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

Antibiotic Exposure of Critically Ill Children at a Tertiary Care Paediatric Intensive Care Unit in Switzerland

Antibiotic overtreatment fosters multidrug-resistance that threatens healthcare systems worldwide as it increases patient morbidity and mortality. Contemporary data on antibiotic usage on tertiary care paediatric intensive care units for in- and external benchmarking are scarce. This was a single-centre retrospective quality control study including all patients with antibiotic treatment during their hospitalization at a paediatric intensive care unit in the time period 2019-2021. Antibiotic treatment was calculated as days of therapy (DOT) per 100 patient days (DOT/100pd). Further, the variables PIM II score, length of stay in intensive care (LOS), gender, age, treatment year, reason for intensive care unit admission, and death were assessed. Two thousand and forty-one cases with a median age of 10 months [IQR 0-64] were included; 53.4% were male, and 4.5% of the included patients died. Median LOS was 2.73 days [0.07-5.90], and PIM II score was 1.98% [0.02-4.86]. Overall, the antibiotic exposure of critically ill children and adolescents was 59.8 DOT/100pd. During the study period, the antibiotic usage continuously increased (2019: 55.2 DOT/100pd; 2020: 59.8 DOT/100pd (+8.2%); 2021: 64.5 DOT/100pd (+8.0%)). The highest antibiotic exposure was found in the youngest patients (0-1 month old (72.7 DOT/100pd)), in patients who had a LOS of >2-7 days (65.1 DOT/100pd), those who had a renal diagnosis (98 DOT/100pd), and in case of death (91.5 DOT/100pd). Critically ill paediatric patients were moderately exposed to antibiotics compared to data from the previously published literature. The current underreporting of antimicrobial prescription data in this cohort calls for future studies for better internal and external benchmarking.

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.

Five-Year Evaluation of the PROA-NEN Pediatric Antimicrobial Stewardship Program in a Spanish Tertiary Hospital

Introduction: Actions to reduce and optimize antimicrobial use are crucial in the management of infectious diseases to counteract the emergence of short- and long-term resistance. This is particularly important for pediatric patients due to the increasing incidence of serious infections caused by resistant bacteria in this population. The aim of this study was to evaluate the impact of a pediatric antimicrobial stewardship program (PROA-NEN) implemented in a Spanish tertiary hospital by assessing the use of systemic antimicrobials, clinical indicators, antimicrobial resistance, and costs. Methods: In this quasi-experimental, single-center study, we included pediatric patients (0-18 years) admitted to specialized pediatric medical and surgical units, as well as pediatric and neonatal intensive care units, from January 2015 to December 2019. The impact of the PROA-NEN program was assessed using process (consumption trends and prescription quality) and outcome indicators (clinical and microbiological). Antibiotic prescription quality was determined using quarterly point prevalence cross-sectional analyses. Results: Total antimicrobial consumption decreased during the initial three years of the PROA-NEN program, followed by a slight rebound in 2019. This decrease was particularly evident in intensive care and surgical units. Antibiotic use, according to the WHO Access, Watch and Reserve (AWaRe) classification, remained stable during the study period. The overall rate of appropriate prescription was 83.2%, with a significant increase over the study period. Clinical indicators did not substantially change over the study period. Direct antimicrobial expenses decreased by 27.3% from 2015 to 2019. Conclusions: The PROA-NEN program was associated with reduced antimicrobial consumption, improved appropriate use, and decreased costs without compromising clinical and/or microbiological outcomes in patients.

The use of information technology to improve interdisciplinary communication during infectious diseases ward rounds on the paediatric intensive care unit

Prospective audit with feedback during infectious diseases ward rounds (IDWR) is a common antimicrobial stewardship (AMS) practice on the Paediatric Intensive Care Unit (PICU). These interdisciplinary meetings rely on the quality of handover, with high risk of omission of information. We developed an electronic platform integrating infection-related patient data (COSARAPed). In the mixed PICU of a Belgian tertiary hospital we conducted an observational prospective cohort study comparing patient handovers during IDWRs using the COSARAPed-platform to those with access only to conventional resources. The quality of handover was investigated directly by assessment if the narrative was in accordance with Situation-Background-Assessment-Recommendation principles and if adequate demonstration of diagnostic information occurred, and also indirectly by registration if this was only achieved after intervention by the non-presenting AMS team members. We also recorded all AMS-recommendations. During a 6-month study period, 24 IDWRs and 82 patient presentations were assessed. We could only find a statistically significant advantage in favor of COSARAPed by indirect evaluation. We registered 92 AMS-recommendations, mainly resulting in reduced antibiotic pressure. We concluded that the IDWR is an appropriate platform for AMS on the PICU and that the utilisation of COSARAPed may enhance the quality of patient handover.

Appropriateness of antibiotic prescribing varies by clinical services at United States children's hospitals

OBJECTIVE

To describe patterns of inappropriate antibiotic prescribing at US children's hospitals and how these patterns vary by clinical service.

