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Published on: August 30, 2018
Antimicrobial Stewardship and Improved Antibiotic Utilization in the Pediatric Cardiac Intensive Care Unit
Margot M Hillyer1, Preeti Jaggi2, Nikhil K Chanani3
1Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine.
Insights
A quality improvement initiative successfully reduced broad-spectrum antibiotic use in a pediatric cardiac intensive care unit. Antimicrobial stewardship team interventions led to sustained decreases in vancomycin and meropenem days of therapy without increasing mortality.
Area of Science:
- Pediatric Critical Care Medicine
- Infectious Diseases
- Health Services Research
Background:
- A multidisciplinary antimicrobial stewardship team was established to optimize antibiotic prescribing in a Pediatric Cardiac Intensive Care Unit (PCICU).
- A quality improvement initiative aimed to reduce unnecessary broad-spectrum antibiotic use by 20% with sustained impact.
- The initiative focused on addressing antibiotic overuse through provider education and practice standardization.
Purpose of the Study:
- To evaluate the effectiveness of a quality improvement initiative in reducing broad-spectrum antibiotic use in a PCICU.
- To assess the impact of antimicrobial stewardship interventions on antibiotic consumption and patient outcomes.
- To determine if reductions in specific antibiotic use led to increased use of alternative broad-spectrum agents or adverse events.
Main Methods:
- The quality improvement initiative utilized Plan-Do-Study-Act (PDSA) cycles within a quaternary care center.
- Primary outcome was measured in days of therapy (DOT) per 1000 patient days for targeted antibiotics.
- Statistical process control charts were used to analyze trends in antibiotic use, with process and balancing measures monitored.
Main Results:
- Significant and sustained reductions in vancomycin (31%) and meropenem (67%) use were observed.
- Overall gram-negative antibiotic use decreased by 26%, with no increase in alternative broad-spectrum agents like cefepime or piperacillin-tazobactam.
- Electronic medical record interventions, including automatic stop times and standardized empiric orders, were key drivers of change. All-cause mortality remained unchanged.
Conclusions:
- The implementation of a dedicated antimicrobial stewardship initiative effectively reduced vancomycin and meropenem utilization in the PCICU.
- The interventions successfully decreased broad-spectrum antibiotic use without negatively impacting patient mortality or increasing the use of alternative broad-spectrum agents.
- Future efforts will focus on expanding stewardship interventions to target other broad-spectrum antimicrobials.
Background:
We developed a multidisciplinary antimicrobial stewardship team to optimize antimicrobial use within the Pediatric Cardiac Intensive Care Unit. A quality improvement initiative was conducted to decrease unnecessary broad-spectrum antibiotic use by 20%, with sustained change over 12 months.
Methods:
We conducted this quality improvement initiative within a quaternary care center. PDSA cycles focused on antibiotic overuse, provider education, and practice standardization. The primary outcome measure was days of therapy (DOT)/1000 patient days. Process measures included electronic medical record order-set use. Balancing measures focused on alternative antibiotic use, overall mortality, and sepsis-related mortality. Data were analyzed using statistical process control charts.
Results:
A significant and sustained decrease in DOT was observed for vancomycin and meropenem. Vancomycin use decreased from a baseline of 198 DOT to 137 DOT, a 31% reduction. Meropenem use decreased from 103 DOT to 34 DOT, a 67% reduction. These changes were sustained over 24 months. The collective use of gram-negative antibiotics, including meropenem, cefepime, and piperacillin-tazobactam, decreased from a baseline of 323 DOT to 239 DOT, a reduction of 26%. There was no reciprocal increase in cefepime or piperacillin-tazobactam use. Key interventions involved electronic medical record changes, including automatic stop times and empiric antibiotic standardization. All-cause mortality remained unchanged.
Conclusions:
The initiation of a dedicated antimicrobial stewardship initiative resulted in a sustained reduction in meropenem and vancomycin usage. Interventions did not lead to increased utilization of alternative broad-spectrum antimicrobials or increased mortality. Future interventions will target additional broad-spectrum antimicrobials.
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