812 infection control & hospital epidemiology july 2018, vol. 39, no. 7


compared to PAFR for audits performed on patients in the NICU. This finding directly contrasts with that of another single-center study that identified NICU and hematology- oncology services as more likely to disagree with PAFR compared to hospitalist service but found no difference with the PICU.9 These conflicting findings suggest that there may be important cultural differences in the reception of PAFR across units in different hospitals or that these units may have unique patient populations that are not comparable across institu- tions. These differences underscore the need for PAF programs to tailor their interventions to the specific needs and intensive care settings of their institution.15–17 Depending on the extent and maturity of additional ASP strategies (eg, antimicrobial restriction, clinical practice guidelines), there may be more or fewer opportunities to impact prescribing by PAF.17–21 Litera- ture supporting ASP interventions in critically ill neonates and children are especially limited, and extrapolation of published PAF success in a specific institution’sICUmaybedifficult due to differences in patient populations served and institutional microorganism resistance patterns.22 Further exploration of the factors impacting the success of stewardship in critically ill children are needed. Interestingly, we did not find that any specific marker of infection (eg, procalcitonin, CRP, fever), antimicrobial, or severity of illness (eg, LOS, ICU LOS, need for mechanical ventilation) impacted adherence to PAFR. To our knowledge, this is the first study to evaluate PAFR disagreement based on these clinical factors associated with infection. Our study has several limitations. The generalizability of our


study is limited by the unique design of PAF at our hospital, where PAFR are typically communicated to the UBP. Although not statistically significant in our final model, some of our success or failure may be related to working through the UBP as opposed to contacting the care team directly. As a quaternary care freestanding children’s hospital, our patient population and their infectious conditions may not mirror that of other institutions, especially nonfreestanding children’s hospitals.23 Our study adds to the literature by identifying important


patient-level, programmatic, and provider-level factors that were associated with provider disagreement of PAFR. Given the time-intensive nature of PAFR, future research should explore ways to improve the acceptance of PAFR. Hospitals should incorporate antimicrobial stewardship into ongoing provider education and future studies should examine whether this improves acceptance of PAFR. ASP programs looking to implement PAF programs should be mindful of the programmatic and provider-level factors that may influence uptake in PAFR and track rates of disagreement to employ targeted interventions as needed.


acknowledgments


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 Hayden T. Schwenk, MD, MPH, Division of


Infectious Diseases, Department of Pediatrics, 300 Pasteur Dr, Room G312, Stanford, CA, 94305 (hschwenk@stanford.edu).


supplementary material


To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2018.85


references 1. CDC: Get Smart for Healthcare. Overview and evidence to support stewardship. Centers for Disease Control and Prevention website. http://www.cdc.gov/getsmart/healthcare/evidence.html. Published 2016. Accessed September 21, 2016.


2. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159–177.


3. Chung GW, Wu JE, Yeo CL, Chan D, Hsu LY. Antimicrobial stewardship: a review of prospective audit and feedback systems and an objective evaluation of outcomes. Virulence 2013;4: 151–157.


4. Hersh AL, De Lurgio SA, Thurm C, et al. Antimicrobial stew- ardship programs in freestanding children’s hospitals. Pediatrics 2015;135:33–39.


5. Newland JG, Stach LM, De Lurgio SA, et al. Impact of a prospective-audit-with-feedback antimicrobial stewardship program at a children’s hospital. J Pediatric Infect Dis Soc 2012;1:179–186.


6. HurstAL, ChildJ,PearceK,Palmer C, Todd JK,ParkerSK. Hand- shake stewardship: a highly effective rounding-based antimicrobial optimization service. Pediatr Infect Dis J 2016;35:1104–1110.


7. Willis ZI, Gillon J, Xu M, Slaughter JC, Di Pentima MC. Redu- cing antimicrobial use in an academic pediatric institution: eva- luation of the effectiveness of a prospective audit with real-time feedback. J Pediatric Infect Dis Soc 2017;6:339–345.


8. Di Pentima MC, Chan S, Hossain J. Benefits of a pediatric anti- microbial stewardship program at a children’s hospital. Pediatrics 2011;128:1062–1070.


9. Goldman JL, Lee BR, Hersh AL, et al. Clinical diagnoses and antimicrobials predictive of pediatric antimicrobial stewardship recommendations: a program evaluation. Infect Control Hosp Epidemiol 2015;36:673–680.


10. Lee BR, Goldman JL, Yu D, et al. Clinical impact of an antibiotic stewardship program at a children’s hospital. Infect Dis Ther 2017;6:103–113.


11. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and man- agement of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010;50:133–164.


12. Lehrnbecher T, Robinson P, Fisher B, et al. Guideline for the management of fever and neutropenia in children with cancer and hematopoietic stem-cell transplantation recipients: 2017 update. J Clin Oncol 2017;35:2082–2094.


13. Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review. J Antimicrob Chemother 2017;194:1–13.


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