prescription.

Establishing Benchmarks for Antimicrobial Use in Canadian Children's Hospitals: Results From 2 National Point Prevalence Surveys

BACKGROUND

Point prevalence surveys (PPS) are potentially useful to measure antimicrobial use across institutions. The objectives of the study were to describe and compare antimicrobial use between pediatric hospitals in Canada.

METHODS

Fifteen pediatric hospitals all with pediatric infectious diseases service participated in 2 single-day PPS in 2018/19. Children <18 years of age who were inpatients were included. Age, service, clinical diagnosis as well as name, route, and start date for each antimicrobial was collected. Antibiotics were grouped according to the World Health Organization AWaRe classification.

RESULTS

There were 3924 inpatient patients-days representing 2729 children and 1195 infants in neonatal intensive care units (NICU) surveyed. Among non-NICU patients, 1210 (44.3%) received 1830 antimicrobials of which 73.9% were for empiric or pathogen-directed therapy and 25.6% for prophylaxis. The mean proportion of core Access and Watch group antibiotics was 45.8% and 63.5%, respectively, with no differences in means between tertiary and quaternary care sites. Among 1195 infants in NICU, 19.7% received 410 antimicrobials of which 17.1% were for prophylaxis and a mean of 45.4% were Watch group antibiotics. Of patients admitted for community-acquired pneumonia, 32.7% received penicillin or aminopenicillins only with variability among sites.

CONCLUSIONS

PPS of antimicrobial use in Canadian pediatric hospitals revealed a high proportion of Watch group (broader spectrum) antibiotics, even among children with community-acquired pneumonia. This study demonstrates the feasibility of PPS to document antimicrobial use and potentially to use this data to establish goals for decreasing both overall and Watch group antibiotics.

Antibiotic appropriateness and guideline adherence in hospitalized children: results of a nationwide study

BACKGROUND

Information on the nature and appropriateness of antibiotic prescribing for children in hospitals is important, but scarce.

OBJECTIVES

To analyse antimicrobial prescribing and appropriateness, and guideline adherence, in hospitalized children across Australia.

PATIENTS AND METHODS

We analysed data from the National Antimicrobial Prescribing Survey (NAPS) from 2014 to 2017. Surveys were performed in hospital facilities of all types (public and private; major city, regional and remote). Participants were admitted children <18 years old. Risk factors associated with inappropriate prescribing were explored using logistic regression models.

RESULTS

Among 6219 prescriptions for 3715 children in 253 facilities, 19.6% of prescriptions were deemed inappropriate. Risk factors for inappropriate prescribing included non-tertiary paediatric hospital admission [OR 1.37 (95% CI 1.20-1.55)] and non-major city hospital location [OR 1.52 (95% CI 1.30-1.77)]. Prescriptions for neonates, immunocompromised children and those admitted to an ICU were less frequently inappropriate. If a restricted antimicrobial was prescribed and not approved, the prescription was more likely to be inappropriate [OR 12.9 (95% CI 8.4-19.8)]. Surgical prophylaxis was inappropriate in 59% of prescriptions.

CONCLUSIONS

Inappropriate antimicrobial prescribing in children was linked to specific risk factors identified here, presenting opportunities for targeted interventions to improve prescribing. This information, using a NAPS dataset, allows for analysis of antimicrobial prescribing among different groups of hospitalized children. Further exploration of barriers to appropriate prescribing and facilitators of best practice in this population is recommended.

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.

The use of continuous electronic prescribing data to infer trends in antimicrobial consumption and estimate the impact of stewardship interventions in hospitalized children

Background

Understanding antimicrobial consumption is essential to mitigate the development of antimicrobial resistance, yet robust data in children are sparse and methodologically limited. Electronic prescribing systems provide an important opportunity to analyse and report antimicrobial consumption in detail.

Objectives

We investigated the value of electronic prescribing data from a tertiary children’s hospital to report temporal trends in antimicrobial consumption in hospitalized children and compare commonly used metrics of antimicrobial consumption.

Methods

Daily measures of antimicrobial consumption [days of therapy (DOT) and DDDs] were derived from the electronic prescribing system between 2010 and 2018. Autoregressive moving-average models were used to infer trends and the estimates were compared with simulated point prevalence surveys (PPSs).

Results

More than 1.3 million antimicrobial administrations were analysed. There was significant daily and seasonal variation in overall consumption, which reduced annually by 1.77% (95% CI 0.50% to 3.02%). Relative consumption of meropenem decreased by 6.6% annually (95% CI −3.5% to 15.8%) following the expansion of the hospital antimicrobial stewardship programme. DOT and DDDs exhibited similar trends for most antimicrobials, though inconsistencies were observed where changes to dosage guidelines altered consumption calculation by DDDs, but not DOT. PPS simulations resulted in estimates of change over time, which converged on the model estimates, but with much less precision.

Conclusions

Electronic prescribing systems offer significant opportunities to better understand and report antimicrobial consumption in children. This approach to modelling administration data overcomes the limitations of using interval data and dispensary data. It provides substantially more detailed inferences on prescribing patterns and the potential impact of stewardship interventions.

Appropriateness of Antibiotic Prescribing in United States Children's Hospitals: A National Point Prevalence Survey

BACKGROUND

Studies estimate that 30%-50% of antibiotics prescribed for hospitalized patients are inappropriate, but pediatric data are limited. Characterization of inappropriate prescribing practices for children is needed to guide pediatric antimicrobial stewardship.

METHODS

Cross-sectional analysis of antibiotic prescribing at 32 children's hospitals in the United States. Subjects included hospitalized children with ≥ 1 antibiotic order at 8:00 am on 1 day per calendar quarter, over 6 quarters (quarter 3 2016-quarter 4 2017). Antimicrobial stewardship program (ASP) physicians and/or pharmacists used a standardized survey to collect data on antibiotic orders and evaluate appropriateness. The primary outcome was the percentage of antibiotics prescribed for infectious use that were classified as suboptimal, defined as inappropriate or needing modification.

