Reducing Antibiotic Use in Respiratory Syncytial Virus—A Quality Improvement Approach to Antimicrobial Stewardship

Quintos-Alagheband, Maria Lyn; Noyola, Estela; Makvana, Sejal; El-Chaar, Gladys M.; Wang, Shan; Calixte, Rose; Krilov, Leonard R.

doi:10.1097/pq9.0000000000000046

Cited by 16 publications

(14 citation statements)

References 16 publications

(22 reference statements)

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“…A systematic review of practice change interventions in paediatric emergency medicine highlighted lack of reporting of methodology being a barrier to future improvement efforts [41]. Other studies report interventions to reduce unnecessary care being developed by expert clinicians [42,43]. While these interventions may have by chance addressed factors influencing the management of bronchiolitis they were not developed in a theory-informed manner.…”

Section: Discussionmentioning

confidence: 99%

Development of targeted, theory-informed interventions to improve bronchiolitis management

Haskell

Tavender

Wilson

et al. 2021

BMC Health Serv Res

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Background Despite international guidelines providing evidence-based recommendations on appropriate management of infants with bronchiolitis, wide variation in practice occurs. This results in infants receiving care of no benefit, with associated cost and is potentially harmful. Theoretical frameworks are increasingly used to develop interventions, utilising behaviour change techniques specifically chosen to target factors contributing to practice variation, with de-implementation often viewed as harder than implementing. This paper describes the stepped process using the Theoretical Domains Framework (TDF) to develop targeted, theory-informed interventions which subsequently successfully improved management of infants with bronchiolitis by de-implementing ineffective therapies. Explicit description of the process and rationale used in developing de-implementation interventions is critical to dissemination of these practices into real world clinical practice. Methods A stepped approach was used: (1) Identify evidence-based recommendations and practice variation as targets for change, (2) Identify factors influencing practice change (barriers and enablers) to be addressed, and (3) Identification and development of interventions (behaviour change techniques and methods of delivery) addressing influencing factors, considering evidence of effectiveness, feasibility, local relevance and acceptability. The mode of delivery for the intervention components was informed by evidence from implementation science systematic reviews, and setting specific feasibility and practicality. Results Five robust evidence-based management recommendations, targeting the main variation in bronchiolitis management were identified: namely, no use of chest x-ray, salbutamol, glucocorticoids, antibiotics, and adrenaline. Interventions developed to target recommendations addressed seven TDF domains (identified following qualitative clinician interviews (n = 20)) with 23 behaviour change techniques chosen to address these domains. Final interventions included: (1) Local stakeholder meetings, (2) Identification of medical and nursing clinical leads, (3) Train-the-trainer workshop for all clinical leads, (4) Local educational materials for delivery by clinical leads, (5) Provision of tools and materials targeting influencing factors, and prompting recommended behaviours, and (6) Audit and feedback. Conclusion A stepped approach based on theory, evidence and issues of feasibility, local relevance and acceptability, was successfully used to develop interventions to improve management of infants with bronchiolitis. The rationale and content of interventions has been explicitly described allowing others to de-implement unnecessary bronchiolitis management, thereby improving care.

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Section: Discussionmentioning

confidence: 99%

Development of targeted, theory-informed interventions to improve bronchiolitis management

Haskell

Tavender

Wilson

et al. 2021

BMC Health Serv Res

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“…Despite published guidelines, reducing the use of antibiotics for this illness continues to be a challenge. 7,8,[13][14][15] In their 2014 study, Parikh et al 16 National guidelines are an effective way of educating physicians and advocating for evidence-based practices; however, uptake among physicians is not uniform. Centerspecific interventions, such as local clinical pathways and antimicrobial stewardship interventions, appear to have the biggest impact on decreasing the use of unnecessary resources for bronchiolitis.…”

Section: Discussionmentioning

confidence: 99%

Antibiotic Use for Inpatient Bronchiolitis: Did National Guidelines Impact Practice at a Pediatric Hospital?

