V Lamba1, S D'souza2, C Carafa3, A Zepf4, C L Bassel4, M Gutierrez5, M Balakrishnan6. 1. Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, TN, USA. vlamba1@uthsc.edu. 2. Wesley Medical Center, Wichita, KS, USA. 3. Department of Pediatrics, UM/Jackson Memorial Hospital, Miami, FL, USA. 4. Tampa General Hospital, Tampa, FL, USA. 5. Tuscon Medical Center, Tucson, AZ, USA. 6. Department of Pediatrics, University of South Florida Health, Tampa, FL, USA.
Abstract
BACKGROUND: Antibiotics are the most prescribed medication in the neonatal intensive care unit (NICU) and there is marked variation in their use. While they are vital for treatment of infections, they put infants at risk for infections with drug resistant organisms, alteration in their microbiome and several other morbidities. Specific guidelines for neonates are often lacking and our NICU is not compliant with late onset sepsis (LOS) guidelines. OBJECTIVE: By January 2019, there will be >75% compliance with our LOS bundle for any infant admitted to Tampa General Hospital's (TGH) NICU undergoing a LOS evaluation at >72 h of life. The bundle includes documented reason for LOS evaluation, appropriate initial antibiotic selection, appropriate initial evaluation considered, and appropriate de-escalation of antibiotics. STUDY DESIGN: The project was implemented in the NICU at TGH, the academic medical center affiliated with the University of South Florida in Tampa, FL. The multidisciplinary antimicrobial stewardship (ASP) team responsible for the project consists of a neonatology attending, three neonatology fellows, a pediatric infectious disease attending, and two NICU pharmacists. The project was started in January 2017 and all data were collected prospectively. We implemented multiple Plan-Do-Study-Act cycles in a stepwise manner; outcome measures included compliance with the LOS bundle and ASP team recommendations. Our process measures were the documented reason for sepsis evaluation, appropriate initial evaluation considered, appropriate antibiotic selection and appropriate antibiotic de-escalation. Patient length of stay was the balancing measure studied. RESULTS: During this 20-month initiative, there were 232 infants who underwent LOS evaluation and there were 98 true positive cultures from blood (28%), urine (35%), and cerebrospinal fluid (3%). Commonly documented rationales for treatment of culture negative sepsis were clinical pneumonia (38%) and necrotizing enterocolitis (38%). Common indications for LOS evaluations were increased respiratory support (51%) and abdominal distension (17%). There was improvement in appropriate initial antibiotic selection (70% vs. 94%); appropriate consideration of initial evaluation (63% vs. 94%, respectively); appropriate de-escalation of antibiotics (86% vs. 100%, respectively) and increase in LOS bundle compliance (44% vs. 87%, respectively). The overall antibiotic utilization rate and length of treatment did not change significantly. CONCLUSIONS: Developing and engaging a NICU ASP team improves compliance with late onset sepsis guidelines through the implementation of a LOS bundle of care.
BACKGROUND: Antibiotics are the most prescribed medication in the neonatal intensive care unit (NICU) and there is marked variation in their use. While they are vital for treatment of infections, they put infants at risk for infections with drug resistant organisms, alteration in their microbiome and several other morbidities. Specific guidelines for neonates are often lacking and our NICU is not compliant with late onset sepsis (LOS) guidelines. OBJECTIVE: By January 2019, there will be >75% compliance with our LOS bundle for any infant admitted to Tampa General Hospital's (TGH) NICU undergoing a LOS evaluation at >72 h of life. The bundle includes documented reason for LOS evaluation, appropriate initial antibiotic selection, appropriate initial evaluation considered, and appropriate de-escalation of antibiotics. STUDY DESIGN: The project was implemented in the NICU at TGH, the academic medical center affiliated with the University of South Florida in Tampa, FL. The multidisciplinary antimicrobial stewardship (ASP) team responsible for the project consists of a neonatology attending, three neonatology fellows, a pediatric infectious disease attending, and two NICU pharmacists. The project was started in January 2017 and all data were collected prospectively. We implemented multiple Plan-Do-Study-Act cycles in a stepwise manner; outcome measures included compliance with the LOS bundle and ASP team recommendations. Our process measures were the documented reason for sepsis evaluation, appropriate initial evaluation considered, appropriate antibiotic selection and appropriate antibiotic de-escalation. Patient length of stay was the balancing measure studied. RESULTS: During this 20-month initiative, there were 232 infants who underwent LOS evaluation and there were 98 true positive cultures from blood (28%), urine (35%), and cerebrospinal fluid (3%). Commonly documented rationales for treatment of culture negative sepsis were clinical pneumonia (38%) and necrotizing enterocolitis (38%). Common indications for LOS evaluations were increased respiratory support (51%) and abdominal distension (17%). There was improvement in appropriate initial antibiotic selection (70% vs. 94%); appropriate consideration of initial evaluation (63% vs. 94%, respectively); appropriate de-escalation of antibiotics (86% vs. 100%, respectively) and increase in LOS bundle compliance (44% vs. 87%, respectively). The overall antibiotic utilization rate and length of treatment did not change significantly. CONCLUSIONS: Developing and engaging a NICU ASP team improves compliance with late onset sepsis guidelines through the implementation of a LOS bundle of care.
Authors: Pavel Prusakov; Debra A Goff; Phillip S Wozniak; Azraa Cassim; Catherine E A Scipion; Soledad Urzúa; Andrea Ronchi; Lingkong Zeng; Oluwaseun Ladipo-Ajayi; Noelia Aviles-Otero; Chisom R Udeigwe-Okeke; Rimma Melamed; Rita C Silveira; Cinzia Auriti; Claudia Beltrán-Arroyave; Elena Zamora-Flores; Maria Sanchez-Codez; Eric S Donkor; Satu Kekomäki; Nicoletta Mainini; Rosalba Vivas Trochez; Jamalyn Casey; Juan M Graus; Mallory Muller; Sara Singh; Yvette Loeffen; María Eulalia Tamayo Pérez; Gloria Isabel Ferreyra; Victoria Lima-Rogel; Barbara Perrone; Giannina Izquierdo; María Cernada; Sylvia Stoffella; Sebastian Okwuchukwu Ekenze; Concepción de Alba-Romero; Chryssoula Tzialla; Jennifer T Pham; Kenichiro Hosoi; Magdalena Cecilia Calero Consuegra; Pasqua Betta; O Alvaro Hoyos; Emmanuel Roilides; Gabriela Naranjo-Zuñiga; Makoto Oshiro; Victor Garay; Vito Mondì; Danila Mazzeo; James A Stahl; Joseph B Cantey; Juan Gonzalo Mesa Monsalve; Erik Normann; Lindsay C Landgrave; Ali Mazouri; Claudia Alarcón Avila; Fiammetta Piersigilli; Monica Trujillo; Sonya Kolman; Verónica Delgado; Veronica Guzman; Mohamed Abdellatif; Luis Monterrosa; Lucia Gabriella Tina; Khalid Yunis; Marco Antonio Belzu Rodriguez; Nicole Le Saux; Valentina Leonardi; Alessandro Porta; Giuseppe Latorre; Hidehiko Nakanishi; Michal Meir; Paolo Manzoni; Ximena Norero; Angela Hoyos; Diana Arias; Rubén García Sánchez; Alexandra K Medoro; Pablo J Sánchez Journal: EClinicalMedicine Date: 2021-01-29