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Toldi G, Majid A. The role of microbial cell free DNA sequencing in sepsis detection in the neonate. Pediatr Res 2024:10.1038/s41390-024-03568-8. [PMID: 39266626 DOI: 10.1038/s41390-024-03568-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2024] [Accepted: 08/27/2024] [Indexed: 09/14/2024]
Affiliation(s)
- Gergely Toldi
- Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - Atif Majid
- Liggins Institute, University of Auckland, Auckland, New Zealand
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2
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Balks J, Grumaz S, Mazzitelli S, Neder U, Lemloh L, Melaku T, Glaser K, Mueller A, Kipfmueller F. Microbial cell-free DNA-sequencing as an addition to conventional diagnostics in neonatal sepsis. Pediatr Res 2024:10.1038/s41390-024-03448-1. [PMID: 39143203 DOI: 10.1038/s41390-024-03448-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/04/2024] [Accepted: 07/24/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Bloodstream infections remain a challenge for neonatologists, as traditional culture-based methods are time-consuming and rely on adequate blood volume. Next-generation sequencing (NGS) offers an alternative, as it can identify microbial cell-free DNA (mcfDNA) in a small blood sample, providing rapid pathogen detection. This study aimed to assess the diagnostic performance of DISQVER®-NGS compared to blood cultures in neonatal patients with suspected sepsis. METHODS In neonates with suspected sepsis, blood cultures and samples for NGS were prospectively collected. Patients were divided into four categories: 1) sepsis, blood culture positive, 2) clinical sepsis, culture negative, 3) suspected sepsis, 4) validation cohort. RESULTS NGS detected bacterial, viral or fungal mcfDNA in 24 of 82 samples. Blood cultures were collected in 46 of 84 patients (15/46 positive). DISQVER® correctly identified pathogens in 9/15 patients with a positive blood culture, two with intrinsic resistance to their antibiotic regimen. In seven samples NGS reported the mcfDNA of bacteria that could have theoretically grown in culture but did not. CONCLUSIONS NGS may enhance sensitivity in sepsis diagnostics by detecting mcfDNA in neonates with suspected sepsis. Interpreting NGS results requires correlation with clinical data, laboratory values, and routine microbiological tests for a comprehensive understanding of the patient's condition. IMPACT Conventional blood culture methods have limitations in accuracy and turnaround time. The study aimed to investigate the diagnostic performance of the Next-Generation Sequencing method DISQVER® compared to traditional blood cultures in neonatal patients with suspected sepsis. Our findings suggest that NGS has the potential to augment the precision of conventional diagnostic techniques, can lead to improved detection of pathogens and targeted treatment approaches in neonatal sepsis. It is emphasized that further validation and integration with clinical and microbiological data are required to ensure optimal clinical utility.
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Affiliation(s)
- Julian Balks
- Division of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
- Institute of Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Bonn, Germany
| | | | | | | | - Lotte Lemloh
- Division of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Tamene Melaku
- Division of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University Medical Center Leipzig, Leipzig, Germany
| | - Andreas Mueller
- Division of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | - Florian Kipfmueller
- Division of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany.
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Singu BS, Pieper CH, Verbeeck RK, Ette EI. Predictors of gentamicin therapy failure in neonates with sepsis. Pharmacol Res Perspect 2024; 12:e1250. [PMID: 39105353 DOI: 10.1002/prp2.1250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/15/2024] [Accepted: 07/04/2024] [Indexed: 08/07/2024] Open
Abstract
Sepsis is a common disease with high morbidity and mortality among newborns in intensive care units world-wide. Gram-negative bacillary bacteria are the major source of infection in neonates. Gentamicin is the most widely used aminoglycoside antibiotic in empiric therapy against early-onset sepsis. However, therapy failure may result due to various factors. The purpose of this study was to identify predictors of gentamicin therapy failure in neonates with sepsis. This was a prospective cross-sectional study at the Neonatal Intensive Care Unit at Windhoek Central Hospital over a period of 5 months in 2019. Neonates received intravenous gentamicin 5 mg/kg/24 h in combination with either benzylpenicillin 100 000 IU/kg/12 h or ampicillin 50 mg/kg/8 h. Logistic regression modeling was performed to determine the predictors of treatment outcomes. 36% of the 50 neonates were classified as having gentamicin treatment failure. Increasing treatment duration by 1 day resulted in odds of treatment failure increasing from 1.0 to 2.41. Similarly, one unit increase in CRP increases odds of gentamicin treatment failure by 49%. The 1 kg increase in birthweight reduces the log odds of treatment failure by 6.848, resulting in 99.9% decrease in the odds of treatment failure. One unit increase in WBC reduces odds of gentamicin treatment failure by 27%. Estimates of significant predictors of treatment failure were precise, yielding odds ratios that were within 95% confidence interval. This study identified the following as predictors of gentamicin therapy failure in neonates: prolonged duration of treatment, elevated C-reactive protein, low birthweight, and low white blood cell count.
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Affiliation(s)
| | | | - Roger Karel Verbeeck
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Ene I Ette
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
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Flannery DD, Coggins SA, Medoro AK. Antibiotic Stewardship in the Neonatal Intensive Care Unit. J Intensive Care Med 2024:8850666241258386. [PMID: 38835250 DOI: 10.1177/08850666241258386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
Antibiotic stewardship is a multidisciplinary, evidence-based approach to optimize antibiotic use and mitigate development of antibiotic resistance. Neonates have high rates of antibiotic exposure, particularly those born preterm and admitted to the NICU, and mounting evidence describes the adverse consequences of such exposures in the absence of infection. Here, we review the general principles of antibiotic stewardship and how they can be applied in NICUs. The unique characteristics of NICUs and patients cared for in this setting, which warrant unique implementation strategies and special considerations are discussed. We summarize current antibiotic use metrics for assessment of responses to stewardship interventions and changes over time, and review evidence-based infection prevention practices in the NICU. Current recommendations for empiric antibiotic use in the NICU and the utility of infection biomarkers are summarized. Lastly, given the growing global threat of increasing antibiotic resistance, specific threats in the NICU are highlighted.
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Affiliation(s)
- Dustin D Flannery
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sarah A Coggins
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra K Medoro
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Hartley C, Morrisette T, Malloy K, Steed LL, Dixon T, Garner SS. Successful Eradication of a Highly Resistant Elizabethkingia anophelis Species in a Premature Neonate With Bacteremia and Meningitis. Pediatr Infect Dis J 2023; 42:e461-e465. [PMID: 37851968 DOI: 10.1097/inf.0000000000004132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Elizabethkingia anophelis is a Gram-negative bacillus that can exhibit highly resistant phenotypes against most antibiotics with evidence of efficacy and safety in the neonatal population. Given the limited antimicrobial options, clinicians may be forced into challenging treatment scenarios when faced with central nervous system infections in premature neonates caused by E. anophelis . We report a case of successful treatment of hospital-acquired meningitis and bacteremia caused by E. anophelis at 11 days of life in a male infant born at 29 weeks, 1 day gestation and birth weight of 1.41 kg. Therapy consisted of vancomycin, dose adjusted to maintain goal troughs of 15-20 mg/L, and rifampin 10 mg/kg/dose every 12 hours, with ciprofloxacin 15 mg/kg/dose every 12 hours and trimethoprim/sulfamethoxazole 5 mg/kg/dose every 12 hours added due to antimicrobial susceptibilities and unsatisfactory response, for a total of 21 days. Following initiation of this multidrug regimen, repeat cultures were negative, laboratory parameters improved [with exception of elevated cerebrospinal fluid (CSF) white blood cell count], the patient remained otherwise stable, and there were no adverse effects noted from therapy. Complications after treatment included the requirement of bilateral hearing aids and the development of hydrocephalus necessitating ventriculoperitoneal shunt placement. To our knowledge, we report the first case of meningitis in a premature neonate initially identified as E. anophelis in the United States treated with this regimen which led to successful microbiologic eradication with no antimicrobial safety concerns.
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Affiliation(s)
- Christopher Hartley
- From the Department of Pharmacy Services, Medical University of South Carolina Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Taylor Morrisette
- From the Department of Pharmacy Services, Medical University of South Carolina Shawn Jenkins Children's Hospital, Charleston, South Carolina
- Department of Clinical Pharmacy & Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, South Carolina
- Department of Pharmacy Services, Medical University of South Carolina Health, Charleston, South Carolina
| | - Katherine Malloy
- From the Department of Pharmacy Services, Medical University of South Carolina Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Lisa L Steed
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Terry Dixon
- Division of Infectious Diseases, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Sandra S Garner
- From the Department of Pharmacy Services, Medical University of South Carolina Shawn Jenkins Children's Hospital, Charleston, South Carolina
- Department of Clinical Pharmacy & Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, South Carolina
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Coggins SA, Willis Z, Benjamin DK, Mukhopadhyay S, Laughon M, Greenberg RG, Clark RH, Puopolo KM. Early antibiotic exposure in very-low birth weight infants and infection risk at 3-7 days after birth. J Perinatol 2023; 43:1158-1165. [PMID: 37491474 PMCID: PMC10529484 DOI: 10.1038/s41372-023-01737-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE To determine rates of late-onset infection (LOI) during postnatal days 3-7 among preterm infants, based on antibiotic exposure during days 0-2. STUDY DESIGN Retrospective cohort study of infants born <1500 grams and ≤30 weeks gestation, 2005-2018. We analyzed the incidence and microbiology of LOI at days 3-7 based on antibiotic exposure during postnatal days 0-2. RESULTS The cohort included 88,574 infants, of whom 85% were antibiotic-exposed. Fewer antibiotic-exposed compared to unexposed infants developed LOI (1.5% vs. 2.1%; adjusted hazard ratio, 0.28, 95% CI 0.24-0.33). Among antibiotic-exposed compared to unexposed infants, Gram-negative (38% vs. 28%, p = 0.002) and fungal (11% vs. 1%, p < 0.001) species were more commonly isolated, and gram-positive organisms (49% vs. 70%, p < 0.001) were less commonly isolated. CONCLUSIONS We observed low overall rates of LOI at days 3-7 after birth, but antibiotic exposure from birth was associated with lower rates, and with differing microbiology, compared to no exposure.
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Affiliation(s)
- Sarah A Coggins
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA.
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Zachary Willis
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Sagori Mukhopadhyay
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Reese H Clark
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL, USA
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Baltogianni M, Giapros V, Kosmeri C. Antibiotic Resistance and Biofilm Infections in the NICUs and Methods to Combat It. Antibiotics (Basel) 2023; 12:antibiotics12020352. [PMID: 36830264 PMCID: PMC9951928 DOI: 10.3390/antibiotics12020352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Neonatal sepsis is an important cause of neonatal morbidity and mortality. A significant proportion of bacteria causing neonatal sepsis is resistant to multiple antibiotics, not only to the usual empirical first-line regimens, but also to second- and third-line antibiotics in many neonatal intensive care units (NICUs). NICUs have unique antimicrobial stewardship goals. Apart from antimicrobial resistance, NICUs have to deal with another problem, namely biofilm infections, since neonates often have central and peripheral lines, tracheal tubes and other foreign bodies for a prolonged duration. The aim of this review is to describe traditional and novel ways to fight antibiotic-resistant bacteria and biofilm infections in NICUs. The topics discussed will include prevention and control of the spread of infection in NICUs, as well as the wise use of antimicrobial therapy and ways to fight biofilm infections.