RESULTS

Of 34 927 children hospitalized on survey days, 12 213 (35.0%) had ≥ 1 active antibiotic order. Among 11 784 patients receiving antibiotics for infectious use, 25.9% were prescribed ≥ 1 suboptimal antibiotic. Of the 17 110 antibiotic orders prescribed for infectious use, 21.0% were considered suboptimal. Most common reasons for inappropriate use were bug-drug mismatch (27.7%), surgical prophylaxis > 24 hours (17.7%), overly broad empiric therapy (11.2%), and unnecessary treatment (11.0%). The majority of recommended modifications were to stop (44.7%) or narrow (19.7%) the drug. ASPs would not have routinely reviewed 46.1% of suboptimal orders.

CONCLUSIONS

Across 32 children's hospitals, approximately 1 in 3 hospitalized children are receiving 1 or more antibiotics at any given time. One-quarter of these children are receiving suboptimal therapy, and nearly half of suboptimal use is not captured by current ASP practices.

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).

Use of multiple metrics to assess antibiotic use in Italian children's hospitals

Quantification of antibiotic utilization is an essential component of antibiotic stewardship programs. In this multicentric study, we used different metrics to evaluate inpatient antibiotic use in children. The study objectives were to describe point prevalence of antibiotic use by indication and patient characteristics, to evaluate DOTs, LOTs and PDDs, and to compare PDDs to DDDs, which assume average maintenance dose per day in adults. All children hospitalized on the days of the study were included. Trained personnel collected demographic and clinical data from patients’ clinical records. We recorded information about antibiotics administered on the date of data collection, and in the previous 30 days of hospitalization. Of 810 patients, 380 (46.9%; CI 95%: 43.4–50.4) received one or more antibiotics; prevalence of use was 27.0% for prophylaxis (219/810), and 20.7% (168/810) for treatment. Overall, 587 drugs were issued to the 380 patients receiving antibiotics (1.5 antibiotic per patient). When considering treatments, DOT and LOT per 100 patient-days were 30.5 and 19.1, respectively, resulting in a DOT/LOT ratio of 1.6. PDDs increased with age and approached DDDs only in children aged ≥ 10 years; the ratio between PDDs estimated in children aged ≥ 10 years and in 0–11 month-old infants ranged from 2 for sulfamethoxazole and trimethoprim, to 25 for meropenem. Our results confirm that DOT, LOT and PDD are better alternatives to DDD in children.

Antimicrobial use across six referral hospitals in Tanzania: a point prevalence survey

OBJECTIVE

To delineate the prevalence and factors associated with antimicrobial use across six referral hospitals in Tanzania using WHO point prevalence survey (PPS) methodology to inform hospital-specific antimicrobial stewardship programmes.

DESIGN

Cross-sectional analytical study.

SETTING

Six referral hospitals in Tanzania.

PARTICIPANTS

Patients irrespective of age and gender (n=948) admitted in the six referral hospital wards before 8:00 hours on each day of the survey were included in December 2019. Using the WHO PPS methodology, data on hospitals, wards, patients, antibiotics, and indications for antibiotics were collected.

OUTCOME MEASURES

We analysed the prevalence of antibiotic use by referral hospital, ward, indication and patient characteristics as the main outcomes. We also described adherence to the Tanzania Standard Treatment Guidelines (STG) and WHO's AWaRe categorisation of antibiotics.

RESULTS

Approximately 62.3% of inpatients were prescribed antibiotics, predominantly from the Access group of antibiotics (ceftriaxone, metronidazole or ampicillin-cloxacillin). The overall adherence of antibiotic prescriptions to the Tanzania STG was high (84.0%), with the exception of Sekou Toure Regional Referral Hospital (68.0%) and Maweni Regional Referral Hospital (57.8%). The most common indication for antibiotic prescriptions was community-acquired infections (39.8%). Children less than 2 years of age (OR 1.73, 95% CI 1.02 to 2.92, p=0.039); admission to surgical wards (OR 4.90, 95% CI 2.87 to 8.36, p <0.001); and admission to paediatric wards (OR 3.93, 95% CI 2.16 to 7.15, p <0.001) were associated with increased odds of antibiotic use. Only 2 of 591 patients were prescribed antibiotics based on culture and antimicrobial susceptibility testing results.

CONCLUSIONS

Empirical use of antibiotics is common, and the Access group of antibiotics is predominantly prescribed in children less than 2 years and patients admitted to surgical and paediatric wards. Lack of utilisation of antimicrobial susceptibility testing services in these hospitals requires urgent interventions. Routine monitoring of antibiotic use is recommended to be part of antibiotic stewardship programmes in Tanzania.

Assessment of antimicrobial use and prescribing practices among pediatric inpatients in Zimbabwe

This study aims to assess antimicrobial consumption in the pediatric department of a tertiary care public hospital in Zimbabwe. Clinical records of pediatric inpatients admitted to Harare Central Hospital over a 3-week period were reviewed prospectively. Antimicrobial consumption was described as days of therapy per 100 inpatient days (DOT/100 PD). Adherence of antimicrobial drug prescriptions to the National Guidelines was also evaluated. A total of 121 (93.1%) children were prescribed at least one antimicrobial out of 130 children admitted. The median age was 14 months (IQR: 3 - 48 months). Overall antimicrobial consumption was 155.4 DOT/100 PD (95% CI 146-165.2). The most frequently prescribed antimicrobials were benzylpenicillin, gentamicin and ceftriaxone. Prescriptions were adherent to national guidelines in 57.7% of children. This study shows that there is high antimicrobial drug usage in hospitalized children in Zimbabwe and a considerable proportion of prescriptions are non-adherent with national guidelines.

Analysis of antibiotic treatment of children in a Shanghai tertiary hospital based on point prevalence surveys

Background

Misuse and overuse of antibiotics by physicians in the treatment of children is common in China. This study aimed to reveal the overall use of antibiotics to treat children hospitalized in four types of pediatric wards.

Methods

Seven independent point prevalence surveys (PPSs) were conducted in Shanghai Children’s Hospital of Shanghai Jiao Tong University over the period 2012 to 2018. Pediatric ward types were defined general pediatric medical, pediatric surgical, pediatric intensive care units (PICU), and neonatal.

