Miriam L Gonzalez1, Paula Aristizabal2,3,4, Adriana Loera-Reyna5, Dara Torres5, Mario Ornelas-Sánchez5, Laura Nuño-Vázquez5, Marco Aguilera5, Alicia Sánchez5, Mitzy Romano5, Rebeca Rivera-Gómez5, George Relyea6, Paola Friedrich1, Miguela A Caniza1,7. 1. Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN. 2. Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of California San Diego, La Jolla, CA. 3. Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA. 4. Population Sciences, Disparities and Community Engagement, Moores Cancer Center, University of California San Diego, La Jolla, CA. 5. Hospital General de Tijuana, Universidad Autónoma de Baja California, Tijuana, Baja California, Mexico. 6. School of Public Health, University of Memphis, Memphis, TN. 7. Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN.
Abstract
PURPOSE: Time to antibiotic administration (TTA) is a commonly used standard of care in pediatric cancer settings in high-income countries. Effective interventions to improve outcomes in cancer patients with febrile neutropenia (FN) often address timely and appropriate antibiotic administration. We assessed the effectiveness of a locally adapted multimodal strategy in decreasing TTA in a resource-constrained pediatric cancer center in Mexico. METHODS: We conducted a prospective observational study between January 2014 and April 2019. A three-phase (phase I: execution, phase II: consolidation, phase III: sustainability) multimodal improvement strategy that combined system change, FN guideline development, education, auditing and monitoring, mentoring, and dissemination was implemented to decrease TTA in inpatient and ambulatory areas. Sustainability factors were measured by using a validated tool during phases I and III. RESULTS: Our population included 105 children with cancer with 204 FN events. The baseline assessment revealed that only 50% of patients received antibiotics within 60 minutes of prescription (median time: inpatient, 75 minutes; ambulatory, 65 minutes). After implementing our improvement strategy, the percentage of patients receiving antibiotics within 60 minutes of prescription increased to 88%. We significantly decreased median TTA in both clinical areas during the three phases of the study. In phase III (sustainability), the median TTA was 40 minutes (P = .023) in the inpatient area and 30 minutes (P = .012) in the ambulatory area. The proportion of patients with sepsis decreased from 30% (baseline) to 5% (phase III) (P = .001). CONCLUSION: Our results demonstrate that locally adapted multimodal interventions can reduce TTA in resource-constrained settings. Mentoring and dissemination were novel components of the multimodal strategy to improve FN-associated clinical outcomes. Improving local infrastructure, ongoing monitoring systems, and leadership engagement have been key factors to achieving sustainability during the 5-year period.
PURPOSE: Time to antibiotic administration (TTA) is a commonly used standard of care in pediatric cancer settings in high-income countries. Effective interventions to improve outcomes in cancerpatients with febrile neutropenia (FN) often address timely and appropriate antibiotic administration. We assessed the effectiveness of a locally adapted multimodal strategy in decreasing TTA in a resource-constrained pediatric cancer center in Mexico. METHODS: We conducted a prospective observational study between January 2014 and April 2019. A three-phase (phase I: execution, phase II: consolidation, phase III: sustainability) multimodal improvement strategy that combined system change, FN guideline development, education, auditing and monitoring, mentoring, and dissemination was implemented to decrease TTA in inpatient and ambulatory areas. Sustainability factors were measured by using a validated tool during phases I and III. RESULTS: Our population included 105 children with cancer with 204 FN events. The baseline assessment revealed that only 50% of patients received antibiotics within 60 minutes of prescription (median time: inpatient, 75 minutes; ambulatory, 65 minutes). After implementing our improvement strategy, the percentage of patients receiving antibiotics within 60 minutes of prescription increased to 88%. We significantly decreased median TTA in both clinical areas during the three phases of the study. In phase III (sustainability), the median TTA was 40 minutes (P = .023) in the inpatient area and 30 minutes (P = .012) in the ambulatory area. The proportion of patients with sepsis decreased from 30% (baseline) to 5% (phase III) (P = .001). CONCLUSION: Our results demonstrate that locally adapted multimodal interventions can reduce TTA in resource-constrained settings. Mentoring and dissemination were novel components of the multimodal strategy to improve FN-associated clinical outcomes. Improving local infrastructure, ongoing monitoring systems, and leadership engagement have been key factors to achieving sustainability during the 5-year period.
Authors: Alison G Freifeld; Eric J Bow; Kent A Sepkowitz; Michael J Boeckh; James I Ito; Craig A Mullen; Issam I Raad; Kenneth V Rolston; Jo-Anne H Young; John R Wingard Journal: Clin Infect Dis Date: 2011-02-15 Impact factor: 9.079
Authors: Stuart H Cohen; Dale N Gerding; Stuart Johnson; Ciaran P Kelly; Vivian G Loo; L Clifford McDonald; Jacques Pepin; Mark H Wilcox Journal: Infect Control Hosp Epidemiol Date: 2010-05 Impact factor: 3.254
Authors: Dara Torres; Miriam L González; Adriana Loera; Marco Aguilera; George Relyea; Paula Aristizabal; Miguela A Caniza Journal: Am J Infect Control Date: 2016-01-05 Impact factor: 2.918
Authors: Asya Agulnik; Gia Ferrara; Maria Puerto-Torres; Srinithya R Gillipelli; Paul Elish; Hilmarie Muniz-Talavera; Alejandra Gonzalez-Ruiz; Miriam Armenta; Camila Barra; Rosdali Diaz; Cinthia Hernandez; Susana Juárez Tobias; Jose de Jesus Loeza; Alejandra Mendez; Erika Montalvo; Eulalia Penafiel; Estuardo Pineda; Dylan E Graetz Journal: JAMA Netw Open Date: 2022-03-01