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Affiliation(s)
- Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
- Correspondence: ; Tel.: +30-26-5100-7546
| | - Chrysoula Kosmeri
- Department of Pediatrics, University Hospital of Ioannina, 45500 Ioannina, Greece
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Brumbaugh JE, Bell EF, Do BT, Greenberg RG, Stoll BJ, DeMauro SB, Harmon HM, Hintz SR, Das A, Puopolo KM. Incidence of and Neurodevelopmental Outcomes After Late-Onset Meningitis Among Children Born Extremely Preterm. JAMA Netw Open 2022; 5:e2245826. [PMID: 36480199 PMCID: PMC9856224 DOI: 10.1001/jamanetworkopen.2022.45826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/24/2022] [Indexed: 12/13/2022] Open
Abstract
Importance Late-onset meningitis (LOM) has been associated with adverse neurodevelopmental outcomes in children born extremely preterm. Objective To report the incidence of LOM during birth hospitalization and neurodevelopmental outcomes at 18 to 26 months' corrected age. Design, Setting, and Participants This cohort study is a secondary analysis of a multicenter prospective cohort of children born at 22 to 26 weeks' gestation between 2003 and 2017 with follow-up from 2004 to 2021. The study was conducted at 25 Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network centers. Exposures Culture-confirmed LOM. Main Outcomes and Measures Incidence and microbiology of LOM (2003-2017); lumbar puncture (LP) performance in late-onset sepsis (LOS) evaluations (2011-2017); composite outcome of death or neurodevelopmental impairment (NDI; 2004-2021). Results Among 13 372 infants (median [IQR] gestational age, 25.4 [24.4-26.1] weeks; 6864 [51%] boys), LOM was diagnosed in 167 (1%); LOS without LOM in 4564 (34%); and neither LOS nor LOM in 8641 (65%). The observed incidence of LOM decreased from 2% (95% CI, 1%-3%) in 2003 to 0.4% (95% CI, 0.7%-1.0%) in 2017 (P < .001). LP performance in LOS evaluations decreased from 36% (95% CI, 33%-40%) in 2011 to 24% (95% CI, 21%-27%) in 2017 (P < .001). Among infants with culture-confirmed LOS, LP performance decreased from 58% (95% CI, 51%-65%) to 45% (95% CI, 38%-51%; P = .008). LP performance varied by center among all LOS evaluations (10%-59%, P < .001) and among those with culture-confirmed LOS (23%-79%, P < .001). LOM occurred in the absence of concurrent LOS in 27 of 167 cases (16%). The most common LOM isolates were coagulase-negative Staphylococcus (98 [59%]), Candida albicans (38 [23%]), and Escherichia coli (27 [16%]). Death or NDI occurred in 22 of 46 children (48%) with LOM due to coagulase-negative Staphylococcus, 43 of 67 (64%) due to all other bacterial pathogens, and 26 of 33 (79%) due to fungal pathogens. The adjusted relative risk of death or NDI was increased among children with LOM (aOR, 1.53; 95% CI, 1.04-2.25) and among those with LOS without LOM (aOR, 1.41; 95% CI, 1.29-1.54) compared with children with neither infection. Conclusions and Relevance In this cohort study, LP was performed with decreasing frequency, and the observed incidence of LOM also decreased. Both LOM and LOS were associated with increased risk of death or NDI; risk varied by LOM pathogen. The full association of LOM with outcomes of children born extremely preterm may be underestimated by current diagnostic practices.
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Affiliation(s)
- Jane E. Brumbaugh
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Barbara T. Do
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | | | - Barbara J. Stoll
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, Georgia
- McGovern Medical School of UTHealth, Houston, Texas
| | - Sara B. DeMauro
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | | | - Susan R. Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Karen M. Puopolo
- Department of Pediatrics, University of Pennsylvania, Philadelphia
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Variation in antibiotic use among neonatal intensive care units in the United States. Infect Control Hosp Epidemiol 2022; 43:1945-1947. [PMID: 34496991 PMCID: PMC9915338 DOI: 10.1017/ice.2021.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Antibiotics are widely used in neonatal intensive care units (NICUs). We conducted a cross-sectional analysis of antibiotic use across US NICUs to evaluate overall, broad-spectrum, and combination antibiotic use. Patterns of antibiotic use varied by medical versus surgical service line, hospital, and geographic location.
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10
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Abstract
Neonatal late-onset sepsis (LOS) continues to threaten morbidity and mortality in the NICU and poses ongoing diagnostic and therapeutic challenges. Early recognition of clinical signs, rapid evaluation, and prompt initiation of treatment are critical to prevent life-threatening deterioration. Preterm infants-born at ever-decreasing gestational ages-are at particularly high risk for life-long morbidities and death. This changing NICU population necessitates continual reassessments of diagnostic and preventive measures and evidence-based treatment for LOS. The clinical presentation of LOS is varied and nonspecific. Despite ongoing research, reliable, specific laboratory biomarkers facilitating early diagnosis are lacking. These limitations drive an ongoing practice of liberal initiation of empiric antibiotics among infants with suspected LOS. Subsequent promotion of multidrug-resistant microorganisms threatens the future of antimicrobial therapy and puts preterm and chronically ill infants at even higher risk of nosocomial infection. Efforts to identify adjunctive therapies counteracting sepsis-driven hyperinflammation and sepsis-related functional immunosuppression are ongoing. However, most approaches have either failed to improve LOS prognosis or are not yet ready for clinical application. This article provides an overview of the epidemiology, risk factors, diagnostic tools, and treatment options of LOS in the context of increasing numbers of extremely preterm infants. It addresses the question of whether LOS could be identified earlier and more precisely to allow for earlier and more targeted therapy and discusses rational approaches to antibiotic therapy to avoid overuse. Finally, this review elucidates the necessity of long-term follow-up of infants with a history of LOS.
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Affiliation(s)
- Sarah A. Coggins
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kirsten Glaser
- Division of Neonatology, Department of Women’s and Children’s Health, University of Leipzig Medical Center, Leipzig, Germany
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Viel-Thériault I, Agarwal A, Bariciak E, Le Saux N, Thampi N. Antimicrobial Prophylaxis Use in the Neonatal Intensive Care Unit: An Antimicrobial Stewardship Target That Deserves Attention! Am J Perinatol 2022; 39:1288-1291. [PMID: 33454950 DOI: 10.1055/s-0040-1722600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Previous analyses of neonatal intensive care units (NICU) antimicrobial stewardship programs have identified key contributors to overall antibiotic use, including prolonged empiric therapy >48 hours for early-onset sepsis (EOS). However, most were performed in mixed NICU settings with onsite birthing units, resulting in a high proportion of inborn patient admissions. The study aimed to describe and analyze the most common reasons for antimicrobial use in an outborn tertiary care NICU. STUDY DESIGN This was a 10-month review of all antimicrobial doses prescribed in a 20-bed level III NICU. The primary outcome was the total days of therapy (DOT) and length of therapy (LOT) for each clinical indication. Secondary outcomes included total DOT for each antimicrobial and appropriateness of antimicrobial courses. RESULTS Of 235 antibiotic courses and 1,899 DOT (519 DOT/1,000 patient days) prescribed in 173 infants during the study period, the most common indications were suspected EOS, followed by prophylaxis. Among the 85 DOT/1,000 patient days (PD; 38 courses) prescribed for prophylaxis, 52.5 DOT/1,000 PD (25 courses; 62%) were for surgical prophylaxis. Of 17 postoperative antibiotic courses, 15 (88.2%) were deemed to be inappropriate mostly due to a duration greater than 24 hours postoperatively (n = 13; median LOT = 3 days). CONCLUSION Surgical prophylaxis is a common reason for antimicrobial misuse in outborn NICU. NICU-based prospective audit and feedback between neonatologists and antimicrobial stewardship teams alone may not be impactful in this setting. Partnerships with neonatologists and surgeons will be key to achieving the target of less than 24 hours of postoperative antimicrobials. KEY POINTS · Surgical prophylaxis is a common reason for antimicrobial misuse in the NICU.. · Antimicrobial prophylaxis duration of less than 24 hours postoperatively should be encouraged.. · NICU-based prospective audit and feedback may not be impactful unless surgeons are involved..
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Affiliation(s)
- Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, Centre Hospitalier de l'Université Laval, Québec, Québec, Canada
| | - Amisha Agarwal
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Erika Bariciak
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nicole Le Saux
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nisha Thampi
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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12
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Ting JY, Yoon EW, Fajardo CA, Daboval T, Bertelle V, Shah PS. Antimicrobial utilization in very-low-birth-weight infants: association with probiotic use. J Perinatol 2022; 42:947-952. [PMID: 35399098 DOI: 10.1038/s41372-022-01382-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 03/12/2022] [Accepted: 03/22/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine the association between probiotic use and antimicrobial utilization. STUDY DESIGN We retrospectively evaluated very-low-birth-weight (VLBW) infants admitted to tertiary neonatal intensive care units in Canada between 2014 and 2019. Our outcome was antimicrobial utilization rate (AUR) defined as number of days of antimicrobial exposure per 1000 patient-days. RESULT Of 16,223 eligible infants, 7279 (45%) received probiotics. Probiotic use rate increased from 10% in 2014 to 68% in 2019. The AUR was significantly lower in infants who received probiotics vs those who did not (107 vs 129 per 1000 patient-days, aRR = 0.89, 95% CI [0.81, 0.98]). Among 13,305 infants without culture-proven sepsis or necrotizing enterocolitis ≥Stage 2, 5931 (45%) received probiotics. Median AUR was significantly lower in the probiotic vs the no-probiotic group (78 vs 97 per 1000 patient-days, aRR = 0.85, 95% CI [0.74, 0.97]). CONCLUSION Probiotic use was associated with a significant reduction in AUR among VLBW infants.
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Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Eugene W Yoon
- Maternal-infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Carlos A Fajardo
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Thierry Daboval
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Valérie Bertelle
- Department of Pediatrics, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Prakesh S Shah
- Maternal-infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada. .,Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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13
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褚 梅, 王 铭, 林 锦, 杨 舸, 丁 颖, 廖 正, 曹 传, 岳 少. [Effect of improvement in antibiotic use strategy on the short-term clinical outcome of preterm infants with a gestational age of <35 weeks]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:521-529. [PMID: 35644192 PMCID: PMC9154368 DOI: 10.7499/j.issn.1008-8830.2201016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/08/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To study the effect of improvement in antibiotic use strategy on the short-term clinical outcome of preterm infants with a gestational age of <35 weeks. METHODS The medical data were retrospectively collected from 865 preterm infants with a gestational age of <35 weeks who were admitted to the Neonatal Intensive Care Unit of Xiangya Hospital of Central South University from January 1, 2014 to December 31, 2016. The improved antibiotic use strategy was implemented since January 1, 2015. According to the time of implementation, the infants were divided into three groups: pre-adjustment (January 1, 2014 to December 31, 2014; n=303), post-adjustment Ⅰ (January 1, 2015 to December 31, 2015; n=293), and post-adjustment Ⅱ (January 1, 2016 to December 31, 2016; n=269). The medical data of the three groups were compared. RESULTS There were no significant differences among the three groups in gestational age, proportion of small-for-gestational-age infants, sex, and method of birth (P>0.05). Compared with the pre-adjustment group, the post-adjustment I and post-adjustment Ⅱ groups had a significant reduction in the rate of use of antibiotics and the duration of antibiotic use in the early postnatal period and during hospitalization (P<0.05), with a significant increase in the proportion of infants with a duration of antibiotic use of ≤3 days or 4-7 days and a significant reduction in the proportion of infants with a duration of antibiotic use of >7 days in the early postnatal period (P<0.05). Compared with the post-adjustment Ⅰ group, the post-adjustment Ⅱ group had a significant reduction in the duration of antibiotic use in the early postnatal period and during hospitalization (P<0.05), with a significant increase in the proportion of infants with a duration of antibiotic use of ≤3 days and a significant reduction in the proportion of infants with a duration of antibiotic use of 4-7 days or >7 days (P<0.05). Compared with the pre-adjustment group, the post-adjustment I and post-adjustment Ⅱ groups had significantly shorter duration of parenteral nutrition and length of hospital stay (P<0.05). There were gradual reductions in the incidence rates of grade ≥Ⅲ intraventricular hemorrhage (IVH) and late-onset sepsis (LOS) after the adjustment of antibiotic use strategy. The multivariate logistic regression analysis showed that the adjustment of antibiotic use strategy had no effect on short-term adverse clinical outcomes, and antibiotic use for >7 days significantly increased the risk of adverse clinical outcomes (P<0.05). CONCLUSIONS It is feasible to reduce unnecessary antibiotic use by the improvement in antibiotic use strategy in preterm infants with a gestational age of <35 weeks, which can also shorten the duration of parenteral nutrition and the length of hospital stay and reduce the incidence rates of grade ≥Ⅲ IVH and LOS.
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Kramer TS, Salm F, Schwab F, Geffers C, Behnke M, Gastmeier P, Piening B. Reduction of antibacterial use in patients with very low birth weight on German NICUs after implementation of a mandatory surveillance system. A longitudinal study with national data from 2013 to 2019. J Infect 2022; 85:8-16. [DOI: 10.1016/j.jinf.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 11/02/2021] [Accepted: 05/10/2022] [Indexed: 11/17/2022]
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Magers J, Prusakov P, Speaks S, Conroy S, Sánchez PJ. Safety and Efficacy of Nafcillin for Empiric Therapy of Late-Onset Sepsis in the NICU. Pediatrics 2022; 149:186703. [PMID: 35380005 DOI: 10.1542/peds.2021-052360] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE In 2014 at Nationwide Children's Hospital, the Neonatal Antimicrobial Stewardship Program recommended nafcillin over vancomycin for empirical therapy of possible late-onset sepsis (LOS) in infants without a history of methicillin-resistant Staphylococcus aureus colonization or infection. We report our experience with this guideline and assess its safety. METHODS We retrospectively reviewed all infants who received nafcillin or vancomycin for empirical treatment of possible LOS at 3 NICUs before (January 2013-May 2014) and after (January 2017-March 2019) implementation of a vancomycin reduction guideline. Safety measures included duration of blood culture positivity, recurrence of infection with the same previously identified pathogen in the 14 days after discontinuation of antibiotic therapy, and mortality. RESULTS Among 366 infants who received a first antibiotic course for possible LOS, 84% (95 of 113) and 25% (62 of 253) received empirical therapy with vancomycin before and after the guideline implementation, respectively, representing a 70% reduction. Nafcillin use increased by 368%. Duration of blood culture positivity did not differ before and after the guidance. In 2 infants, antibiotic therapy was restarted within 14 days of discontinuation of the initial therapy for recurrence of the same infection; both had received empirical vancomycin. Overall in-hospital mortality was 10%, and there was no difference before (9%) and after (10%) implementation of the vancomycin reduction guidance (odds ratio, 0.97). CONCLUSIONS Nafcillin can be a safe alternative to vancomycin for empirical therapy of LOS among NICU infants who do not have a history of methicillin-resistant S aureus infection or colonization.
