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Implementation of an Antimicrobial Stewardship Program in a Neonatal Intensive Care Unit

  • Nneka I. Nzegwu (a1), Michelle R. Rychalsky (a2), Loren A. Nallu (a3), Xuemei Song (a4), Yanhong Deng (a4), Amber M. Natusch (a5), Robert S. Baltimore (a3) (a6), George R. Paci (a6) and Matthew J. Bizzarro (a3)...

Abstract

OBJECTIVE

To evaluate antimicrobial utilization and prescription practices in a neonatal intensive care unit (NICU) after implementation of an antimicrobial stewardship program (ASP).

DESIGN

Quasi-experimental, interrupted time-series study.

SETTING

A 54-bed, level IV NICU in a regional academic and tertiary referral center.

PATIENTS AND PARTICIPANTS

All neonates prescribed antimicrobials from January 1, 2011, to June 30, 2016, were eligible for inclusion.

INTERVENTION

Implementation of a NICU-specific ASP beginning July 2012.

METHODS

We convened a multidisciplinary team and developed guidelines for common infections, with a focus on prescriber audit and feedback. We conducted an interrupted time-series analysis to evaluate the effects of our ASP. Our primary outcome measure was days of antibiotic therapy (DOT) per 1,000 patient days for all and for select antimicrobials. Secondary outcomes included provider-specific antimicrobial prescription events for suspected late-onset sepsis (blood or cerebrospinal fluid infection at >72 hours of life) and guideline compliance.

RESULTS

Antibiotic utilization decreased by 14.7 DOT per 1,000 patient days during the stewardship period, although this decrease was not statistically significant (P=.669). Use of ampicillin, the most commonly antimicrobial prescribed in our NICU, decreased significantly, declining by 22.5 DOT per 1,000 patient days (P=.037). Late-onset sepsis evaluation and prescription events per 100 NICU days of clinical service decreased significantly (P<.0001), with an average reduction of 2.65 evaluations per year per provider. Clinical guidelines were adhered to 98.75% of the time.

CONCLUSIONS

Implementation of a NICU-specific antimicrobial stewardship program is feasible and can improve antibiotic prescribing practices.

Infect Control Hosp Epidemiol 2017;38:1137–1143

Copyright

Corresponding author

Address correspondence to Matthew J. Bizzarro, MD, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, PO Box 208064, New Haven, CT 06520-8064 (matthew.bizzarro@yale.edu).

