Individualized Antibiotic Plans as a Quality Improvement Initiative to Reduce Carbapenem Use for Hematopoietic Cell Transplant Patients at a Freestanding Pediatric Hospital

BACKGROUND

Providers must balance effective empiric therapy against toxicity risks and collateral damage when selecting antibiotic therapy for patients receiving hematopoietic cell transplant (HCT). Antimicrobial stewardship interventions during HCT are often challenging due to concern for undertreating potential infections.

METHODS

In an effort to decrease unnecessary carbapenem exposure for patients undergoing HCT at our pediatric center, we implemented individualized antibiotic plans (IAPs) to provide recommendations for preengraftment neutropenia prophylaxis, empiric treatment of febrile neutropenia, and empiric treatment for hemodynamic instability. We compared monthly antibiotic days of therapy (DOT) adjusted per 1000 patient-days for carbapenems, antipseudomonal cephalosporins, and all antibiotics during two 3-year periods immediately before and after the implementation of IAPs to measure the impact of IAP on prescribing behavior. Bloodstream infection (BSIs) and Clostridioides difficile (CD) positivity test rates were also compared between cohorts. Last, providers were surveyed to assess their experience of using IAPs in antibiotic decision making.

RESULTS

Overall antibiotic use decreased after the implementation of IAPs (monthly reduction of 19.6 DOT/1000 patient-days; P = .004), with carbapenems showing a continuing decline after IAP implementation. BSI and CD positivity rates were unchanged. More than 90% of providers found IAPs to be either extremely or very valuable for their practice.

CONCLUSIONS

Implementation of IAPs in this high-risk HCT population led to reduction in overall antibiotic use without increase in rate of BSI or CD test positivity. The program was well received by providers.

Current state of antimicrobial stewardship in organ transplantation in Singapore

BACKGROUND

Antibiotic stewardship programs (ASPs) are well established in the public hospitals in Singapore, but they are not mandatory for transplant programs. Given the positive impact of ASPs in non-organ transplant patients (improved use of broad-spectrum antibiotics, reduced length of stay and lower healthcare costs), stewardship principles are likely to benefit transplant recipients.

METHODS

We reviewed the progress made in ASPs in the Asia Pacific region as well as the progress of our ASP over the last decade since it was established. We also described how stewardship strategies have evolved for the purposes of our transplant program.

RESULTS

Currently, pressing stewardship issues for our transplant program include high antibiotic consumption, as well as the burden, morbidity and mortality associated with drug-resistant bacterial infections. Transplanting the model of stewardship onto a transplant program ignores the intricacies of transplant patients; the bespoke form of stewardship, "handshake stewardship", is more appropriate.

CONCLUSION

To advance the cause of ASP in the transplant unit in Singapore, stakeholder buy-in is key; empowering transplant physicians to be stewardship focused would be more sustainable in the long run. In addition, expanding our diagnostic armamentarium, optimizing existing therapeutics and multi-disciplinary team involvement (including stakeholders from microbiology, infection prevention teams) is vital. This article is protected by copyright. All rights reserved.

Impact of Antibiotic Stewardship Rounds in the Intensive Care Setting: a prospective cluster-randomized crossover study

BACKGROUND

Few groups have formally studied the effect of dedicated antibiotic stewardship rounds (ASRs) on antibiotic use (AU) in intensive care units (ICUs).

METHODS

We implemented weekly ASRs using a two-arm, cluster-randomized, crossover study in 5 ICUs at Duke University Hospital from 11/2017 to 6/2018. We excluded patients without an active antibiotic order, or if they had a marker of high complexity including an existing infectious disease consult, transplant, ventricular assist device, or ECMO. AU during and following ICU stay for patients with ASRs was compared to the controls. We recorded the number of reviews, recommendations delivered, and responses. We evaluated change in ICU-specific AU during and after the study.

RESULTS

Our analysis included 4,683 patients: 2330 intervention and 2353 controls. Teams performed 761 reviews during ASRs, which excluded 1569 patients: 60% of patients off antibiotics, and 8% complex patients. Exclusions affected 88% the cardiac surgery ICU (CTICU) patients. AU rate ratio (RR) was 0.97 (0.91-1.04). When CTICU was removed, the RR was 0.93 (0.89-0.98). AU in the post-study period decreased by 16% (95% CI 11-24%) compared to the AU in the baseline period. Change in AU was differential among units: largest in the neurology ICU (-28%) and smallest in the CTICU (-2%).

CONCLUSION

Weekly multi-disciplinary ASRs was a high-resource intervention associated with a small AU reduction. The noticeable ICU AU decline over time is possibly due to indirect effects of ASRs. Effects differed among specialty ICUs, emphasizing the importance of customizing ASRs to match unit-specific population, workflow, and culture.

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.

Attitudes and Perceptions amongst Critical Care Physicians towards Handshake Antimicrobial Stewardship Rounds

Rationale In an era of antimicrobial resistance, antimicrobial stewardship programs are tasked with reducing inappropriate use of antimicrobials in community and hospital settings. Intensive care units are unique, high-stakes environments where high usage of broad-spectrum antimicrobials is often seen. Handshake stewardship has emerged as an effective mode of prospective audit and feedback to help optimize antimicrobial usage, emphasizing an in-person approach to providing feedback. Objectives Six months following the implementation of handshake stewardship rounds in our intensive care unit, we performed a cross-sectional survey of critical care physicians to assess their attitudes and perceptions towards handshake stewardship rounds and preferred mode of delivery of antimicrobial stewardship prospective audit and feedback strategies. Methods A web-based survey was distributed to 22 critical care physicians working in our hospital and responses were collected over a two-week period. Measurements and Main Results Most critical care physicians believe that handshake stewardship rounds improve the quality of patient care (85.7%) and few believe that handshake stewardship rounds are an ineffective use of their time (14.3%). The majority of critical care physicians believe formal, scheduled rounds with face-to-face verbal interaction are very useful compared to providing written suggestions in the absence of face-to-face interaction (71.4% vs 0%). Conclusions Based upon our survey results, handshake stewardship is valued amongst the majority of critical care physicians. Antimicrobial stewardship prospective audit and feedback strategies emphasizing face-to-face interaction are favored amongst critical care physicians.

Intervention and Acceptance Rates Support Handshake-Stewardship Strategy

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