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Affiliation(s)
| | | | - Sunday Speaks
- Department of Pharmacy, Riverside Methodist Hospital, Columbus, Ohio
| | - Sara Conroy
- Biostatistics Resource at Nationwide Children's Hospital(BRANCH), Nationwide Children's Hospital, Columbus, Ohio.,Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Pablo J Sánchez
- Divisions of Neonatology and Pediatric Infectious Diseases, Departments of Pediatrics.,Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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Bianchini S, Nicoletti L, Monaco S, Rigotti E, Corbelli A, Colombari A, Auriti C, Caminiti C, Conti G, De Luca M, Donà D, Galli L, Garazzino S, Inserra A, La Grutta S, Lancella L, Lima M, Lo Vecchio A, Pelizzo G, Petrosillo N, Piacentini G, Pietrasanta C, Principi N, Puntoni M, Simonini A, Tesoro S, Venturini E, Staiano A, Caramelli F, Gargiulo GD, Esposito S. Peri-Operative Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Cardiac and Thoracic Surgery: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:554. [PMID: 35625198 PMCID: PMC9137830 DOI: 10.3390/antibiotics11050554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
Surgical site infections (SSIs) represent a potential complication of surgical procedures, with a significant impact on mortality, morbidity, and healthcare costs. Patients undergoing cardiac surgery and thoracic surgery are often considered patients at high risk of developing SSIs. This consensus document aims to provide information on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing cardiac and non-cardiac thoracic surgery. The following scenarios were considered: (1) cardiac surgery for the correction of congenital heart disease and/or valve surgery; (2) cardiac catheterization without the placement of prosthetic material; (3) cardiac catheterization with the placement of prosthetic material; (4) implantable cardiac defibrillator or epicardial pacemaker placement; (5) patients undergoing ExtraCorporal Membrane Oxygenation; (6) cardiac tumors and heart transplantation; (7) non-cardiac thoracic surgery with thoracotomy; (8) non-cardiac thoracic surgery using video-assisted thoracoscopy; (9) elective chest drain placement in the pediatric patient; (10) elective chest drain placement in the newborn; (11) thoracic drain placement in the trauma setting. This consensus provides clear and shared indications, representing the most complete and up-to-date collection of practice recommendations in pediatric cardiac and thoracic surgery, in order to guide physicians in the management of the patient, standardizing approaches and avoiding the abuse and misuse of antibiotics.
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Affiliation(s)
- Sonia Bianchini
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Laura Nicoletti
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Sara Monaco
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
| | - Erika Rigotti
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Agnese Corbelli
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Annamaria Colombari
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Cinzia Auriti
- Neonatology and Neonatal Intensive Care Unit, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Caterina Caminiti
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy; (C.C.); (M.P.)
| | - Giorgio Conti
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00165 Rome, Italy;
| | - Maia De Luca
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (M.D.L.); (L.L.)
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, 35100 Padua, Italy;
| | - Luisa Galli
- Pediatric Infectious Diseases Unit, Meyer’s Children Hospital, 50139 Florence, Italy; (L.G.); (E.V.)
| | - Silvia Garazzino
- Pediatric Infectious Diseases Unit, Regina Margherita Children’s Hospital, University of Turin, 10122 Turin, Italy;
| | - Alessandro Inserra
- General Surgery Department, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Stefania La Grutta
- Institute of Translational Pharmacology IFT, National Research Council, 90146 Palermo, Italy;
| | - Laura Lancella
- Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy; (M.D.L.); (L.L.)
| | - Mario Lima
- Pediatric Surgery, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Lo Vecchio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples “Federico II”, 80138 Naples, Italy;
| | - Gloria Pelizzo
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (G.P.); (A.S.)
| | - Nicola Petrosillo
- Infectious Disease and Infection Control Unit, Campus Bio-Medico, Medicine University Hospital, 00128 Rome, Italy;
| | - Giorgio Piacentini
- Pediatric Clinic, Azienda Ospedaliera Universitaria Integrata, 37134 Verona, Italy; (E.R.); (A.C.); (A.C.); (G.P.)
| | - Carlo Pietrasanta
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Mother, Child and Infant, 20122 Milan, Italy;
| | | | - Matteo Puntoni
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43126 Parma, Italy; (C.C.); (M.P.)
| | - Alessandro Simonini
- Pediatric Anesthesia and Intensive Care Unit, Salesi Children’s Hospital, 60123 Ancona, Italy;
| | - Simonetta Tesoro
- Division of Anesthesia, Analgesia, and Intensive Care, Department of Surgical and Biomedical Sciences, University of Perugia, 06129 Perugia, Italy;
| | - Elisabetta Venturini
- Pediatric Infectious Diseases Unit, Meyer’s Children Hospital, 50139 Florence, Italy; (L.G.); (E.V.)
| | - Annamaria Staiano
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy; (G.P.); (A.S.)
| | - Fabio Caramelli
- General and Pediatric Anesthesia and Intensive Care Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Gaetano Domenico Gargiulo
- Department of Cardio-Thoracic and Vascular Medicine, Adult Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Susanna Esposito
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.B.); (L.N.); (S.M.)
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Hou S, Wang X, Wang F, Li Z, Wang H, Li J, Wang J, He H, Deng L, Feng Y, Fan X, Li W, Lu Q, Ma Y, Zhao G, Reddy S, Wu Y, Yu Y. Excessively Prolonged Early Antibiotic Duration in Very-Low-Birth-Weight Infants: A Multicenter Prospective Cohort Study in a Developing Country. Infect Drug Resist 2022; 15:1921-1931. [PMID: 35469306 PMCID: PMC9034863 DOI: 10.2147/idr.s349478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/16/2022] [Indexed: 01/17/2023] Open
Abstract
Purpose Significant antibiotic overuse due to prolonged antibiotic duration has not draw enough attention in developing countries with high antibiotic consumption. We aimed to describe the current status of prolonged early antibiotic duration in very-low-birth-weight (VLBW) infants in a large regional multicenter cohort in China. Patients and Methods Institution-based prospective cohort study was conducted in all VLBW infants admitted to 16 Grade A tertiary hospitals between January 1, 2019 and December 31, 2020. Early antibiotic use was defined as antibiotic initiation within the first 3 days of life. Prolonged early antibiotic course was defined as early antibiotic initiation for more than 7 days in infants with early-onset sepsis (EOS) or more than 3 days in infants with unlikely EOS. Antibiotic use was described as days of therapy (DOT) per 1000 patient days (PD). Results Among 1684 eligible VLBW infants, 1544 (91.7%) infants were prescribed with prolonged early antibiotic course, including 618 infants with EOS and 926 infants with unlikely EOS. The median duration of early antibiotic course was 13 (IQR 8;20) days, with 78.0% of courses >7 days and 43.6% of courses >14 days. Total early antibiotic use was 408.3DOT/1000Pd, of which prolonged antibiotic courses accounted for 98.2% of all antibiotic use days. More than three antibiotics used, escalation antibiotic therapy, antibiotics for special use and the use of third generation cephalosporins and carbapenems were significantly common in prolonged courses compared to short courses in both infants with EOS and unlikely EOS group (P<0.05). Conclusion A large proportion of VLBW infants had excessively prolonged early antibiotic durations in the regional multicenter in China. Timely discontinuation of antibiotics in VLBW infants according to standardized guidelines and limit on the use of third-generation cephalosporins and carbapenems may be key drivers in reducing the antibiotic overuse in developing countries like ours.
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Affiliation(s)
- Shanshan Hou
- Department of Neonatology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, People's Republic of China
- Department of Pediatric, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, People's Republic of China
| | - Xiaokang Wang
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, People's Republic of China
| | - Fang Wang
- Department of Neonatology, Liaocheng People's Hospital, Liaocheng, 252000, People's Republic of China
| | - Zhongliang Li
- Department of Neonatology, W.F. Maternal and Child Health Hospital, Weifang, 261011, People's Republic of China
| | - Hui Wang
- Department of Neonatology, Hebei PetroChina Central Hospital, Langfang, 065000, People's Republic of China
| | - Jiahui Li
- Department of Neonatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, People's Republic of China
| | - Jing Wang
- Department of Neonatology, Women and Children's Healthcare Hospital of Linyi, Linyi, 276000, People's Republic of China
| | - Haiying He
- Department of Neonatology, Baogang Third Hospital of Hongci Group, Baotou, 014010, People's Republic of China
| | - Liping Deng
- Department of Neonatology, Heze Municipal Hospital, Heze, 274031, People's Republic of China
| | - Yushu Feng
- Department of Neonatology, Linyi People's Hospital, Linyi, 276000, People's Republic of China
| | - Xiufang Fan
- Department of Neonatology, Jinan Maternity and Child Health Care Hospital, Jinan, 250001, People's Republic of China
| | - Wen Li
- Department of Neonatology, Qilu Hospital of Shandong University, Jinan, 250012, People's Republic of China
| | - Qinghua Lu
- Department of Neonatology, Shandong Maternal and Child Health Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250014, People's Republic of China
| | - Yanying Ma
- Department of Neonatology, Jinan Second Maternal and Child Health Care Hospital, Jinan, 271100, People's Republic of China
| | - Guoying Zhao
- Department of Neonatology, Binzhou Medical University Hospital, Binzhou, 256603, People's Republic of China
| | - Simmy Reddy
- Cheeloo College of Medicine, Shandong University, Jinan, 250021, People's Republic of China
| | - Yanqiu Wu
- Department of Pediatric, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, People's Republic of China
| | - Yonghui Yu
- Department of Neonatology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, People's Republic of China
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, People's Republic of China
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Morales-Betancourt C, De la Cruz-Bértolo J, Muñoz-Amat B, Bergón-Sendín E, Pallás-Alonso C. Reducing Early Antibiotic Use: A Quality Improvement Initiative in a Level III Neonatal Intensive Care Unit. Front Pediatr 2022; 10:913175. [PMID: 35712636 PMCID: PMC9192948 DOI: 10.3389/fped.2022.913175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Antibiotic burden is a critical issue in neonatal intensive care units (NICU) and antibiotic use is considered a quality indicator of neonatal care. Our aim was to optimize antibiotic use through a quality improvement (QI) initiative that included revision of departmental protocols and implementation of a surveillance system based on process indicators. METHODS This is descriptive study of a cohort of all very low birth weight (VLBW) infants admitted to the NICU from 2014 to 2019. A series of QI interventions were made during the study period and included departmental protocols and the implementation of a surveillance system based on process indicators. The primary outcome was the percentage of VLBW infants who had received early antibiotics (ampicillin, gentamicin, or cefotaxime on the day of birth or day 1 or 2 after birth), antibiotics for longer than 3 days (despite negative blood culture), or no antibiotics. RESULTS During the study period, a significant relative reduction was seen in the proportion of VLBW infants administered early antibiotics (46%; p < 0.01) and in infants provided antibiotics for longer than 3 days (90%; p < 0.01). Additionally, the percentage of VLBW with "no antibiotics" during their NICU stay increased fivefold (6 to 30%; p < 0.001). CONCLUSIONS In our NICU, the implementation of a QI initiative that is based on affordable methods to track process indicators and evaluate the results led into a significant reduction in antibiotic exposure in VLBW infants. This approach is easy to implement in other NICUs as well.