DESIGN

Serial, cross-sectional study using quarterly surveys.

SETTING

Surveys were completed in quarter 1 2019-quarter 3 2020 across 28 children's hospitals in the United States.

PARTICIPANTS

Patients at children's hospitals with ≥1 antibiotic order at 8:00 a.m. on institution-selected quarterly survey days.

METHODS

Antimicrobial stewardship physicians and pharmacists collected data on antibiotic orders and evaluated appropriateness of prescribing. The primary outcome was percentage of inappropriate antibiotics, stratified by clinical service and antibiotic class. Secondary outcomes included reasons for inappropriate use and association of infectious diseases (ID) consultation with appropriateness.

RESULTS

Of 13,344 orders, 1,847 (13.8%) were inappropriate; 17.5% of patients receiving antibiotics had ≥1 inappropriate order. Pediatric intensive care units (PICU) and hospitalists contributed the most inappropriate orders (n = 384 and n = 314, respectively). Surgical subspecialists had the highest percentage of inappropriate orders (22.5%), and 56.8% of these were for prolonged or unnecessary surgical prophylaxis. ID consultation in the previous 7 days was associated with fewer inappropriate orders (15% vs 10%; P < .001); this association was most pronounced for hospitalist, PICU, and surgical and medical subspecialty services.

CONCLUSIONS

Inappropriate antibiotic use for hospitalized children persists and varies by clinical service. Across 28 children's hospitals, PICUs and hospitalists contributed the most inappropriate antibiotic orders, and surgical subspecialists' orders were most often judged inappropriate. Understanding service-specific prescribing patterns will enable antimicrobial stewardship programs to better design interventions to optimize antibiotic use.

Antimicrobial use among paediatric inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program, 2017/2018

BACKGROUND

Antimicrobial resistance threatens the ability to successfully prevent and treat infections. While hospital benchmarks regarding antimicrobial use (AMU) have been well documented among adult populations, there is less information from among paediatric inpatients. This study presents benchmark rates of antimicrobial use (AMU) for paediatric inpatients in nine Canadian acute-care hospitals.

METHODS

Acute-care hospitals participating in the Canadian Nosocomial Infection Surveillance Program submitted annual AMU data from paediatric inpatients from 2017 and 2018. All systemic antimicrobials were included. Data were available for neonatal intensive care units (NICUs), pediatric ICUs (PICUs), and non-ICU wards. Data were analyzed using days of therapy (DOT) per 1000 patient days (DOT/1000pd).

RESULTS

Nine hospitals provided paediatric AMU data. Data from seven NICU and PICU wards were included. Overall AMU was 481 (95% CI 409-554) DOT/1000pd. There was high variability in AMU between hospitals. AMU was higher on PICU wards (784 DOT/1000pd) than on non-ICU (494 DOT/1000pd) or NICU wards (333 DOT/1000pd). On non-ICU wards, the antimicrobials with the highest use were cefazolin (66 DOT/1000pd), ceftriaxone (59 DOT/1000pd) and piperacillin-tazobactam (48 DOT/1000pd). On PICU wards, the antimicrobials with the highest use were ceftriaxone (115 DOT/1000pd), piperacillin-tazobactam (115 DOT/1000pd), and cefazolin (111 DOT/1000pd). On NICU wards, the antimicrobials with the highest use were ampicillin (102 DOT/1000pd), gentamicin/tobramycin (78 DOT/1000pd), and cefotaxime (38 DOT/1000pd).

CONCLUSIONS

This study represents the largest collection of antimicrobial use data among hospitalized paediatric inpatients in Canada to date. In 2017/2018, overall AMU was 481 DOT/1000pd. National surveillance of AMU among paediatric inpatients is necessary for establishing benchmarks and informing antimicrobial stewardship efforts.

Impact of an antibiotic stewardship program on antibiotic utilization, bacterial susceptibilities, and cost of antibiotics

Antimicrobial misuse is a worldwide issue, and antimicrobial resistance is considered the most challenging aspect of health care. It has been reported that as much as 30-50% of antimicrobials prescribed in hospitals are deemed unnecessary or inappropriate. Antibiotic stewardship programs (ASPs) include policies that apply continuous management of judicious anti-infectious treatment in the clinical setting. Therefore, the objectives of this study were to evaluate the effect of ASPs on antibiotic consumption, the costs of antibiotic expenditure, and the sensitivity of antimicrobials. A retrospective, quasi-experimental study was performed to assess the effect of ASP at An-Najah National University Hospital, a tertiary care hospital in the West Bank, Palestine, over a period of 20 months before and 17 months after the implementation of the ASP. Data on antibiotic consumption were reported monthly as days of therapy per 1000 patient-days and monthly costs (USD/1000 patient-days). A total of 2367 patients who received one or more of the targeted antibiotics (meropenem, colistin and tigecycline) during their hospital stay were included in the study. They have split into two groups: 1710 patients in the pre-ASP group, and 657 patients in the post ASP group. The most significant reduction in DOT per 1000 patient-days was seen with tigecycline, with a percentage of change of - 62.08%. Furthermore, the mean cost of the three antibiotics decreased significantly by 55.5% in the post-ASP phase compared to the pre-ASP phase. After the implementation of ASP, there was a statistically significant increase in susceptibility to meropenem, piperacillin and piperacillin/tazobactam with respect to Pseudomonas aeruginosa. However, changes in mortality rates were not statistically significant (p = 0.057). ASP positively reduced costs and antimicrobial consumption, with no statistically significant effect on the overall mortality rate. However, a long-term evaluation of the ASP's impact is needed to conclude its lasting impact on infection-related mortality and antimicrobial susceptibility pattern.

