The Positive Impact of Antimicrobial Stewardship Programs in Pediatrics

Abstract & Commentary

By Hal B. Jenson, MD, FAAP, Dean, Western Michigan University School of Medicine, Kalamazoo, Michigan. Dr. Jenson reports no financial relationships in this field of study.

This article originally appeared in the December 2012 issue of Infectious Disease Alert. It was edited by Stan Deresinski, MD, FACP, FIDSA, and peer reviewed by Timothy Jenkins, MD. Dr. Deresinski is Clinical Professor of Medicine, Stanford University, and Dr. Jenkins is Assistant Professor of Medicine, University of Colorado, Denver Health Medical Center. Dr. Deresinski does research for the National Institutes of Health, and is an advisory board member and consultant for Merck, and Dr. Jenkins reports no financial relationships relevant to this field of study.

Sources: Newland JG, et al. Impact of a prospective-audit-with-feedback antimicrobial stewardship program at a children’s hospital. J Pediatr Infect Dis Soc 2012;1:179-186.

Stach LM, et al. Clinicians’ attitudes towards an antimicrobial stewardship program at a children’s hospital. J Pediatr Infect Dis Soc 2012;1:190-197.

In the first report (Newland et al), a quasi-experimental study with a control group (also known as a nonrandomized, postintervention design) was performed from 2004–2010 to determine the impact of an antimicrobial stewardship program (ASP) implemented in March 2008 in a tertiary care children’s hospital that was based on prospective-audit-with-feedback. The control group included 25 children’s hospitals.

A 5-step process was followed to develop the ASP. The team included an infectious disease physician, clinical pharmacist, and data analyst that worked closely with infection control, information systems, and the clinical microbiology laboratory. The clinical pharmacist documented use of broad-spectrum antimicrobials using an electronic health record system. Recommendations were communicated to the clinician caring for the child, with infectious diseases consultation for complex issues.

The team reviewed 10,460 antibiotics prescribed to 8,765 patients over the 30 months following the intervention in March 2008. The most common antibiotics reviewed included ceftriaxone, cefotaxime, ceftazidime, and vancomycin. A total of 2,378 recommendations were made in 1,703 (19%) patients, with the most common recommendation being to stop antibiotics (41%). Agreement with the recommendations occurred initially in 80% of cases, with overall compliance determined to be 92%, which did not change over time. In the intervention group, there was a strong temporal relationship between the ASP and a decline in the use of all antibiotics of 7% (P=0.045) in days of therapy per 1000 patient-days, and 8% (P=0.045) in length of therapy per 1000 patient-days. There were no increases seen in mortality or readmission rates during the study period.

In the second report (Stach et al), an electronic survey was administered to clinicians two years after the implementation to assess their attitudes toward the ASP. There were 205 of 365 participants (56%) that responded. Of these, 80% (160 of 199) had never worked with an ASP before the intervention. Respondents agreed that the ASP decreased the improper use of antibiotics (162 of 194, 84%), improved the quality of care of hospitalized children (159 of 194, 82%), and provided knowledge and education about appropriate antibiotic use (177 of 194, 91%). Adverse interpretations included a perceived loss of autonomy (22 of 194, 11%), perceived interference with clinical decision-making (12 of 194, 6%), and feeling threatened (9 of 194, 5%).

A majority of respondents (116 of 189, 61%) did not have a preference on whether the infectious disease physician or clinical pharmacist should communicate with the clinicians. However, many clinicians preferred communication from the infectious disease physician (44 of 189, 23%) or both the physician and pharmacist (29 of 189, 15%). Many clinicians (76 of 189, 40%) appreciated face-to-face interaction for communication rather than a page. Among attending physicians, most (71 of 96, 74%) felt that it was acceptable to be informed of recommendations through residents or nurse practitioners.

Commentary

This study documents that a prospective ASP can successfully decrease the use of broad-spectrum antibiotics in a tertiary care children’s hospital. The magnitude of decrease was comparable to that observed among adult institutions.

The clinician’s compliance with recommendations using this type of ASP was very high, providing insight to the potential benefit of using a prospective-audit-with-feedback over other strategies such as requiring preauthorization. There were substantial positive feelings among clinicians with this approach, with the vast majority believing that the ASP improved the quality of care for hospitalized children. Also, the clinicians reported minimal negative impact, such as a sense of interference with clinical decision-making and threatened autonomy.

This report illustrates that the five steps to successfully implement a prospective-audit-with-feedback antibiotic stewardship program are:

(1) developing the ASP team;

(2) determining the stewardship strategies and antimicrobials to monitor;

(3) establishing a method of identifying patients;

(4) designing an evaluation of the program;

(5) implementing the program.