Clinical Impact of an Antibiotic Stewardship Program at a Children's Hospital.

INTRODUCTION: Antibiotic stewardship programs (ASP) improve appropriate antibiotic use. Data are limited on the clinical benefit of ASPs in children's hospitals. This study's objective was to determine the impact of an ASP on length of stay (LOS) and readmission rate among patients admitted to children's hospitals. METHODS: Data from a prospective-audit-with-feedback ASP were used to examine the ASP review characteristics, including antibiotic(s) prescribed, clinical indication, recommendations made by the ASP, and agreement with recommendations. Propensity score analysis was utilized to determine the impact of the ASP on LOS and 30-day readmission based on whether the patient received an ASP recommendation and if the clinician agreed with recommendations. Patients were stratified on if they had a complex chronic condition status (CCC) and their service line, medical or surgical. RESULTS: Of the 8038 reviews included, 1362 (16.9%) resulted in a recommendation that was agreed with in 1116 (81%) cases. Propensity score analysis demonstrated a significantly longer LOS for the non-CCC medicine group who received an ASP recommendation (80.9 vs. 67.6 h, p < 0.001). However, for CCC medicine patients that agreed with the ASP recommendation, a clinically relevant decrease in LOS (158.1 vs. 180.3 h, p = 0.095) was observed. The 30-day readmission rate was significantly greater in CCC medicine patients when comparing those who did not receive a recommendation versus those who did receive a recommendation (7.3% vs 4.2%, respectively; p = 0.005). CONCLUSION: Children without a CCC who received an ASP recommendation had a longer length of stay. For children with CCCs, the ASP appeared to decrease LOS and significantly reduce 30-day readmission rates. Overall, this study demonstrate that ASPs offer meaningful clinical benefit justifying resource allocation needed to develop and maintain ASP programs.

Preoperative Antibiotic Orders: Protocol-Initiated Pharmacist Order Entry.

OBJECTIVE: To evaluate the antibiotic selection of preoperative orders before and after a pharmacist order entry protocol for patients with methicillin-resistant Staphylococcus aureus (MRSA) colonization. METHODS: A retrospective chart review of orthopedic surgery procedures on patients with MRSA colonization at a free-standing, academic pediatric hospital, between February 2010 and February 2012. RESULTS: Procedures that were performed pre protocol (n = 27) implementation had a 63% rate of appropriate antibiotic selection compared to 81% in the postprotocol group (n = 32; p = 0.1155). The preprotocol group dose accuracy was 96% compared to 97% in the postprotocol group (p = 0.81). Two procedures, 1 in each group, were redosed appropriately for extended surgery duration. Correct timing of antibiotic administration occurred in 82% of cases pre protocol versus 68% post protocol (p = 0.42). CONCLUSIONS: Patients with MRSA colonization had a greater rate of appropriate drug selection after the implementation of a pharmacist-initiated preoperative protocol. Correct antibiotic dose and redose remained consistent between the study groups. Most of the orthopedic procedures performed included patients on antibiotic coverage at steady state for ongoing infections, which impacted the analysis of preoperative timing. Further studies should be conducted to assess whether the increase in the number of appropriate antibiotic selections decreases the rate of postoperative MRSA infections.

Clinical diagnoses and antimicrobials predictive of pediatric antimicrobial stewardship recommendations: a program evaluation.

BACKGROUND: The number of pediatric antimicrobial stewardship programs (ASPs) is increasing and program evaluation is a key component to improve efficiency and enhance stewardship strategies. OBJECTIVE: To determine the antimicrobials and diagnoses most strongly associated with a recommendation provided by a well-established pediatric ASP. DESIGN AND SETTING: Retrospective cohort study from March 3, 2008, to March 2, 2013, of all ASP reviews performed at a free-standing pediatric hospital. METHODS: ASP recommendations were classified as follows: stop therapy, modify therapy, optimize therapy, or consult infectious diseases. A multinomial distribution model to determine the probability of each ASP recommendation category was performed on the basis of the specific antimicrobial agent or disease category. A logistic model was used to determine the odds of recommendation disagreement by the prescribing clinician. RESULTS: The ASP made 2,317 recommendations: stop therapy (45%), modify therapy (26%), optimize therapy (19%), or consult infectious diseases (10%). Third-generation cephalosporins (0.20) were the antimicrobials with the highest predictive probability of an ASP recommendation whereas linezolid (0.05) had the lowest probability. Community-acquired pneumonia (0.26) was the diagnosis with the highest predictive probability of an ASP recommendation whereas fever/neutropenia (0.04) had the lowest probability. Disagreement with ASP recommendations by the prescribing clinician occurred 22% of the time, most commonly involving community-acquired pneumonia and ear/nose/throat infections. CONCLUSIONS: Evaluation of our pediatric ASP identified specific clinical diagnoses and antimicrobials associated with an increased likelihood of an ASP recommendation. Focused interventions targeting these high-yield areas may result in increased program efficiency and efficacy.

Antibiotic Management of Animal Bites in Children During the Methicillin-Resistant Staphylococcus aureus Era.

Children presenting to an emergency department following an animal bite were found to be at risk for infection if they had puncture wounds, crush wounds, or were bitten by a cat. Of the infected wounds that were cultured, methicillin-resistant Staphylococcus aureus was not isolated as a pathogen.

Development of criteria for gentamicin monitoring in a neonatal intensive care unit.

