Implementing an Inpatient Pediatric Prospective Audit and Feedback Antimicrobial Stewardship Program Within a Larger Medical Center

Pediatric Antimicrobial Stewardship Programs Reduce Antibiotic Use at Combined Adult-Pediatric Hospitals

Implementation of dedicated pediatric antimicrobial stewardship programs (ASPs) at 2 combined adult-pediatric hospitals with existing ASPs was associated with sustained decreases in pediatric antibiotic use out of proportion to declines seen in adult inpatient units. ASPs in combined hospitals may not detect excessive pediatric antibiotic use without incorporating pediatric expertise.

Position statement of the Spanish Society of Paediatric Infectious Diseases on the introduction, implementation and assessment of antimicrobial stewardship programmes in paediatric hospitals

In the past few years, antimicrobial resistance has increased, becoming a serious public health problem. The irrational use of antimicrobials is one of the main contributors to antimicrobial resistance. The paediatric population is not free from this problem, as antimicrobials are widely prescribed in this age group, often inappropriately. The introduction of antimicrobial stewardship programmes (ASPs) has proven crucial in curbing the emergence of antimicrobial resistance. At the international level, the need to develop specific paediatric ASPs has been recognised on account of the differences between adult and paediatric patients as concerns infection and approaches to diagnosis and treatment. For this reason, paediatric ASPs should be multidisciplinary programmes led by paediatric infectious disease specialists and use specific paediatric indicators (such as days of treatment, antimicrobial susceptibility patterns in the paediatric population, or clinical indicators) to help identify areas of improvement and develop effective targeted interventions. On the other hand, the support and leadership of the pertinent scientific societies are also essential. The purpose of this document is to present the position of the Sociedad Española de Infectología Pediátrica (SEIP, Spanish Society of Paediatric Infectious Diseases) concerning the implementation of paediatric ASPs in hospitals in Spain and to provide tools to facilitate their application in hospitals throughout the regional health care systems in the country.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pediatric Antimicrobial Stewardship Programs: Current Perspectives

With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.

Identification of High-Yield Targets for Antimicrobial Stewardship Program Efforts Within a Nonfreestanding Children's Hospital

OBJECTIVES

Identify diagnoses with the highest likelihood of prompting antimicrobial stewardship program (ASP) recommendations and lowest probability of recommendation acceptance, investigate the impact of provider years in practice on recommendation receipt and acceptance, and simultaneously assess the influence of patient and provider-level variables associated with recommendations within a nonfreestanding children's hospital.

METHODS

Retrospective cohort study of antibiotic courses reviewed by the ASP staff from December 1, 2014 to November 30, 2016. Poisson regression was used to detect associations between diagnoses, provider years in practice, and the probability of recommendation receipt and acceptance. Multivariable logistic regression was used to simultaneously examine the influence of patient and provider-level characteristics on recommendation probability.

RESULTS

A total of 938 inpatient encounters and 1170 antibiotic courses were included. Diagnoses were associated with provider receipt (P < .001) and acceptance (P < .001) of recommendations, with ear, nose, and throat and/or sinopulmonary diagnoses most likely to prompt recommendations (56%; 95% confidence interval [CI], 48-64) and recommendations for neonatal and/or infant diagnoses accepted least often (67%; 95% CI, 58-76). No associations were initially found between provider experience and recommendation receipt or acceptance, although multivariable analysis revealed a trend between increasing years in practice and recommendation likelihood (P = .001). Vancomycin usage (64%; 95% CI, 56-72) and ear, nose, and throat and/or sinopulmonary diagnoses (56%; 95% CI, 47-65) had the highest probability of a recommendation. Sensitivity analyses revealed that use of diagnosis-related clinical practice guidelines decreased recommendations and increased acceptance rates, especially for the surgery diagnosis category.

CONCLUSIONS

High-yield targets for ASP activities at our nonfreestanding children's hospital were identified. Clinical practice guidelines have the potential to decrease ASP workload, and their development should be particularly encouraged for ASPs with limited resources.

