Prospective audit and feedback on antibiotic use in neonatal intensive care: a retrospective cohort study

A Systematic Review of Antimicrobial Stewardship Interventions Implemented in Intensive Care Units

Antimicrobial stewardship (AS) is essential to ensure appropriate antimicrobial usage and subsequently reduce the emergence of microbial resistance. The intensive care unit is a crucial place for monitoring antimicrobial usage due the frequent exposure to infections. This review provides an update on the current status of antimicrobial stewardship intervention utilized in intensive care settings. A comprehensive search was performed in Cochrane, Web of Science, and PubMed using keywords grouped into Antimicrobial, Stewardship, and Intensive care unit. The search was restricted to original articles published from April 2015 to November 2024. Out of 1,234 records retrieved from the databases, 55 studies were included in this systematic review. Most of the studies were conducted in the United States (n = 9), followed by China (n = 8), India (n = 5), and Italy (n = 4). We identified seven key antimicrobial stewardship (AS) strategies: multi-interventions ASP (22 studies, 40%), prospective feedback and audit (11 studies, 20%), procalcitonin (PCT) protocols for guiding antimicrobial use (12 studies, 21.8%), protocols for antimicrobial de-escalation (4 studies, 7.3%), antimicrobial restrictions or preapprovals (4 studies, 7.3%), diagnostic stewardship (1 study, 1.8%), and guidelines for antimicrobial prescription (1 study, 1.8%). A reduction in targeted or overall antimicrobial usage was reported in most studies (34/42). Specifically, all studies implementing multi-invention ASPs reported a successful reduction in antimicrobial utilization. Some antimicrobial stewardship interventions significantly enhanced the appropriateness of antimicrobial prescriptions. In addition, patient health outcomes were not compromised by antimicrobial reduction. Nonetheless, future studies at a larger scale over a longer time are recommended to accurately assess the impact of AS programme on patient health outcomes.

Applying quality improvement methods to reduce antibiotic use in neonates: a systematic review and meta-analysis

BACKGROUND

This study aims to explore effective interventions and observation indicators for reducing antibiotic use in neonates through quality improvement (QI) methods, while quantitatively analysing whether these methods increase the risk of neonatal mortality and serious adverse outcomes.

METHODS

By 27 August 2024, we reviewed all pertinent literature. A descriptive statistical analysis was conducted on all intervention measures, outcome indicators, process indicators, and balance indicators. The group utilizing QI interventions was designated as the intervention group, with the baseline period serving as the control group. The mortality rates and incidence of serious adverse outcomes were treated as dichotomous variables. The risk ratio (RR) and 95% CIs were effect indicators.

RESULTS

In total, 57 studies published between 2016 and 2024 were included. All studies were uncontrolled before-and-after studies. The most studied country was the United States of America. From these 57 studies, 27 effective intervention measures were identified, and all observation indicators and main results were presented in tabular form. According to the meta-analysis, the mortality rate in the intervention group decreased by 30% compared with the control group (RR = 0.7; 95% CI: 0.604-0.81; P < 0.001), while there was no statistically significant difference in the risk of serious adverse outcomes between the two groups.

CONCLUSIONS

QI methods can safely and effectively reduce the use of antibiotics in neonates, highlighting their potential for clinical applications.

Re-Thinking the Norms of Antibiotic Prescribing in the Neonatal Intensive Care Unit

Antibiotics are among the most commonly prescribed medications in neonatal care. Newborns are particularly vulnerable to severe infections and the adverse effects associated with inappropriate antibiotic use. Antibiotic stewardship programs are designed to actively monitor antimicrobial resistance, encourage the judicious use of antibiotics, and collaborate with infection control programs and pharmacy departments to curb the spread of resistant organisms. In this article, the authors will examine studies assessing the impact of excessive antibiotic use and explore the effectiveness of various stewardship strategies aimed at reducing unnecessary antibiotic consumption.

