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Antimicrobial Prophylaxis Use in the Neonatal Intensive Care Unit: An Antimicrobial Stewardship Target That Deserves
Isabelle Viel-Thériault1, Amisha Agarwal2, Erika Bariciak3
1Division of Infectious Diseases, Department of Pediatrics, Centre Hospitalier de l'Université Laval, Québec, Québec, Canada.
Insights
Antimicrobial misuse in neonatal intensive care units (NICUs) is common, particularly for surgical prophylaxis. Reducing postoperative antibiotic duration to under 24 hours requires collaboration between neonatologists and surgeons.
Area of Science:
- Neonatal Medicine
- Infectious Diseases
- Health Services Research
Background:
- Antimicrobial stewardship in neonatal intensive care units (NICUs) is crucial for combating antibiotic resistance.
- Previous studies often focused on mixed NICU settings, limiting applicability to specialized outborn tertiary care centers.
- Identifying specific drivers of antibiotic use in outborn NICUs is essential for targeted interventions.
Purpose of the Study:
- To analyze the primary indications for antimicrobial use in an outborn tertiary care NICU.
- To evaluate the appropriateness of antimicrobial therapy duration, particularly for surgical prophylaxis.
- To inform strategies for optimizing antimicrobial stewardship in this unique patient population.
Main Methods:
- A 10-month retrospective review of all antimicrobial prescriptions in a 20-bed level III NICU.
- Calculation of total days of therapy (DOT) and length of therapy (LOT) for each indication.
- Assessment of the appropriateness of antimicrobial courses based on established guidelines.
Main Results:
- Suspected early-onset sepsis (EOS) and prophylaxis were the most common indications for antimicrobial use.
- Surgical prophylaxis accounted for a significant portion of antimicrobial prescriptions (62% of prophylaxis).
- A high rate of inappropriate antimicrobial use was observed for postoperative prophylaxis (88.2%), primarily due to exceeding the 24-hour duration.
Conclusions:
- Surgical prophylaxis represents a key area for antimicrobial misuse in outborn NICUs.
- Achieving optimal antimicrobial use requires collaborative efforts between neonatologists and surgeons.
- Prospective audit and feedback alone may be insufficient without surgeon engagement to reduce prolonged postoperative antibiotic use.
Objective:
Previous analyses of neonatal intensive care units (NICU) antimicrobial stewardship programs have identified key contributors to overall antibiotic use, including prolonged empiric therapy >48 hours for early-onset sepsis (EOS). However, most were performed in mixed NICU settings with onsite birthing units, resulting in a high proportion of inborn patient admissions. The study aimed to describe and analyze the most common reasons for antimicrobial use in an outborn tertiary care NICU.
Study Design:
This was a 10-month review of all antimicrobial doses prescribed in a 20-bed level III NICU. The primary outcome was the total days of therapy (DOT) and length of therapy (LOT) for each clinical indication. Secondary outcomes included total DOT for each antimicrobial and appropriateness of antimicrobial courses.
Results:
Of 235 antibiotic courses and 1,899 DOT (519 DOT/1,000 patient days) prescribed in 173 infants during the study period, the most common indications were suspected EOS, followed by prophylaxis. Among the 85 DOT/1,000 patient days (PD; 38 courses) prescribed for prophylaxis, 52.5 DOT/1,000 PD (25 courses; 62%) were for surgical prophylaxis. Of 17 postoperative antibiotic courses, 15 (88.2%) were deemed to be inappropriate mostly due to a duration greater than 24 hours postoperatively (n = 13; median LOT = 3 days).
Conclusion:
Surgical prophylaxis is a common reason for antimicrobial misuse in outborn NICU. NICU-based prospective audit and feedback between neonatologists and antimicrobial stewardship teams alone may not be impactful in this setting. Partnerships with neonatologists and surgeons will be key to achieving the target of less than 24 hours of postoperative antimicrobials.
Key Points:
· Surgical prophylaxis is a common reason for antimicrobial misuse in the NICU.. · Antimicrobial prophylaxis duration of less than 24 hours postoperatively should be encouraged.. · NICU-based prospective audit and feedback may not be impactful unless surgeons are involved..
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