Improving the Quality of Hospital Antibiotic Use: Impact on Multidrug-Resistant Bacterial Infections in Children

Antimicrobial resistance (AMR) is considered a rapidly growing global public health emergency. Neonates and children are among patients for whom antibiotics are largely prescribed and for whom the risk of AMR development is high. The phenomenon of increasing AMR has led to the need to develop measures aimed at the rational and effective use of the available drugs also in children and antimicrobial stewardship (AS), which is one of the measures that in adults has showed the highest efficacy in reducing antibiotic abuse and misuse, appears as an attractive approach. The aim of this manuscript is to analyze the basic principles and strategies of pediatric AS. To this end, we searched in PubMed articles published in years 2000 to 2019 containing "antimicrobial resistance," "antibiotic use," "antimicrobial stewardship," and "children" or "pediatric" as keywords. Our review showed that the balance between multi-resistant organisms and new antimicrobials is extremely precarious. The AS tools are the most important weapon at our disposal to stem the phenomenon. Careful monitoring of prescriptions, continuous training of prescribing physicians and collaboration with highly qualified multidisciplinary staff, creation of local and national guidelines, use of rapid diagnostic tests, technological means of support, and research activities by testing new broad-spectrum antibiotics are mandatory. However, all of these measures must be supported by adequate investment by national and international health organizations. Only by making AS daily practice, through the use of financial resources and dedicated staff, we can fight AMR to ensure safe and effective care for our young patients.

The effect of preauthorization and prospective audit and feedback system on oral antimicrobial prescription for outpatients at a children's hospital in Japan

Antimicrobial stewardship programs (ASP) for oral antibiotics is still uncommon, despite the fact that oral antibiotics prescription accounts for 90% of total antibiotic consumption in developed countries. We introduced preauthorization and prospective audit and feedback (PAF) system on broad-spectrum oral antimicrobials as a part of ASP intervention from October 2015 in a tertiary children's hospital in Japan. Antimicrobial consumption and cost of targeted oral antimicrobials decreased from 11.1 days of therapy (DOT) per 1000 outpatient visits and 860,040 yen ($ 7167: 1 $ = 120 yen) to 1.9 DOT per 1000 outpatient visits and 142,200 yen ($ 1185) annually, respectively (p < 0.001). Interrupted time-series analysis showed that prescriptions for targeted antimicrobials decreased rapidly after initiation of preauthorization (p < 0.001). Prescriptions for non-targeted oral antimicrobial increased temporarily (p < 0.001), but a decreasing trend was found after the initiation (p < 0.001). In pre-intervention period, the main indications for using targeted antimicrobials were upper and lower respiratory infection, urinary tract infections, prophylaxis for medical procedures and otitis media, but only 21.4% of them were appropriate prescription. The appropriate prescription rate of post -intervention period increased to 58.5%. During the study period, the susceptibility pattern of major bacteria to these antimicrobials did not change. In conclusion, introduction of the preauthorization and PAF for selected oral antimicrobials decreased the antimicrobial use of both targeted and non-targeted antimicrobials. This intervention may be an effective method of ASP for other children's hospitals.

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

Background

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

Methods

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

Results

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

Conclusions

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

Scope of Antibiotic Stewardship Programs in Pediatrics

This review of pediatric antibiotic stewardship programs (ASPs) summarized the antibiotic prescribing interventions and their impact on antibiotic use and antimicrobial resistance. We reviewed studies of pediatric ASP, including the search terms "antimicrobial stewardship," "antibiotic stewardship," "children," and "pediatric." The articles' selection and review were performed independently by 2 investigators, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Twenty-one studies were included, from the past 15 years, increasing after the 2007 IDSA (Infectious Diseases Society of America) guidelines for ASP with a large variability of the programs, and the virtual exclusive focus on inpatient settings (90%): 16 formalized ASP and 5 non-ASP actions. A reduction in antibiotic prescribing in ASP has been demonstrated in the studies reporting pediatric ASP, but only one ASP showed a significant impact on antimicrobial resistance. However, the impact on antibiotic consumption in pediatrics demonstrated the important contribution of these strategies to improve antibiotic use in children, without complications or negative issues.

Pediatric Antimicrobial Stewardship: State of the Art

PURPOSE OF REVIEW

We aim to systematically review the literature on the effectiveness of pediatric antimicrobial stewardship programs (ASPs) and antimicrobial stewardship (AS) strategies in the United States (US) inpatient setting. Furthermore, we review current gaps and challenges for unique pediatric populations and those in ambulatory settings.

RECENT FINDINGS

Misuse and overuse of antimicrobials have been identified as key factors for antimicrobial resistance (AR). Multiple professional organizations support the implementation of hospital-based ASPs to decrease antimicrobial consumption, improve patient outcomes, and reduce healthcare costs. There is limited data on the effectiveness of inpatient pediatric ASPs and AS strategies in unique populations. Furthermore, there is a paucity of evidence on ASPs in ambulatory settings. This review contributes to the growing body of evidence that supports the use of pediatric ASPs to optimize antimicrobial therapy in the inpatient setting as well as in unique patient populations and ambulatory settings. Active stewardship is critical and antimicrobial consumption is a key outcome metric for programs.