Antimicrobial Stewardship Programs in Neonates: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Neonatal sepsis is a significant contributor to mortality and morbidity; however, the uncontrolled use of antimicrobials is associated with significant adverse effects. Our objective with this article is to review the components of neonatal antimicrobial stewardship programs (ASP) and their effects on clinical outcomes, cost-effectiveness, and antimicrobial resistance.

METHODS

We selected randomized and nonrandomized trials and observational and quality improvement studies evaluating the impact of ASP with a cutoff date of May 22, 2023. The data sources for these studies included PubMed, Medline, Embase, Cochrane CENTRAL, Web of Science, and SCOPUS. Details of the ASP components and clinical outcomes were extracted into a predefined form.

RESULTS

Of the 4048 studies retrieved, 70 studies (44 cohort and 26 observational studies) of >350 000 neonates met the inclusion criteria. Moderate-certainty evidence reveals a significant reduction in antimicrobial initiation in NICU (pooled risk difference [RD] 19%; 95% confidence interval [CI] 14% to 24%; 21 studies, 27 075 infants) and combined NICU and postnatal ward settings (pooled RD 8%; 95% CI 6% to 10%; 12 studies, 358 317 infants), duration of antimicrobial agents therapy (pooled RD 20%; 95% CI 10% to 30%; 9 studies, 303 604 infants), length of therapy (pooled RD 1.82 days; 95% CI 1.09 to 2.56 days; 10 studies, 157 553 infants), and use of antimicrobial agents >5 days (pooled RD 9%; 95% CI 3% to 15%; 5 studies, 9412 infants). Low-certainty evidence reveals a reduction in economic burden and drug resistance, favorable sustainability metrices, without an increase in sepsis-related mortality or the reinitiation of antimicrobial agents. Studies had heterogeneity with significant variations in ASP interventions, population settings, and outcome definitions.

CONCLUSIONS

Moderate- to low-certainty evidence reveals that neonatal ASP interventions are associated with reduction in the initiation and duration of antimicrobial use, without an increase in adverse events.

A Neonatologist-Driven Antimicrobial Stewardship Program in a Neonatal Tertiary Care Center in Oman

OBJECTIVE

The overuse of antimicrobials in neonates is not uncommon and has resulted in a global health crisis of antibiotic resistance. This study aimed to evaluate changes associated with a neonatologist-driven antimicrobial stewardship program (ASP) in antibiotic usage.

STUDY DESIGN

We conducted a pre-post retrospective cohort study in a tertiary care hospital in Oman. Neonates admitted in 2014 to 2015 were considered as the pre-ASP cohort. In 2016, a neonatologist-driven ASP was launched in the unit. The program included the optimization and standardization of antibiotic use for early- and late-onset sepsis using the Centers for Disease Control and Prevention's "broad principles," an advanced antimicrobial decision-support system to resolve contentious issues, and placed greater emphasis on education and behavior modification. Data from the years 2016 to 2019 were compared with previous data. The outcome of interest included days of therapy (DOT) for antimicrobials. Baseline characteristics and outcomes were compared using standard statistical measures.

RESULTS

The study included 2,098 neonates in the pre-ASP period and 5,464 neonates in the post-ASP period. There was no difference in baseline characteristics. The antibiotic use decreased from 752 DOT per 1,000 patient-days (PD) in the pre-ASP period to 264 DOT in the post-ASP period (64.8% reduction, p < 0.001). The proportion of neonates who received any antibiotics declined by 46% (pre-ASP = 1,161/2,098, post-ASP = 1,676/5,464). The most statistically significant reduction in DOT per 1,000 PD was observed in the use of cefotaxime (82%), meropenem (74%), and piperacillin-tazobactam (74%). There was no change in mortality, culture-positive microbial profile, or multidrug-resistant organism incidence in the post-ASP period.

CONCLUSION

Empowering frontline neonatologists to drive ASPs was associated with a sustained reduction in antibiotic utilization.