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Affiliation(s)
| | | | - Bárbara Muñoz-Amat
- Department of Neonatology, 12 de Octubre University Hospital, Madrid, Spain
| | - Elena Bergón-Sendín
- Department of Neonatology, 12 de Octubre University Hospital, Madrid, Spain.,Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Pallás-Alonso
- Department of Neonatology, 12 de Octubre University Hospital, Madrid, Spain.,Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), Instituto de Salud Carlos III, Madrid, Spain
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Mundal HS, Rønnestad A, Klingenberg C, Stensvold HJ, Størdal K. Antibiotic Use in Term and Near-Term Newborns. Pediatrics 2021; 148:183440. [PMID: 34814187 DOI: 10.1542/peds.2021-051339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES We aimed to study whether national and local antibiotic stewardship projects have reduced the antibiotic use in newborns and to monitor potential changes in adverse outcomes. METHODS In a nationwide, population-based study from Norway, we included all hospital live births from 34 weeks' gestation (n = 282 046) during 2015 to 2019. The primary outcome was the proportion of newborns treated with antibiotics from 0 to 28 days after birth. The secondary outcomes were the overall duration of antibiotic treatment and by categories: culture-positive sepsis, clinical sepsis, and no sepsis. RESULTS A total of 7365 (2.6%) newborns received intravenous antibiotics during the period, with a reduction from 3.1% in 2015 to 2.2% in 2019 (30% decrease; P < .001). Hospitals with antibiotic stewardship projects experienced the largest reduction (48% vs 23%; P < .001). We found a small decrease in the median duration of antibiotic treatment in newborns without sepsis from 2.93 to 2.66 days (P = .011), and geographical variation was reduced during the study period. The overall number of days with antibiotic treatments was reduced by 37% from 2015 to 2019 (119.1 of 1000 vs 75.6 of 1000; P < .001). Sepsis was confirmed by blood culture in 206 newborns (incidence rate: 0.73 cases per 1000 live births). We found no increase in sepsis with treatment onset >72 hours of life, and sepsis-attributable deaths remained at a low level. CONCLUSIONS During the study period, a substantial decrease in the proportion of newborns treated with antibiotics was observed together with a decline in treatment duration for newborns without culture-positive sepsis.
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Affiliation(s)
| | - Arild Rønnestad
- NICU, Clinic of Pediatric and Adolescent Medicine.,Neonatal Clinical and Epidemiological Research Group, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine
| | - Claus Klingenberg
- Paediatric Research Group, Faculty of Health Sciences, University of Tromsø-The Arctic University of Norway, Tromsø, Norway.,Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
| | - Hans Jørgen Stensvold
- NICU, Clinic of Pediatric and Adolescent Medicine.,Neonatal Clinical and Epidemiological Research Group, Oslo University Hospital, Oslo, Norway
| | - Ketil Størdal
- NICU, Clinic of Pediatric and Adolescent Medicine.,Pediatric Research Institute, Faculty of Medicine, University of Oslo, Oslo, Norway
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Donnelly KA, Zocchi MS, Katy TA, Fox ER, Pines JM, van den Anker JN, Mazer-Amirshahi ME. Prescription Drug Shortages: Pediatric Emergency and Critical Care Medications. Pediatr Emerg Care 2021; 37:e726-e731. [PMID: 30829846 DOI: 10.1097/pec.0000000000001773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Drug shortages have been increasing over the past 2 decades. There are limited data on drug shortages and their effect on pediatric emergency and critical care. Our objective was to describe pediatric emergency and critical care drug shortages. METHODS Drug shortage data from January 2001 to December 2015 were obtained from the University of Utah Drug Information Services. Shortages were reviewed, identifying agents used in pediatric emergency and critical care. Shortage data were analyzed for the type of drug, formulation, shortage reason, duration, marketing status (generic vs brand name), or if it was a pediatric-friendly formulation, used for a high-acuity condition, or a single-source product. The availability of a substitute was also described. RESULTS Of 1883 products on shortage, 779 were used in pediatric emergency or critical care. The annual number of shortages decreased from 2001 to 2004, but then increased, reaching a high in 2011. The median duration for resolved shortages was 7.6 months (interquartile range, 3.0-17.6 months). The most common category affected was infectious disease drugs. High-acuity agents were involved in 27% of shortages and in 11% of pediatric-friendly formulations. An alternative agent was available for 95% of drugs, yet 43% of alternatives were also affected at some time during the study period. The most common reported reason for a shortage was manufacturing problems. CONCLUSIONS From 2001 to 2015, drug shortages affected a substantial number of agents used in pediatric emergency and critical care. This has had implications to the medications available for use and may impact patient outcomes. Providers must be aware of current shortages and implement mitigation strategies to optimize patient care.
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Affiliation(s)
| | | | - Tamara A Katy
- MedStar Georgetown University Hospital, Washington, DC
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21
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Villanueva P, Freyne B, Hickey L, Carr J, Bryant PA. Impact of an antimicrobial stewardship intervention in neonatal intensive care: Recommendations and implementation. J Paediatr Child Health 2021; 57:1208-1214. [PMID: 33729615 DOI: 10.1111/jpc.15427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/10/2021] [Accepted: 02/17/2021] [Indexed: 12/18/2022]
Abstract
AIM To (i) determine the appropriateness of antimicrobial prescribing in the neonatal intensive care unit (NICU) and (ii) assess the impact of a collaborative antimicrobial stewardship (AMS) intervention on prescribing practices. METHODS The intervention was a weekly AMS audit-feedback joint ward round (6-month period) of Neonatology and Infectious Diseases clinicians in a tertiary neonatal intensive care unit in Melbourne, Australia. Antibiotic prescriptions were audited and recommendations delivered in real time. The proportion of recommendations implemented was used to assess acceptability of the intervention. RESULTS During the study period, there were 23 AMS rounds, during which 249 patients were reviewed at 627 separate episodes. Of these, 233 (37%) episodes were for patients receiving antimicrobials. Of these, 147 (63%) received empirical antimicrobial treatment, 43 (18%) targeted antimicrobial treatment and 43 (18%) antimicrobial prophylaxis. There were 58 (25%) of 233 episodes of inappropriate antibiotic use, and 62 recommendations for improvement. Most common recommendations were to narrow (33/62, 53%) or stop (12/62, 19%) antimicrobials. The majority (45, 73%) of recommendations were accepted, resulting in significant improvement in the proportion of the 233 episodes that had completely appropriate antibiotic prescribing: 175 (75%) to 217 (93%) (relative risk 1.2, 95% confidence intervals 1.1-1.3, P < 0.001). CONCLUSIONS A collaborative audit-feedback AMS intervention was effective in identifying inappropriate antimicrobial prescriptions and impacted positively on treatment plans. Ancillary benefits were improved communication between departments and the revision of antimicrobial prescribing guidelines.
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Affiliation(s)
- Paola Villanueva
- Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Bridget Freyne
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Leah Hickey
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Neonatal Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Jeremy Carr
- Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
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22
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Antimicrobial use for treatment of healthcare-associated infections and bacterial resistance in a reference neonatal unit. J Pediatr (Rio J) 2021; 97:329-334. [PMID: 32592659 PMCID: PMC9432030 DOI: 10.1016/j.jped.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The use of broad-spectrum antimicrobials, such as third and fourth-generation, are responsible for emergence of multidrug-resistant microorganisms in neonatal units. Furthermore, antimicrobial daily doses are not standardized in neonatology. This study aimed to investigate the association between the use of antimicrobial broad spectrum to bacterial sensitivity profile in a referral unit of neonatal progressive care. METHODS This is a cohort study conducted in a referral neonatal progressive care unit from January 2008 to December 2016. The data of all hospitalized neonates was collected daily. The infection criteria used were the standardized national criteria, based on definitions of Center for Diseases Control and Prevention. In this study, the use of antimicrobials was evaluated as antimicrobial-day (ATM-day) and the ratio of multidrug-resistant microorganisms per 1000 ATM-day of broad spectrum was also calculated. The study was approved by the Institutional Review Board of the Universidade Federal de Minas Gerais (ETIC 312/08 e CAAE 58973616.2.0000.5149). RESULTS From 2008 to 2016, 2751 neonates were hospitalized, corresponding to 60,656 patient-days. The ratio of multidrug-resistant microorganisms per 1000 ATM-day of broad spectrum was 1,3 in the first period and 4,3 in the second period (p=0,005). CONCLUSION It was observed that use of broad-spectrum antimicrobials, especially those with coverage for Gram-negative bacteria, was associated with an increase of multidrug-resistant bacteria.
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23
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Martin-Mons S, Lorrain S, Iacobelli S, Gouyon B, Gouyon JB. Antibiotics Prescription Over Three Years in a French Benchmarking Network of 23 Level 3 Neonatal Wards. Front Pharmacol 2021; 11:585018. [PMID: 33568992 PMCID: PMC7868323 DOI: 10.3389/fphar.2020.585018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/13/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Prescribing antibiotics to newborns is challenging, as excess antibiotics are a risk factor for increased morbidity and mortality. The objective of this study was to describe the evolution of antibiotic exposure over three years in a large network of level 3 neonatal wards where each center is informed yearly of its own results and the results of other centers and has full autonomy to improve its performance. Patients and Methods: This is a prospective, observational study of antibiotics prescriptions over the 2017-2019 period in a network of 23 French level 3 neonatal wards. The network relied on an internal benchmarking program based on a computerized prescription ordering system. Among others, antibiotics exposure, treatment duration, and antibiotics spectrum index were analyzed. Results: The population consisted of 39,971 neonates (51.5% preterm), 44.3% of which were treated with antibiotics. Of the treated patients, 78.5% started their first antibiotic treatment in the first three days of life. Antibiotic exposure rate significantly declined from 2017 to 2019 (from 46.8% to 42.8%, p < 0.0001); this decline was significant in groups with gestational age >26 weeks, but not in the group with extremely low gestational age <27 weeks. Gentamicin, cefotaxime, amoxicillin (ampicillin), vancomycin, and amikacin were the antibiotics most prescribed. The lower the gestational age, the higher the exposure for cefotaxime, vancomycin, and amikacin. Compared to 2017, cefotaxime exposure in 2019 declined by 12.6%, but the change was only significant in the gestational age group of 32-36 weeks (17.4%) and at term (20.3%). The triple combination of antibiotics in the first three days decreased by 28.8% from 2017 to 2019, and this was significant in each gestational age group. During the study, the delayed ending of antibiotics in unconfirmed early-onset neonatal infection increased from 9.6% to 11.9%. Conclusion: This study showed that a strategy characterized by the collection of information via a computerized order-entry system, analysis of the results by a steering committee representative of all neonatal wards, and complete autonomy of neonatal wards in the choice of prescription modalities, is associated with a significant reduction in the use of antibiotics in newborns with gestational age greater than 26 weeks.
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Affiliation(s)
- Séverine Martin-Mons
- Centre D’Etudes Périnatales de L’Océan Indien (Université de La Réunion), CHU de La Réunion Site Sud, Saint-Pierre, France
- Société LogipremF, Saint-Pierre, France
| | - Simon Lorrain
- Centre D’Etudes Périnatales de L’Océan Indien (Université de La Réunion), CHU de La Réunion Site Sud, Saint-Pierre, France
| | - Silvia Iacobelli
- Centre D’Etudes Périnatales de L’Océan Indien (Université de La Réunion), CHU de La Réunion Site Sud, Saint-Pierre, France
| | - Béatrice Gouyon
- Centre D’Etudes Périnatales de L’Océan Indien (Université de La Réunion), CHU de La Réunion Site Sud, Saint-Pierre, France
- Société LogipremF, Saint-Pierre, France
| | - Jean-Bernard Gouyon
- Centre D’Etudes Périnatales de L’Océan Indien (Université de La Réunion), CHU de La Réunion Site Sud, Saint-Pierre, France
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24
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Ting JY, Roberts A, Tilley P, Robinson JL, Dunn MS, Paquette V, Lee KS, Shah V, Yoon E, Richter LL, Lodha A, Shivananda S, Thampi N, Autmizguine J, Shah PS. Development of a national neonatal intensive care unit-specific antimicrobial stewardship programme in Canada: protocol for a cohort study. BMJ Open 2020; 10:e043403. [PMID: 33303471 PMCID: PMC7733165 DOI: 10.1136/bmjopen-2020-043403] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/23/2020] [Accepted: 11/27/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Early empiric treatment with broad-spectrum antimicrobials is common in neonatal intensive care units (NICU) due to the non-specific clinical presentation of infection. However, excessive and inappropriate antimicrobial use can lead to the emergence of drug-resistant organisms and adverse neonatal outcomes. This study aims to develop and implement a nationwide NICU-specific antimicrobial stewardship programme (ASP) to promote judicious antimicrobial use and control the emergence of multidrug-resistant organisms (MDROs) in Canada. METHODS AND ANALYSIS Our study population will include all very low-birth-weight neonates admitted to participating tertiary NICU in Canada. Based on the existing limited literature, we will develop consensus on NICU antimicrobial stewardship interventions to enhance best practices. Using an expanded Canadian Neonatal Network (CNN) platform, we will collect data on antimicrobial use and the susceptibility of organisms identified in clinical samples from blood and cerebrospinal fluid over a period of 2 years. These data will be used to provide all NICU stakeholders with benchmarked centre-adjusted antimicrobial use and MDRO prevalence reports. An ASP plan will be developed at both individual unit and national levels in the subsequent years. Knowledge translation strategies will be implemented through the well-established Evidence-based Practice for Improving Quality methodology. ETHICS AND DISSEMINATION Ethics for the study has been granted by the University of British Columbia Children's & Women's Research Ethics Board (H19-02490) and supported by CNN Executive Committee. The study results will be disseminated through national organisations and open access peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT04388293.
