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Nomura Y, Garcia M, Child J, Hurst AL, Hyman D, Poppy A, Palmer C, Ranade D, Pyle L, Parker SK. Effect of provider-selected order indications on appropriateness of antimicrobial orders in a pediatric hospital. Am J Health Syst Pharm 2018; 75:213-221. [PMID: 29436467 DOI: 10.2146/ajhp160557] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The effect of mandatory provider-selected order indications (PSOIs) on appropriateness of antimicrobial ordering in a tertiary pediatric hospital was evaluated. METHODS Mandatory PSOIs for 14 antimicrobials were implemented in September 2013. Data on initial and final orders in the first 24 hours after ordering were collected from the electronic medical record. Orders from pre-PSOI and post-PSOI implementation were randomly selected and compared with documentation at the time of order to elicit the documentation-determined clinical indication (DDCI). Appropriateness of the order for the DDCI was evaluated and compared between groups using 2-sample t tests, chi-square tests, and logistic regression. RESULTS Among the total 1,304 orders included in the review, 275 (21.1%) were inappropriate based on DDCI. The indications associated with the greatest number of inappropriate orders in both groups were suspected sepsis/bacteremia, meningitis/central nervous system infection, and pneumonia. A total of 128 (18.3%) of 700 initial orders were inappropriate compared with the DDCI in the pre-PSOI period, and 82 (17.8%) of 461 initial orders were inappropriate in the post-PSOI period (p = 0.83). A total of 78 (11.1%) of 700 final orders were inappropriate in the pre-PSOI period, and 29 (6.3%) of 461 final orders were inappropriate in the post-intervention period (p = 0.01). Overall, 84 (12%) of 700 inappropriate orders reached the patient in the pre-PSOI period versus 43 (9.3%) of 461 inappropriate orders in the post-PSOI period (p = 0.15). CONCLUSION PSOIs were effective in reducing inappropriate antimicrobial orders in the first 24 hours after ordering if the correct indication was selected.
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Affiliation(s)
- Yosuke Nomura
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Madeleine Garcia
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Jason Child
- Department of Pharmacy, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Amanda L Hurst
- Department of Pharmacy, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Daniel Hyman
- Department of Quality and Patient Safety and Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Amy Poppy
- Department of Quality and Patient Safety, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Claire Palmer
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Daksha Ranade
- Department of Clinical Informatics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Laura Pyle
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Sarah K Parker
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
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Dassner AM, Girotto JE. Evaluation of a Second-Sign Process for Antimicrobial Prior Authorization. J Pediatric Infect Dis Soc 2018; 7:113-118. [PMID: 28407067 DOI: 10.1093/jpids/pix015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 03/23/2017] [Indexed: 11/14/2022]
Abstract
BACKGROUND A second-sign prospective restriction of select broad-spectrum antimicrobials was fully implemented in January 2015 as a pediatric antimicrobial stewardship program (ASP) initiative to help ensure the most appropriate empiric use of ceftaroline, cefepime, fidaxomicin, linezolid, and vancomycin (intravenous). The objective of this evaluation is to assess the effectiveness of a forced second-sign process in the electronic medical record as a pediatric ASP strategy. We anticipated that the second-sign process for antibiotics would increase the appropriateness of empiric antibiotic use, as defined by preapproved criteria, clinical pathways, national guidelines, and pediatric-specific infectious diseases reference texts, while not causing significant delay in the initial administration of antibiotic therapy. METHODS This was a retrospective before and after intervention chart review conducted from July 2014 to June 2015. The study was conducted at a 187-bed, freestanding teaching children's hospital that included the following: level-1 pediatric trauma center, 18-bed pediatric intensive care unit, and 32-bed neonatal intensive care unit. RESULTS A total of 1178 orders were identified, and 389 met inclusion criteria. The vast majority of second-sign orders were for vancomycin (92%), 61% were written for males, and the median age was 6 years old. Appropriateness of second-sign restricted antibiotic use significantly increased after second-sign implementation (84.5% to 92.9%, P = .01). The secondary outcome of time from initial order entry to medication administration was not different between the before and after groups (median time, 184.5 [interquartile range, 110.25-280.75] vs 174 [interquartile range, 104-228] minutes; P = .342). CONCLUSIONS The use of a second-sign approval process for antimicrobial restriction can lead to increased appropriateness of antibiotic use at a pediatric hospital, without causing a delay in administration.