KEY POINTS

· Overuse of antimicrobials is not uncommon in neonatal intensive care units.. · ASPs and infection control and prevention measures may help in decreasing antibiotic consumption and culture-positive sepsis.. · Empowering frontline neonatologists resulted in a sustained decrease in antimicrobial use without extra resources or financial burden..

Audit of adherence to international guidelines (IDSA) in the treatment of infectious meningitis in pediatric patients in Jordan

OBJECTIVE

This study aims to audit the adherence of Jordanian medical care staff to the guidelines provided by the Infectious Disease Society of America (IDSA) for managing pediatric patients admitted with suspected cases of meningitis.

METHODS

A retrospective observational study was conducted at Jordan University Hospital (JUH). All pediatric patients admitted to JUH with suspected meningitis between January 1, 2019, and September 30, 2022, who underwent Cerebrospinal Fluid (CSF) and blood culture tests were recruited in this study unless there was a reason for exclusion. The study collected data on the empiric antibiotics prescribed prior to diagnostic cultures and susceptibility results. Additionally, the length of hospital stay and all-cause mortality were observed. The appropriateness of antibiotics prescription before culture results was compared to IDSA guidelines, and an overall adherence rate was calculated.

RESULTS

A total of 332 pediatric patients were included in this study, of whom 12.3% (n = 41) were diagnosed with bacterial meningitis. Among the enrolled pediatric patients, only 27 patients (8.1%) received appropriate treatment adhering to the IDSA guidelines. The remaining 91.9% (n = 305) showed various forms of non-adherence to recommendations. The highest adherence rate was observed for performing CSF culture (n = 330, 99.4%), while the lowest adherence rate was found in selecting the appropriate dose and duration for empiric antibiotics (n = 107, 41.3% and n = 133, 51.0%, respectively).

CONCLUSION

This study revealed a low overall adherence in the management of pediatric patients with meningitis in Jordan. Establishing an antimicrobial stewardship program may improve the outcomes of meningitis infections found in Jordan, and prevent dangerous adverse effects and bacterial resistance.

Evaluation of antimicrobial consumption in the neonatal population undergoing to stewardship programs: A systematic review Antimicrobial consumption in neonatal population

BACKGROUND

The indiscriminate antimicrobials use in neonatal sepsis treatment contributes to abusive consumption and optimize prescription programs are encouraged as way to reduce the inappropriate use. Thus, the objective was to evaluate the impact of intervention programs for adequate antimicrobial use (Antimicrobial Stewardship Programs - ASP) in consumption measurements of such drugs in neonatology.

METHODS

The search for articles was performed in electronic databases and manual search for citations in publications initially identified. Electronic databases searched were BVS, Cochrane Library, Embase, MEDLINE/PubMed, SciELO, Scopus and Web of Science. There was no date or period limit for including of articles. The PICO question was defined as populations of neonates admitted to neonatal intensive care units (NICU) (P) undergoing an intervention program to optimize antimicrobial therapy (I) in relation to neonates not exposed to the program (C) and the outcome obtained in antimicrobials consumption (O).

RESULTS

The initial search in databases resulted in 1223 articles. Articles were screened and sixteen original studies related to subject were selected, which conducted a quantitative approach to antimicrobials consumption for population of interest. Most articles used days of therapy (DOT) as the main measure of antimicrobial consumption and have had a high-quality rating by Newcastle Ottawa scale (NOS). All studies were carried out in local hospitals at a single-centre and most ones in high-income countries.

CONCLUSION

Of all studies resulting from search, few evaluated antimicrobial consumption in Neonatology. New studies are needed, and DOT proved to be the most adequate metric to measure consumption.

Effectiveness of a neonatal intensive care unit-specific antimicrobial stewardship program: A ten-year review

OBJECTIVE

To evaluate the change in consumption of specific antibiotics in a neonatal intensive care unit after the implementation of an antimicrobial stewardship program (ASP).

DESIGN

Retrospective cohort study between January 1, 2010, and December 31,2019.

SETTING

The neonatal intensive care unit at British Columbia Women's Hospital (Vancouver Canada), a tertiary-care center.

