Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature Review

Abstract

Background: Antimicrobial stewardship (AMS) is an important strategy of quality improvement for every hospital. Leadership is an important factor for implementation of quality improvement and AMS programs. Recent publications show successful AMS programs in children's hospitals, but successful implementation is often difficult to achieve and literature of AMS in neonatal and pediatric intensive care units (NICU/PICU) is scarce. Lack of resources and prescriber opposition are reported barriers. A leadership style focusing on empowering frontline staff to take responsibility is one approach to implement changes in health care institutions.Aim: Literature review regarding empowering leadership and AMS in health care and assessment of the impact of such a leadership style on AMS in a NICU/PICU over 3 years.Methods: Assessment of the impact of a leadership change September 1, 2015 from control-driven to an empowering leadership style on antibiotic use and hospital acquired infections. Prospective analysis and annual comparison of antibiotic use, rate of suspected and confirmed ventilator-associated pneumonia (VAP) and central-line associated blood stream infection (CLABSI) including antibiotic use overall, antibiotic therapy for culture-negative and culture-proven infections including correct initial choice and streamlining of antibiotics in the NICU/PICU of the Children's Hospital of Lucerne between January 1, 2015 and December 31, 2017.Results: Five articles were included in the literature review. All five studies concluded that an empowering leadership style may lead to a higher engagement of physicians. Three out of five studies reported improved AMS as reduced rate in hospital-acquired infections and improved prevention of MRSA infections. From 2015 to 2017, antibiotic days overall and antibiotic days for culture-negative situations (suspected infections and prophylaxis) per 1000 patient days declined significantly from 474.1 to 403.9 and from 418.2 to 309.4 days, respectively. Similar, the use of meropenem and vancomycin declined significantly. Over the 3 years, suspected and proven VAP- and CLABSI-episodes decreased with no confirmed episodes in 2017.Conclusion: An empowering leadership style which focuses on enabling frontline physicians to take direct responsibilities for their patients may be a successful strategy of antimicrobial stewardship allowing to overcome reported barriers of AMS implementation.

Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program

“…Moreover, a continuous dialogue with prescribers and other target groups for the intervention, including involvement of local key opinion leaders, can increase adherence and acceptance and are potential factors for success. 124,125…”

Increasing use of linezolid in a tertiary NICU during a 10-year period: reasons and concerns for the future

“…Along with the choice of drugs, the removal of central line is recommended in case of persistent bacteremia and should not be forgotten. Finally the control of antibiotics’ use and the presence of a referring infectious disease specialist in NICUs may help to reduce antibiotic pressure [ 27 ], using for example care bundle methods of antibiotic stewardship as Ting et al implemented in 2014 in British Columbia Women’s Hospital and Health Centre [ 28 ]. The implementation of such care bundles is currently considered in the study NICU.…”

Colonization Screening Targeting Multidrug-Resistant Gram-Negative Pathogens Does Not Increase the Use of Carbapenems in Very Low Birth Weight Infants

“…This may have a negative impact on antibiotic stewardship ( 7 , 22 ). On the other hand, the DoT for carbapenems and LoT might not be substantially affected if carbapenems are used in MRGN-colonized infants as first-line empirical therapy but de-escalated to other antibiotics with a narrower spectrum of activity after an antibiotic “time-out” after 48 to 72 h of treatment ( 34 ); such an approach is part of an ABS program ( 34 ). Since no ABS program was implemented in our NICU/NIMC, a systematic de-escalation strategy was not followed.…”