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Affiliation(s)
- Aimee M Dassner
- Department of Pharmacy, Connecticut Children's Medical Center, Hartford.,Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs
| | - Jennifer E Girotto
- Department of Pharmacy, Connecticut Children's Medical Center, Hartford.,Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, Hartford.,Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs
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3
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Choe PG, Koo HL, Yoon D, Bae JY, Lee E, Hwang JH, Song KH, Park WB, Bang JH, Kim ES, Kim HB, Park SW, Oh MD, Kim NJ. Effect of an intervention targeting inappropriate continued empirical parenteral vancomycin use: a quasi-experimental study in a region of high MRSA prevalence. BMC Infect Dis 2018; 18:178. [PMID: 29661158 PMCID: PMC5902846 DOI: 10.1186/s12879-018-3081-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 04/03/2018] [Indexed: 12/13/2022] Open
Abstract
Background Despite vancomycin use is a major risk factor for the emergence of vancomycin resistance, it is frequently inappropriately prescribed, especially as empirical treatment. We evaluated the effect of an antimicrobial stewardship intervention targeting for inappropriate continued empirical vancomycin use. Methods This was a quasi-experimental study comparing vancomycin use in a 6-month pre-intervention and 6-month intervention period. If empirical vancomycin was continued for more than 96 h without documentation of beta-lactam-resistant gram-positive microorganisms, it was considered inappropriate continued empirical vancomycin use. The intervention consisted of the monitoring of appropriateness by a pharmacist and direct discussion with the prescribing physicians by infectious disease specialists when empirical vancomycin was continued inappropriately. An interrupted time series analysis was used to compare vancomycin use before and during the intervention. Results Following implementation of the intervention, overall vancomycin consumption decreased by 14.6%, from 37.6 defined daily doses (DDDs)/1000 patient-days in the pre-intervention period to 32.1 DDDs/1000 patient-days in the intervention period (P < 0.001). The inappropriate consumption of vancomycin also declined from 8.0 DDDs/1000 patient-days to 5.8 DDDs/1000 patient-days (P = 0.009). Conclusion Interventions such as direct communication with prescribing physicians and infectious disease clinicians can help reduce the inappropriate continued use of vancomycin.
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Affiliation(s)
- Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea.,Infection Control Office, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hei Lim Koo
- Infection Control Office, Seoul National University Hospital, Seoul, Republic of Korea
| | - Doran Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ji Yun Bae
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Eunyoung Lee
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Joo-Hee Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea.,Present address: Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Republic of Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea.,Infection Control Office, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji Hwan Bang
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sang Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Myoung-Don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea.,Infection Control Office, Seoul National University Hospital, Seoul, Republic of Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea. .,Infection Control Office, Seoul National University Hospital, Seoul, Republic of Korea.