PATIENTS

Admitted neonates prescribed antibiotics.

METHODS

We implemented an ASP with an early implementation phase starting in January 2014 (period 2) and a later phase starting in January 2017 (period 3). Patient demographics were collected, including birth weight, gestational age, history of necrotizing enterocolitis (NEC), and surgical operations from existing databases. Interrupted time-series analysis was used, and comparison of antibiotic days of therapy (DOT) averages were conducted across the preimplementation period (period 1), period 2, and period 3 regarding total patients and subgroups.

RESULTS

We identified 4,512 infants. There was a significant decrease in DOT from 472 (95% confidence interval [CI], 431-517) in period 1 to 405 (95% CI, 367-446) in period 2 to 313 (95% CI, 280-350) in period 3. We detected a significant decrease in the use of ampicillin, aminoglycosides, cloxacillin, and linezolid but not in vancomycin or cefotaxime. Subgroup analyses of infants <1,500 g and those without NEC or surgery showed decreases in the use of cloxacillin, aminoglycosides, and linezolid.

CONCLUSIONS

The implementation of an ASP was associated with a significant decrease in the overall DOT and use of certain antibiotics. This study presents important targets for ongoing ASP work.

An overview of the hospitals’ antimicrobial stewardship programs implemented to improve antibiotics’ utilization, cost and resistance patterns

Introduction: The high reliance of the physicians and surgeons on the antibiotics since their discovery has led to an irrational antibiotic utilization which not only has raised the incidence of antimicrobial resistance (AMR) but also increased the cost of treatment with antibiotics as high use of antibiotics has been found related to the occurrence of certain nosocomial infections which need extra antibiotic courses to be cured. In order to overcome these antibiotic utilization related problems an antimicrobial stewardship (AMS) program being the set of various persuasive, restrictive and structural interventions is considered an effective tool to rationalize the in-patient antimicrobial utilization worldwide. Method: The focus of this review is on the interventions that are being implemented during the in-patient AMS programs and have been described effective in controlling the antibiotic utilization, their cost of treatment and an overall infection control. The literature containing the information about various AMS interventions effecting the utilization and cost patterns along with the impact on AMR was searched in various databases such as PubMed, Google Scholar, Science Direct, Ovid (Medline) and Scopus. The categorical sorting of the published data is based on various AMS interventions such as the guideline development, formulary restriction (pre-authorization), educative interventions, clinical pathway development and prospective (post prescription) audit. Considering the objectives of the study such as the goal to curb overutilization of antibiotics, control of their cost of treatment for in-patients and infection control the sorted literature is presented in three different tables describing the AMS impact on the said outcomes. Results: The post AMS changes in utilization patterns are described as fall of antibiotics defined daily doses (DDD) and days of therapy (DOT) which resulted in the reduction of the cost of treatment with antibiotics. The reduction of the cost of treatment with antibiotics also resulted due to the AMS impact on the control of various nosocomial and multi-drug resistant (MDR) infections. Conclusion:  It has been concluded that the AMS program if implemented under the supervision of an expert AMS team mainly comprising of an infectious disease (ID) physician, clinical pharmacists and microbiologists with considerable support by the hospital authorities could be a highly efficient tool of the pharmacovigilance for rationalizing the in-patient antimicrobial practice.

Reducing Early Antibiotic Use: A Quality Improvement Initiative in a Level III Neonatal Intensive Care Unit

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.

Impact of pharmacist intervention in antibiotic stewardship programmes for critically ill neonates: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Antibiotic stewardship programmes (ASPs) are introduced to ensure effective antibiotic use. Pharmacists can be involved in ASPs to facilitate the appropriate antibiotic use. Prolonged use of antibiotics causes adverse events in critically ill neonates. Hence, this systematic review and meta-analysis was aimed at investigating pharmacists' functions in ASPs in critically ill neonates and the effect of ASP implementation on antibiotic use.