Results

A total of 3975 pediatric patients were included in the study, of which 63.9% received at least one dose antibiotic. The top five classes of antibiotics administered were cephalosporins (43.8%, n = 1743), penicillins (13.2%, n = 526), carbapenems (8.7%, n = 347), nitroimidazoles (7.1%, n = 281) and macrolides (6.5%, n = 257). The five most commonly used generic antibiotics were cefuroxime (14.9%, n = 594), ceftriaxone (9.7%, n = 387), cefotaxime (9.0%, n = 358), meropenem (8.1%, n = 320) and ampicillin/sulbactam (6.0%, n = 239). Meropenem was among top five antibiotics prescribed in the general pediatric, PICU and neonatal wards and sixth in the pediatric surgical wards. Of all children on antibiotics, 23.4% received prophylactic treatment, and prophylaxis accounted for 68.1% of indications for treatment in the pediatric surgical wards.

Conclusions

Given that over-treatment with third-generation cephalosporins and carbapenems has been associated with treatment-resistant infections, the prescription of these drugs should be strictly controlled and monitored, and measures should be taken to improve the management of surgical prophylaxis in hospitalized children in China.

Population pharmacokinetic meta-analysis of individual data to design the first randomized efficacy trial of vancomycin in neonates and young infants

OBJECTIVES

In the absence of consensus, the present meta-analysis was performed to determine an optimal dosing regimen of vancomycin for neonates.

METHODS

A 'meta-model' with 4894 concentrations from 1631 neonates was built using NONMEM, and Monte Carlo simulations were performed to design an optimal intermittent infusion, aiming to reach a target AUC0-24 of 400 mg·h/L at steady-state in at least 80% of neonates.

RESULTS

A two-compartment model best fitted the data. Current weight, postmenstrual age (PMA) and serum creatinine were the significant covariates for CL. After model validation, simulations showed that a loading dose (25 mg/kg) and a maintenance dose (15 mg/kg q12h if <35 weeks PMA and 15 mg/kg q8h if ≥35 weeks PMA) achieved the AUC0-24 target earlier than a standard 'Blue Book' dosage regimen in >89% of the treated patients.

CONCLUSIONS

The results of a population meta-analysis of vancomycin data have been used to develop a new dosing regimen for neonatal use and to assist in the design of the model-based, multinational European trial, NeoVanc.

Point prevalence survey of antimicrobial use in three hospitals in North-Eastern Tanzania

Background

Antimicrobial resistance (AMR) is one of the most urgent global health threats with low-resource countries being disproportionately affected. Targeted interventions require insight in antibiotic prescription practices. A point prevalence survey (PPS) is a well-known tool to get insight in antibiotic dispensing practices in hospitals and identify areas for improvement. Here, we describe the results of a PPS performed in a tertiary, regional and district hospital in Kilimanjaro region in Tanzania.

Methods

A PPS was performed in the Kilimanjaro Christian Medical Centre (KCMC; tertiary hospital), Mawenzi (regional) and St. Joseph (district) hospital in November and December 2016. Antibiotic use in all patients admitted more than 24 h and those undergoing surgery was recorded. All clinical wards were included except the pediatrics. Data from a single ward were collected on the same day.

Results

A total of 399 patients were included in the PPS: 232 patients from KCMC, 94 from Mawenzi hospital and 73 patients from St. Joseph hospital. Overall prevalence of antibiotic use was 44.0%: 38% in KCMC, 59% in Mawenzi and 63% in St. Joseph. Ceftriaxone (n = 94, 29.8%), metronidazole (n = 79, 23.9%) and other antibiotics belonging to the penicillin class (n = 89, 28.3%) were most commonly prescribed. Antibiotics prescribed for surgical prophylaxis were continued for more than 3 days in 57% of cases.

Conclusion

Our study shows a rate of broad-spectrum antibiotic use in Tanzanian hospitals and prolonged surgical antibiotic prophylaxis being a common practice. PPS is an important tool to improve future antibiotic use in Tanzania hospitals.

The drivers of antimicrobial use across institutions, stakeholders and economic settings: a paradigm shift is required for effective optimization

OBJECTIVES

Significant antimicrobial overuse persists worldwide, despite overwhelming evidence of antimicrobial resistance and knowledge that optimization of antimicrobial use will slow the development of resistance. It is critical to understand why this occurs. This study aims to consider the social influences on antimicrobial use within hospitals in Australia, via an in-depth, multisite analysis.

METHODS

We used a qualitative multisite design, involving 222 individual semi-structured interviews and thematic analysis. Participants (85 doctors, 79 nurses, 31 pharmacists and 27 hospital managers) were recruited from five hospitals in Australia, including four public hospitals (two metropolitan, one regional and one remote) and one private hospital.

RESULTS

Analysis of the interviews identified social relationships and institutional structures that may have a strong influence on antimicrobial use, which must be addressed concurrently. (i) Social relationships that exist across settings: these include the influence of personal risk, hierarchies, inter- and intraprofessional dynamics and sense of futility in making a difference long term in relation to antimicrobial resistance. (ii) Institutional structures that offer context-specific influences: these include patient population factors (including socioeconomic factors, geographical isolation and local infection patterns), proximity and resource issues.

CONCLUSIONS

The success of antimicrobial optimization rests on adequate awareness and incorporation of multilevel influences. Analysis of the problem has tended to emphasize individual 'behaviour improvement' in prescribing rather than incorporating the problem of overuse as inherently multidimensional and necessarily incorporating personal, interpersonal and institutional variables. A paradigm shift is urgently needed to incorporate these critical factors in antimicrobial optimization strategies.

Antibiotic use in Kenyan public hospitals: Prevalence, appropriateness and link to guideline availability

•

We report findings from a point prevalence survey across 14 Kenyan public hospitals.

•

About half of the hospitalised patients received appropriate antibiotic therapy.

•

Laboratory investigations supported less than 1% of the antibiotic prescriptions.

•

Physical availability of treatment guidelines influenced treatment appropriateness.

•

There is need for context-specific, up-to-date, and accessible treatment guidelines.

Objective

To examine prescription patterns and explore to what extent guidelines are available and how they might influence treatment appropriateness among hospitalised patients in Kenyan hospitals.

Methods

Data on antimicrobial usage were collected from hospitalised patients across 14 Kenyan public hospitals. For each prescription, appropriateness of treatment was defined using available local and international treatment guidelines and through consensus with local medical specialists. Association between appropriate treatment, guideline availability and other possible explanatory factors was explored using univariate and multiple regression analysis.

