1142 infection control & hospital epidemiology october 2017, vol. 38, no. 10
reduced the proportion of newborns undergoing invasive evaluation and antibiotic treatment without any apparent adverse effects.33 Continued efforts such as these are a key component in further reducing unnecessary antimicrobial prescription in the NICU. Baseline antibiotic utilization in our NICU was low com-
pared to peer NICUs, yet we still demonstrated a statistically significant reduction in ampicillin utilization (the most fre- quently prescribed antibiotic in our NICU) in the stewardship period. This finding is likely the result of implementation of several aspects of our clinical guidelines which incorporate ampicillin use, including limiting the duration of postoperative antibiotic prophylaxis, eliminating the need for antibiotic prophylaxis after a single, uncomplicated urinary tract infection, and setting limitations for duration of treatment for NEC and early-onset clinical sepsis. No statistically significant changes in utilization of other commonly prescribed antibiotics, however, were
observed.Alowrate of tobramycin use was observed in the preintervention period that correlated with a gentamicin shortage, but not with changes in demographics or the burden of infection or NEC. The shortage may therefore have led to more judicious prescription practices. Clindamycin utilization remained unchanged over the study period. In our NICU, clindamycin is utilized as treatment for NEC. No significant changes in NEC rates observed over the study period may partly explain this finding. Vancomycin and cefotaxime utilization appeared to decline prior to ASP implementation. We experi- enced a substantial reduction in NICU-acquired infections from 2008 to 2010 after implementing an initiative to improve central-line–associated bloodstream infections,34 which may partially explain this observation. Our study has several limitations. DOT per 1,000 PD was used
as our main outcome measure, but the optimal metric for antibiotic stewardship has not been defined.4,35 Our primary focus was on improving antibiotic prescription, but we did not delve deeper into whether antimicrobial prescription practices are affected by specific conditions. We cannot prove that ASP implementation was directly responsible for any of the changes observed. Lastly, we were not powered to show differences in other outcome measures such as antimicrobial resistance between periods, so the impact of our programon this important metric remains undetermined. In summary, we demonstrated the successful design and
implementation of a multidisciplinary ASP in a level IV NICU, with improvements noted in antibiotic prescription practices. Our success is likely multifactorial, but we believe a key component was prospective audit and feedback to (and from) the prescriber. There has recently been a great deal of increased attention and resources allocated to the reduction of inappropriate antibiotic use on a national level, including international collaborative efforts among NICUs.36 Our efforts, as well as the overall reduction in antimicrobial utilization observed among NICUs in the Pediatric Health Information System, may exemplify a growing awareness that ASPs have the potential to not only reduce antibiotic overuse and misuse but
also to impact common neonatal morbidities and mortality faced by these extremely vulnerable infants.
acknowledgments
We would like to thank the NICU staff at YNHCH, and in the Division of Pediatric Surgery for their dedication, support, and diligence in improving antibiotic utilization. Financial support: No financial support was provided relevant to this article. Potential conflicts of interest: All authors report no conflicts of interest
relevant to this article. Address correspondence to Matthew J. Bizzarro, MD, Department of
Pediatrics, Division of Neonatal-Perinatal Medicine, PO Box 208064, New Haven, CT 06520-8064 (
matthew.bizzarro@
yale.edu).
references
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3. Wirtschafter DD, Padilla G, Suh O, Wan K, Trupp D, Fayard EE. Antibiotic use for presumed neonatally acquired infections far exceeds that for central line-associated blood stream infections: an exploratory critique. J Perinatol 2011;31:514–518.
4. Cantey JB, Wozniak PS, Sanchez PJ. Prospective surveillance of antibiotic use in the neonatal intensive care unit: results from the SCOUT study. Pediatr Infect Dis J 2015;34:267–272.
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