METHODS

A comprehensive search of PubMed/Medline, Embase, and Cochrane Library databases until January 2021 was conducted and studies that reported the functions of pharmacists in ASPs for critically ill neonates and the results of ASP implementation were included in this review. All processes were performed by two reviewers independently, and any discordance between the two was resolved by discussion.

RESULTS AND DISCUSSION

In all, 19 studies were included in this review. Pharmacists were found to have various functions in ASPs, such as participating in the development of antibiotic use guidelines, auditing antibiotic prescriptions, participating in multidisciplinary ward rounds, educating other ASP team members, checking blood culture or laboratory data, and monitoring antibiotic use. A meta-analysis revealed that ASP implementation in critically ill neonates was significantly associated with a 23% reduction in the overall antibiotic use rate (ratio of means: 0.77, 95% confidence interval: 0.69-0.87, p < 0.001). Moreover, the overall duration of antibiotic therapy significantly reduced by 15% with ASP implementation (ratio of means: 0.85, 95% confidence interval: 0.78-0.91, p < 0.001).

WHAT IS NEW AND CONCLUSION

The implementation of ASPs involving pharmacists, especially in critically ill neonates, was associated with the reduced use and duration of antibiotic treatment. Thus, pharmacists played a key role in ASPs in critically ill neonates.

The road to zero nosocomial infections in neonates-a narrative review

Aim

Nosocomial infections (NI) in neonates are associated with prolonged hospitalisation, adverse neurodevelopmental outcome and high mortality. Over the past decade, numerous prevention strategies have resulted in significant reductions in NI rates. In this review, we aim to provide an overview of current NI rates from large, geographically defined cohorts.

Methods

PubMed, Web of Science, EMBASE and Cochrane Library were searched for evidence regarding epidemiology and prevention of NI in neonates. Extracted studies were synthesised in a narrative form with experiential reflection.

Results

Despite the abundance of geographically defined incidence proportions, an epidemiological overview of NI is difficult to provide, given the lack of consensus definition for neonatal NI and different baseline populations being compared. Successful prevention efforts have focused on implementing evidence‐based practices while eliminating outdated strategies. The most promising model for reduction in infection rates is based on quality improvement (QI) collaboratives and benchmarking, involving identification and implementation of best practices, selection of measurable outcomes and fostering a sense of community and transparency.

Conclusion

The preventative rather than curative approach forms the new paradigm for reducing the burden of neonatal infections. Despite progress achieved, continued work towards improved prevention practices is required in the strive towards zero NIs.

Antibiotic Stewardship for the Neonatologist and Perinatologist

Antibiotic use is common in the neonatal intensive care unit. The density and heterogeneity of antibiotic prescribing suggests inappropriate and overuse of these agents. Potential antibiotic stewardship targets include sepsis, necrotizing enterocolitis, and perioperative prophylaxis. Diagnostic stewardship principles, including appropriately obtained cultures, may be leveraged to decrease unnecessary antibiotic prescribing. Strategies including guideline development, prospective audit and feedback, and formulary restriction have been successfully deployed in the neonatal intensive care unit to improve the quality of antibiotic prescribing. Implementation of antibiotic stewardship in the neonatal intensive care unit requires multidisciplinary collaboration between neonatologists, surgeons, infectious diseases specialists, pharmacists, and nurses.

Reducing Duration of Antibiotic Use for Presumed Neonatal Early-Onset Sepsis in Greek NICUs. A "Low-Hanging Fruit" Approach

