infection control & hospital epidemiology october 2017, vol. 38, no. 10 original article
Implementation of an Antimicrobial Stewardship Program in a Neonatal Intensive Care Unit
Nneka I. Nzegwu, DO;1Michelle R. Rychalsky, PharmD;2 Loren A. Nallu,MD;3 Xuemei Song,MA, MS;4 Yanhong Deng, MPH, MS;4 AmberM. Natusch, RNC-NIC;5 Robert S. Baltimore, MD;3,6 George R. Paci, RN, CIC;6 Matthew J. Bizzarro,MD3
objective. To evaluate antimicrobial utilization and prescription practices in a neonatal intensive care unit (NICU) after implementation of an antimicrobial stewardship program (ASP).
design. Quasi-experimental, interrupted time-series study. setting. A 54-bed, level IV NICU in a regional academic and tertiary referral center. patients and participants. All neonates prescribed antimicrobials from January 1, 2011, to June 30, 2016, were eligible for inclusion. intervention. Implementation of a NICU-specific ASP beginning July 2012.
methods. Weconvened a multidisciplinary team and developed guidelines for common infections, with a focus on prescriber audit and feedback. We conducted an interrupted time-series analysis to evaluate the effects of our ASP. Our primary outcome measure was days of antibiotic therapy (DOT) per 1,000 patient days for all and for select antimicrobials. Secondary outcomes included provider-specific antimicrobial prescription events for suspected late-onset sepsis (blood or cerebrospinal fluid infection at >72 hours of life) and guideline compliance.
results. Antibiotic utilization decreased by 14.7 DOT per 1,000 patient days during the stewardship period, although this decrease was not statistically significant (P=.669). Use of ampicillin, the most commonly antimicrobial prescribed in our NICU, decreased significantly, declining by 22.5 DOT per 1,000 patient days (P=.037). Late-onset sepsis evaluation and prescription events per 100 NICU days of clinical service decreased significantly (P<.0001), with an average reduction of 2.65 evaluations per year per provider. Clinical guidelines were adhered to 98.75% of the time.
conclusions. Implementation of a NICU-specific antimicrobial stewardship program is feasible and can improve antibiotic prescribing practices.
Infect Control Hosp Epidemiol 2017;38:1137–1143
Antibiotics are among the most commonly prescribed medications in the neonatal intensive care unit (NICU).1,2 Unlike in children and adults, neonates often exhibit nonspecific clinical and laboratory signs, making it difficult to distinguish infections from other disease processes.3,4 While timely interventions for a true infection are critical, repeated and unnecessary exposures to broad-spectrum antibiotics can result in the development of antimicrobial resistance among certain organisms, as well as an increased risk of candidemia, necrotizing enterocolitis (NEC), hospital-acquired infections, and death in preterm infants.5–13 Organizations have published guidelines aimed at improving
antibiotic prescription practices of healthcare providers and, based on these guidelines, some children’s hospitals have successfully implemented antimicrobial stewardship programs (ASPs).14–20 Information on the design and implementation of
NICU-specific ASPs, however, remains extremely limited. In 2012, Patel and Saiman21 modified aspects of the Get Smart for Healthcare campaign17 and created a blueprint for such a pro- gram. Utilizing these guidelines, we designed and implemented anASPintheYale-New HavenChildren’s Hospital (YNHCH) NICU. The primary objective of this investigation was to assess theimpactof thatASPon antimicrobial prescription practices and utilization in our NICU.
methods Study Setting and Population
The YNHCH NICU is a 54-bed, level 4 NICU within a non– free-standing children’s hospital in New Haven, Connecticut, with all pediatric medical and surgical subspecialties available on site. Approximately 9%–10% of our NICU population
Affiliations: 1. Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; 2. Pharmacy Services, Yale-New
Haven Hospital, New Haven, Connecticut; 3. Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut; 4. Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut; 5. Neonatal Intensive Care Unit, Yale-New Haven Children’s Hospital, New Haven, Connecticut; 6. Hospital Epidemiology and Infection Control, Yale-New Haven Hospital, New Haven, Connecticut.
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2017/3810-0001. DOI: 10.1017/ice.2017.151 Received May 3, 2017; accepted June 12, 2017; electronically published July 26, 2017
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