Results

There were 1675 (46.7%) of the 3590 hospitalised patients on antimicrobials with 3145(94%) of the 3363 antimicrobial prescriptions being antibiotics. Two patients (0.1%), had treatment based on available antibiotic susceptibility tests. Appropriate treatment was assessed in 1502 patients who had a single diagnosis. Of these, 805 (53.6%) received appropriate treatment. Physical availability of treatment guidelines increased the odds of receiving appropriate treatment Odds Ratio 6.44[95% CI 4.81–8.64].

Conclusion

Appropriate antibiotic prescription remains a challenge in Kenyan public hospitals. This may be improved by the availability of context-specific, up-to-date, and readily accessible treatment guidelines across all the departments, and by providing better diagnostic support.

Antimicrobial prescription patterns in a tertiary-care pediatric unit in Thailand

BACKGROUND

Antimicrobial resistance is one of the greatest public health threats worldwide. The improper prescription of antibiotics is one factor that promotes antibiotic resistance. Access to antimicrobial surveillance data is essential when assessing the pattern and appropriateness of antimicrobial prescriptions in hospitals and for the establishment of an antimicrobial stewardship program. This study aimed to describe the rate of antimicrobial use and the pattern of prescriptions in a tertiary care pediatric unit in Thailand.

METHODS

A point prevalence survey on antimicrobial use was conducted monthly between January and June 2016, using standardized tools. The survey included all inpatient pediatric beds and identified all children receiving antimicrobial treatment on the day of the survey.

RESULTS

The study included 644 children, 43.3% of whom received antimicrobial treatment during hospitalization. In general wards, the rate of antimicrobial prescriptions was 37.2%; in oncology wards it was 47.0%; in intensive care units it was 38.7%, and in surgical wards it was 67.7%. Meropenem was the most prescribed antimicrobial in the general wards (24.5%) and intensive care units (28.6%), whereas antipseudomonas was the most commonly prescribed antimicrobial in the oncology ward (26.6%). For the surgical ward, the most prescribed antimicrobial was third-generation cephalosporin for both prophylaxis and treatment (39.0%). The most common reason for antimicrobial use was the treatment of infections.

CONCLUSIONS

Nearly half of hospitalized children received at least one antimicrobial. This was comparable with other pediatric tertiary care centers, although the high use of meropenem was different. This study provides important baseline information on antimicrobial use in a large tertiary-care pediatric unit and could lead to a nationwide survey in the future.

Use of the WHO Access, Watch, and Reserve classification to define patterns of hospital antibiotic use (AWaRe): an analysis of paediatric survey data from 56 countries

BACKGROUND

Improving the quality of hospital antibiotic use is a major goal of WHO's global action plan to combat antimicrobial resistance. The WHO Essential Medicines List Access, Watch, and Reserve (AWaRe) classification could facilitate simple stewardship interventions that are widely applicable globally. We aimed to present data on patterns of paediatric AWaRe antibiotic use that could be used for local and national stewardship interventions.

METHODS

1-day point prevalence survey antibiotic prescription data were combined from two independent global networks: the Global Antimicrobial Resistance, Prescribing, and Efficacy in Neonates and Children and the Global Point Prevalence Survey on Antimicrobial Consumption and Resistance networks. We included hospital inpatients aged younger than 19 years receiving at least one antibiotic on the day of the survey. The WHO AWaRe classification was used to describe overall antibiotic use as assessed by the variation between use of Access, Watch, and Reserve antibiotics, for neonates and children and for the commonest clinical indications.

FINDINGS

Of the 23 572 patients included from 56 countries, 18 305 were children (77·7%) and 5267 were neonates (22·3%). Access antibiotic use in children ranged from 7·8% (China) to 61·2% (Slovenia) of all antibiotic prescriptions. The use of Watch antibiotics in children was highest in Iran (77·3%) and lowest in Finland (23·0%). In neonates, Access antibiotic use was highest in Singapore (100·0%) and lowest in China (24·2%). Reserve antibiotic use was low in all countries. Major differences in clinical syndrome-specific patterns of AWaRe antibiotic use in lower respiratory tract infection and neonatal sepsis were observed between WHO regions and countries.

INTERPRETATION

There is substantial global variation in the proportion of AWaRe antibiotics used in hospitalised neonates and children. The AWaRe classification could potentially be used as a simple traffic light metric of appropriate antibiotic use. Future efforts should focus on developing and evaluating paediatric antibiotic stewardship programmes on the basis of the AWaRe index.

FUNDING

GARPEC was funded by the PENTA Foundation. GARPEC-China data collection was funded by the Sanming Project of Medicine in Shenzhen (SZSM2015120330). bioMérieux provided unrestricted funding support for the Global-PPS.

Point prevalence surveys of antimicrobial use: a systematic review and the implications

Introduction: In view of increasing concerns with antimicrobial resistance (AMR), the World Health Organization (WHO) instituted a Global Action Plan (GAP) to address this. Area covered: One of the strategies to achieve the goals of GAP is to conduct regular surveillance of antimicrobial use through point prevalence surveys (PPS). In this review, PubMed, EBSCO, Proquest, Cinahl, and Scopus were searched for PPS of antimicrobial use published in English between January 2000 and December 2019. After systematic database screening of 2,893 articles, 60 PPS met the inclusion criteria and consequently were incorporated in this systematic review. Expert opinion: This review highlighted that most of the PPS were conducted in upper-middle and high-income countries. Prevalence of antimicrobial use was significantly higher in non-European hospitals compared with European hospitals. The domination of third-generation cephalosporin and fluoroquinolones use across all the regions suggests substantial use of broad-spectrum antimicrobials across countries. Among all identified regions around the world, India was the region where the highest use of antimicrobials was observed. Although PPS is a useful tool to assess the pattern of antimicrobial use and provides a robust baseline; however, a standardized surveillance method is needed. In order to optimize antimicrobial use, more efforts are required to improve antimicrobial use.

Improving paediatric antimicrobial stewardship in hospital-based settings: why, where and how?

Background

Antimicrobial resistance (AMR) is being recognized as a priority by healthcare organizations across the world. However, many children are managed on IV antimicrobials in hospital with very little consideration of antimicrobial stewardship issues.

Objectives

A nurse-led paediatric ambulatory outpatient parenteral antimicrobial therapy (OPAT) service, managing children with common infections being ambulated on short courses of IV antimicrobials, was introduced within Southampton Children’s Hospital in January 2018. We evaluated the impact of this service in terms of the quality of antimicrobial prescribing and timing of ambulation in children presenting with common infections.

