Antimicrobial Stewardship in a Tertiary Neonatal Intensive Care Unit with Limited Resources
American Journal of Pediatrics
Volume 6, Issue 3, September 2020, Pages: 295-299
Received: Jun. 25, 2020; Accepted: Jul. 16, 2020; Published: Jul. 28, 2020
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Fouzia Naeem, Department of Pediatric Infectious Disease, Valley Children’s Hospital, Madera, the United States; Department of Pediatrics, Stanford University School of Medicine (affiliated), Stanford, the United States
Ashley Thomas, Department of Pharmacy, Valley Children’s Hospital, Madera, the United States
Brenik Kuzmic, Department of Pharmacy, Valley Children’s Hospital, Madera, the United States
Indira Chandrasekar, Department of Pediatrics, Stanford University School of Medicine (affiliated), Stanford, the United States; Department of Neonatal Intensive Care Unit, Valley Children’s Hospital, Madera, the United States
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Background: Antimicrobial stewardship programs (ASP) have been recognized nationally as an effective way to combat antimicrobial resistance. Using data from the Pediatric Health Information System (PHIS) database, we noticed high utilization of antimicrobials in our hospital particularly in our tertiary level neonatal intensive care unit (NICU). This prompted focused efforts in the NICU consisting of development of management guidelines and prospective audit with intervention and feedback. Method: Using the PHIS database, we retrospectively measured days of therapy per 1000 patient days (DOT/1000 PD) in the NICU during the pre-implementation, implementation and post-implementation phases to determine the change in antimicrobial utilization. All antimicrobials administered between 01/01/14 to 12/31/19 were included in this review. Secondary outcomes including late-onset sepsis (LOS), necrotizing enterocolitis (NEC), mortality rates and hospital-wide antimicrobial utilization were also evaluated. Comparison of means among groups was performed by analysis of variance (ANOVA). Results: Overall, mean DOT/1000 PD for the NICU decreased 32% from the pre-implementation to the post-implementation phase (656.86 vs 480.81 vs 431.90 DOT/1000 PD, P < 0.01). NICU LOS rates decreased from 2.4% to 1.5%. NEC and mortality rates remained unchanged from 4.2% to 4.9% and 3.4% to 4.4%, respectively. Mean DOT/1000 PD for the entire hospital decreased 22% overall (857.09 vs 739.71 vs 667.76 DOT/1000 PD, P < 0.01). Conclusions: Implementation of a NICU ASP helped reduce antimicrobial utilization in the NICU without increasing morbidity and mortality. Hospitals with limited resources may consider targeted unit-based stewardship to help reduce antimicrobial utilization.
Antimicrobial Stewardship, NICU, DOT, Early Onset Sepsis, Late Onset Sepsis, NEC, Antibiotics
To cite this article
Fouzia Naeem, Ashley Thomas, Brenik Kuzmic, Indira Chandrasekar, Antimicrobial Stewardship in a Tertiary Neonatal Intensive Care Unit with Limited Resources, American Journal of Pediatrics. Vol. 6, No. 3, 2020, pp. 295-299. doi: 10.11648/j.ajp.20200603.30
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R. H. Clark, B. T. Bloom, A. R. Spitzer, and D. R. Gerstmann, "Empiric use of ampicillin and cefotaxime, compared with ampicillin and gentamicin, for neonates at risk for sepsis is associated with an increased risk of neonatal death," Pediatrics, vol. 117, no. 1, pp. 67-74, Jan 2006, doi: 10.1542/peds.2005-0179.
N. Krzyzaniak, I. Pawlowska, and B. Bajorek, "Review of drug utilization patterns in NICUs worldwide," J Clin Pharm Ther, vol. 41, no. 6, pp. 612-620, Dec 2016, doi: 10.1111/jcpt.12440.
J. Schulman, R. J. Dimand, H. C. Lee, G. V. Duenas, M. V. Bennett, and J. B. Gould, "Neonatal intensive care unit antibiotic use," Pediatrics, vol. 135, no. 5, pp. 826-33, May 2015, doi: 10.1542/peds.2014-3409.
N. Tripathi, C. M. Cotten, and P. B. Smith, "Antibiotic use and misuse in the neonatal intensive care unit," Clin Perinatol, vol. 39, no. 1, pp. 61-8, Mar 2012, doi: 10.1016/j.clp.2011.12.003.
C. M. Cotten et al., "Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for extremely low birth weight infants," Pediatrics, vol. 123, no. 1, pp. 58-66, Jan 2009, doi: 10.1542/peds.2007-3423.
V. S. Kuppala, J. Meinzen-Derr, A. L. Morrow, and K. R. Schibler, "Prolonged initial empirical antibiotic treatment is associated with adverse outcomes in premature infants," J Pediatr, vol. 159, no. 5, pp. 720-5, Nov 2011, doi: 10.1016/j.jpeds.2011.05.033.
A. Society for Healthcare Epidemiology of, A. Infectious Diseases Society of, and S. Pediatric Infectious Diseases, "Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS)," Infect Control Hosp Epidemiol, vol. 33, no. 4, pp. 322-7, Apr 2012, doi: 10.1086/665010.