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Smith MJ, Gerber JS, Hersh AL. Inpatient Antimicrobial Stewardship in Pediatrics: A Systematic Review. J Pediatric Infect Dis Soc 2015; 4:e127-35. [PMID: 26582880 DOI: 10.1093/jpids/piu141] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 12/12/2014] [Indexed: 11/13/2022]
Abstract
BACKGROUND The clinical and economic outcomes associated with pediatric antimicrobial stewardship programs (ASPs) and other supplemental antimicrobial stewardship (AS) interventions have not been well described or reviewed. METHODS We performed a systematic review using PubMed to identify studies with any of the following terms in the title or abstract: "antimicrobial stewardship," "antimicrobial control," "antibiotic control," or "antibiotic stewardship." Studies were further limited to inpatient studies in the United States that contained the terms: "child," "children," "pediatric*" ("*" includes all terms with the same stem), "paediatric,*" "newborn," "infant," or "neonat,*" in the title or abstract. Clinical and economic outcomes from each relevant study were summarized. RESULTS Nine original studies reported outcomes related to formal pediatric ASPs. An additional 8 studies focused on specific AS interventions; 3 on management of community-acquired pneumonia, 2 on vancomycin-specific initiatives, and 1 each on clinical support, antibiotic restriction, and antibiotic rotation. Reported outcomes include decreases in antimicrobial utilization (11 studies), prescribing errors (3 studies), and drug costs (3 studies). Five studies assessed the potential adverse effects of AS interventions on patient safety and found none. Data to support an association between pediatric AS interventions and antimicrobial resistance are limited. CONCLUSIONS A small number of pediatric studies evaluating ASPs or other AS strategies have been published. These studies demonstrate reductions in antimicrobial utilization, cost, and prescribing errors with no apparent negative impact on patient safety. Although the studies are promising, the current evidence base is limited. Additional studies focusing on the appropriateness and outcomes of antimicrobial prescribing practices as well as more formalized economic evaluations are needed.
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Affiliation(s)
- Michael J Smith
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Jeffrey S Gerber
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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5
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Powell SL, Liebelt E. Appropriate use of vancomycin in a pediatric emergency department through the use of a standardized electronic guideline. J Pediatr Nurs 2015; 30:494-7. [PMID: 25618611 DOI: 10.1016/j.pedn.2014.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 12/22/2014] [Accepted: 12/24/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVES (a) Compare utilization of vancomycin in the ED prior to and after implementation of standardized treatment guideline and order template (STGOT); (b) assess the appropriate use as initial therapy based on indication versus admitting diagnosis. METHODS Chart audits on all patients who received vancomycin and were admitted. Overall utilization and appropriateness of starting therapy were compared pre-and post-STGOT implementation. RESULTS Overall utilization of vancomycin was 4% pre-STGOT compared to 3% post-STGOT; 98% of patients pre-STGOT compared to 99% post-STGOT received vancomycin appropriately. CONCLUSION There was no difference in vancomycin utilization and appropriateness of initiating therapy after STGOT implementation.
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Affiliation(s)
| | - Erica Liebelt
- University of Alabama at Birmingham School of Medicine
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6
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Morris AM. Antimicrobial Stewardship Programs: Appropriate Measures and Metrics to Study their Impact. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2014; 6:101-112. [PMID: 25999798 PMCID: PMC4431704 DOI: 10.1007/s40506-014-0015-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antimicrobial stewardship is a new field that struggles to find the right balance between meaningful and useful metrics to study the impact of antimicrobial stewardship programs (ASPs). ASP metrics primarily measure antimicrobial use, although microbiological resistance and clinical outcomes are also important measures of the impact an ASP has on a hospital and its patient population. Antimicrobial measures looking at consumption are the most commonly used measures, and are focused on defined daily doses, days of therapy, and costs, usually standardized per 1,000 patient-days. Each measure provides slightly different information, with their own upsides and downfalls. Point prevalence measurement of antimicrobial use is an increasingly used approach to understanding consumption that does not entirely rely on sophisticated electronic information systems, and is also replicable. Appropriateness measures hold appeal and promise, but have not been developed to the degree that makes them useful and widely applicable. The primary reason why antimicrobial stewardship is necessary is the growth of antimicrobial resistance. Accordingly, antimicrobial resistance is an important metric of the impact of an ASP. The most common approach to measuring resistance for ASP purposes is to report rates of common or important community- or nosocomial-acquired antimicrobial-resistant organisms, such as methicillin-resistant Staphylococcus aureus and Clostridium difficile. Such an approach is dependent on detection methods, community rates of resistance, and co-interventions, and therefore may not be the most accurate or reflective measure of antimicrobial stewardship interventions. Development of an index to reflect the net burden of resistance holds theoretical promise, but has yet to be realized. Finally, programs must consider patient outcome measures. Mortality is the most objective and reliable method, but has several drawbacks. Disease- or organism-specific mortality, or cure, are increasingly used metrics.