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Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Tilley
- Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joan L Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Michael S Dunn
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Vanessa Paquette
- School of Pharmaceutical Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kyong-Soon Lee
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Vibhuti Shah
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Eugene Yoon
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Abhay Lodha
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Sandesh Shivananda
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nisha Thampi
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Autmizguine
- Department of Pediatrics, University of Montreal, Montreal, Québec, Canada
| | - Prakesh S Shah
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
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25
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Aleem S, Wohlfarth M, Cotten CM, Greenberg RG. Infection control and other stewardship strategies in late onset sepsis, necrotizing enterocolitis, and localized infection in the neonatal intensive care unit. Semin Perinatol 2020; 44:151326. [PMID: 33158599 PMCID: PMC7550069 DOI: 10.1016/j.semperi.2020.151326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Suspected or proven late onset sepsis, necrotizing enterocolitis, urinary tract infections, and ventilator associated pneumonia occurring after the first postnatal days contribute significantly to the total antibiotic exposures in neonatal intensive care units. The variability in definitions and diagnostic criteria in these conditions lead to unnecessary antibiotic use. The length of treatment and choice of antimicrobial agents for presumed and proven episodes also vary among centers due to a lack of supportive evidence and guidelines. Implementation of robust antibiotic stewardship programs can encourage compliance with appropriate dosages and narrow-spectrum regimens.
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Affiliation(s)
- Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC, USA
| | | | | | - Rachel G. Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA,Corresponding author at: Department of Pediatrics, Duke University, Durham, NC, USA
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26
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Abstract
Preterm infants are susceptible to infections that can rapidly progress to disastrous outcomes. Antibiotics are lifesaving, but their prolonged and inappropriate use are associated with adverse outcomes. In this review, we discuss the current status of antimicrobial use in the preterm neonatal population, and the challenges in determining the initiation, duration, and choice of antibiotics. Finally, we review the clinical studies on the potential consequences of prolonged antimicrobial exposure in prematurely born infants.
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27
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Kazzaz YM, AlTurki H, Aleisa L, Alahmadi B, Alfattoh N, Alattas N. Evaluating antimicrobial appropriateness in a tertiary care pediatric ICU in Saudi Arabia: a retrospective cohort study. Antimicrob Resist Infect Control 2020; 9:173. [PMID: 33143749 PMCID: PMC7640689 DOI: 10.1186/s13756-020-00842-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 10/27/2020] [Indexed: 02/07/2023] Open
Abstract
Background Inappropriate antibiotic utilization is associated with the emergence of antimicrobial resistance (AMR) and a decline in antibiotic susceptibility in many pathogenic organisms isolated in intensive care units. Antibiotic stewardship programs (ASPs) have been recommended as a strategy to reduce and delay the impact of AMR. A crucial step in ASPs is understanding antibiotic utilization practices and quantifying the problem of inappropriate antibiotic use to support a targeted solution. We aim to characterize antibiotic utilization and determine the appropriateness of antibiotic prescription in a tertiary care pediatric intensive care unit. Methods A retrospective cohort study was conducted at King Abdullah Specialized Children’s Hospital, Riyadh, Saudi Arabia, over a 6-month period. Days of therapy (DOT) and DOT per 1000 patient-days were used as measures of antibiotic consumption. The appropriateness of antibiotic use was assessed by two independent pediatric infectious disease physicians based on the Centers for Disease Control and Prevention 12-step Campaign to prevent antimicrobial resistance among hospitalized children. Results During the study period, 497 patients were admitted to the PICU, accounting for 3009 patient-days. A total of 274 antibiotic courses were administered over 2553 antibiotic days. Forty-eight percent of antibiotic courses were found to be nonadherent to at least 1 CDC step. The top reasons were inappropriate antibiotic choice (empirical or definitive) and inappropriate prophylaxis durations. Cefazolin and vancomycin contributed to the highest percentage of inappropriate DOTs. Conclusions Antibiotic consumption was high with significant inappropriate utilization. These data could inform decision-making in antimicrobial stewardship programs and strategies. The CDC steps provide a more objective tool and limit biases when assessing antibiotic appropriateness
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Affiliation(s)
- Yasser M Kazzaz
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia. .,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia. .,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Haneen AlTurki
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Lama Aleisa
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Bashaer Alahmadi
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Nora Alfattoh
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Nadia Alattas
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
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28
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Hamdy RF, Bhattarai S, Basu SK, Hahn A, Stone B, Sadler ED, Hammer BM, Galiote J, Slomkowski J, Casto AM, Korzuch KP, Chase H, Nzegwu N, Greenberg I, Ortiz N, Blake C, Chang J, Bost JE, Payne AS, Shah RK, Soghier L. Reducing Vancomycin Use in a Level IV NICU. Pediatrics 2020; 146:peds.2019-2963. [PMID: 32611807 DOI: 10.1542/peds.2019-2963] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Vancomycin remains one of the most commonly prescribed antibiotics in NICUs despite recommendations to limit its use for known resistant infections. Baseline data revealing substantially higher vancomycin use in our NICU compared to peer institutions informed our quality improvement initiative. Our aim was to reduce the vancomycin prescribing rate in neonates hospitalized in our NICU by 50% within 1 year and sustain for 1 year. METHODS In the 60-bed level IV NICU of an academic referral center, we used a quality improvement framework to develop key drivers and interventions including (1) physician education with benchmarking antibiotic prescribing rates; (2) pharmacy-initiated 48-hour antibiotic time-outs on rounds; (3) development of clinical pathways to standardize empirical antibiotic choices for early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis; coupled with (4) daily prospective audit with feedback from the antimicrobial stewardship program. RESULTS We used statistical process u-charts to show vancomycin use declined from 112 to 38 days of therapy per 1000 patient-days. After education, pharmacy-initiated 48-hour time-outs, and development of clinical pathways, vancomycin use declined by 29%, and by an additional 52% after implementation of prospective audit with feedback. Vancomycin-associated acute kidney injury also declined from 1.4 to 0.1 events per 1000 patient-days. CONCLUSIONS Through a sequential implementation approach of education, standardization of care with clinical pathways, pharmacist-initiated 48-hour time-outs, and prospective audit with feedback, vancomycin days of therapy declined by 66% over a 1-year period and has been sustained for 1 year.
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Affiliation(s)
- Rana F Hamdy
- Infectious Diseases, .,Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and
| | | | - Sudeepta K Basu
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and.,Neonatology
| | - Andrea Hahn
- Infectious Diseases.,Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and
| | - Brian Stone
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and.,Neonatology
| | | | | | - John Galiote
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and.,Neonatology
| | - Julie Slomkowski
- Pharmacy Residency Preceptor Program, Boston Medical Center, Boston, Massachusetts
| | - Anne M Casto
- Neonatology.,Department of Nursing, Children's National Hospital, Washington, District of Columbia
| | | | - Hannah Chase
- Children's National Research Institute and.,Divisions of Biostatistics and Study Methodology
| | - Nneka Nzegwu
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and.,Neonatology
| | | | - Noelle Ortiz
- Children's National Research Institute and.,Divisions of Biostatistics and Study Methodology
| | - Carmen Blake
- Department of Nursing, Children's National Hospital, Washington, District of Columbia
| | | | - James E Bost
- Children's National Research Institute and.,Divisions of Biostatistics and Study Methodology
| | | | | | - Lamia Soghier
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and.,Neonatology
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29
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Rhea S, Jones K, Endres-Dighe S, Munoz B, Weber DJ, Hilscher R, MacFarquhar J, Sickbert-Bennett E, DiBiase L, Marx A, Rineer J, Lewis J, Bobashev G. Modeling inpatient and outpatient antibiotic stewardship interventions to reduce the burden of Clostridioides difficile infection in a regional healthcare network. PLoS One 2020; 15:e0234031. [PMID: 32525887 PMCID: PMC7289388 DOI: 10.1371/journal.pone.0234031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 05/19/2020] [Indexed: 12/14/2022] Open
Abstract
Antibiotic exposure can lead to unintended outcomes, including drug-drug interactions, adverse drug events, and healthcare-associated infections like Clostridioides difficile infection (CDI). Improving antibiotic use is critical to reduce an individual's CDI risk. Antibiotic stewardship initiatives can reduce inappropriate antibiotic prescribing (e.g., unnecessary antibiotic prescribing, inappropriate antibiotic selection), impacting both hospital (healthcare)-onset (HO)-CDI and community-associated (CA)-CDI. Previous computational and mathematical modeling studies have demonstrated a reduction in CDI incidence associated with antibiotic stewardship initiatives in hospital settings. Although the impact of antibiotic stewardship initiatives in long-term care facilities (LTCFs), including nursing homes, and in outpatient settings have been documented, the effects of specific interventions on CDI incidence are not well understood. We examined the relative effectiveness of antibiotic stewardship interventions on CDI incidence using a geospatially explicit agent-based model of a regional healthcare network in North Carolina. We simulated reductions in unnecessary antibiotic prescribing and inappropriate antibiotic selection with intervention scenarios at individual and network healthcare facilities, including short-term acute care hospitals (STACHs), nursing homes, and outpatient locations. Modeled antibiotic prescription rates were calculated using patient-level data on antibiotic length of therapy for the 10 modeled network STACHs. By simulating a 30% reduction in antibiotics prescribed across all inpatient and outpatient locations, we found the greatest reductions on network CDI incidence among tested scenarios, namely a 17% decrease in HO-CDI incidence and 7% decrease in CA-CDI. Among intervention scenarios of reducing inappropriate antibiotic selection, we found a greater impact on network CDI incidence when modeling this reduction in nursing homes alone compared to the same intervention in STACHs alone. These results support the potential importance of LTCF and outpatient antibiotic stewardship efforts on network CDI burden and add to the evidence that a coordinated approach to antibiotic stewardship across multiple facilities, including inpatient and outpatient settings, within a regional healthcare network could be an effective strategy to reduce network CDI burden.
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Affiliation(s)
- Sarah Rhea
- RTI International, Research Triangle Park, North Carolina
- * E-mail:
| | - Kasey Jones
- RTI International, Research Triangle Park, North Carolina
| | | | - Breda Munoz
- RTI International, Research Triangle Park, North Carolina
| | | | | | - Jennifer MacFarquhar
- North Carolina Department of Health and Human Services, Raleigh, North Carolina
- Career Epidemiology Field Officer Program, Division of State and Local Readiness, Center for Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Ashley Marx
- UNC Health Care, Chapel Hill, North Carolina
- UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - James Rineer
- RTI International, Research Triangle Park, North Carolina
| | - James Lewis
- North Carolina Department of Health and Human Services, Raleigh, North Carolina
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30
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Chautrakarn S, Anugulruengkitt S, Puthanakit T, Rattananupong T, Hiransuthikul N. Antimicrobial prescription patterns in a tertiary-care pediatric unit in Thailand. Pediatr Int 2020; 62:683-687. [PMID: 31957141 DOI: 10.1111/ped.14153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/08/2020] [Accepted: 01/15/2020] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Sineenart Chautrakarn
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Faculty of Public Health, Chiang Mai University, Chiang Mai, Thailand
| | - Suvaporn Anugulruengkitt
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Thanyawee Puthanakit
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Thanapoom Rattananupong
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Narin Hiransuthikul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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31
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Ahmad NJ, Althemery AU, Haseeb A, Yusuf RF, Hassali AA, Khan AH. Inclining Trend of the Researchers Interest in Antimicrobial Stewardship: A Systematic Review. J Pharm Bioallied Sci 2020; 12:11-15. [PMID: 32801595 PMCID: PMC7397995 DOI: 10.4103/jpbs.jpbs_186_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/06/2019] [Accepted: 11/09/2019] [Indexed: 11/09/2022] Open
Abstract
Introduction: The implementation of antibiotic stewardship programs (ASPs) can improve the treatment of infections and can decrease the adverse events that result from antibiotics use. In the last decades, there is an increasing interest of the researchers in the implementation of ASPs. Materials and Methods: The articles published in different journals were retrieved by searching many research databases such as Cochrane library, Europe PMC, PubMed, and Web of Science; we searched these databases for all published articles till November 2018. Results and Discussion: The searching results using Cochrane library showed an increase in the number of randomized clinical trials that related to the keyword of “antimicrobial stewardship” specially in the last 5 years. Using Europe PMC, we found 6178 results. From these results, there are 3874 free full texts. In addition, there are 2132 original articles in PubMed and by searching Web of Science database till November 8 there are 3085 results. These results show that the number of trusted published articles was increased continuously; this shows the increasing interest of the researchers in ASPs. These researches will help health-care providers to use antibiotics appropriately and to overcome the barriers of implementing ASPs. Conclusion: The results of this study show that the researchers had high levels of interest in participating in research activities related to the appropriate use on antibiotics and the implementation of antimicrobial stewardship programs.