PURPOSE: The results of a study to identify factors associated with serum gentamicin levels outside the therapeutic range in a neonatal population are reported. METHODS: A single-center retrospective chart review was conducted to identify cases involving gentamicin use in the neonatal intensive care unit; a sample of cases sufficient for risk-factor analysis (n = 225) was selected for evaluation. In all evaluated cases, gentamicin was administered according to a standardized dosing protocol based on gestational age and weight. Selected clinical factors and laboratory values potentially associated with undesirably high or low serum drug levels were analyzed. RESULTS: Of the 225 patient cases included in the analysis, 184 (82%) involved appropriate (i.e., per protocol) gentamicin dosing. Of the 41 doses classified as inappropriate, 33 were higher and 8 were lower than those recommended by the protocol. Six (18%) of the newborns who received doses classified as inappropriately high had supratherapeutic serum trough concentrations, and 3 (9%) had subtherapeutic trough values. Among the neonates with supratherapeutic peak values, none had an elevated trough value and only 1 received a gentamicin dose deemed to be inappropriately high. Factors associated with an increased relative risk (RR) of a supratherapeutic trough included inappropriate dosing (RR, 2.9; 95% confidence interval [CI], 1.18-6.9), an elevated serum creatinine (SCr) concentration (>0.8 mg/dL) on the day of blood sampling for drug level assessment (RR, 25.6; 95% CI, 9.1-71.4), low urine output (<1 mL/kg/hr) on the day of blood sampling (RR, 7.8; 95% CI, 3.0-15.4), and shock (RR, 3.16; 95% CI, 1.32-7.57). CONCLUSION: When adhering to a weight-based gentamicin dosing protocol, the SCr level and urine output are the best indicators for identifying neonatal patients at risk for supratherapeutic gentamicin trough levels. Shock and inappropriate dosing strategies also put patients at increased risk for supratherapeutic troughs.

Impact of a Prospective-Audit-With-Feedback Antimicrobial Stewardship Program at a Children's Hospital.

BACKGROUND: The emergence of antibiotic-resistant organisms and the lack of development of new antimicrobials have made it imperative that additional strategies be developed to maintain the effectiveness of these existing antibiotics. The objective of this study was to describe the impact of a prospective-audit-with-feedback antimicrobial stewardship program (ASP) on antibiotic use in a children's hospital. METHOD: A quasi-experimental study design with a control group was performed to assess the impact of a prospective-audit-with-feedback ASP. The control group was the combined antibiotic use at 25 similar children's hospitals that are members of the Child Health Corporation of America. RESULTS: The ASP reviewed 10 460 broad-spectrum or select antibiotics in 8765 patients in the 30 months following the intervention. The most common select antibiotics reviewed were ceftriaxone/cefotaxime (43%), vancomycin (18%), ceftazidime (12%), and meropenem (7%). A total of 2378 recommendations were made in 1703 (19%) patients; the most common recommendation was to stop antibiotics (41%). Clinicians were compliant with agreed-upon ASP recommendations in 92% of patients. When comparing our antibiotic use with that of the control group, a monthly decline in all antibiotics of 7% (P = .045) and 8% (P = .045) was observed for days of therapy (DoT) and length of therapy (LoT) per 1000 patient-days, respectively. An even greater effect was observed in the select antibiotics as the monthly DoT per 1000 patient-days declined 17% (P < .001) and the monthly LoT per 1000 patient-days declined 18% (P < .001). CONCLUSIONS: A prospective-audit-with-feedback ASP can have a significant impact on decreasing antibiotic use at a children's hospital.

Clinicians' Attitudes Towards an Antimicrobial Stewardship Program at a Children's Hospital.

BACKGROUND: In pediatrics, limited data are available on how to develop and implement an antimicrobial stewardship program (ASP). In addition, no data exist on clinicians' impression of such programs. The objectives of this study were to describe the development and implementation of an ASP in a children's hospital and to describe the thoughts and attitudes of the clinicians interacting with the ASP. METHODS: A qualitative description of the development and implementation of an ASP is provided. In addition, 2 years after the implementation of a prospective-audit-with-feedback ASP, an electronic survey was administered to clinicians to assess their attitudes toward the ASP. RESULTS: A 5-step process for developing this ASP included the following: team development; selecting the stewardship strategy(ies) and antimicrobials to monitor; establishing a method to identify patients; program evaluation; and implementation. Of 365 participants surveyed, 205 (56%) responded, and 80% (160 of 199) had never worked with an ASP before its implementation. Clinicians agreed that the ASP decreased inappropriate use of antibiotics (84%, 162 of 194), improved the quality of patient care (82%, 159 of 194), and provided knowledge and education about appropriate antibiotic use (91%, 177 of 194). Negative feelings regarding the ASP included the following: 11% (22 of 194) felt a loss of autonomy; 6% (12 of 194) felt that it interfered with clinical decision-making; and 5% (9 of 194) felt threatened. Clinicians thought that to further decrease inappropriate antibiotic use, guidelines of empiric antibiotic choices (80%, 152 of 189) should be developed, and better training in medical school and residency should be provided (80%, 152 of 189). Finally, our clinicians felt that the problem of antibiotic resistance and inappropriate antibiotic use was worse nationally than at our institution. CONCLUSIONS: A prospective-audit-with-feedback ASP was successfully developed and implemented at a children's hospital. The ASP was perceived by clinicians to reduce inappropriate antibiotic use and to improve the quality of care of hospitalized children, with minimal loss of physician autonomy or interference in clinical decision-making.