F. Fouhy et al., "High-throughput sequencing reveals the incomplete, short-term recovery of infant gut microbiota following parenteral antibiotic treatment with ampicillin and gentamicin," Antimicrob Agents Chemother, vol. 56, no. 11, pp. 5811-20, Nov 2012, doi: 10.1128/AAC.00789-12.
J. Y. Ting et al., "Association of Antibiotic Utilization and Neurodevelopmental Outcomes among Extremely Low Gestational Age Neonates without Proven Sepsis or Necrotizing Enterocolitis," Am J Perinatol, vol. 35, no. 10, pp. 972-978, Aug 2018, doi: 10.1055/s-0038-1632390.
A. A. Resistance. "Center for Disease Control and Prevention." (accessed February 14, 2020).
T. F. Barlam et al., "Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America," Clin Infect Dis, vol. 62, no. 10, pp. e51-77, May 15 2016, doi: 10.1093/cid/ciw118.
J. G. Newland et al., "Prevalence and characteristics of antimicrobial stewardship programs at freestanding children's hospitals in the United States," Infect Control Hosp Epidemiol, vol. 35, no. 3, pp. 265-71, Mar 2014, doi: 10.1086/675277.
M. W. Kuzniewicz, E. M. Walsh, S. Li, A. Fischer, and G. J. Escobar, "Development and Implementation of an Early-Onset Sepsis Calculator to Guide Antibiotic Management in Late Preterm and Term Neonates," Jt Comm J Qual Patient Saf, vol. 42, no. 5, pp. 232-9, May 2016, doi: 10.1016/s1553-7250(16)42030-1.
K. R. Lee, B. Bagga, and S. R. Arnold, "Reduction of Broad-Spectrum Antimicrobial Use in a Tertiary Children's Hospital Post Antimicrobial Stewardship Program Guideline Implementation," Pediatr Crit Care Med, vol. 17, no. 3, pp. 187-93, Mar 2016, doi: 10.1097/PCC.0000000000000615.
A. L. Hersh et al., "Antimicrobial stewardship programs in freestanding children's hospitals," Pediatrics, vol. 135, no. 1, pp. 33-9, Jan 2015, doi: 10.1542/peds.2014-2579.
A. L. Hurst, J. Child, K. Pearce, C. Palmer, J. K. Todd, and S. K. Parker, "Handshake Stewardship: A Highly Effective Rounding-based Antimicrobial Optimization Service," Pediatr Infect Dis J, vol. 35, no. 10, pp. 1104-10, Oct 2016, doi: 10.1097/INF.0000000000001245.
N. I. Nzegwu et al., "Implementation of an Antimicrobial Stewardship Program in a Neonatal Intensive Care Unit," Infect Control Hosp Epidemiol, vol. 38, no. 10, pp. 1137-1143, Oct 2017, doi: 10.1017/ice.2017.151.
N. Thampi et al., "Prospective audit and feedback on antibiotic use in neonatal intensive care: a retrospective cohort study," BMC Pediatr, vol. 19, no. 1, p. 105, Apr 11 2019, doi: 10.1186/s12887-019-1481-z.
S. J. Patel et al., "Antibiotic use in neonatal intensive care units and adherence with Centers for Disease Control and Prevention 12 Step Campaign to Prevent Antimicrobial Resistance," Pediatr Infect Dis J, vol. 28, no. 12, pp. 1047-51, Dec 2009, doi: 10.1097/INF.0b013e3181b12484.
M. W. Kuzniewicz et al., "A Quantitative, Risk-Based Approach to the Management of Neonatal Early-Onset Sepsis," JAMA Pediatr, vol. 171, no. 4, pp. 365-371, Apr 1 2017, doi: 10.1001/jamapediatrics.2016.4678.
T. Ho et al., "Adherence of Newborn-Specific Antibiotic Stewardship Programs to CDC Recommendations," Pediatrics, vol. 142, no. 6, Dec 2018, doi: 10.1542/peds.2017-4322.
T. Ho, D. Dukhovny, J. A. Zupancic, D. A. Goldmann, J. D. Horbar, and D. M. Pursley, "Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value," Pediatrics, vol. 136, no. 2, pp. e482-9, Aug 2015, doi: 10.1542/peds.2015-0737.
J. B. Cantey, P. S. Wozniak, J. E. Pruszynski, and P. J. Sanchez, "Reducing unnecessary antibiotic use in the neonatal intensive care unit (SCOUT): a prospective interrupted time-series study," Lancet Infect Dis, vol. 16, no. 10, pp. 1178-1184, Oct 2016, doi: 10.1016/S1473-3099(16)30205-5.
M. C. Astorga et al., "Antibiotic Stewardship in the Neonatal Intensive Care Unit: Effects of an Automatic 48-Hour Antibiotic Stop Order on Antibiotic Use," J Pediatric Infect Dis Soc, vol. 8, no. 4, pp. 310-316, Sep 25 2019, doi: 10.1093/jpids/piy043.
J. Y. Ting et al., "Association Between Antibiotic Use and Neonatal Mortality and Morbidities in Very Low-Birth-Weight Infants Without Culture-Proven Sepsis or Necrotizing Enterocolitis," JAMA Pediatr, vol. 170, no. 12, pp. 1181-1187, Dec 1 2016, doi: 10.1001/jamapediatrics.2016.2132.
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