Implementation of an antimicrobial stewardship program in a pediatric hospital slashed Clostridium difficile infection (CDI) rates by almost three-fold, relieving both patient symptoms and parental worries, researchers reported recently in San Diego at IDWeek 2015.
“[CDI] is stressful for parents because even after release from the hospital, if their children don’t feel well they have to stay out of school and daycare while they have symptoms,” said Jean Wiedeman, MD, PhD, co-author of the study and medical director of pediatric antimicrobial stewardship at the University of California-Davis Medical Center in Sacramento. “[By preventing CDIs] you’re improving quality of care [because] children don’t have to undergo cramping, abdominal pain and watery diarrhea, which often leads to electrolyte imbalances.”
Wiedeman and colleagues compared rates of C. difficile and antibiotic-related costs at UC Davis Children’s Hospital before and after implementation of the antibiotic stewardship program. Looking at the pre-program period (2008-2010) they recorded a CDI rate of 9.2 per 10,000 patient days. The CDI rate plummeted to 2.8 per 10,000 patient days in the period after the program was implemented (2011-2014). In addition, cost savings generated by decreased antibiotic use of the 16 most commonly targeted drugs in the program fell from $164,112 to $120,540 annually — an annual savings of $43,572.
The physician-led stewardship program calls for prospectively auditing charts of hospitalized patients to determine if antimicrobial prescribing is appropriate and providing immediate, real-time feedback to prescribing physicians. Inpatient prescribing providers are paged and antibiotic recommendations provided over the phone. Another key tenet is requiring prescribers to obtain authorization from an ID specialist prior to the use of certain restricted broad-spectrum or expensive antibiotics. Infectious disease physicians are available for consults at any time by pager in the ongoing program. Antibiotic use in pediatric patients at the Children’s Hospital is reviewed three times a week. Recommended interventions in the program include stopping unnecessary antibiotics and other options:
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de-escalating therapy by prescribing a more narrow-spectrum antibiotic than was being used;
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adjusting the dose based on obesity, kidney or liver dysfunction;
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switching from intravenous to oral antibiotics;
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changing to an equally effective but less expensive antibiotic.
“We find that that we have a very acceptable program, with over 90% of our physicians [agreeing to] interventions,” Wiedeman said at an Oct. 9 IDWeek press conference. “It has actually now expanded to the point where we are probably going to need another physician because we are also rounding with our intensivists in the cardiac ICU and neonatal ICU. Then we help with infection prevention interventions such as looking at central line and Foley catheters as well as making interventions for antimicrobial use.”
Hospital Infection Control & Prevention asked the physician about the role of infection preventionists in the UC program.
“I’m also the medical director at Children’s Hospital for infection prevention and epidemiology, so our infection preventionists are critical members of our team,” Wiedeman said. “They are not only involved in review of HAIs, but are very important in education and monitoring — in a very time-consuming fashioning — hand washing and appropriate infection control isolation. It is a little more difficult for an IP to be involved in making recommendations to a physician team to remove a central venous catheter or a Foley catheter. That does require, in my opinion, a physician [decision].”
The implementation of such an audit and feedback stewardship program can have downstream benefits and indirect cost savings, said another press conference participant, Andi Shane, MD, MPH, MSc, an infectious disease physician at Emory University School of Medicine in Atlanta. “When you have an opportunity to discuss with a physician the reasons or rationale for prescribing an antibiotic you not only make an impact on that particular child in consultation, but then the physician takes that knowledge and applies it to other patients. So indirect costs and benefits of antibiotic stewardship are also extremely important.”
In general, CDI rates can serve as “a canary in the mine” surrogate for how effectively a hospital is using antibiotics, she added.
The Children’s Hospital data regarding all antimicrobial drugs administered from 2008-2014 were retrospectively obtained from the electronic medical record, including antibiotic drug name, route of administration, and dosage. Antimicrobial drug costs were calculated based on representative average wholesale prices obtained from the Red Book Online. Monthly pediatric CDI rates (per 10,000 patient days) were compared between the pre- and post-antibiotic stewardship using linear regression.
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Nakhra N, Wiedeman J. Antimicrobial Cost Savings and Reduction in Clostridium Difficile Infection Rates Following Implementation of a Pediatric Antimicrobial Stewardship Program. Poster 1468. IDWeek Oct. 7-11 2015. San Diego, CA.