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Affiliation(s)
- Nehad J Ahmad
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town, Penang, Malaysia.,Clinical Pharmacy Department, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Abdullah U Althemery
- Clinical Pharmacy Department, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Abdul Haseeb
- Clinical Pharmacy Department, College of Pharmacy, Umm AlQura University, Mecca, Saudi Arabia
| | - Reham F Yusuf
- College of Pharmacy, University of Jordan, Amman, Jordan
| | - Azmi Ahmed Hassali
- Discipline of Social Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town, Penang, Malaysia
| | - Amer H Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town, Penang, Malaysia
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32
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Viel-Thériault I, Martin B, Thompson-Desormeaux F, Blackburn J, Moussa A, Autmizguine J. Vancomycin drug monitoring in infants with CoNS sepsis-target attainment, microbiological response and nephrotoxicity. J Perinatol 2020; 40:97-104. [PMID: 31576000 DOI: 10.1038/s41372-019-0519-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To characterize residual vancomycin concentrations (Cmin) and assess the relationships between Cmin, the risk of nephrotoxicity and persistent CoNS sepsis. METHODS In this 5-year retrospective study among infants treated with vancomycin, the primary outcome was the proportion of those with a steady state Cmin between 10 and 20 mg/L. The secondary outcomes were nephrotoxicity and persistent CoNS sepsis. RESULTS Of 120 infants included, the median first steady state Cmin was 12.4 mg/L and 77 (64%) had a Cmin between 10 and 20 mg/L. Six percent developed nephrotoxicity. This risk was not associated with Cmin. Of the 30 infants with CoNS sepsis, 17 (57%) had persistent bacteremia, and this risk did not correlate significantly with Cmin, CoNS minimal inhibitory concentration (MIC) for vancomycin, or Cmin/MIC. CONCLUSIONS The majority of infants achieved targeted levels of vancomycin, but persistent bacteremia was common. We did not identify a Cmin threshold associated with nephrotoxicity, nor with microbiological clearance.
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Affiliation(s)
| | - Brigitte Martin
- Department of Pharmacy, CHU Sainte-Justine, Montreal, QC, Canada
| | | | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montréal, Montreal, QC, Canada
| | - Ahmed Moussa
- Department of Pediatrics, Université de Montréal, Montreal, QC, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Julie Autmizguine
- Department of Pediatrics, Université de Montréal, Montreal, QC, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada.,Clinical Pharmacology Unit, Université de Montréal, Montreal, QC, Canada
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Wagstaff JS, Durrant RJ, Newman MG, Eason R, Ward RM, Sherwin CMT, Enioutina EY. Antibiotic Treatment of Suspected and Confirmed Neonatal Sepsis Within 28 Days of Birth: A Retrospective Analysis. Front Pharmacol 2019; 10:1191. [PMID: 31680968 PMCID: PMC6803465 DOI: 10.3389/fphar.2019.01191] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 09/17/2019] [Indexed: 01/16/2023] Open
Abstract
Neonatal sepsis causes significant mortality and morbidity worldwide. Diagnosis is usually confirmed via blood culture results. Blood culture sepsis confirmation can take days and suffer from contamination and false negatives. Empiric therapy with antibiotics is common. This study aims to retrospectively describe and compare treatments of blood culture-confirmed and unconfirmed, but suspected, sepsis within the University of Utah Hospital system. Electronic health records were obtained from 1,248 neonates from January 1, 2006, to December 31, 2017. Sepsis was categorized into early-onset (≤3 days of birth, EOS) and late-onset (>3 and ≤28 days of birth, LOS) and categorized as culture-confirmed sepsis if a pathogen was cultured from the blood and unconfirmed if all blood cultures were negative with no potentially contaminated blood cultures. Of 1,010 neonates in the EOS cohort, 23 (2.3%) were culture-confirmed, most with Escherichia coli (42%). Treatment for unconfirmed EOS lasted an average of 6.1 days with primarily gentamicin and ampicillin while confirmed patients were treated for an average of 12.3 days with increased administration of cefotaxime. Of 311 neonates in the LOS cohort, 62 (20%) were culture-confirmed, most culturing coagulase negative staphylococci (46%). Treatment courses for unconfirmed LOS lasted an average of 7.8 days while confirmed patients were treated for an average of 11.4 days, these patients were primarily treated with vancomycin and gentamicin. The use of cefotaxime for unconfirmed EOS and LOS increased throughout the study period. Cefotaxime administration was associated with an increase in neonatal mortality, even when potential confounding factors were added to the logistic regression model (adjusted odds ratio 2.8, 95%CI [1.21, 6.88], p = 0.02). These results may not be generalized to all hospitals and the use of cefotaxime may be a surrogate for other factors. Given the low rate of blood culture positive diagnosis and the high exposure rate of empiric antibiotics, this patient population might benefit from improved diagnostics with reevaluation of antibiotic use guidelines.
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Affiliation(s)
- Jadon S Wagstaff
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Robert J Durrant
- Division of Medical Laboratory Science, Department of Pathology, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Michael G Newman
- University of Utah Health Science Center, Salt Lake City, UT, United States
| | - Rachael Eason
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States.,Division of Medical Laboratory Science, Department of Pathology, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Robert M Ward
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, OH, United States
| | - Elena Y Enioutina
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States.,Division of Medical Laboratory Science, Department of Pathology, School of Medicine, University of Utah, Salt Lake City, UT, United States.,Pharmaceutics & Pharmaceutical Chemistry, College of Pharmacy, University of Utah, Salt Lake City, UT, United States
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Chautrakarn S, Anugulruengkitt S, Puthanakit T, Rattananupong T, Hiransuthikul N. Impact of a Prospective Audit and Feedback Antimicrobial Stewardship Program in Pediatric Units in Tertiary Care Teaching Hospital in Thailand. Hosp Pediatr 2019; 9:851-858. [PMID: 31611418 DOI: 10.1542/hpeds.2019-0027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) have been proven to be beneficial in reducing the use of antimicrobial agents, antibiotic resistance, and health care costs. The data supporting the utility of ASPs has come largely from adult hospital units, but few pediatric hospital units have implemented ASPs. Our objective for this study was to assess the impact of ASPs in pediatric units in tertiary care teaching hospitals. METHODS We conducted a retrospective chart review to compare antimicrobial use pre- and post-ASP over a 6-month period in a tertiary care hospital in which an ASP had been in use since July 2017. Meropenem, vancomycin, and colistin were selected to be monitored. ASP rounds were conducted twice a week to assess and provide feedback on antimicrobial prescriptions. Antimicrobial use was measured as days of therapy (DOTs) per 1000 patient-days and was compared pre- and post-ASP by using independent t tests. RESULTS Charts of children hospitalized who were in antimicrobial treatment pre-ASP (44.3%) and post-ASP (41.7%) were reviewed. The percentages of children who received selected antimicrobial agents did not differ between pre- and post-ASP. During the post-ASP period, a significant reduction in DOT with vancomycin and colistin was observed. Vancomycin use decreased from 58.5 to 40.2 DOTs per 1000 patient-days (P = .038), and colistin decreased from 36.3 to 13.8 DOTs per 1000 patient-days (P = .026). Meropenem use decreased from 126.8 to 111.2 DOTs per 1000 patient-days (P = .467). Between the 2 periods, there was no effect on length of stay and mortality. CONCLUSIONS ASPs can lead to a significant reduction in selected antimicrobial use in children who are hospitalized, with no effect on length of stay or mortality rate.
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Affiliation(s)
| | - Suvaporn Anugulruengkitt
- Division of Pediatric Infectious Diseases, Departments of Pediatrics and.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Thanyawee Puthanakit
- Division of Pediatric Infectious Diseases, Departments of Pediatrics and.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
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Rittmann B, Stevens MP. Clinical Decision Support Systems and Their Role in Antibiotic Stewardship: a Systematic Review. Curr Infect Dis Rep 2019; 21:29. [PMID: 31342180 DOI: 10.1007/s11908-019-0683-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW The purpose of this article is to perform a systematic review over the past 5 years on the role and effectiveness of clinical decision support systems (CDSSs) on antibiotic stewardship. RECENT FINDINGS CDDS interventions found a significant impact on multiple outcomes relevant to antibiotic stewardship. There are various types of CDSS implementations, both active and passive (provider initiated). Passive interventions were associated with more significant outcomes; however, both interventions appeared effective. In the reviewed literature, CDSSs were consistently associated with decreasing antibiotic consumption and narrowing the spectrum of antibiotic usage. Generally, guideline adherence was improved with CDSS, although this was not universal. The effect on other outcomes, such as mortality, Clostridiodes difficile infections, length of stay, and cost, inconsistently showed a significant difference. Overall, CDDS implementation has effectively decreased antibiotic consumption and improved guideline adherence across the various types of CDSS. Other positive outcomes were noted in certain settings, but were not universal. When creating a new intervention, it is important to identify the optimal structure and deployment of a CDSS for a specific setting.
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Affiliation(s)
- Barry Rittmann
- Virginia Commonwealth University Health Systems, Richmond, USA. .,, 825 Fairfax Avenue, 4th Floor, Norfolk, VA, 23507, USA.
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Adams M, Bassler D. Practice variations and rates of late onset sepsis and necrotizing enterocolitis in very preterm born infants, a review. Transl Pediatr 2019; 8:212-226. [PMID: 31413955 PMCID: PMC6675686 DOI: 10.21037/tp.2019.07.02] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/08/2019] [Indexed: 01/01/2023] Open
Abstract
The burden of late onset sepsis (LOS) and necrotizing enterocolitis (NEC) remains high for newborns in low- and high-income countries. Very preterm born infants born below 32 weeks gestation are at highest risk because their immune system is not yet adapted to ex-utero life, providing intensive care frequently compromises their skin or mucosa and they require a long duration of hospital stay. An epidemiological overview is difficult to provide because there is no mutually accepted definition available for either LOS or NEC. LOS incidence proportions are generally reported based on identified blood culture pathogens. However, discordance in minimum day of onset and whether coagulase negative staphylococci or fungi should be included into the reported proportions lead to variation in reported incidences. Complicating the comparison are the absence of biomarkers, ancillary lab tests or prediction models with sufficiently high positive and/or negative predictive values. The only high negative predictive values result from negative blood culture results with negative lab results allowing to discontinue antibiotic treatment. Similar difficulties exist in reporting and diagnosing NEC. Although most publications base their proportions on a modified version of Bell's stage 2 or 3, comparisons are made difficult by the multifactorial nature of the disease reflecting several pathways to intestinal necrosis, the absence of a reliable biomarker and the unclear differentiation from spontaneous intestinal perforations. Comparable reports in very low birthweight infants range between 5% and 30% for LOS and 1.6% to 7.1% for NEC. Evidence based guidelines to support treatment are missing. Treatment for LOS remains largely empirical and focused mainly on antibiotics. In the absence of a clear diagnosis, even unspecific early warning signals need to be met with antibiotic treatment. Cessation after negative blood culture is difficult unless the child was asymptomatic from the beginning. As a result, antibiotics are the most commonly prescribed medications, but unnecessary exposure may result in increased risk for mortality, NEC, further infections and childhood obesity or asthma. Finding ways to limit antibiotic use are thus important and have shown a large potential for improvement of care and limitation of cost. Over recent decades, none of the attempts to establish novel therapies have succeeded. LOS and NEC proportions remained mostly stable. During the past 10 years however, publications emerged reporting a reduction, sometimes by almost 50%. Most concern units participating in a surveillance system using quality improvement strategies to prevent LOS or NEC (e.g., hand hygiene, evidence based "bundles", feeding onset, providing own mother's milk). We conclude that these approaches display a potential for wider spread reduction of LOS and NEC and for a subsequently more successful development of novel therapies as these often address the same pathways as the prevention strategies.
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Affiliation(s)
- Mark Adams
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Kumbhare SV, Patangia DVV, Patil RH, Shouche YS, Patil NP. Factors influencing the gut microbiome in children: from infancy to childhood. J Biosci 2019; 44:49. [PMID: 31180062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The human microbiota plays a crucial role in educating the immune system and influencing host health right since birth. Various maternal factors along with the vertical microbial transfer from the mother, as well as the horizontal environmental transmission and internal factors relating to the infant, play a crucial role in modulating the gut microbiota. The early life microflora is highly unstable and undergoes dynamic changes during the first few years, converging towards a more stabilized adult microbiota by co-evolving with the host by the age of 3-4 years. Microbiota studies have underlined the role of dysbiosis in developing several metabolic disorders like obesity, diabetes and immune-related disorders like asthma, to name a few. Thus, understanding early life microbial composition and various factors affecting the microbial community will provide a platform for developing strategies/techniques to maintain host health by restoring gut microbial flora. This review focuses on the factors that affect the microbial composition of the foetus in utero, during birth, infancy through childhood.
