infection control & hospital epidemiology october 2017, vol. 38, no. 10 commentary


A Blueprint for Targeted Antimicrobial Stewardship in Neonatal Intensive Care Units


Candace L. Johnson, MD;1 Lisa Saiman, MD, MPH1,2


(See the article by Bizzarro et al. on pages 1137–1143.) The concern that antibiotic overuse contributes to the deve- lopment of resistant pathogens is not new; Sir Ian Fleming famously warned of the dangers of antibiotic-resistant organisms in 1945, less than 20 years after he discovered penicillin.1 However, only in the last 20 years has the concept of antimicrobial stewardship gained traction as a critical tool in our armamentarium against the emergence of drug-resistant pathogens and as an important metric for patient safety and quality. Indeed, the necessity for rapid implementation of antimicrobial stewardship nationally and globally has emerged as an urgent priority. Early efforts at developing antimicrobial stewardship pro-


grams (ASPs)—and thus much of the data available on the feasibility and outcomes of such programs—were concentrated in acute-care settings and established the utility of the core antimicrobial stewardship strategies of formulary restriction and prospective audit and feedback.2 In recent years, as stewardship has expanded to ambulatory care and nursing homes, it has become clear that a “one size fits all” blueprint for antimicrobial stewardship cannot accommodate the needs of all healthcare settings. A prominent example of the necessity of modifying antimicrobial stewardship for special settings and populations is the Centers for Disease Control and Prevention’s campaign for ASP implementation in nursing homes.3 Prioritizing antimicrobial stewardship initiatives for vulnerable populations who are at high risk of infections and who have high antibiotic utilization, such as infants in the neonatal intensive care unit (NICU), is crucial. Infants in the NICU have an increased risk of infections due to immature immune systems and the need for invasive medical devices. Infections are difficult to diagnose because of non-specific symptoms and laboratory findings.4 Also, NICUs often have a unique ‘ecology’ including multibed rooms and frequent overcrowding, as well as infants in frequent physical contact with physicians, nurses, and other support staff. These factors contribute to the risk of infection transmission and, by extension, antibiotic use. Concerns about the consequences of inappropriately treat- ing or not treating an infection generally outweigh concerns


about the consequences of antibiotic overuse. However, antimicrobial overuse in the NICU population can have grave unintended consequences for individual patients beyond the emergence of drug-resistant pathogens. These additional unintended consequences of prolonged, and potentially inappropriate, antibiotic use include an increased risk of invasive candidiasis or necrotizing enterocolitis (NEC)5 as well as disruptions to the infant gut microbiome.6 While the implications of antimicrobial-induced disruptions to the microbiome have yet to be fully elucidated, data suggest that the consequences may be long lasting and include asthma, obesity, and other chronic conditions.6 Recognizing the need for measures to avert the con- sequences of inappropriate antibiotic use in the NICU popu- lation, Bizzarro et al7 conducted a quasiexperimental study describing the implementation of an ASP in their 54-bed, level IV NICU. They formed a multidisciplinary team that included physicians, a nurse, a pharmacist, and an infection control practitioner and utilized a modified template from the Get Smart for Healthcare campaign3,8 to design a NICU-specific ASP. Their program consisted of 3 primary components: (1) design and implementation of clinical guidelines for common neonatal infections including clinical sepsis and post-operative prophylaxis, (2) educational sessions, and (3) prospective audit and feedback. Using an interrupted time series analysis, they evaluated antimicrobial utilization in the 18 months before (ie, the “preintervention” period) and the 48 months after (ie, the “stewardship” period) the imple- mentation of their ASP. Although they did observe a decrease in antibiotic utiliza-


tion of 14.7 days of therapy per 1,000 patient days (DOT per 1,000 PD) during the stewardship period, this decrease was not statistically significant and not likely to be clinically significant (P=.669). While a cursory glance at their primary outcome might tempt the dismissal of the study, this result alone does not tell the whole story. The authors drilled down into the utilization of individual


antibiotics and found that the use of gentamicin/tobramycin, vancomycin, and cefotaxime all decreased over the stewardship


New York-Presbyterian Hospital, New York, New York. © 2017 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2017/3810-0002. DOI: 10.1017/ice.2017.183


Affiliations: 1. Department of Pediatrics, Columbia University Medical Center, New York, New York; 2. Department of Infection Prevention and Control, Received July 19, 2017; accepted July 22, 2017


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