Page 34 - Christiana Care Focus January 2018

PHARMACY SERVICES
THERAPEUTIC NOTES
Antibiotic Stewardship in the NICU Barbara McKinney, Pharm.D.
The increase in antibiotic resistance has become a serious threat
to public health throughout the world. Organizations such as the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the Infectious Diseases Society of America (IDSA) and the Pediatric Infectious Disease Society have called for initiatives to reduce the overuse and misuse of antibiotics. The Joint Commission implemented a new medication management standard in January 2017 that addresses antibiotic stewardship.
The proportion of drug-resistant organisms causing infection in the neonatal intensive care unit (NICU) is increasing. Approximately one- third of infants colonized with a resistant organism will develop an infection with the same organism.
Antibiotics are among the most frequently prescribed medications
in the NICU. Suspected sepsis is one of the most common reasons for NICU admission. Neonates often exhibit non-specific clinical and laboratory signs of infection making it difficult to distinguish between neonatal sepsis and the many other non-infectious clinical conditions common to neonates. Neonatal sepsis is associated with a high
risk of morbidity and mortality. Therefore, timely interventions for true infection are critical. However, repeated unnecessary exposure to broad-spectrum antibiotics may result in the development of antibiotic resistance, risk of adverse drug reactions, increased risk of candidemia, late-onset sepsis, multi drug resistant infection, necrotizing enterocolitis (NEC), alterations in the microbiome and death in premature infants.
Approximately 40% of pregnant women in the U.S. receive antibiotics prior to delivery to prevent infectious complications in both the mother and the fetus. Indications for the use of antibiotics include Group B Streptococcus (GBS) colonization, asymptomatic bacteriuria, pyelonephritis, preterm premature rupture of membranes and chorioamnionitis. While the benefits of antibiotics are well known, there are potential risks of the frequent exposure of the maternal-fetal dyad to antibiotics. The antibiotics administered prior to delivery may disrupt the developing fetal microbiome with potential long-lasting effects such as increases in childhood obesity and asthma.
Clinical scenarios where the routine use and choice of antibiotics may be reevaluated include: (1) empiric antibiotics for suspected sepsis in term and late preterm infants born to mothers with chorioamnionitis (2) continued and prolonged courses of antibiotics in culture-negative sepsis and (3) selection of antibiotics for late onset sepsis.
Maternal chorioamnionitis is a clinical diagnosis with inconsistent definitions resulting in variation in practice and unnecessary evaluation and treatment of both mother and newborn. The term chorioamnionitis has been changed to Intrauterine Inflammation or Infection or both, and abbreviated Triple I. This new terminology and diagnostic criteria reduces the variation in diagnosis and treatment. Kaiser Permanente developed a Sepsis Calculator that utilizes maternal risk factors and the newborn’s clinical presentation to determine the probability of early onset sepsis per 1000 babies. For asymptomatic, well appearing newborns delivered at ≥ 35 weeks of gestation and whose mother had a fever of ≥ 38° C in the 24 hours prior to delivery, the use of the Triple I classification together with
the Sepsis calculator decreases the number of unnecessary NICU admissions. This reduces the use of empiric antibiotics and improves the maternal-newborn bonding. Christiana Hospital adopted this practice in January of 2017 which is referred to as T.I.M.E., Triple-I to Manage Early-onset sepsis.
In 2016, the Christiana Hospital NICU began participation in the Vermont Oxford Network (VON) Collaborative initiative that focused
on choosing antibiotics wisely. The CDC and VON developed a partnership to improve patient safety and raise the quality of neonatal care recognizing the dangers presented by increased antibiotic resistance.
The Christiana Care NICU work group identified key populations that could be the target for reduction of antibiotic use. These included: (1) term newborns admitted to the NICU only for a sepsis evaluation based on the maternal diagnosis of chorioamnionitis, (2) premature newborns without risk factors delivered for maternal indications, (3) newborns with congenital pneumonia and (4) newborns treated for culture negative sepsis. The goal is to safely reduce antibiotic use in low risk NICU patients by 20%. Performance measures used are antibiotic utilization rate, antibiotic initiation rate, and admissions receiving antibiotics during stay.
The group developed and implemented treatment guidelines and order sets for early onset sepsis, necrotizing enterocolitis and surgical prophylaxis that will be evaluated ongoing for adherence. Other initiatives include: NICU education and increased awareness of newer diagnostic technology for sepsis evaluation, the limitations of the CBC and blood culture results in NICU patients, adherence to the 48 hour rule out sepsis, guidance for antibiotic escalation and de-escalation and the design of treatment guidelines for late-onset sepsis. This NICU work group has now transformed into a subcommittee of the systemwide Antimicrobial Stewardship Program (ASP) committee. ●
References
Ledger WJ, Blaser MJ. Are we using too many antibiotics during pregnancy? Br J Obstet Gynaecol 2013;120:1450e2.
Ramasethu J, Kawakita T, Antibiotic stewardship in perinatal and neonatal care. Seminars in Fetal & Neonatal Medicine 22 (2017) 278e283
34 • FOCUS JANUARY 2018