Opportunities for Antibiotic Stewardship Interventions in a Pediatric Hospital

Abstract

Objective This study's objective was to assess an antibiotic stewardship intervention, compare pediatric antibiotic usage in a non-university hospital (Children's Hospital Traunstein [TS]) with a university hospital (Dr. von Hauner Children's Hospital, Ludwig Maximilians University Munich [MUC]), and assess adherence to national guidelines.

Methods Antibiotic usage pre- and post-antibiotic stewardship (ABS) intervention was compared, and antibiotic prescriptions over 4 months were prospectively recorded. ABS intervention consisted of weekly teaching sessions, antibiotic pocket cards, and rounds with pediatric infectious disease staff. Medical records were reviewed to describe antibiotic consumption, antibiotic dosages and length of use, and adherence to national guidelines. Pediatric antibiotic usage was compared between hospitals and patient groups.

Results After the ABS intervention, the use of second-generation cephalosporins decreased, while penicillin with β-lactamase inhibitors (BLI) increased. Survey of antibiotic prescriptions over the 4 months study period in the non-university hospital showed a high administration rate of second-generation cephalosporins and extended-spectrum penicillins in the non-intensive care units (ICU) wards (48.53 and 38.93 days of therapy [DoT]/1,000 patient days [PD], respectively) and a high rate of third-generation cephalosporins in the ICU ward (110.33 DoT/1,000PD). A high prescriptions rate was seen in the neonatal intensive care unit (NICU) wards (DoT/ length of therapy [LoT] ratio of 2.185). Reserve group antibiotics were only given in the ICU. Adherence to national guidelines was highest in the NICU and pediatric ICU wards. Striking was the relatively high rate of incorrect usage of second-generation cephalosporins. Comparing the pediatric wards of the non-university hospital (TS) and the university hospital (MUC), the prescription ratio was 11.1% (TS) versus 30.6% (MUC), and DoT/1,000PD 198.9 (TS) versus 483.6 (MUC), p = 0.02. ABS intervention changed the choice of described antibiotics, but not the overall frequency.

Conclusion Adherence to national guidelines was highest in fields with standardized therapy recommendations, like in the NICU. In MUC, antibiotics, in particular restricted ones, were prescribed more frequently, probably due to higher severity of illness.

These data indicate that the usage of antibiotics and adherence to national guidelines show a wide variety, but ABS interventions were effective in changing prescription behavior.

Keywords

antibiotic prescription - days of therapy per 1000 patient days - defined daily dose per 100 patient days - antibiotic stewardship

Ethical Approval

Only completely anonymized raw data were used for the study, and the ethics commission of the Ludwig-Maximilians-University Munich was informed about the planned study prior to the start of the study and the need for informed consent and ethics approval was waived.

Availability of Data and Materials

The datasets analyzed during the current study are available from G.G.-K., M.D., on reasonable request.

Authors' Contributions

G. G.-K. performed data analysis; G. G.-K., J. H., A. P., and G. W. all contributed to writing the manuscript; external statistical consultation was obtained by G. G.-K.; the manuscript was discussed on a regular basis between all authors; and all authors read the final version of the manuscript and approved submission to the journal.

Publication History

Received: 04 August 2021

Accepted: 03 December 2021

Article published online:
28 February 2022

• References

• 1 Gerber JS, Newland JG, Coffin SE. et al. Variability in antibiotic use at children's hospitals. Pediatrics 2010; 126 (06) 1067-1073
• 2 Tribble AC, Lee BR, Flett KB. et al; Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative. Appropriateness of antibiotic prescribing in United States Children's Hospitals: a national point prevalence survey. Clin Infect Dis 2020; 71 (08) e226-e234
• 3 Charani E, Castro-Sanchez E, Sevdalis N. et al. Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette”. Clin Infect Dis 2013; 57 (02) 188-196
• 4 Kreitmeyr K, von Both U, Pecar A, Borde JP, Mikolajczyk R, Huebner J. Pediatric antibiotic stewardship: successful interventions to reduce broad-spectrum antibiotic use on general pediatric wards. Infection 2017; 45 (04) 493-504
• 5 Renk H, Sarmisak E, Spott C, Kumpf M, Hofbeck M, Hölzl F. Antibiotic stewardship in the PICU: impact of ward rounds led by paediatric infectious diseases specialists on antibiotic consumption. Sci Rep 2020; 10 (01) 8826
• 6 Methodology WCCfDS. ATC/DDD Index 2018. Accessed on July 26, 2021 at: https://www.whocc.no/atc_ddd_index/
• 7 WHO. AWaRe Classification Antibiotics 2019. Accessed on July 26, 2021 from: https://adoptaware.org/
• 8 Berner. DGPI Handbuch: Thieme. 2018 Deutsche Gesellschaft für Pädiatrische Infektiologie e.V. (DGPI); Berner, Reinhard; Bialek, Ralf; et al: 2018
• 9 Borde JP, Kaier K, Steib-Bauert M. et al. Feasibility and impact of an intensified antibiotic stewardship programme targeting cephalosporin and fluoroquinolone use in a tertiary care university medical center. BMC Infect Dis 2014; 14: 201
• 10 Borde JP, Batin N, Rieg S. et al. Adherence to an antibiotic stewardship bundle targeting Staphylococcus aureus blood stream infections at a 200-bed community hospital. Infection 2014; 42 (04) 713-719
• 11 Borde JP, Kern WV, Hug M. et al. Implementation of an intensified antibiotic stewardship programme targeting third-generation cephalosporin and fluoroquinolone use in an emergency medicine department. Emerg Med J 2015; 32 (07) 509-515
• 12 Autore G, Bernardi L, Esposito S. Update on acute bone and joint infections in paediatrics: a narrative review on the most recent evidence-based recommendations and appropriate antinfective therapy. Antibiotics (Basel) 2020; 9 (08) E486