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Affiliation(s)
- Shreyas V Kumbhare
- National Centre for Cell Science, Savitribai Phule University of Pune Campus, Pune, Maharashtra 411007, India
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Charron AC, Carl MA, Warner BB, Newland JG, McPherson CC. Determinants of Initial Antibiotic Duration in Very Low Birth Weight Neonates. Infect Dis Ther 2019; 8:209-217. [PMID: 30825133 PMCID: PMC6522625 DOI: 10.1007/s40121-019-0241-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Very low birth weight (VLBW) neonates (< 1500 g) are commonly exposed to prolonged antibiotic courses related to concerns for presumed early onset sepsis often with unclear indications. While antibiotics can be life-saving medications, prolonged antibiotic exposure (> 5 days) increases an infant's risk for necrotizing enterocolitis, late onset sepsis, colonization or infection with resistant organisms, and death. The aim of this study is to describe clinical and laboratory factors that influence the length of initial antibiotic courses in VLBW neonates. METHODS Demographics, perinatal factors, and neonatal clinical and laboratory data were compared in a single-center retrospective cohort of VLBW neonates who received ≤ 3 days versus > 5 days of initial antibiotics. RESULTS A total of 121 patients were analyzed of which 117 (97%) were started on antibiotics empirically on admission, and 71 (59%) received ≤ 3 days and 50 (41%) received > 5 days of antibiotics. One (0.8%) infant had a positive blood culture (S. oralis). Demographics [gestational age (p < 0.001) and birth weight (p < 0.001)] and neonatal clinical status [Apgar score at 5 min (p = 0.001), CRIB II (p < 0.001), need for inotropes (p = 0.001), and maximum ventilator support (p < 0.001)] were significantly different between the short and prolonged course of antibiotics groups on bivariate analysis. There were no significant differences in perinatal factors or common laboratory markers of sepsis. Maximum ventilator support remained significant on multivariate analysis (p = 0.007). CONCLUSION In the VLBW population, the clinical status of the neonate, as represented by maximum ventilator support in this study, was the most important factor in determining the duration of initial antibiotic treatment. Laboratory values and perinatal risk factors did not significantly influence prescribing patterns.
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Affiliation(s)
- Alexandra C Charron
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Mike A Carl
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Barbara B Warner
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jason G Newland
- Department of Pediatrics, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Christopher C McPherson
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Wati DK, Gustawan IW, Fatmawati NND, Tunas IK, Setiawan PA. Antibiotic Surveillance in the Pediatric Intensive Care Unit (PICU) at Sanglah Hospital Denpasar in the Year of 2015-2017. Open Microbiol J 2019. [DOI: 10.2174/1874285801913010146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Antibiotic surveillance in hospital settings is mandatory for optimal antibiotic therapy for the patient. Only a small number of studies have focused on antibiotic surveillance in hospitalized newborns, infants, and children.
Objectives:
The goal was to evaluate antibiotic use in our Pediatric Intensive Care Unit (PICU) and evaluate it for a possible association with the length of PICU stay.
Methods:
A retrospective, observational, cohort study was conducted from January 2015 to April 2017, involving subjects who were hospitalized in the PICU at Sanglah Hospital. The inclusion criteria were children aged between 1-month-12-years old, who had a blood culture and antibiotic sensitivity test result in their medical record. The exclusion criteria were incomplete medical records, blood cultures showing 2 types of bacteria at the same time (gram-positive and negative), or contaminated blood results. Factors associated with mortality were analyzed using a Chi-square test, with p < 0.05 considered to be statistically significant and the Risk Ratio (RR) of the associated factors was determined by 95% CI.
Results:
Multivariate analysis showed that the significant predictors of PICU length of stay were the appropriate continuation of antibiotics (RR 1.19; 95% CI 1.043 to 1.373; P = 0.047). There were also significant results for antibiotic compatibility and length of stay (RR 3.6; 95% CI 0.869 to 15.428; P = 0.049).
Conclusion:
Appropriate continuation of antibiotics and the compatibility of continuation antibiotics were significant predictors of length of PICU stay based on multivariate analysis.
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Gkentzi D, Kortsalioudaki C, Cailes BC, Zaoutis T, Kopsidas J, Tsolia M, Spyridis N, Siahanidou S, Sarafidis K, Heath PT, Dimitriou G. Epidemiology of infections and antimicrobial use in Greek Neonatal Units. Arch Dis Child Fetal Neonatal Ed 2019; 104:F293-F297. [PMID: 29954881 DOI: 10.1136/archdischild-2018-315024] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/07/2018] [Accepted: 06/09/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To describe the epidemiology of neonatal infections and of antimicrobial use in Greek Neonatal Units (NNUs) in order to develop national, evidence-based guidelines on empiric antimicrobial use for neonatal sepsis in Greece. DESIGN Retrospective analysis of prospectively collected infection surveillance data from 2012 to 2015, together with a Point Prevalence Survey (PPS) on antimicrobial use and the collection of data on local empiric antimicrobial policies. SETTING 16 NNUs in Greece participating in the neonIN infection surveillance network PATIENTS: Newborns in participating NNUs who had a positive blood, cerebrospinal fluid or urine culture and were treated with at least 5 days of antibiotics. RESULTS 459 episodes were recorded in 418 infants. The overall incidence of infection was 50/1000 NNU-admissions. The majority of episodes were late-onset sepsis (LOS) (413, 90%). Coagulase-negative Staphylococci (80%) were the most common Gram-positive organisms causing LOS and Klebsiella spp (39%) the most common Gram-negative. Nearly half (45%) of the Klebsiella spp were resistant to at least one aminoglycoside. The PPS revealed that 196 of 484 (40%) neonates were on antimicrobials. The survey revealed wide variation in empiric antimicrobial policies for LOS. CONCLUSIONS This is the largest collection of data on the epidemiology of neonatal infections in Greece and on neonatal antimicrobial use. It provides the background for the development of national evidence-based guidelines. Continuous surveillance, the introduction of antimicrobial stewardship interventions and evidence-based guidelines are urgently required.
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Affiliation(s)
- Despoina Gkentzi
- Department of Paediatrics, Patras Medical School, University Hospital of Patras, Patras, Greece
| | | | | | - Theoklis Zaoutis
- The Stavros Niarchos Foundation-Collaborative Centre for Clinical Epidemiology and Outcomes Research, School of Medicine, University of Athens, Athens, Greece
| | - John Kopsidas
- The Stavros Niarchos Foundation-Collaborative Centre for Clinical Epidemiology and Outcomes Research, School of Medicine, University of Athens, Athens, Greece
| | - Maria Tsolia
- Paediatric Infectious Diseases Unit, Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Nikos Spyridis
- Paediatric Infectious Diseases Unit, Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Soultana Siahanidou
- Neonatal Unit, First Department of Pediatrics, Athens University Medical School, Athens, Greece
| | - Kosmas Sarafidis
- 1st Department of Neonatology and Neonatal Intensive Care Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Paul T Heath
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Gabriel Dimitriou
- Department of Paediatrics, Patras Medical School, University Hospital of Patras, Patras, Greece
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Thampi N, Shah PS, Nelson S, Agarwal A, Steinberg M, Diambomba Y, Morris AM. Prospective audit and feedback on antibiotic use in neonatal intensive care: a retrospective cohort study. BMC Pediatr 2019; 19:105. [PMID: 30975119 PMCID: PMC6458619 DOI: 10.1186/s12887-019-1481-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/31/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Antimicrobial stewardship programs potentially lead to appropriate antibiotic use, yet the optimal approach for neonates is uncertain. Such a program was implemented in a tertiary care neonatal intensive care unit in October 2012. We evaluated the impact of this program on antimicrobial use and its association with clinical outcomes. METHODS In a retrospective cohort study, we examined 1580 neonates who received antimicrobials in the 13-months before and 13-months during program implementation. Prospective audit and feedback was given 5 days a week on each patient who was receiving antibiotic. Pharmacy and microbiology data were linked to clinical data from the local Canadian Neonatal Network database. The primary outcome was days of antibiotic therapy per 1000 patient-days; secondary outcomes included mortality, necrotizing enterocolitis, and antibiotic duration for culture-positive and culture-negative late-onset sepsis. The breadth of antibiotic exposure was compared using the Antibiotic Spectrum Index. RESULTS Overall antibiotic use decreased to 339 days of therapy per 1000 patient-days from 395 (14%, P < 0.001), without an increase in mortality. There was no difference in duration of therapy in culture-negative or culture-positive sepsis, rates of necrotizing enterocolitis, or breadth of antibiotic exposure. Fewer antibiotic starts occurred during program implementation (63% versus 59%, P < 0.001). The use of narrow-spectrum agents decreased (P < 0.001) whereas the use of cefotaxime increased (P = 0.016) during program implementation. CONCLUSIONS Daily prospective audit and feedback was not associated with a change in antibiotic duration or clinical outcomes, however there were fewer babies started on antibiotics, suggesting that additional interventions are required to inform and sustain changes in antibiotic prescribing practices.
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Affiliation(s)
- Nisha Thampi
- Department of Pediatrics, CHEO, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Prakesh S. Shah
- Department of Pediatrics, Sinai Health System, 600 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Sandra Nelson
- Antimicrobial Stewardship Program, Sinai Health System-University Health Network, 600 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Amisha Agarwal
- Research Institute, CHEO, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Marilyn Steinberg
- Antimicrobial Stewardship Program, Sinai Health System-University Health Network, 600 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Yenge Diambomba
- Department of Pediatrics, Sinai Health System, 600 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Andrew M. Morris
- Antimicrobial Stewardship Program, Sinai Health System-University Health Network, 600 University Avenue, Toronto, ON M5G 1X5 Canada
- Department of Medicine, Sinai Health System, University Health Network, 600 University Avenue, Toronto, ON M5G 1X5 Canada
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Litz JE, Goedicke-Fritz S, Härtel C, Zemlin M, Simon A. Management of early- and late-onset sepsis: results from a survey in 80 German NICUs. Infection 2019; 47:557-564. [DOI: 10.1007/s15010-018-1263-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022]
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Al-Sayyed B, Le J, Al-Tabbaa MM, Barnacle B, Ren J, Tapping R, Aiyer M. Uncomplicated Urinary Tract Infection in Ambulatory Primary Care Pediatrics: Are We Using Antibiotics Appropriately? J Pediatr Pharmacol Ther 2019; 24:39-44. [PMID: 30837813 DOI: 10.5863/1551-6776-24.1.39] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Antimicrobial stewardship programs target antimicrobial use within the inpatient care setting. However, most antimicrobials are prescribed at ambulatory sites. We aim to determine the appropriateness of the diagnosis and treatment of uncomplicated urinary tract infection (UTI) in children within the outpatient setting at our institution, and to evaluate the cost of antibiotic treatment in our patient cohort. METHODS This retrospective study was conducted by reviewing electronic records of patients aged 2 to 18 years diagnosed with uncomplicated UTI and treated with antibiotics in the outpatient setting from January 1, 2016, to April 30, 2016. Appropriate diagnosis was defined as confirmed UTI that included: pyuria (>5 white blood cells per high-power field or positive for leukocyte esterase), a positive urine culture (≥50,000 colony units/mL of a single uropathogen for a catheterized sample or ≥100,000 colony units/mL for a clean catch urine sample), and lower urinary tract symptoms. Treatment was considered appropriate if the patient was prescribed first-line antibiotic for the susceptible isolate (trimethoprim sulfamethoxazole, amoxicillinclavulanate, nitrofurantoin, and cephalexin), and if the appropriate dose was used. RESULTS We included 178 patients receiving a diagnosis of uncomplicated UTI and treated with antibiotics. Of these, 70% received an inappropriate diagnosis (n = 125). 58% (n= 72) of improperly diagnosed patients had polymicrobial growth in their urine cultures. Antibiotics prescribed mostly in this group were trimethoprim-sulfamethoxazole (53%, n = 66) and cephalexin (22%, n = 27). Only 30% of all included patients received an appropriate diagnosis (n = 53). Of all appropriate diagnosis patients (n = 53), 26% were treated inappropriately (n = 14) with either wide-spectrum antibiotics (n = 8) or with low calculated dose (n = 6). The estimated cost of antibiotic treatment for the inappropriate diagnosis group (n = 125) was $10,755.87. CONCLUSION Antimicrobial stewardship programs should target the pediatric outpatient setting and antibiograms should be developed. Education of providers about the appropriate diagnosis and treatment of uncomplicated UTI in children is essential for reducing the cost of inappropriate therapy.