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.

Opportunities for Antibiotic Stewardship Interventions in a Pediatric Hospital

Objective This study's objective was to assess an antibiotic stewardship intervention, compare pediatric antibiotic usage in a non-university hospital (Children's Hospital Traunstein [TS]) with a university hospital (Dr. von Hauner Children's Hospital, Ludwig Maximilians University Munich [MUC]), and assess adherence to national guidelines.

Methods Antibiotic usage pre- and post-antibiotic stewardship (ABS) intervention was compared, and antibiotic prescriptions over 4 months were prospectively recorded. ABS intervention consisted of weekly teaching sessions, antibiotic pocket cards, and rounds with pediatric infectious disease staff. Medical records were reviewed to describe antibiotic consumption, antibiotic dosages and length of use, and adherence to national guidelines. Pediatric antibiotic usage was compared between hospitals and patient groups.

Results After the ABS intervention, the use of second-generation cephalosporins decreased, while penicillin with β-lactamase inhibitors (BLI) increased. Survey of antibiotic prescriptions over the 4 months study period in the non-university hospital showed a high administration rate of second-generation cephalosporins and extended-spectrum penicillins in the non-intensive care units (ICU) wards (48.53 and 38.93 days of therapy [DoT]/1,000 patient days [PD], respectively) and a high rate of third-generation cephalosporins in the ICU ward (110.33 DoT/1,000PD). A high prescriptions rate was seen in the neonatal intensive care unit (NICU) wards (DoT/ length of therapy [LoT] ratio of 2.185). Reserve group antibiotics were only given in the ICU. Adherence to national guidelines was highest in the NICU and pediatric ICU wards. Striking was the relatively high rate of incorrect usage of second-generation cephalosporins. Comparing the pediatric wards of the non-university hospital (TS) and the university hospital (MUC), the prescription ratio was 11.1% (TS) versus 30.6% (MUC), and DoT/1,000PD 198.9 (TS) versus 483.6 (MUC), p = 0.02. ABS intervention changed the choice of described antibiotics, but not the overall frequency.

Conclusion Adherence to national guidelines was highest in fields with standardized therapy recommendations, like in the NICU. In MUC, antibiotics, in particular restricted ones, were prescribed more frequently, probably due to higher severity of illness.

These data indicate that the usage of antibiotics and adherence to national guidelines show a wide variety, but ABS interventions were effective in changing prescription behavior.

Round multiprofissional com checklist: associação com a melhoria na segurança do paciente em terapia intensiva

RESUMO Objetivo Verificar a associação entre round multiprofissional com uso de checklist e práticas de segurança do paciente por profissionais de saúde de uma unidade de terapia intensiva. Método Estudo de método misto, delineado pela abordagem sequencial explanatória, realizado em um hospital do sul do Brasil. Os dados quantitativos foram analisados por meio de regressão de Poisson e os dados qualitativos, pela análise de conteúdo. Fez-se a análise integrada por meio da combinação explicada/conectada. Resultados No período pós-implementação dos rounds com uso sistemático de checklist houve melhora significativa da profilaxia de tromboembolia venosa, sedação leve, redução dos dias de uso de ventilação mecânica, cateter venoso central e de sonda vesical de demora. Conclusão O round multiprofissional com uso sistemático de checklist, associado com a melhoria nas práticas de segurança do paciente, foi considerado como uma estratégia que assegura melhores cuidados em terapia intensiva e favorece a satisfação no trabalho.

Multiprofessional round with checklist: association with the improvement in patient safety in intensive care

ABSTRACT Objective To verify the association between a multiprofessional round with the use of checklists and patient safety practices by health professionals in an intensive care unit. Method Mixed-method study, delineated by the sequential explanatory approach, conducted in a hospital in southern Brazil. Quantitative data were analyzed using Poisson regression, and qualitative data, using content analysis. The integrated analysis was performed through the explained/connected combination. Results In the post-implementation period of the rounds with systematic use of the checklist, there was a significant improvement in the prophylaxis of venous thromboembolism, light sedation, reduction in the days of use of mechanical ventilation, central venous catheter and indwelling urinary catheter. Conclusion The multiprofessional round with the systematic use of checklist, associated with the improvement in patient safety practices, was considered as a strategy that ensures better care in intensive care and favors job satisfaction.

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.