Methods

All cases managed within the service were reviewed in two separate 2 month time periods: prior to introduction of the service (September–October 2016) and then prospectively after its introduction (September–October 2018).

Results

A total of 96% of IV antibiotic management decisions at 48 h were deemed appropriate in 2018, compared with 75% in 2016. A total of 64% of patients were ambulated on IV antibiotics at some point during their treatment course in 2018, compared with 19% in 2016. However, a significant proportion of antimicrobial decisions made at the point of presentation to hospital remained suboptimal in 2018.

Conclusions

Children are commonly managed with IV antibiotics in hospital. We demonstrate marked improvements in appropriate antimicrobial use through the introduction of a nurse-led ambulatory OPAT service. In addition, such a service can promote a greater proportion of children being ambulated from hospital, freeing up valuable inpatient beds and potentially delivering cost savings that can be used to fund such services.

Inappropriate antibiotic prescriptions among pediatric inpatients in different type hospitals

To investigate the situation of antibiotic consumption and to assess the inappropriate use on pediatric inpatients of different types hospitals in Sichuan, China.A cross-sectional survey of antibiotic prescriptions among hospitalized children aged 1month -14years were conducted from April 2018 to June 2018 in southwestern China. Antibiotic prescriptions were extracted from electronic records during hospitalization of each inpatient in five different types hospitals.In this study, the antibiotic prescription rate of hospitalized children was 66.9% (1176/1758). Compared with tertiary children hospital (TC) (46.1%), general hospitals and non-tertiary children hospitals has higher rate of antibiotic prescription (almost 85%) (P < .001). 93.4% of inpatients received parenteral antibiotic. Overall, the most common antibiotics were Cefoperazone and enzyme inhibitor, Cefixime and Azithromycin. Lower respiratory tract infection (LRTI) was the leading reason for antibiotic consumption in pediatric wards (56.8%), followed by upper respiratory tract infection (URTI) (22.2%). For children with LRTI, Cephalosporins were heavy prescribed, especially broad-spectrum third-generation Cephalosporins (60.3%). The antibiotic prescription proportion of URTI in general hospitals and non-tertiary children hospitals (more than 18%) was higher than TC (8.1%) (P < .001).There was inappropriate use of antibiotic in hospitalized children including overuse of parenteral administration, overprescribing of antibiotic on URTI and misuse of third-generation Cephalosporins in pediatric inpatients with LRTI. Compared with tertiary freestanding children hospital, the irrational antibiotic prescription of general hospitals and non-tertiary children hospitals were more serious. Management strategy should be implementer on quality improvement of antibiotic use.

Condition-specific surveillance in health care-associated urinary tract infections as a strategy to improve empirical antibiotic treatment: an epidemiological modelling study

Background

Health care-associated urinary tract infection (HAUTI) consists of unique conditions (cystitis, pyelonephritis and urosepsis). These conditions could have different pathogen diversity and antibiotic resistance impacting on the empirical antibiotic choices. The aim of this study is to compare the estimated chances of coverage of empirical antibiotics between conditions (cystitis, pyelonephritis and urosepsis) in urology departments from Europe.

Methods

A mathematical modelling based on antibiotic susceptibility data from a point prevalence study was carried. Data were obtained for HAUTI patients from multiple urology departments in Europe from 2006 to 2017. The primary outcome of the study is the Bayesian weighted incidence syndromic antibiogram (WISCA) and Bayesian factor. Bayesian WISCA is the estimated chance of an antibiotic to cover the causative pathogens when used for first-line empirical treatment. Bayesian factor is used to compare if HAUTI conditions did or did not impact on empirical antibiotic choices.

Results

Bayesian WISCA of antibiotics in European urology departments from 2006 to 2017 ranged between 0.07 (cystitis, 2006, Amoxicillin) to 0.89 (pyelonephritis, 2009, Imipenem). Bayesian WISCA estimates were lowest in urosepsis. Clinical infective conditions had an impact on the Bayesian WISCA estimates (Bayesian factor > 3 in 81% of studied antibiotics). The main limitation of the study is the lack of local data.

Conclusions

Our estimates illustrate that antibiotic choices can be different between HAUTI conditions. Findings can improve empirical antibiotic selection towards a personalized approach but should be validated in local surveillance studies.

Electronic supplementary material

The online version of this article (10.1007/s00345-019-02963-9) contains supplementary material, which is available to authorized users.

Antimicrobial Use in a Swedish Pediatric Hospital: Results From Eight Point-prevalence Surveys Over a 15-Year Period (2003-2017)

BACKGROUND

Antimicrobial resistance is increasing, and data on antimicrobial use in Swedish children are limited. We evaluated trends in antimicrobial use and attempted to identify targets for improving the quality of antimicrobial prescribing in a tertiary care center.

METHODS

One-day hospital-wide point prevalence surveys were conducted 8 times during 2003-2017 at Astrid Lindgren Children's Hospital. Children <17 years old were included. Medical records were evaluated for risk factors, indications for treatment, and antibiotic agents used.

RESULTS

Among 946 admitted patients, 36% (336/946) received antimicrobial treatment. The total number of prescriptions increased (P = 0.031), but the proportion of patients treated remained unchanged. The proportion of patients receiving prophylactic treatment increased from 11% to 43% (P = 0.005). The rate of hospital-acquired infections remained unchanged. The primary indication for antimicrobial therapy was sepsis, fever of unknown origin, or fever in neutropenia, followed by intra-abdominal infections and pneumonia. The most frequently used antibiotics were cephalosporins, but consumption decreased, and in 2017 piperacillin-tazobactam was the most frequently used. Antimicrobial use was generally appropriate, although guidelines were often missing. The number of pediatric hospital beds decreased, and the bed occupancy was 71% (101/142) in 2003 and 121% (110/91) in 2017. The patient mix changed toward more patients with underlying risk factors for infectious diseases.

CONCLUSIONS

Antimicrobial use changed during the study period, mainly due to increased prophylactic use in at-risk patients. Antimicrobial stewardship programs including infection control interventions and increasing the availability of guidelines may reduce and improve antimicrobial therapy.