Antibiotics are commonly prescribed in Neonatal Intensive Care Units (NICU), where stewardship interventions are challenging. Lowering antibiotic consumption is desperately needed in Greece, a country with high antibiotic resistance rates. We sought to assess the effectiveness of a low-cost and -resource intervention to reduce antibiotic use in Greek NICUs implementing a "low-hanging fruit" approach. A prospective quasi-experimental study was conducted in 15/17 public NICUs in Greece (9/2016-06/2019). The intervention selected was discontinuation of antibiotics within 5 days for neonates with gestational age ≥ 37 weeks, no documented signs or symptoms of sepsis, CRP ≤ 10 mg/L and negative cultures within 3 days of antibiotic initiation. Impact was evaluated by the percentage of discontinued regimens by day 5, length of therapy (LOT) and stay. Trends of antibiotic consumption were assessed with days of therapy (DOT) per 1000 patient-days. Overall, there was a 9% increase (p = 0.003) of antibiotic discontinuation in ≤5 days. In total, 7/13 (53.8%) units showed a ≥10% increase. Overall, 615 days on antibiotics per 1000 patients were saved. Interrupted time-series analysis established a declining trend in DOT/1000 patient-days relative to the pre-intervention trend (p = 0.002); a monthly decrease rate of 28.96 DOT/1000 patient-days (p = 0.001, 95%CI [-45.33, -12.60]). The intervention had no impact on antibiotic choice. Antibiotic use was successfully reduced in Greek NICUs using a "low-hanging fruit" approach. In resource-limited settings, similar targeted stewardship interventions can be applied.

Infection control and other stewardship strategies in late onset sepsis, necrotizing enterocolitis, and localized infection in the neonatal intensive care unit

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.

A Narrative Review of Antimicrobial Stewardship Interventions within In-patient Settings and Resultant Patient Outcomes

The overuse of antibiotics has led to various healthcare problems such as the emergence of resistance in infectious microbes and mortality due to antibiotic resistant healthcare associated infections (HAIs). An antimicrobial stewardship (AMS) program is the set of interventions used worldwide to enhance the rational use of antibiotics especially for the hospitalized patients. This review aimed to describe the characteristics of the implemented AMS programs in various hospitals of the world mainly focusing on the interventions and patients outcomes. The literature about AMS program was searched through various databases such as PubMed, Google Scholar, Science Direct, Cochran Library, Ovid (Medline), Web of Science and Scopus. In this review the literature pertaining to the AMS programs for hospitalized patients is sorted on the basis of various interventions that are categorized as formulary restriction (pre-authorization), guideline development, clinical pathway development, educative interventions and prospective audit. Moreover a clear emphasis is laid on the patient outcomes obtained as a result of these interventions namely the infection control, drop in readmission rate, mortality control, resistance control and the control of an overall cost of antibiotic treatment obtained mainly by curbing the overuse of antibiotics within the hospital wards. AMS program is an efficient strategy of pharmacovigilance to rationalize the antimicrobial practice for hospitalized patients as it prevents the misuse of antibiotics, which ultimately retards the health threatening effects of various antibiotics.

Abuse of Antibiotics in Perinatology: Negative Impact for Health and the Economy

To use medications appropriately, patients need to be treated based on their clinical conditions, in doses that are based on their individual requirements, for an adequate amount of time, and at the lowest expense. The perinatal period is characterized by an excessive use of antibiotics. This antibiotic abuse can lead to antibiotic resistance, microbiome alterations, and dysbiosis, which have been associated with serious complications such as infections, abnormal brain development, allergies, autoimmune disorders, obesity, and an increase in mortality as well as an increase in health care expenditures. The need to optimize antibiotic utilization in perinatal medicine has never been more urgent; there is not much more time to wait.

[Use (and abuse) of antibiotics in perinatal medicine]

INTRODUCTION

The rational use of antibiotics (ATB) implies that patients receive those adequate for their clinical needs, in correct doses according to their individual conditions, during an adequate period of time, and at the lowest cost for them and their community. The highest rate of ATB abuse occurs during the perinatal period, despite the fact that there is evidence of multiple short- and long-term negative effects. Furthermore, this abuse is associated with increased costs of medical care.

OBJECTIVE

To update and report the evidence on the use, abuse, and adverse effects of ATB in perinatal medicine, and possible measures to prevent them, and thus improve health care outcomes and costs.

METHODS

A review and analysis was performed from the literature related to the use of ATB in perinatal medicine up to February 2020.