Lopez¹,

Aslanova

Bridger

et al. 2020

Hospital Pediatrics

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BACKGROUND AND OBJECTIVES: Bronchiolitis is a common lower respiratory tract infection that affects infants and young children. Because of variability in physician practice, inpatient management varies among pediatricians. In 2014, the Canadian Pediatric Society published national guidelines aimed at standardizing the inpatient management of this illness, which included recommending against the need for antibiotics for most patients. The study objective was to evaluate antibiotic prescription and supportive investigations for inpatient management of bronchiolitis before and after the publication of national guidelines. METHODS: This study was a single-center retrospective chart review of inpatients with bronchiolitis. We included healthy children 1 to 24 months of age who were admitted from November 2011 to October 2016. Those admitted before December 2014 were analyzed in the preguidelines cohort; the remaining, in the postguidelines cohort. The main outcome was antibiotic prescription. The secondary outcome was the frequency of chest radiographs, nasopharyngeal swabs, and blood cultures. RESULTS: A total of 131 patients were included in the first cohort; 71, in the second cohort. The rates of antibiotic initiation were almost equal in both cohorts (∼44%; P 5 .98). More antibiotics were discontinued during hospitalization in the second cohort compared with the first cohort (10% vs 20%; P 5 .001). Significantly fewer patients were discharged with antibiotics in the second cohort (31% vs 16%; P 5 .02). CONCLUSIONS: Our study revealed a reduction in antibiotic use after the release of national guidelines, illustrating that antibiotic prescribing practices can change. However, there is still a pressing need for local initiatives to continue to reduce the unnecessary use of antibiotics within the pediatric setting.

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“…The reduction in DOT per 1,000 patient-days in the >28 days old age group is greater than the 30% decrease in antimicrobial use for a similar population of children (excluded children <28 days old) and follow-up time where investigators used both educational initiatives aimed at both the ED and ward staff in addition to stewardship rounds in the hospital. 10 This reduction in antimicrobial use appears to be on the higher end when comparing overall reduction seen inpatient pediatric settings (6%–38%) following the implementation of stewardship programs. 11–13 AAP and CPS guidelines on bronchiolitis were published in 2014 and may have contributed to the willingness to discontinue antimicrobials, but literature is conflicted as to whether guidelines can significantly reduce use to the extent that we observed in our study.…”

Section: Discussionmentioning

confidence: 99%

Pediatric Inpatient Antimicrobial Stewardship Program Safely Reduces Antibiotic Use in Patients with Bronchiolitis Caused by Respiratory Syncytial Virus: A Retrospective Chart Review

Kalil

Bowes

Reddy

et al. 2019

Pediatric Quality &Amp; Safety

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Introduction:Bronchiolitis is a common lower respiratory tract illness in young children often caused by the respiratory syncytial virus (RSV). Antimicrobials are not recommended in infants with bronchiolitis unless there is strong evidence that a bacterial coinfection exists.Methods:We conducted a retrospective chart review comparing antimicrobial use and outcomes in previously healthy infants ≤24 months of age with RSV bronchiolitis at a single Canadian tertiary pediatric hospital during RSV seasons (December–April) from 2011 to 2016. An audit and feedback antimicrobial stewardship program was introduced in this hospital in August 2014.Results:Compared with the 2011–2012 cohort, the 2015–2016 cohort showed a decrease of 46% in mean days of therapy per 1,000 patient-days in the >28 days old age group of patients. There was also a 15.1% absolute reduction in the proportion of patients who received any antimicrobials in the hospital between the 2 cohorts (neonates included). The proportion of patients receiving antimicrobial prescriptions at discharge also decreased from 33.5% to 19%. The use of second-generation cephalosporins was eliminated in the 2016 cohort. There was a significant decrease in length of stay between the 2011–2012 and 2015–2016 cohorts, and no readmissions were documented.Conclusions:This study adds to the accumulating literature that antimicrobial stewardship program interventions along with guidelines and order sets can safely contribute to a reduction in antimicrobial use both in hospital and at discharge in children <2 years of age hospitalized due to RSV. Further research in identifying those who would or would not benefit from antibiotics should be promoted.

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Reducing Antibiotic Use in Respiratory Syncytial Virus—A Quality Improvement Approach to Antimicrobial Stewardship

Abstract: Supplemental Digital Content is available in the text.

Cited by 16 publications

References 16 publications

Development of targeted, theory-informed interventions to improve bronchiolitis management

Development of targeted, theory-informed interventions to improve bronchiolitis management

Antibiotic Use for Inpatient Bronchiolitis: Did National Guidelines Impact Practice at a Pediatric Hospital?

Pediatric Inpatient Antimicrobial Stewardship Program Safely Reduces Antibiotic Use in Patients with Bronchiolitis Caused by Respiratory Syncytial Virus: A Retrospective Chart Review

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