The Point Prevalence Survey Research of Antibacterial Drugs' Prescription for Outpatient Treatment of Urinary System Infections

BACKGROUND:

Antibiotic resistance of microorganisms is the subject of numerous discussions and initiatives, it has a well-defined tendency to increase which is largely related to a big number of errors when prescribing antibacterial drugs at the outpatient stage of treatment and disease prevention, as well as a lack of information and data on the quantity and quality of antimicrobial therapy. One of the elements aimed at reducing antibiotic resistance growth is audit and analysis of application practice.

AIM:

To assess qualitative and quantitative characteristics for urinary tract infections treatment using antimicrobial drugs by general physicians at the outpatient level.

MATERIALS AND METHODS:

The Point Prevalence Survey (PPS) analysis of antimicrobial drugs prescription was conducted by general physicians of No. 1, 4, 5 Hospitals of Karaganda city. There was carried out a daily prospectively data collecting on antibacterial drugs prescription by Doctor of Medical institutions, which was performed during patients’ visit. For each person who was prescribed the AD, there was filled a special questionnaire developed by the European Center for Disease Prevention and Control, including passport data, data on disease and prescription of antibacterial drugs. There were considered 200 cases of antibiotic prescription. The study included patients of both sexes, all age groups, who were prescribed the antibiotic therapy for the UTI treatment.

RESULTS:

When selecting antimicrobial therapy, the Protocols for diagnosis and treatment indicate the need for a microbiological study to determine sensitivity to antibacterial drugs, that was not performed in 100% of cases, and initial treatment was empirically prescribed, namely, in 34% of cases there were used drugs from the cephalosporin group (Ceftriaxone), nitrofurans (Furazidin)-42%, fluoroquinolones (Levofloxacin)-24%. In treating acute cystitis, in most cases, alternative medications were prescribed, though according to current recommendations, first-line therapy includes fosfomycin trometamol, pivmecillins and nitrofurantoin macrocrystals, which according to the results of this study were not used at all.

CONCLUSION:

In most cases (71%), alternative antibacterial drugs were prescribed for initial treatment of urinary tract infections. In majority cases, the dosage regimen of antibacterial drugs, dosage frequency, treatment course did not meet current recommendations.

The impact of paediatric antimicrobial stewardship programmes on patient outcomes

PURPOSE OF REVIEW

Although there has been an unprecedented global effort to reduce the spread of antimicrobial resistance, little emphasis has been placed on children. This review aims to evaluate the impact of paediatric antimicrobial stewardship programmes as well as providing a practical approach for effectively implementing them in community-based settings and in hospitals.

RECENT FINDINGS

Although rates of serious bacterial infection are low in children, the rates of antimicrobial use and resistance are comparable with adults. Different strategies are required to implement antimicrobial stewardship in community-based settings compared to in hospitals. Nationally coordinated, whole-system approaches have achieved long-term, sustainable reductions in antimicrobial prescribing, as well as reductions in resistance rates at population level, with no evidence of an increase in rate of serious infection or bacterial complications.

SUMMARY

Antimicrobial stewardship programmes in neonates and children have unique characteristics and issues. There is currently no consensus on how to measure consumption of antimicrobials in neonates and children. This is a research priority. Benchmarking and clinical networks in neonates and paediatrics are important to share practice and drive best use of antimicrobials.

Prevalence of antimicrobial use and active healthcare-associated infections in acute care hospitals: a multicentre prevalence survey in Japan

OBJECTIVE

To determine the prevalence of antimicrobial drug use and active healthcare-associated infections (HAIs) and to evaluate the appropriateness of antimicrobial therapy in acute care hospitals in Japan.

DESIGN

A prospective multicentre cross-sectional study.

PARTICIPANTS

All hospitalised patients on a survey day.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of patients receiving any antimicrobial agents. The secondary outcome was the proportion of patients with active HAIs. The reasons for antimicrobial drug use and appropriateness of antibiotic therapy were also investigated.

RESULTS

Eight hundred twenty eligible patients were identified. The median patient age was 70 years (IQR 55-80); 380 (46.3%) were women, 150 (18.3%) had diabetes mellitus and 107 (13.1%) were immunosuppressive medication users. The proportion of patients receiving any antimicrobial drugs was 33.5% (95% CI 30.3% to 36.8%). The proportion of patients with active HAIs was 7.4% (95% CI 5.6% to 9.2%). A total of 327 antimicrobial drugs were used at the time of the survey. Of those, 163 (49.8%), 101 (30.9%) and 46 (14.1%) were used for infection treatment, surgical prophylaxis and medical prophylaxis, respectively. The most commonly used antimicrobial drugs for treatment were ceftriaxone (n=25, 15.3%), followed by piperacillin-tazobactam (n=22, 13.5%) and cefmetazole (n=13, 8.0%). In the 163 antimicrobial drugs used for infection treatment, 62 (38.0%) were judged to be inappropriately used.

CONCLUSIONS

The prevalence of antimicrobial use and active HAIs and the appropriateness of antimicrobial therapy in Japan were similar to those of other developed countries. A strategy to improve the appropriateness of antimicrobial therapy provided to hospitalised patients is needed.

TRIAL REGISTRATION NUMBER

UMIN000033568.

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

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.

Prevalence of antibiotic use in a tertiary care hospital in Italy, 2008-2016

Background

Few data are available about temporal trends of antibiotic use in hospitalized children. The aim of the current study was to investigate the pattern and trends of antibiotic use over the years 2008–2016 in the largest children’s hospital in Italy.

Methods

Annual point prevalence surveys of antibiotic use were conducted by reviewing medical charts of 0–17 year-old children hospitalized for ≥48 h. Prevalence of antibiotic use was computed by year, type of ward and indication. Trends in prevalence over time were evaluated using the Cochrane-Armitage test. Possibile determinants of antibiotic use were assessed at univariate analysis and through a logistic regression model.

Results

Out of 3015 children, 1516 (50.3%) received antibiotics, 58.1% of which for medical/surgical prophylaxis. Prevalence of antibiotic use increased from 42.0% in 2008 to 56.2% in 2016 (p = 0.001). The prevalence of patients receiving antibiotics for medical prophylaxis increased from 6.1% in 2008 to 24.2% in 2016 (p < 0.001), whereas the prevalence of patients receiving antibiotics for surgical prophylaxis significantly decreased (from 13.7 to 11.8%; p = 0.04); no significant temporal trends were found in antibiotic use for treating infections.

