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Purpose Medications are commonly associated with acute kidney injury (AKI). However, in both clinical practice and research, consideration of specific medications as nephrotoxic varies widely. The Nephrotoxic Injury Negated by Just-in-time Action quality improvement collaborative was formed to focus on prevention or reduction of nephrotoxic medication-associated AKI in noncritically ill hospitalized children. However, there were discrepancies among institutions as to which medications should be considered nephrotoxic. The collaborative convened a Nephrotoxic Medication (NTMx) Subcommittee to develop a consensus for the classification of nephrotoxic medications. Summary The NTMx Subcommittee initially included pediatric nephrologists, a pharmacist, and a pediatric intensivist. The committee reviewed NTMx lists from the collaborative and identified changes from the initial NTMx list. The NTMx Subcommittee conducted a literature review of the disputed medications and assigned an evidence grade based on the reported association with nephrotoxicity and the quality of the data. The association between medication exposure and AKI was also determined using administrative data from the Pediatric Health Information Systems database. The NTMx Subcommittee then came to a majority consensus regarding which medications should be included on the list. The subcommittee’s recommendations were presented to the larger collaborative for approval, and consensus was achieved. The list continues to be reviewed and updated annually. Conclusion Formation of a multicenter quality-improvement initiative exposed current limitations as to which medications are considered nephrotoxic in clinical and research settings and presented an opportunity to approach this problem using an evidence-based process. A consensus definition of nephrotoxic-medication exposure was achieved.

Purpose To evaluate the effectiveness and safety of mandatory antimicrobial indications and durations (MAID) and a pharmacist-driven 48-hour time-out in a pediatric hospital. Methods MAID and a 48-hour time-out were implemented on February 14, 2017. Antibiotic days of therapy (DOT) per 1,000 patient days were compared between the pre- and postperiod for select antibiotics using unadjusted Poisson models. A prepost comparison was used to compare antimicrobial stewardship program (ASP) intervention rates between time periods. A 2-step process, including distribution of a discontinuation (DC) report to pharmacists and ASP-prompted reorders, was instituted to reduce unintentional antimicrobial discontinuation with MAID. ASP-prompted reorders occurred only when a discrepancy persisted between the order and provider-desired duration. Missed antimicrobial doses were identified by ASP and the institutional event reporting system. Safety of MAID was assessed by reviewing the rate and details of ASP-prompted reorders and missed antimicrobial doses. Results A significant decrease in DOT per 1,000 patient days was observed for cefazolin (39.7 to 36.9; P < 0.001), ampicillin (39.9 to 35.7; P < 0.001), clindamycin (38.2 to 35.9; P < 0.001), ceftriaxone (46.5 to 43.4; P < 0.001), and meropenem (8.7 to 6.6; P < 0.001) following implementation. No change in ASP intervention rate occurred between the pre- and postperiod (16.9 vs 16.8%; P = 0.94). With MAID, ASP-prompted reorder occurred on 7.3% of orders. Unintentional discontinuations resulting in missed antimicrobial doses occurred in 3 orders (0.07%); no patient harm resulted. Conclusion MAID and a 48-hour time-out significantly reduced DOT of select antibiotics. No patient harm occurred with the 2-step safety process.

Children presenting to an emergency department following an animal bite were found to be at risk for infection if they had puncture wounds, crush wounds, or were bitten by a cat. Of the infected wounds that were cultured, methicillin-resistant Staphylococcus aureus was not isolated as a pathogen.

Hospital-wide antibiograms provide general susceptibility patterns. Specific antibiograms were created for methicillin-resistant Staphylococcus aureus isolates based on infection process and epidemiology. Using clinical microbiology laboratory data and patient profiles, high clindamycin resistance rates were seen for nonskin and soft tissue infections and noncommunity-associated methicillin-resistant S. aureus isolates.

BackgroundRequired indication/duration and a 48-hour antimicrobial time out are an integral part of antimicrobial stewardship standards; however, limited data are available to demonstrate an effect on antimicrobial use and stewardship practice. We evaluated the impact of mandatory declared indications/durations along with a 48-hour time out on antimicrobial utilization and antimicrobial stewardship program (ASP) interventions.MethodsWe performed a retrospective evaluation of ASP interventions and antimicrobial use following implementation of mandatory indication/duration at the point of order entry. A 48-hour antimicrobial time out was introduced on the same date. This study was conducted at Children’s Mercy Kansas City, a freestanding pediatric hospital located in Kansas City, Missouri. Data were collected from February 1, 2016 to January 31, 2018. A pre- and postcomparison was performed; interventions were implemented hospital-wide on February 14, 2017. ASP intervention rates were measured. Days of therapy (DOT) per 1,000 patient-days of antibiotics were evaluated. Poisson models were utilized to compare DOT rates pre- and postimplementation, and seasonal decomposition analyses were performed to account for seasonal variability.ResultsA significant decrease in DOT rates was observed in non-ASP monitored antibiotics postimplementation, including cefazolin (39.7 to 36.9; P < 0.001), ampicillin (39.9 to 35.7; P < 0.001), and clindamycin (38.2 to 35.9; P < 0.001). Additionally, a decrease also occurred in ASP monitored antibiotics including ceftriaxone (46.5 to 43.4; P < 0.001) and meropenem (8.7 to 6.6; P < 0.001). Vancomycin usage was unchanged. Cefepime and piperacillin/tazobactam were excluded due to the impact of drug shortages. ASP intervention rates did not decrease (16.9% vs. 16.8%, P = 0.94). ConclusionImplementation of additional stewardship practices, including mandatory antimicrobial indication/duration and a 48-hour time out, decreased the use of antimicrobials, including those not monitored by our ASP. These efforts augmented, but did not replace existing stewardship efforts. These results support initiatives highlighted by national organizations to minimize unnecessary antimicrobial use through ASP.Disclosures All authors: No reported disclosures.

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