RESULTS

ATB abuse in perinatal medicine ranges from 50% to 70%, with even higher rates in some neonatal centres. Adverse effects include death, increased microbial resistance, along with microbiome abnormalities and dysbiosis that lead to serious life-long complications such as infections, allergies, autoimmune disorders, gastrointestinal disorders, arthritis, asthma, obesity, and perhaps cancer. Preventing and reducing the abuse of ATB would lead to better health and to significant savings in the health sector. In only 4neonatal intensive care units, with 1000 admissions per year, savings are estimated at US$230,000 per year.

CONCLUSION

The need to optimise the use of ATB in perinatal medicine has never been more urgent.

Auditing use of antibiotics in Zimbabwean neonates

BACKGROUND

Neonatal sepsis is a major cause of morbidity and mortality in low-income settings. As signs of sepsis are non-specific and deterioration precipitous, antibiotics are often used profusely in these settings where diagnostics may not be readily available. Harare Central Hospital, Zimbabwe, delivers 12000 babies per annum admitting ∼4800 to the neonatal unit. Overcrowding, understaffing and rapid staff turnover are consistent problems. Suspected sepsis is highly prevalent, and antibiotics widely used. We audited the impact of training and benchmarking intervention on rationalizing antibiotic prescription using local, World Health Organization-derived, guidelines as the standard.

METHODS

An initial audit of admission diagnosis and antibiotic use was performed between 8th May - 6th June 2018 as per the audit cycle. An intern training programme, focusing on antimicrobial stewardship and differentiating between babies 'at risk of' versus 'with' clinically-suspected sepsis was instituted post-primary audit. Re-audit was conducted after 5 months.

RESULTS

Sepsis was the most common admitting diagnosis by interns at both time points but reduced at repeat audit (81% versus 59%, P<0.0001). Re-audit after 5 months demonstrated a decrease in antibiotic prescribing at admission and discharge. Babies prescribed antibiotics at admission decreased from 449 (98%) to 96 (51%), P<0.0001. Inpatient days of therapy (DOT) reduced from 1243 to 1110/1000 patient-days. Oral amoxicillin prescription at discharge reduced from 349/354 (99%) to 1% 1/161 (P<0.0001).

CONCLUSION

A substantial decrease in antibiotic use was achieved by performance feedback, training and leadership, although ongoing performance review will be key to ensuring safety and sustainability.

Effect of Weekly Antibiotic Round on Antibiotic Use in the Neonatal Intensive Care Unit as Antibiotic Stewardship Strategy

Background: Antibiotics are commonly used in the neonatal intensive care unit (NICU). The objective was to observe the effect of weekly antibiotic round in NICU (WARN) to the antibiotic use in NICU. Methods: A retrospective observational study was performed. Departmental-level diagnosis categories and the parameters of antibiotic usage in NICU for the period of 2016-2017 (Phase 1) and 2018-2019 (Phase 2) were collected. WARN in NICU was started since January 2018. A time series forecasting was used to predict the quarterly antibiotic use in Phase 2, based on data from Phase 1. The actual antibiotic use of each quarter in Phase 2 was compared with the predicted values. Results: Totally 9297 neonates were included (4743 in Phase 1, 4488 in Phase 2). The composition of the disease spectrum between Phase 1 and Phase 2 was not different (P > 0.05). In Phase 1 and Phase 2, the overall antibiotic rate was 94.4 and 74.2%, the average accumulative defined daily dose per month was 199.00 ± 55.77 and 66.80 ± 45.64, the median antibiotic use density per month was 10.31 (9.00-13.27) and 2.48 (1.92-4.66), the median accumulative defined daily dose per case per month was 0.10 (0.09-0.13) and 0.03 (0.02-0.47), the number of patients who received any kind of antibiotic per 1000 hospital days per month was 103.45 (99.30-107.48) and 78.66 (74.62-82.77), rate of culture investigation before antibiotics was 64 to 92%, respectively, and all were better than the predicted values (P < 0.01). Conclusion: The implementation of periodical antibiotic rounds was effective in reducing the antibiotics use in the NICU.