The administration of third-generation cephalosporins for surgical and medical prophylaxis significantly decreased over time, while the proportion of antibiotics prescribed to treat infections after microbiological investigations significantly increased. Year (ORadj: 1.8 in 2016 compared to 2008, p < 0.001), age (ORadj ≥1.5 in children ≥1 year, compared to infants ≤2 months, p < 0.001), length of stay (LOS) (OR_adj: 1.4 in case of LOS between 8 and 30 days compared to LOS ≤ 7 days, p < 0.001), and type of ward (ORadj: ≥1.3 in intensive-care, surgical and medical-subspecialty units compared to medical units, p < 0.001) were significantly and independently associated with antibiotic use.

Conclusions

Comparing prevalence rates of antibiotic use among hospitals and over time should consider differences in patient characteristics, such as age, ward of hospitalization and length of stay. Over the years, we documented an improvement in the choice of antibiotics prescribed for medical and surgical prophylaxis. However, further efforts are needed to avoid antibiotic misuse for medical prophylaxis, and to reduce the empirical use of broad spectrum antibiotics.

Electronic supplementary material

The online version of this article (10.1186/s13052-019-0645-7) contains supplementary material, which is available to authorized users.

Potential for More Rational Use of Antibiotics in Hospitalized Children in a Country With Low Resistance: Data From eight Point Prevalence Surveys

BACKGROUND

Antimicrobial resistance is low in Norway, but to prevent an increase, the Norwegian Government has launched a National Strategy including a 30% reduction of broad-spectrum antibiotics (BSA) in hospitals within 2020. BSA are defined as second- and third-generation cephalosporins, carbapenems, piperacillin/tazobactam and quinolones. There are no recent studies of antibiotic use in Norwegian hospitalized children. The aim of this study was to describe the use of antibiotics with emphasis on BSA in Norwegian hospitalized children and neonates to detect possibilities for optimization.

METHODS

Data were extracted from 8 national point prevalence surveys of systemic antibiotic prescriptions in Norwegian hospitals between 2015 and 2017. The choices of antibiotics were compared with the empirical recommendations given in available Norwegian guidelines. In total, 1323 prescriptions were issued for 937 patients.

RESULTS

Twenty-four percent of pediatric inpatients were given antibiotics. Adherence to guidelines was 48%, and 30% (95% confidence interval: 27%-33%) of all patients on antibiotics received BSA. We identified only small variations in use of BSA between hospitals. One-third of the patients on antibiotic therapy received prophylaxis whereof 13% were given BSA. In 30% of prescriptions with BSA, no microbiologic sample was obtained before treatment.

CONCLUSIONS

This study reveals an excess of prescriptions with BSA in relation to the low resistance rate in Norway. Our findings reveal areas for improvement that can be useful in the forthcoming antibiotic stewardship programs in Norwegian pediatric departments.

Point prevalence survey of antimicrobial prescription in a tertiary hospital in South East Nigeria: A call for improved antibiotic stewardship

OBJECTIVES

Antimicrobial prescribing practices and use contribute to the growing threat of antimicrobial resistance (AMR) to global health. Information on antimicrobial prescribing and use are lacking in most developing countries, including Nigeria. This information is crucial for antimicrobial stewardship programmes, an effective tool in minimising AMR. This study was performed to gather baseline information on antimicrobial prescribing practices in Nigeria.

METHODS

A cross-sectional survey was conducted on all inpatients of a tertiary hospital in South East Nigeria. All patients on admission on the day of the survey formed the study population. A standardised questionnaire, web-based data entry and validation process designed by the University of Antwerp, Belgium, were adopted. Information on basic patient demographics, antimicrobial agents used, indication for treatment, laboratory data prior to treatment and stop/review date was collected.

RESULTS

Of 220 inpatients surveyed, 78.2% were receiving at least one antimicrobial agent. The highest prevalence of antimicrobial use was in the ICU (100%), adult surgical ward (82.9%) and paediatric medical ward (82.9%). Agents used were mainly third-generation cephalosporins (ceftriaxone 25.1%) and nitroimidazole (metronidazole 24.6%). Antimicrobial prescription was empirical (91.1% in medical wards, 96.8% in surgical wards and 100% in ICU). There was limited use of guidelines but clear documentation of stop/review dates and reasons for antimicrobial use.

CONCLUSION

Although a majority of antimicrobial prescriptions were made with indications, they were mostly prescribed empirically and the majority of prescriptions were parenteral formulations. There is a need to develop antibiotic guidelines, to educate prescribers on antimicrobial stewardship and to encourage targeted prescription.

Association between early life antibiotic use and childhood overweight and obesity: a narrative review

Background

Recent research implicates antibiotic use as a potential contributor to child obesity risk. In this narrative review, we examine current observational evidence on the relation between antibiotic use in early childhood and subsequent measures of child body mass.

Methods

We searched PubMed, Web of Science and the Cochrane Library to identify studies that assessed antibiotic exposure before 3 years of age and subsequent measures of body mass or risk of overweight or obesity in childhood.

Results

We identified 13 studies published before October 2017, based on a total of 6 81 332 individuals, which examined the relation between early life antibiotic exposure and measures of child body mass. Most studies did not appropriately account for confounding by indication for antibiotic use. Overall, we found no consistent and conclusive evidence of associations between early life antibiotic use and later child body mass [minimum overall adjusted odds ratio (aOR) reported: 1.01, 95% confidence interval (95% CI) 0.98-1.04, N = 2 60 556; maximum overall aOR reported: 2.56, 95% CI 1.36-4.79, N = 616], with no clinically meaningful increases in weight reported (maximum increase: 1.50 kg at 15 years of age). Notable methodological differences between studies, including variable measures of association and inclusion of confounders, limited more comprehensive interpretations.

Conclusions

Evidence to date is insufficient to indicate that antibiotic use is an important risk factor for child obesity, or leads to clinically important differences in weight. Further comparable studies using routine clinical data may help clarify this association.