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Affiliation(s)
- Andrew M. Morris
- Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, ON Canada
- Faculty of Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
- Mount Sinai Hospital, 415-600 University Avenue, Toronto, ON M5G 1X5 Canada
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7
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Brett A, Bielicki J, Newland JG, Rodrigues F, Schaad UB, Sharland M. Neonatal and pediatric antimicrobial stewardship programs in Europe-defining the research agenda. Pediatr Infect Dis J 2013; 32:e456-65. [PMID: 23958812 DOI: 10.1097/inf.0b013e31829f0460] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The relationship between suboptimal use of antimicrobials and antimicrobial resistance has become increasingly clear. Despite significant international effort aimed at reducing inappropriate antimicrobial prescribing in hospitals, antimicrobial resistance remains a major public health threat. Antimicrobial Stewardship Programs (ASPs) comprise a series of measures aimed at optimizing the use of antimicrobials, while improving the quality of patient care and promoting cost-effectiveness. This discussion article aims to summarize some of the approaches that have been used in neonatal and pediatric ASPs, with a particular focus on the European healthcare setting. Current evidence demonstrates neonatal and pediatric ASPs to be safe, practical to implement, generally cost-effective and possibly associated with a reduction in antimicrobial resistance rates. This review identified that, despite the recognized need for additional evidence and information on implementation, published data on pediatric ASPs derives mainly from the United States, with very few published reports on formal ASPs in European children's hospitals. Consequently, the optimal method of implementation remains unknown within a European setting. Future research needs to include novel study designs on how best to introduce ASPs, monitoring of clinically relevant outcomes and cost-effectiveness with improved measurement of the impact on antimicrobial resistance.
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Affiliation(s)
- Ana Brett
- From the *Infectious Diseases Unit and Emergency Service, Hospital Pediátrico, Centro, Hospitalar e Universitário de Coimbra, Coimbra, Portugal; †Paediatric Infectious Diseases Research Group, St George's University London, London, United Kingdom; ‡Division of Pediatric Infectious Diseases, Children's Mercy Hospital and Clinics, University of Missouri-Kansas City, MO; and §Paediatric Infectious Diseases Division, University Children's Hospital, Basel, Switzerland
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8
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May L, Cosgrove S, L'Archeveque M, Talan DA, Payne P, Jordan J, Rothman RE. A call to action for antimicrobial stewardship in the emergency department: approaches and strategies. Ann Emerg Med 2012; 62:69-77.e2. [PMID: 23122955 DOI: 10.1016/j.annemergmed.2012.09.002] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 08/27/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Larissa May
- Department of Emergency Medicine, George Washington University, Washington, DC, USA.
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9
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Newland JG, Banerjee R, Gerber JS, Hersh AL, Steinke L, Weissman SJ. Antimicrobial Stewardship in Pediatric Care: Strategies and Future Directions. Pharmacotherapy 2012; 32:735-43. [DOI: 10.1002/j.1875-9114.2012.01155.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jason G. Newland
- Section of Infectious Diseases; Department of Pediatrics; University of Missouri-Kansas City; Children's Mercy Hospitals & Clinics; Kansas City; Missouri
| | - Ritu Banerjee
- Division of Pediatric Infectious Diseases; Department of Pediatrics and Adolescent Medicine; Mayo Clinic College of Medicine; Mayo Children's Hospital; Rochester; Minnesota
| | - Jeffrey S. Gerber
- Division of Infectious Diseases; Department of Pediatrics; University of Pennsylvania School of Medicine; Children's Hospital of Philadelphia; Philadelphia; Pennsylvania
| | - Adam L. Hersh
- Division of Infectious Diseases; Department of Pediatrics; University of Utah; Primary Children's Medical Center; Salt Lake City; Utah
| | - Leah Steinke
- Department of Pharmacy; Children's Hospital of Michigan; Detroit Medical Center; Detroit; Michigan
| | - Scott J. Weissman
- Division of Infectious Diseases; Department of Pediatrics; University of Washington Medical Center; Seattle Children's Hospital; Seattle; Washington
