Interventions to Reduce Antibiotic Overuse in NICUs

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Overuse of antibiotics in one level 3 NICU successfully identified areas of stewardship without reducing safety.
Overuse of antibiotics in one level 3 NICU successfully identified areas of stewardship without reducing safety.

Application of interventions to reduce antibiotic use in neonatal intensive care during the Surveillance and Correction of Unnecessary Antibiotic Therapy (SCOUT) study of practices at a single major US hospital were highly successful, with no reductions in safety, according to results published in the Lancet Infectious Disease.

The observational study, led by Joseph B. Cantey, MD, from the Department of Pediatrics at the University of Texas Southwestern Medical Center in Dallas, found that unnecessary use of antibiotics could be significantly reduced with intervention, and resulted in targeting more antibiotic therapy to proven infections or necrotizing enterocolitis, where it is highly beneficial. The single area of greatest decline in antibiotic use (12%) was administration to rule out sepsis, which most physicians in the study already believed was given erroneously. They were less inclined to reduce over-long antibiotic dosing (< 5 days) for pneumonia or culture negative sepsis.

For the SCOUT study, investigators from various institutions evaluated the impact of specific measures to reduce the use of antibiotics at a single level 3 neonatal unit. Through the course of a 9-month intervention period when 895 infants were admitted to the neonatal intensive care unit (NICU) at Parkland Hospital in Dallas, Texas, antibiotic use decreased by 27%, compared to an earlier 14-month baseline period in 1607 infants. Total antibiotic use was reduced from 343 2-day periods of therapy per 1000 days in the baseline period to 252 in the intervention period.

While antibiotics are necessary in neonates to prevent infections such as sepsis and pneumonia, misuse or overuse is associated with greater mortality and other adverse outcomes including an infection from multidrug-resistant bacteria, invasive candidosis, respiratory dysplasia, necrotizing enterocolitis, and a late-developing sepsis.

The most common reasons for antibiotic treatment were sepsis, which was treated with ampicillin/gentamicin for early onset or oxacillin/gentamicin for later onset, and vancomycin for bacteria or Staphyloccocus aureus that is resistant to other antibiotics. Decreases in the use of ampicillin, gentamicin, and oxacillin due to intervention were all significant, and were maintained until the end of the study.

Three prominent practice behaviors that were identified during the study for modification were the use of antibiotics for culture-negative sepsis, courses to rule out sepsis, and prolonged use that extended beyond the recommended 5-day course (7-14 days total), most often in cases of pneumonia. These practices accounted for the majority of antibiotic administration in the baseline period (63%, 8%, and 26%, respectively), and decreases in all were achieved in the intervention period, with no increases in negative outcomes.

The investigators concluded that the best immediate target for reduction of inappropriate use of antibiotics was rule-out sepsis, and that greater effort needs to be given to convincing neonatal physicians not to extend antibiotic courses beyond 5 days or once negative cultures are achieved.

Reference

Cantey JB, Wozniak PS, Pruszynski JE, Sánchez PJ. Reducing unnecessary antibiotic use in the neonatal intensive care unit (SCOUT): a prospective interrupted time-series study. Lancet Infect Dis. 2016;16:1178-1184. doi: 10.1016/S1473-3099(16)30205-5

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