A Quality Assessment of a Collaborative Model of a Pediatric Antimicrobial Stewardship Program

Abstract

BACKGROUND: Infectious Diseases Society of America guidelines recommend that key antimicrobial stewardship program (ASP) personnel include an infectious disease (ID) physician leader and dedicated ID-trained clinical pharmacist. Limited resources prompted development of an alternative model by using ID physicians and service-based clinical pharmacists at a pediatric hospital. The aim of this study was to analyze the effectiveness and impact of this alternative ASP model. METHODS: The collaborative ASP model incorporated key strategies of education, antimicrobial restriction, day 3 audits, and practice guidelines. High-use and/or high-cost antimicrobial agents were chosen with audits targeting vancomycin, caspofungin, and meropenem. The electronic medical record was used to identify patients requiring day 3 audits and to communicate ASP recommendations. Segmented regression analyses were used to analyze quarterly antimicrobial agent prescription data for the institution and selected services over time. RESULTS: Initiation of ASP and day 3 auditing was associated with blunting of a preexisting increasing trend for caspofungin drug starts and use and a significant downward trend for vancomycin drug starts (relative change –12%) and use (–25%), with the largest reduction in critical care areas. Although meropenem use was already low due to preexisting requirements for preauthorization, a decline in drug use (–31%, P = .021) and a nonsignificant decline in drug starts (–21%, P = .067) were noted. A 3-month review of acceptance of ASP recommendations found rates of 90%, 93%, and 100% for vancomycin, caspofungin, and meropenem, respectively. CONCLUSIONS: This nontraditional ASP model significantly reduced targeted drug usage demonstrating acceptance of integration of service-based clinical pharmacists and ID consultants.

Implementation and Impact of an Antimicrobial Stewardship Program at a Non-freestanding Children's Hospital

“…When consensus opinion determined that a recommendation was warranted, team members would jointly present the advice to providers immediately following conclusion of the standing meeting, while also concurrently discussing with providers the team's rationale underlying the proposed recommendations-consistent with the successful "prospective audit-with-feedback" approach as described elsewhere. [2][3][4][5][6][7][8][9][10][12][13][14][15] In the event of a recommendation's verbal acceptance by a provider, documentation (in the form of a progress note indicating the mutually agreed upon recommendation) would be placed in the patient's electronic medical record.…”

“…The framework for successful ASP implementation requires understanding institutional expectations, limitations likely to be encountered, and awareness of available resources that can facilitate successful program establishment and maintenance. 2,3 In contrast to multiple studies in the medical literature describing successful outcomes associated with formal ASP implementation at large freestanding US children's hospitals, 1,[4][5][6][7][8][9] to the best of our knowledge only one prior study describes outcomes associated with ASP establishment at a non-freestanding pediatric institution, 10 and implementation of a non-freestanding pediatric hospital ASP has yet to be described in detail. Patient populations and antibiotic prescribing practices at such institutions often differ from those at freestanding children's hospitals, and resources for successful program implementation and monitoring may be more limited.…”

Expanding Existing Antimicrobial Stewardship Programs in Pediatrics: What Comes Next

“…Prospective audit and feedback, formulary restriction, and clinical guidelines were commonly cited (87%) by these programs as strategies used. Although most ASPs follow the model of using dedicated clinical pharmacy and infectious disease (ID) specialists, at least 1 pediatric ASP uses an alternative model to operationalize its program and integrates ASP activities into the daily function of service-based clinical pharmacists and of ID physicians during weekends and holidays [10]. Several reports that described ASPs in adult institutions also described a model of including multiple clinical pharmacists' participation in their ASP activities [11,12].…”

“…A limitation of DOT is that it cannot account for spectrum of activity, so the use of a narrow-spectrum multidrug regimen will increase the DOT metric more than the use of a single very-broad-spectrum agent. Similarly, the DOT measure alone cannot capture desired therapy changes, such as deescalation from a single broad-spectrum agent to a more targeted one, but this limitation can be addressed by tracking consumption of specific targeted agents [10]. Complementary metrics, such as the antibiotic spectrum index, have been developed to measure patterns of antibiotic selection and deescalation and address these limitations [16].…”

A One Health future to meet the AMR challenge?

“…The New Zealand Veterinary Association has set an aspirational goal that "By 2030 New Zealand Inc. will not need antibiotics for the maintenance of animal health and wellness"; a goal that could have some resonance for situations where doctors prescribe antimicrobials when there is no clear evidence of a bacterial infection that will respond better to antimicrobials than to supportive care. Hospitals are successfully employing antimicrobial stewardship pharmacists to directly influence antimicrobial prescribing, including improving the appropriateness of antimicrobial choice and enforcing rules such as limiting prescription of particular antimicrobials without special authorisation (Roberts et al 2015;Nguyen-Ha et al 2016). This type of approach might be a useful model for thinking about how to reduce the use of some products in veterinary medicine that are convenient but not best practice in many situations, e.g.…”