References

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1. Clark, RH, Bloom, BT, Spitzer, AR, Gerstmann, DR. Reported medication use in the neonatal intensive care unit: data from a large national data set. Pediatrics 2006;117:19791987.
2. Fonseca, SN, Ehrenkranz, RA, Baltimore, RS. Epidemiology of antibiotic use in a neonatal intensive care unit. Infect Control Hosp Epidemiol 1994;15:156162.
3. Wirtschafter, DD, Padilla, G, Suh, O, Wan, K, Trupp, D, Fayard, EE. Antibiotic use for presumed neonatally acquired infections far exceeds that for central line-associated blood stream infections: an exploratory critique. J Perinatol 2011;31:514518.
4. Cantey, JB, Wozniak, PS, Sanchez, PJ. Prospective surveillance of antibiotic use in the neonatal intensive care unit: results from the SCOUT study. Pediatr Infect Dis J 2015;34:267272.
5. Almuneef, MA, Baltimore, RS, Farrel, PA, Reagan-Cirincione, P, Dembry, LM. Molecular typing demonstrating transmission of gram-negative rods in a neonatal intensive care unit in the absence of a recognized epidemic. Clin Infect Dis 2001;32:220227.
6. Bizzarro, MJ, Gallagher, PG. Antibiotic-resistant organisms in the neonatal intensive care unit. Semin Perinatol 2007;31:2632.
7. Patel, SJ, Saiman, L. Antibiotic resistance in neonatal intensive care unit pathogens: mechanisms, clinical impact, and prevention including antibiotic stewardship. Clin Perinatol 2010;37:547563.
8. Shane, AL, Stoll, BJ. Recent developments and current issues in the epidemiology, diagnosis, and management of bacterial and fungal neonatal sepsis. Am J Perinatol 2013;30:131141.
9. Aliaga, S, Clark, RH, Laughon, M, et al. Changes in the incidence of candidiasis in neonatal intensive care units. Pediatrics 2014;133:236242.
10. Tripathi, N, Cotten, CM, Smith, PB. Antibiotic use and misuse in the neonatal intensive care unit. Clin Perinatol 2012;39:6168.
11. Alexander, VN, Northrup, V, Bizzarro, MJ. Antibiotic exposure in the newborn intensive care unit and the risk of necrotizing enterocolitis. J Pediatr 2011;159:392397.
12. Cotten, CM, Taylor, S, Stoll, B, et al. Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for extremely low birth weight infants. Pediatrics 2009;123:5866.
13. Kuppala, VS, Meinzen-Derr, J, Morrow, AL, Schibler, KR. Prolonged initial empirical antibiotic treatment is associated with adverse outcomes in premature infants. J Pediatr 2011;159:720725.
14. 12-Step program to prevent antimicrobial resistance in healthcare settings. Centers for Disease Control and Prevention website. http://www.cdc.gov/drugresistance/healthcare/. Published 2002. Accessed April 5, 2017.
15. Barlam, TF, Cosgrove, SE, Abbo, LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62:e51e77.
16. Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol 2012;33:322327.
17. Get smart for healthcare. Centers for Disease Control and Prevention website. https://www.cdc.gov/getsmart/healthcare/. Last updated March 2017. Accessed April 5, 2017.
18. Newland, JG, Stach, LM, De Lurgio, SA, et al. Impact of a prospective-audit-with-feedback antimicrobial stewardship program at a children’s hospital. J Pediatric Infect Dis Soc 2012;1:179186.
19. Di Pentima, MC, Chan, S, Hossain, J. Benefits of a pediatric antimicrobial stewardship program at a children’s hospital. Pediatrics 2011;128:10621070.
20. Metjian, TA, Prasad, PA, Kogon, A, Coffin, SE, Zaoutis, TE. Evaluation of an antimicrobial stewardship program at a pediatric teaching hospital. Pediatr Infect Dis J 2008;27:106111.
21. Patel, SJ, Saiman, L. Principles and strategies of antimicrobial stewardship in the neonatal intensive care unit. Semin Perinatol 2012;36:431436.
22. A primer on healthcare epidemiology, infection control and antimicrobial stewardship: online course. Society for Healthcare Epidemiology website. http://www.fellowscourse.shea-online.org/Default.aspx. Published 2015. Accessed June 26, 2017.
23. Kliegman, RM, Walsh, MC. Neonatal necrotizing enterocolitis: pathogenesis, classification, and spectrum of illness. Curr Probl Pediatr 1987;17:213288.
24. Polin, RA; Committee on fetus and newborn. Management of infants with suspected or proven early-onset bacterial sepsis. Pediatrics 2012;129:10061115.
25. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. ACOG Committee Opinion No. 485: prevention of early-onset group B streptococcal disease in newborns. Obstet Gynecol 2011;117:10191027.
26. Brady, MT, Polin, RA. Prevention and management of infants with suspected or proven neonatal sepsis. Pediatrics 2013;132:166168.
27. The National Action Plan for Combating Antibiotic-resistant Bacteria. 2015; The White House website. https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf. Published 2015. Accessed October 14, 2015.
28. Schulman, J, Dimand, RJ, Lee, HC, Duenas, GV, Bennett, MV, Gould, JB. Neonatal intensive care unit antibiotic use. Pediatrics 2015;135:826833.
29. Patel, SJ, Oshodi, A, Prasad, P, et al. Antibiotic use in neonatal intensive care units and adherence with Centers for Disease Control and Prevention 12 step campaign to prevent antimicrobial resistance. Pediatr Infect Dis J 2009;28:10471051.
30. Patel, SJ, Rosen, E, Zaoutis, T, Prasad, P, Saiman, L. Neonatologists’ perceptions of antimicrobial resistance and stewardship in neonatal intensive care units. Infect Control Hosp Epidemiol 2010;31:12981300.
31. Kiser, C, Nawab, C, McKenna, K, Aghai, ZA. Role of guidelines on length of therapy in chorioamnionitis in neonatal sepsis. Pediatrics 2014;133:992998.
32. Higgins, RD, Saade, G, Polin, RA, et al. Evaluation and management of newborns with a maternal diagnosis of chorioamnionitis: summary of a workshop. Obstet Gynecol 2016;127:426436.
33. Kuzniewicz, MW, Puopolo, KM, Fischer, A, et al. A quantitative approach to the management of neonatal early-onset sepsis. JAMA Pediatr 2017;171:365371.
34. Bizzarro, MJ, Shabanova, V, Baltimore, RS, Dembry, LM, Ehrenkranz, RA, Gallagher, PG. Neonatal sepsis, 2004–2013; the rise and fall of coagulase-negative staphylococci. J Pediatr 2015;166:11931199.
35. Cantey, JB, Patel, SJ. Antimicrobial stewardship in the NICU. Infect Dis Clin North Am 2014;28:247261.
36. iNICQ 2016: Choosing antibiotics wisely. Vermont Oxford Network website. https://public.vtoxford.org/quality-education/inicq-2016-choosing-antibiotics-wisely/. Published 2016. Accessed June 4, 2017.

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