Observational Study of Antibiotic Usage at the Children's Clinical University Hospital in Riga, Latvia

Background and objectives: Many pediatric patients have been treated with antibiotics during their hospitalization. There is a need to improve antibiotic prescribing for pediatric patients because many of these prescriptions are inappropriate. Antibiotic consumption analysis was conducted at the Children's Clinical University Hospital to identify targets for quality improvement. Materials and Methods: A one day cross-sectional point prevalence survey (PPS) was conducted in May and November 2011⁻2013 using a previously validated and standardized method. The survey included all inpatient pediatric and neonatal beds and identified all children receiving an antibiotic treatment on the day of survey. Total consumption of systemic antibiotics belonging to the ATC J01 class (except amphenicols (J01B) and a combination of antibacterials (J01R)) was also analyzed by using a defined daily dose (DDD) approach and antibiotic drug utilization (90%DU) for the period 2006⁻2015. Results were compared with results in 2017 using the DDD and 90%DU methodology. Results: The most commonly used antibiotic group in all PPS, except in May and November 2011, was other β-lactam antibiotics (J01D): 42 (40%) prescriptions in May 2013 and 66 (42%) and November 2011. In 2006⁻2015 and also in 2017, the most commonly used antibiotic groups were penicillins (J01C) and other β-lactam antibiotics (J01D)-76% (90%DU) of the total antibiotic consumption registered in 2006, 73% in 2015 and 70% in 2017. Starting in 2008, amoxicillin was the most commonly used antibiotic at the hospital. The usage of ceftriaxone increased from 3% in 2006 to 13% in 2015, but decreased in 2017 (7%). Conclusions: Study results from 2006⁻2015 showed that there was a need to establish a stronger antibiotic prescribing policy in the hospital reducing the use of broad-spectrum antibiotics (especially 3rd generation cephalosporins) and increasing the use of narrower spectrum antibiotics. It was partly achieved in 2017 with some reduction in ceftriaxone use.

Detecting and Visualizing Outliers in Provider Profiling Using Funnel Plots and Mixed Effects Models-An Example from Prescription Claims Data

When prescribing a drug for a patient, a physician also has to consider economic aspects. We were interested in the feasibility and validity of profiling based on funnel plots and mixed effect models for the surveillance of German ambulatory care physicians’ prescribing. We analyzed prescriptions issued to patients with a health insurance card attending neurologists’ and psychiatrists’ ambulatory practices in the German federal state of Saarland. The German National Association of Statutory Health Insurance Physicians developed a prescribing assessment scheme (PAS) which contains a systematic appraisal of the benefit of drugs for so far 12 different indications. The drugs have been classified on the basis of their clinical evidence as “standard”, “reserve” or “third level” medication. We had 152.583 prescriptions in 56 practices available for analysis. A total of 38.796 patients received these prescriptions. The funnel plot approach with additive correction for overdispersion was almost equivalent to a mixed effects model which directly took the multilevel structure of the data into account. In the first case three practices were labeled as outliers, the mixed effects model resulted in two outliers. We suggest that both techniques should be routinely applied within a surveillance system of prescription claims data.

Trends in paediatric inpatient antibiotic therapy in a secondary care setting

There is growing attention for antimicrobial stewardship in paediatrics. Currently, little is known about secondary care antibiotic practice. We analysed trends in time with respect to inpatient antibiotic use in a secondary paediatric care setting. Total inpatient antibiotic consumption per year (2010-2015) and antibiotic prescriptions for urinary tract infection (UTI) and lower respiratory tract infection (LRTI) were analysed. Variables were total, antibiotic-specific, and intravenous days of therapy (DOT/100PD) and for UTI/LRTI treatment type, route and duration. Third-generation cephalosporin use decreased (DOT/100PD 11.6 in 2011 vs. 5.1 in 2015; p < 0.001); intravenous antibiotics were prescribed less often (p = 0.06). These findings were confirmed for the specific diseases: third-generation cephalosporin use decreased for both UTI (93% vs. 45%; p = 0.002) and LRTI (14% vs. 6%; p = 0.18); the duration of intravenous therapy decreased (UTI p = 0.02; LRTI p < 0.001). Median LRTI treatment duration was 9.2 days in 2008 and 6.6 in 2015 (p < 0.001); penicillin prescriptions were more narrow in spectrum (p = 0.02).

CONCLUSION

A decrease in third-generation cephalosporin use and intravenous route was identified. LRTI treatment was significantly shorter and more narrow in spectrum. This could be explained by awareness and interventions in the context of antimicrobial stewardship. A decrease in antibiotic use is also feasible and important in non-tertiary paediatric wards. What is Known: • Antimicrobial stewardship programmes are effective in reduction of total and broad-spectrum antibiotic use in tertiary paediatric hospitals • The majority of hospitalised paediatric patients are admitted at general, secondary care wards, often for infectious diseases What is New: • Antimicrobial stewardship interventions in secondary care are also effective in establishing a reduction in broad-spectrum antibiotic use, intravenous route and days on antibiotic therapy.

Point Prevalence Surveys of Antimicrobial Use among Hospitalized Children in Six Hospitals in India in 2016

The prevalence of antimicrobial resistance in India is among the highest in the world. Antimicrobial use in inpatient settings is an important driver of resistance, but is poorly characterized, particularly in hospitalized children. In this study, conducted as part of the Global Antimicrobial Resistance, Prescribing, and Efficacy in Neonates and Children (GARPEC) project, we examined the prevalence of and indications of antimicrobial use, as well as antimicrobial agents used among hospitalized children by conducting four point prevalence surveys in six hospitals between February 2016 and February 2017. A total of 681 children were hospitalized in six hospitals across all survey days, and 419 (61.5%) were prescribed one or more antimicrobials (antibacterials, antivirals, antifungals). Antibacterial agents accounted for 90.8% (547/602) of the total antimicrobial prescriptions, of which third-generation cephalosporins (3GCs) accounted for 38.9% (213/547) and penicillin plus enzyme inhibitor combinations accounted for 14.4% (79/547). Lower respiratory tract infection (LRTI) was the most common indication for prescribing antimicrobials (149 prescriptions; 24.8%). Although national guidelines recommend the use of penicillin and combinations as first-line agents for LRTI, 3GCs were the most commonly prescribed antibacterial agents (55/149 LRTI prescriptions; 36.9%). In conclusion, 61.5% of hospitalized children were on at least one antimicrobial agent, with excessive use of 3GCs. Hence there is an opportunity to limit their inappropriate use.