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Reduction of Inappropriate Antimicrobial Prescriptions in a Tertiary Neonatal Intensive Care Unit After Antimicrobial Stewardship Care Bundle Implementation. Pediatr Infect Dis J 2019; 38:54-59. [PMID: 30531528 DOI: 10.1097/inf.0000000000002039] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Our objective was to evaluate the appropriateness of antibiotic prescriptions in the neonatal intensive care unit using standardized criteria and determine the effects of an antimicrobial stewardship program (ASP) on patterns of antibiotic usage. METHODS A retrospective audit of antibiotic use from July 2010 to June 2013 was conducted, focusing on prescriptions of vancomycin, cefotaxime, meropenem and linezolid for >3 calendar-days. We evaluated the appropriateness of each course of antibiotic treatment based on the Centers for Disease Control and Prevention 12-Step Guidelines to Prevent Antimicrobial Resistance (steps 4, 6 and 9). An ASP was introduced in August 2014, and the same audit criteria were applied to review antimicrobial use in the subsequent 12 months. RESULTS In the pre-ASP era, 26.3%, 12.1%, 11.4% and 0% of meropenem, cefotaxime, vancomycin and linezolid courses, respectively, were inappropriate. The most common instance of inappropriate utilization included failure to use narrow-spectrum antimicrobials when appropriate. After the introduction of ASP program, 22.2%, 7.5%, 5.4% and 0% of meropenem, cefotaxime, vancomycin and linezolid courses, respectively, were inappropriate. The numbers of inappropriate antibiotic-days/1000 days of therapy with meropenem, cefotaxime and vancomycin changed from 1.89 to 1.96 [rate ratio (RR), 1.04 (0.70-1.52)], 3.56 to 1.73 [RR, 0.49 (0.33-0.71)] and 2.70 to 1.01 [RR, 0.37 (0.22-0.60)], respectively. In subgroup analysis, very low birth weight infants (birth weight, <1500 g) showed no improvement in the rates of inappropriate antibiotic prescriptions. CONCLUSIONS In this study, we found that ASP initiatives can be applied in neonatal populations to reduce inappropriate antimicrobial prescriptions, though a different approach may be needed among very low birth weight infants.
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Ho T, Buus-Frank ME, Edwards EM, Morrow KA, Ferrelli K, Srinivasan A, Pollock DA, Dukhovny D, Zupancic JAF, Pursley DM, Soll RF, Horbar JD. Adherence of Newborn-Specific Antibiotic Stewardship Programs to CDC Recommendations. Pediatrics 2018; 142:e20174322. [PMID: 30459258 PMCID: PMC6589084 DOI: 10.1542/peds.2017-4322] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2018] [Indexed: 11/24/2022] Open
Abstract
: media-1vid110.1542/5839992664001PEDS-VA_2017-4322Video Abstract BACKGROUND: The Centers for Disease Control and Prevention (CDC) published the Core Elements of Hospital Antibiotic Stewardship Programs (ASPs), while the Choosing Wisely for Newborn Medicine Top 5 list identified antibiotic therapy as an area of overuse. We identify the baseline prevalence and makeup of newborn-specific ASPs and assess the variability of NICU antibiotic use rates (AURs). METHODS Data were collected using a cross-sectional audit of Vermont Oxford Network members in February 2016. Unit measures were derived from the 7 domains of the CDC's Core Elements of Hospital ASPs, including leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. Patient-level measures included patient demographics, indications, and reasons for therapy. An AUR, defined as the number of infants who are on antibiotic therapy divided by the census that day, was calculated for each unit. RESULTS Overall, 143 centers completed structured self-assessments. No center addressed all 7 core elements. Of the 7, only accountability (55%) and drug expertise (62%) had compliance >50%. Centers audited 4127 infants for current antibiotic exposure. There were 725 infants who received antibiotics, for a hospital median AUR of 17% (interquartile range 10%-26%). Of the 412 patients on >48 hours of antibiotics, only 26% (107 out of 412) had positive culture results. CONCLUSIONS Significant gaps exist between CDC recommendations to improve antibiotic use and antibiotic practices during the newborn period. There is wide variation in point prevalence AURs. Three-quarters of infants who received antibiotics for >48 hours did not have infections proven by using cultures.
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Affiliation(s)
- Timmy Ho
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts;
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Madge E Buus-Frank
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, The Robert Larner, M.D., College of Medicine, and
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Mathematics and Statistics, University of Vermont, Burlington, Vermont
| | | | | | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; and
| | - Daniel A Pollock
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; and
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Roger F Soll
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, The Robert Larner, M.D., College of Medicine, and
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, The Robert Larner, M.D., College of Medicine, and
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McPherson C, Liviskie C, Zeller B, Nelson MP, Newland JG. Antimicrobial Stewardship in Neonates: Challenges and Opportunities. Neonatal Netw 2018; 37:116-123. [PMID: 29615159 DOI: 10.1891/0730-0832.37.2.116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neonatal infections result in significant morbidity and mortality. Antibiotics are vital for the treatment of infections but disrupt the neonatal microbiome, put the infant at risk for an adverse drug reaction, and may lead to the development of antibiotic resistance. Immediately after birth, clinicians must determine which infants require empiric antibiotics. Online risk stratification tools may provide a superior approach to decision trees. In infants who require empiric therapy for early-onset sepsis, ampicillin and an aminoglycoside with dosing based on recent pharmacokinetic studies represents the most appropriate first-line agents; third-generation cephalosporins should be reserved for patients with a high likelihood of Gram-negative meningitis. An antistaphylococcal penicillin and gentamicin should be utilized for suspected late-onset sepsis. Vancomycin and other broad-spectrum agents are reserved for patients with a history of resistant organisms. Antibiotic duration should be guided by understanding the clinical indications and obtaining the necessary cultures appropriately (i.e., adequate volume blood cultures). In the absence of a positive culture, antibiotic duration should often be limited. Individual institutions should leverage a multidisciplinary, interprofessional team to identify opportunities for antimicrobial stewardship. A collaborative, transparent system is required to change unit culture and generate a sustained impact on antibiotic utilization with optimal patient outcomes.
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D’Agata EM, Tran D, Bautista J, Shemin D, Grima D. Clinical and Economic Benefits of Antimicrobial Stewardship Programs in Hemodialysis Facilities: A Decision Analytic Model. Clin J Am Soc Nephrol 2018; 13:1389-1397. [PMID: 30139804 PMCID: PMC6140563 DOI: 10.2215/cjn.12521117] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 06/20/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Infections caused by multidrug-resistant organisms and Clostridium difficile are associated with substantial morbidity and mortality as well as excess costs. Antimicrobial exposure is the leading cause for these infections. Approximately 30% of antimicrobial doses administered in outpatient hemodialysis facilities are considered unnecessary. Implementing an antimicrobial stewardship program in outpatient hemodialysis facilities aimed at improving prescribing practices would have important clinical and economic benefits. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We developed a decision analytic model of antimicrobial use on the clinical and economic consequences of implementing a nationwide antimicrobial stewardship program in outpatient dialysis facilities. The main outcomes were total antimicrobial use, infections caused by multidrug-resistant organisms and C. difficile, infection-related mortality, and total costs. The analysis considered all patients on outpatient hemodialysis in the United States. The value of implementing antimicrobial stewardship programs, assuming a 20% decrease in unnecessary antimicrobial doses, was calculated as the incremental differences in clinical end points and cost outcomes. Event probabilities, antimicrobial regimens, and health care costs were informed by publicly available sources. RESULTS On a national level, implementation of antimicrobial stewardship programs was predicted to result in 2182 fewer infections caused by multidrug-resistant organisms and C. difficile (4.8% reduction), 629 fewer infection-related deaths (4.6% reduction), and a cost savings of $106,893,517 (5.0% reduction) per year. The model was most sensitive to clinical parameters as opposed to antimicrobial costs. CONCLUSIONS The model suggests that implementation of antimicrobial stewardship programs in outpatient dialysis facilities would result in substantial reductions in infections caused by multidrug-resistant organisms and C. difficile, infection-related deaths, and costs.
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Affiliation(s)
| | - Diana Tran
- Cornerstone Research Group, Burlington, Ontario, Canada; and
| | - Josef Bautista
- Hypertension and Nephrology Inc., Providence, Rhode Island
| | - Douglas Shemin
- Nephrology, Rhode Island Hospital, Brown University, Providence, Rhode Island
| | - Daniel Grima
- Cornerstone Research Group, Burlington, Ontario, Canada; and
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Silva ACB, Anchieta LM, Lopes MFDP, Romanelli RMDC. Inadequate use of antibiotics and increase in neonatal sepsis caused by resistant bacteria related to health care assistance: a systematic review. Braz J Infect Dis 2018; 22:328-337. [PMID: 30125532 PMCID: PMC9428021 DOI: 10.1016/j.bjid.2018.07.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Technologies and life support management have enhanced the survival of preterm infants. The immune system of newborns is immature, which contributes to the occurrence of healthcare-associated infections. The overlap of several conditions with neonatal sepsis and the difficulty of diagnosis and laboratory confirmation during this period result in a tendency to over-treat neonatal sepsis. The use of antimicrobial agents is a risk factor for multidrug-resistant bacterial infections. This work aimed to perform a systematic review of the relationship between inadequate use of antimicrobial agents and increase in neonatal sepsis related to healthcare assistance, due to bacterial resistance. METHODS Our population, exposition, comparison, outcome and study type was as follows: P: hospitalized neonates with sepsis diagnosis, E: inappropriate use of antimicrobial agents, C: adequate use of antimicrobial agents or no indication of infection, O: resistant bacterial infection, and S: original studies. We performed searches in the PubMed, Scopus, Virtual Health Library (Scielo, LILACS, and MEDLINE), and Embase without limits on time, language, and the references of the articles found. Fourteen studies were included and assessed using the Grading of Recommendations, Assessment, Development, and Evaluation, Newcastle, and the Strengthening the Reporting of Observacional Studies in Epidemiology methodologies. RESULTS All studies found were observational and started with a low-quality evidence level in the Grading of Recommendations, Assessment, Development, and Evaluation. CONCLUSIONS Despite their low-quality evidence, the studies demonstrated the association between inadequate use of antimicrobial agents and increase of neonatal resistant bacterial healthcare-associated infections in neonatal units. However, there is significant difficulty in conducting high-quality studies in this population due to ethical issues tied to randomized trials. Therefore, new studies should be encouraged to recommend adequate treatment of newborns without increasing the risk of healthcare-associated infections by multidrug-resistant bacteria.
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Affiliation(s)
| | - Leni Marcia Anchieta
- Universidade Federal de Minas Gerais, Departamento de Pediatria, Belo Horizonte, MG, Brazil
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Rezaei-Hachesu P, Samad-Soltani T, Yaghoubi S, GhaziSaeedi M, Mirnia K, Masoumi-Asl H, Safdari R. The design and evaluation of an antimicrobial resistance surveillance system for neonatal intensive care units in Iran. Int J Med Inform 2018; 115:24-34. [PMID: 29779717 DOI: 10.1016/j.ijmedinf.2018.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 01/11/2018] [Accepted: 04/13/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Neonatal intensive care units (NICUs) have complex patients in terms of their diagnoses and required treatments. Antimicrobial treatment is a common therapy for patients in NICUs. To solve problems pertaining to empirical therapy, antimicrobial stewardship programs have recently been introduced. Despite the success of these programs in terms of data collection, there is still inefficiency in terms of analyzing and reporting the data. Thus, to successfully implement these stewardship programs, the design of antimicrobial resistance (AMR) surveillance systems is recommended as a first step. As a result, this study aimed to design an AMR surveillance system for use in the NICUs in northwestern Iranian hospitals to cover these information gaps. METHODS The recommended system is compatible with the World Health Organization (WHO) guidelines. The business intelligence (BI) requirements were extracted in an interview with a product owner (PO) using a valid and reliable checklist. Following this, an AMR surveillance system was designed and evaluated in relation to user experiences via a user experience questionnaire (UEQ). Finally, an association analysis was performed on the database, and the results were reported by identifying the important multidrug resistances in the database. RESULTS A customized software development methodology was proposed. The three major modules of the AMR surveillance are the data registry, dashboard, and decision support modules. The data registry module was implemented based on a three-tier architecture, and the Clinical Decision Support System (CDSS) and dashboard modules were designed based on the BI requirements of the Scrum product owner (PO). The mean values of UEQ measures were in a good range. This measures showed the suitable usability of the AMR surveillance system. CONCLUSION Applying efficient software development methodologies allows for the systems' compatibility with users' opinions and requirements. In addition, the construction of interdisciplinary communication models for research and software engineering allows for research and development concepts to be used in operational environments.
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Affiliation(s)
- Peyman Rezaei-Hachesu
- School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Taha Samad-Soltani
- School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.
| | | | - Marjan GhaziSaeedi
- School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Kayvan Mirnia
- Paediatrics Research Centre, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Masoumi-Asl
- Centre for Communicable Disease Control, Ministry of Health and Medical Education, Tehran, Iran
| | - Reza Safdari
- School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
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