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10
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Levy ER, Swami S, Dubois SG, Wendt R, Banerjee R. Rates and appropriateness of antimicrobial prescribing at an academic children's hospital, 2007-2010. Infect Control Hosp Epidemiol 2012; 33:346-53. [PMID: 22418629 DOI: 10.1086/664761] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE AND DESIGN Antimicrobial use in hospitalized children has not been well described. To identify targets for antimicrobial stewardship interventions, we retrospectively examined pediatric utilization rates for 48 antimicrobials from 2007 to 2010 as well as appropriateness of vancomycin and cefepime use in 2010. PATIENTS AND SETTING All children hospitalized between 2007 and 2010 at the Mayo Clinic Children's Hospital, a 120-bed facility within a larger adult hospital in Rochester, Minnesota. METHODS We calculated antimicrobial utilization rates in days of therapy per 1,000 patient-days. Details of vancomycin and cefepime use in 2010 were abstracted by chart review. Two pediatric infectious disease physicians independently assessed appropriateness of antibiotic use. RESULTS From 2007 to 2010, 9,880 of 17,242 (57%) hospitalized children received 1 or more antimicrobials. Antimicrobials (days of therapy per 1,000 patient-days) used most frequently in 2010 were cefazolin (97.8), vancomycin (97.1), fluconazole (76.4), piperacillin-tazobactam (70.7), and cefepime (67.6). Utilization rates increased significantly from 2007 to 2010 for 10 antimicrobials, including vancomycin, fluconazole, piperacillin-tazobactam, cefepime, trimethoprim-sulfamethoxazole, caspofungin, and cefotaxime. In 2010, inappropriate use of vancomycin and cefepime was greater in the pediatric intensive care unit than ward (vancomycin: 17.8% vs 6.4%, P = .001; cefepime: 9.2% vs 3.9%, P = .142) and on surgical versus medical services (vancomycin: 20.5% vs 8.0%, P = .001; cefepime: 19.4% vs 3.4%, P ≤ .001). The most common reason for inappropriate antibiotic use was failure to discontinue or de-escalate therapy. CONCLUSIONS In our children's hospital, use of 10 antimicrobials increased during the study period. Inappropriate use of vancomycin and cefepime was greatest on the critical care and surgical services, largely as a result of failure to de-escalate therapy, suggesting targets for future antimicrobial stewardship interventions.
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Affiliation(s)
- E R Levy
- Department of Pediatrics, University of California, San Francisco, California 94143, USA.
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11
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Abstract
BACKGROUND Increasing rates of resistant gram-positive coccal infections led to an increased use of vancomycin. We evaluated the impact of implementing an Antimicrobial Stewardship Program on density of vancomycin use at a pediatric tertiary-care teaching hospital. METHODS An Antimicrobial Stewardship Program was implemented April 1, 2004. Indications for vancomycin use were incorporated as mandatory fields using the integrated computerized information system. An automated report of vancomycin prescriptions, doses, patient demographics, and microbiology data was reviewed by an infectious disease pharmacist Monday through Friday. Interventions were discussed with a pediatric infectious disease physician and real-time feedback provided to clinicians. Density of vancomycin use was evaluated by measuring the number of doses administered/1000 patient-days. RESULTS Density of vancomycin use declined overtime from 378 doses administered/1000 patient-days to 255 doses administered/1000 patient-days despite increasing rates of Staphylococcus aureus infected patients, and was not associated with increased use of other antibiotics with similar antimicrobial activity. Nonapproved vancomycin indications were selected in 28% of vancomycin doses administered. Of the 317 Antimicrobial Stewardship Program interventions performed, 190 qualified as vancomycin prescription errors, most commonly, vancomycin dosing and premature stop. After the implementation of the program, the rate of vancomycin prescription errors decreased. CONCLUSIONS Implementation of an integrated Antimicrobial Stewardship Program using real-time evaluation and feedback to physicians, and optimization of the clinical informatics system, reduced vancomycin utilization and vancomycin prescribing errors, improving the quality of care and safety of hospitalized children in our institution.
