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Reducing Second Gram-Negative Antibiotic Therapy on Pediatric Oncology and Hematopoietic Stem Cell Transplantation Services

Published online by Cambridge University Press:  31 July 2017

Rachel L. Wattier ,
Emily R. Levy ,
Amit J. Sabnis ,
Christopher C. Dvorak  and
Andrew D. Auerbach
Rachel L. Wattier*
Affiliation:
Division of Infectious Diseases and Global Health, Department of Pediatrics, University of California San Francisco, San Francisco, California
Emily R. Levy
Affiliation:
Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
Amit J. Sabnis
Affiliation:
Division of Hematology/Oncology, Department of Pediatrics, University of California San Francisco, San Francisco, California
Christopher C. Dvorak
Affiliation:
Division of Allergy, Immunology, and Blood and Marrow Transplant, Department of Pediatrics, University of California San Francisco, San Francisco, California
Andrew D. Auerbach
Affiliation:
Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
*
Address correspondence to Rachel L. Wattier, MD, MHS, 550 16th St 4th Floor Box 0434, San Francisco, CA, 94143-0434 (rachel.wattier@ucsf.edu).
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Abstract

OBJECTIVE

To evaluate interventions to reduce avoidable antibiotic use on pediatric oncology and hematopoietic stem cell transplantation (HSCT) services.

DESIGN

Interrupted time series.

SETTING

Academic pediatric hospital with separate oncology and HSCT services.

PARTICIPANTS

Children admitted to the services during baseline (October 2011–August 2013) and 2 intervention periods, September 2013–June 2015 and July 2015–June 2016, including 1,525 oncology hospitalizations and 301 HSCT hospitalizations.

INTERVENTION

In phase 1, we completed an update of the institutional febrile neutropenia (FN) guideline for the pediatric oncology service, recommending first-line β-lactam monotherapy rather than routine use of 2 gram-negative agents. Phase 2 included updating the HSCT service FN guideline and engagement with a new pediatric antimicrobial stewardship program. The use of target antibiotics (tobramycin and ciprofloxacin) was measured in days of therapy per 1,000 patient days collected from administrative data. Intervention effects were evaluated using interrupted time series with segmented regression.

RESULTS

Phase 1 had mixed effects–long-term reduction in tobramycin use (97% below projected at 18 months) but rebound with increasing slope in ciprofloxacin use (+18% per month). Following phase 2, tobramycin and ciprofloxacin use on the oncology service were both 99% below projected levels at 12 months. On the HSCT service, tobramycin use was 99% below the projected level and ciprofloxacin use was 96% below the projected level at 12 months.

CONCLUSIONS

Locally adapted guidelines can facilitate practice changes in oncology and HSCT settings. More comprehensive and ongoing interventions, including follow-up education, feedback, and engagement of companion services may be needed to sustain changes.

Infect Control Hosp Epidemiol 2017;38:1039–1047

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 38 , Issue 9 , September 2017 , pp. 1039 - 1047
Copyright
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

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Footnotes

PREVIOUS PRESENTATION. This work was presented in part as a poster at the 7th Annual Pediatric Antimicrobial Stewardship Conference in Kansas City, Missouri, on June 3, 2016, and at the UCSF Health Improvement Symposium in San Francisco, California, on September 22, 2016.

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