EVALUATION OF A PEDIATRIC ANTIMICROBIAL STEWARDSHIP PROGRAM IN A ...

[Pages:117]EVALUATION OF A PEDIATRIC ANTIMICROBIAL STEWARDSHIP PROGRAM IN A TERTIARY CARE MEDICAL CENTER

By Chou-Cheng Lai

A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy

Baltimore, Maryland January, 2014

ABSTRACT

Background: The problem of antibiotic resistance is increasing globally. The inappropriate use of antibiotics has been linked to the emergence of antibiotic resistance and other adverse effects. Antimicrobial stewardship programs (ASPs) have been developed to improve antibiotic use, with the goals of maintaining the effectiveness of current antimicrobials and improving patient safety and outcomes. There are several methods by which the use of antimicrobials can be intervened upon by ASPs; most fall into two basic categories: restriction of antimicrobial before they are dispensed initially, often called "prior approval" and review and feedback regarding antimicrobial use sometime after prescription, often called "post-prescription review." Relatively few studies evaluating either approach have been conducted in pediatric settings. This study aims to assess if a prior-approval program combined with post-prescription review program decreases antimicrobial use, reduces the proportion of inappropriate antimicrobial course and is associated with a higher compliance rate with following recommendations compared to a prior-approval program alone among pediatric inpatients. Additionally, the study aims to determine the frequency and risk factors of inaccurate requests submitted in a pediatric web-based prior-approval program.

Methods:

We conducted a prospective, randomized controlled study at the Johns Hopkins Children Center a 180 bed tertiary pediatric center from September 2011 to November 2012. Patients in 4 general pediatric floors who were assessed by ASP team to be receiving inappropriate antibiotics after being on therapy within 25-96 hours were randomized to

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either receive the intervention (a phone call with the recommendations by ASP team to the treating physician) or no additional feedback. Patients who were cystic fibrosis patients, in oncology-hematology, ICU and patients for whom ID consult had been obtained were excluded from the study. Data collected included days of antibiotic therapy, the proportion of inappropriate antimicrobial course, the acceptance rate of ASP recommendations and some patient's outcome ( such as inconsistence between the antimicrobial susceptibilities of any recovered organism and the recommended alternative therapy, any subsequent infection after ASP's recommendation of stopping therapy) at follow up between the two groups. Wilcoxon rank-sum test was taken to compare measures of antibiotic use. Chisquare test was used to compare the proportion of inappropriate antimicrobial course and the acceptance rate of ASP recommendations.

In addition, a retrospective review of patients whose providers ordered antimicrobial using the web-based prior-approval program was carried out from December 2011 to March 2012 for 4 months to determine the frequency of inaccurate information contained within the requests. Multivariate logistic regression was performed to evaluate potential risk factors of inaccurate information in the prior-approval program.

Results:

The pediatric ASP team identified 60 pediatric patients (30 patients in the intervention group and 30 patients in the control group) for whom use of restricted antimicrobials was inappropriate. There were no significant differences of the amount of restricted antimicrobial use between the intervention group and the control group (median DOTs: 750 vs. 816.7, p=0.932; median duration of antimicrobial agent per episode of infection (days): 3.5 vs. 5, p=0.094). In the comparison of total antimicrobial use, differences were also not

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significant. However, the prevalence of inappropriate antimicrobial use at follow up was significantly lower in the intervention group than the control group (34.4% vs. 75.8%, p=0.001). The acceptance rate was significantly higher in the intervention group (the treating physician accepted the recommendation) than in the control group (the treating physician auto-corrected antibiotic use so that it was the same as what would have recommended by the ASP team) (67.6% vs. 22.9%, p ................
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