A Culture Change: Impact of a Pediatric Antimicrobial Stewardship Program Based on Guideline Implementation and Prospective Audit with Feedback

Abstract

Reports analyzing the impact of pediatric antimicrobial stewardship programs (ASP) over long periods of time are lacking. We thus report our ASP experience in a pediatric tertiary referral center over a long-term period from 2011 to 2018. Our ASP was implemented in 2011. The program was based primarily on guideline development with key stakeholders, engaging and educating providers, followed by prospective audit with feedback (PAF). Monitored antibiotics included meropenem, piperacillin–tazobactam, and cefepime, followed by the addition of ceftriaxone, ceftazidime, cefotaxime, ciprofloxacin, levofloxacin, linezolid, and vancomycin at various time points. Specifically, the program did not implemented the core strategy of formulary restriction with prior authorization. Process- and outcome-related ASP measures were analyzed. We saw a 32% decrease in overall antibiotic utilization, a 51% decrease in the utilization of antibiotics undergoing PAF, and a 72% reduction in the use of broad-spectrum antibiotics such as meropenem. There was a concomitant increase in organism susceptibility and a reduction in yearly drug purchasing costs of over USD 560,000 from baseline without changes in sepsis-related mortality. Our study highlights that a pediatric ASP based primarily on the principles of guideline development and PAF can improve antibiotic utilization and institutional bacterial susceptibilities without a detrimental impact on patient outcomes by changing the culture of antimicrobial utilization within the institution.

Inappropriate Antibiotic Use in Zimbabwe in the COVID-19 Era: A Perfect Recipe for Antimicrobial Resistance

“…A combination of proper guideline development and education on the appropriate use of antimicrobials will empower prescribing clinicians and lead to a sustained cultural change in antimicrobial utilisation without compromising patient outcomes and improvements in resistance patterns and costs [ 4 ]. Even though the ongoing pandemic is stretching the limits of optimal antibiotic stewardship, a coordinated approach to developing a consensus on the evidence-based guidelines for empirical use of an antimicrobial, and the continued survey of their use by local stewardship teams, are essential to arrest the continued AMR risk [ 12 ].…”

“…The availability of effective antimicrobial agents, especially in sub-Saharan Africa, where the burden of infectious diseases is high, remains critical for adequate patient outcomes. However, over the years, antimicrobials, and in particular antibiotics, have prevailed as the most prescribed medications for patients, when their use has not been appropriate [ 4 ]. Both the overuse and improper use of antibiotics (including in humans, livestock, and food production), poor infection prevention and control practices, and international travel are considered some of the leading drivers for the emergence and spread of AMR [ 5 ].…”

Factors influencing receipt of an antibiotic prescription among insured patients in Tanzania: a cross-sectional study

“…47 48 Despite the challenges of implementing ASPs in paediatrics, clinical education, caregiver education, updated facility-specific guidelines and prospective audit and feedback are stewardship interventions shown to decrease antibiotic utilisation. [49][50][51] Being attended by a clinical officer or dental therapist is another factor which appears to influence prescription of an antibiotic. The prevalence of receipt of an antibiotic prescription was about 1.7 times higher in patients who were attended by either a clinical officer or dental therapists when compared with those seen by consultants.…”

“…ASPs should be strengthened in paediatrics so as to decrease antibiotic prescriptions as there is strong evidence supporting such an approach 47 48. Despite the challenges of implementing ASPs in paediatrics, clinical education, caregiver education, updated facility-specific guidelines and prospective audit and feedback are stewardship interventions shown to decrease antibiotic utilisation 49–51…”

“…This observation may be attributed to limited resources in terms of medications and diagnostic capabilities resulting in empirical prescribing of antibiotics. Indeed, targeting lower-level health facilities with antimicrobial stewardship interventions such clinical education, facility-specific guidelines for common infections, and antibiotic oversight through prospective audit and feedback may decrease antibiotic prescriptions 48 50…”