Program Aims to Curb Inappropriate Antibiotics in Newborns

Neil Canavan

May 22, 2013

WASHINGTON, DC — An antimicrobial stewardship program eliminated some, but not all, inappropriate antibiotic use for more than 6000 babies in 4 neonatal intensive care units, new research shows.

"Although total antibiotic use was unchanged," admitted the study's principle investigator, Sameer Patel, MD, from the Columbia University Medical Center in New York City, "we may have decreased selective pressure due to decreased redundant use — the use of 2 drugs from the same drug class — and the unwarranted use of broad spectrum antibiotics."

Most studies of antimicrobial programs have been performed in hospitalized adults; what has been learned in that setting could have limited relevance to infants in neonatal intensive care.

"The unique features of antibiotic stewardship in neonates include diagnosis of culture-negative sepsis; difficulty in distinguishing infection from causation, such as with coagulase-negative staphylococci; and a relative lack of antimicrobial efficacy and pharmacokinetic data in children and, in particular, newborns," Dr. Patel explained.

The randomized controlled trial, presented here at the Pediatric Academic Societies 2013 Annual Meeting, compared total antibiotic use, failure to target therapy, and redundant therapy pre- and postintervention.

There were 4 programs:

  • Education — a series of 8 lectures on stewardship principles

  • Education and clinical decision support — in addition to the lectures, a tool was embedded in the electronic medical record system that provided patient-specific information on previous microbiology reports, including patterns of resistance, relevant drug levels, and measures of inflammatory markers

  • Education, clinical decision support, and audit, feedback — education and clinical decision support plus bimonthly prescribing data

  • Usual care (control group)

Although there were some notable successes, Dr. Patel noted that the study could have been underpowered, and it included outliers. "For example, in a given month, if you use vancomycin to treat methicillin-susceptible Staphylococcus aureus for an entire antibiotic course, you can have up to 10 or 11 days — so, nontargeted use; in the next month, it could drop down to 0 again because we encounter no other infections of that nature."

Table. Effect of the Program on Antibiotic Misuse

Outcome Education Education and Clinical Support Education, Clinical Support, and Audit, Feedback Usual Care
Total antibiotic use per 100 patient-days Up 1.6% (< .005) Unchanged Unchanged Unchanged
Days of redundant antibiotic use Unchanged Down 14.5% (< .001) Down 3.74% (< .039) Unchanged
Days of nontargeted use Unchanged Unchanged Unchanged Unchanged
Third- and fourth-generation cephalosporin and carbapenem use Down 5.37% (< .001) Down 14.9% (< .001) Down 9.12% (< .001) Unchanged
Days of vancomycin use Down 3.57% (= .002) Unchanged Down 1.43% (< .045) Unchanged

 

This approach could become part of an algorithm, Joern-Hendrik Weitkamp, MD, from Vanderbilt University School of Medicine in Nashville, Tennessee, who was not involved in the study, told Medscape Medical News.

"We used a similar algorithm, although not for a stewardship program per se," explained Dr. Weitkamp.

"We did a study using a computerized physician order entry system and a clinical decision support system to recommend stopping antibiotics when there is a negative blood culture." That program relied on reductions in C-reactive protein, which is commonly used in neonatal intensive care units to gauge when to back off antibiotic treatment in culture-negative sepsis, Dr. Weitkamp explained.

He speculated that the absence of active intervention to aid decision-making about when to stop antibiotics for culture-negative sepsis might have contributed to the modest results in the study by Dr. Patel and colleagues.

Session chair Margaret Hammerschlag, MD, from the State University of New York in Brooklyn, asked Dr. Patel if there were any compliance measures to gauge whether or not the staff had attended all of the prescribed educational lectures.

Dr. Patel explained that data are available, but they were not considered in the analysis. "Ongoing analysis will adjust for infection rates, gestational age, and surgeries," he noted.

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