Anti-infective Acquisition Costs for a Stewardship Program: Getting to the Bottom Line

Extending the Reach of Antimicrobial Stewardship to Pediatric Patients

Guidance for developing and implementing antimicrobial stewardship programs for children is lacking. This review article describes unique considerations for planning antimicrobial management of children that may impact stewardship strategies. A variety of methods and training tools are described along with metrics specific to measuring antibiotic use and outcomes in children. Handshake stewardship is specifically explained and is considered a best practice. Information on stewardship in unique settings, including the neonatal intensive care unit and outpatient settings, are included.

An Evaluation of Antimicrobial Prescribing and Risk-adjusted Mortality

Supplemental Digital Content is available in the text.

The Centers for Disease Control and Prevention recommends tracking risk-adjusted antimicrobial prescribing. Prior studies have used prescribing variation to drive quality improvement initiatives without adjusting for severity of illness. The present study aimed to determine the relationship between antimicrobial prescribing and risk-adjusted ICU mortality in the Pediatric Health Information Systems (PHIS) database, assessed by IBM-Watson risk of mortality. A nested analysis sought to assess an alternative risk model incorporating laboratory data from federated electronic health records.

The Institute for Health care Quality, Safety, and Efficiency: A Comprehensive Approach to Improving Organization-Level Quality Performance

Despite decades of effort to drive quality improvement, many health care organizations still struggle to optimize their performance on quality metrics. The advent of publicly reported quality rankings and ratings allows for greater visibility of overall organizational performance, but has not provided a roadmap for sustained improvement in these assessments. Most quality training programs have focused on developing knowledge and skills in pursuit of individual and project-level improvements. To date, no training program has been associated with improvements in overall organization-level, publicly reported measures. In 2012, the Institute for Health care Quality, Safety, and Efficiency was launched, which is an integrated set of quality and safety training programs, with a focus on leadership development and support of performance improvement through data analytics and intensive coaching. This effort has trained nearly 2000 individuals and has been associated with significant improvement in organization-level quality rankings and ratings, offering a framework for organizations seeking systematic, long-term improvement.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Anti-infective Waste in a Pediatric Institution: Pinpointing Problems in the Process

Purpose: At Children's Hospital Colorado (CHCO), there are approximately 40 000 inpatient anti-infective orders every year resulting over 100 000 dispenses. Significant quantities of anti-infectives are wasted, incurring roughly $100 000 in waste annually. Identifying areas for improvement will result in cost savings and ameliorate the impact of drug shortages. Summary: This descriptive report discusses the reasons for anti-infective waste at a free-standing, quaternary-care, pediatric hospital. The anti-infectives with the highest cost in waste ($) included meropenem ($38 084), micafungin ($21 690), amphotericin B liposome ($15 913). An internal audit of CHCO anti-infective waste revealed that drugs are wasted for the following reasons: patient discharge, medication order discontinuation or change, and misplaced doses. Conclusion: The CHCO Antimicrobial Stewardship Program and the Pharmacy have proposed 4 process improvement measures that will target anti-infective waste to reduce pharmaceutical waste and hospital costs. These measures may be applicable to other drug classes that likely suffer from a similar proportion of waste.

Inpatient Treatment of Acute Otitis Media at a Pediatric Hospital: A Missed Teaching Opportunity for Antimicrobial Stewardship

BACKGROUND

Acute otitis media (AOM) is a common pediatric condition known to contribute to excessive antibiotic use in the outpatient setting. Treatment of AOM in the inpatient setting has not been described. The objective was to describe the clinical features and inpatient management of AOM to harness this entity to teach learners about judicious antibiotic prescribing in all settings.

METHODS

This is a single-center retrospective cohort study of inpatients treated for AOM from January 2015 to December 2018. Patients were included if they had an antibiotic ordered and either a provider-selected order indication of otitis media or an International Classification of Diseases, 10th Revision billing code of AOM. A chart review was performed to identify primary diagnoses, examination features, and treatment, including excess days of therapy.

RESULTS

We included 840 hospitalized patients treated for AOM in this study. At least 71% of patients had a concurrent viral respiratory illness. Examinations were frequently discordant (34%), and 47% lacked documentation of a physical examination finding of a bulging tympanic membrane, contributing to 3417 potential excess days of therapy. Of the total patients treated for AOM, 40% were given excess duration of therapy. The vast majority (97%) of patients who qualified for a wait-and-watch approach were treated.

CONCLUSIONS

AOM is not being rigorously diagnosed or treated in a guideline-adherent manner in the inpatient setting. This is a lost opportunity for teaching antibiotic stewardship. Interventions, such as promoting the wait-and-watch approach and deferring treatment decisions to inpatient providers, could help promote the judicious use of antibiotics.

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

Background

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

Methods

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

Results

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

Conclusions

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

Hospital-wide Description of Clinical Indications for Pediatric Anti-infective Use

PURPOSE

This study is the first description of hospital-wide anti-infective use according to clinical indication for a pediatric hospital. Children's Hospital Colorado (CHCO) is uniquely poised to examine its anti-infective use after the implementation of provider-selected order indications (PSOIs), which are distinct from Diagnosis Related Group classifications in that they are used for clinical treatment as opposed to final diagnosis codes for billing and thus are more granular.

METHODS

This study used our institution's mandatory PSOIs to describe overall clinical indications for anti-infective use. For 2016, all anti-infective orders were extracted from the electronic medical record (Epic), including drug name, route, prescribing unit, and PSOI. We calculated the number of times each drug was associated with each indication and the number of times an indication was attributed to each drug, and then analyzed these data in Excel.

FINDINGS

There were 29,258 orders at CHCO in 2016 with at least 1 indication. The most common clinical indication was "prophylaxis-medical/surgical," accounting for 23% of all orders and commonly associated with cefazolin (42% of prophylaxis-medical/surgical orders). This was followed by the indications of "sepsis/bacteremia" and "pneumonia/sinusitis." The most commonly prescribed anti-infectives for nonprophylactic clinical indications were IV vancomycin (14%), ceftriaxone (11%), and ampicillin (6%).

IMPLICATIONS

Knowledge of the clinical reasons for hospital-wide anti-infective use enables hospitals to identify targets for improved use through education and guideline and policy development. This description provides better details than billing codes about the clinical reasons anti-infectives are used and offers a useful template for implementation at other hospitals.

Intervention and Acceptance Rates Support Handshake-Stewardship Strategy

We instituted a new antimicrobial stewardship approach that involves review of all antimicrobial agents and communication of interventions in person by a pharmacist-physician team termed handshake stewardship. The acceptance rate in this study was 86%, intervention rates were higher with a physician, and interventions on antibiotics not reviewed by other strategies were made frequently.