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12
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Antibiotic Stewardship: Possibilities when Resources Are Limited. Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Valcourt K, Norozian F, Lee H, Raszynski A, Torbati D, Totapally BR. Drug use density in critically ill children and newborns: analysis of various methodologies. Pediatr Crit Care Med 2009; 10:495-9. [PMID: 19451853 DOI: 10.1097/pcc.0b013e3181a3101e] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare in the pediatric, cardiac, and neonatal intensive care units, three methods of assessing vancomycin and linezolid drug use density by number of: defined daily doses (DDDs), prescribed daily doses, and days of drug use per 100 patient days. DESIGN Retrospective study. SETTING A tertiary care children's hospital. PATIENTS We reviewed the charts of patients admitted to the cardiac intensive care unit and neonatal intensive care unit in 2005 who were treated with vancomycin, and those admitted to the pediatric intensive care unit who were treated with vancomycin or linezolid during 2004 and 2005. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The number of patients, treatment days, total amount of vancomycin/linezolid, total intensive care unit admissions, and patient days were recorded. We used the World Health Organization definition of DDD for vancomycin and linezolid (2000 and 1200 mg, respectively). The prescribed daily dose for each intensive care unit was calculated for each year by dividing the total amount of the medication administered by the total number of treatment days. The drug use densities were then calculated as the total DDDs, prescribed daily doses, and days of drug use per 100 patient days. The vancomycin use densities were significantly different among the three intensive care units when compared by each method. They were significantly lower in all three units when expressed as DDDs per 100 patient days. The vancomycin drug use density in the pediatric intensive care unit was significantly decreased during 2005 compared with 2004 by all three methods. CONCLUSIONS In critically ill children, drug use density of vancomycin is significantly less when evaluated by the DDD method compared with the prescribed daily dose method, a more appropriate method in children. However, the simplest and most accurate method of assessing drug use density is the number of days of drug use method, which allows comparison of drug use density between different pediatric facilities or clinical units.
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Affiliation(s)
- Karl Valcourt
- Division of Critical Care Medicine, Miami Children's Hospital, Miami, FL, USA
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14
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Patel SJ, Larson EL, Kubin CJ, Saiman L. A review of antimicrobial control strategies in hospitalized and ambulatory pediatric populations. Pediatr Infect Dis J 2007; 26:531-7. [PMID: 17529873 DOI: 10.1097/inf.0b013e3180593170] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antimicrobial resistance is a growing crisis in healthcare. Various antimicrobial stewardship strategies have been used to control antibiotic use in efforts to reduce antibiotic resistance. We conducted a systematic review of antimicrobial stewardship programs in pediatric settings. Twenty-eight published studies met inclusion criteria. The majority (21 of 28) of studies had positive outcomes, but only 6 measured the impact of interventions on antimicrobial resistance. Prescriber education for a specific diagnosis (eg, otitis media) was the most effective intervention in the outpatient setting. Ancillary laboratory tests (eg, rapid diagnostic assays for viral pathogens) were most effective in the inpatient setting. Most studies had moderate to high risk of bias, mainly because of selection bias, inadequate preintervention data for time series analysis, and contamination between treatment groups. To date, there are a limited number of studies assessing antimicrobial stewardship in pediatric settings and these have heterogeneous study designs. Thus, it is difficult to determine the most effective interventions. Future studies should be designed to overcome the biases encountered in current publications.
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Affiliation(s)
- Sameer J Patel
- Department of Pediatrics, Division of Pediatric Infectious Diseases, New York-Presbyterian Hospital, New York, NY 10032, USA.
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15
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Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA, Burke JP, Huskins WC, Paterson DL, Fishman NO, Carpenter CF, Brennan PJ, Billeter M, Hooton TM. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2006; 44:159-77. [PMID: 17173212 DOI: 10.1086/510393] [Citation(s) in RCA: 2318] [Impact Index Per Article: 128.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 10/04/2006] [Indexed: 12/31/2022] Open
Affiliation(s)
- Timothy H Dellit
- Harborview Medical Center and the University of Washington, Seattle, USA
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