Brief in
Antimicrobial Stewardship: A National Priority Beatriz Larru, MD, PhD The Children’s Hospital of Philadelphia, Philadelphia, PA. Pranita D. Tamma, MD, MHS Charlotte Bloomberg Children’s Center, The Johns Hopkins University School of Medicine, Baltimore, MD.
AUTHOR DISCLOSURE Drs Larru and Tamma have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/ device.
Antibiotic Resistance Threats. Atlanta, GA: US Dept of Health and Human Services, Centers for Diseases Control and Prevention; 2013. http://www.cdc.gov/drugresistance/ threatreport-2013. Accessed May 30, 2014 Antimicrobial Stewardship in Pediatrics: How Every Pediatrician Can Be a Steward. Hyun DY, Hersh AL, Namtu K, et al. JAMA Pediatr. 2013;167(9):859–866 Prevalence and Characteristics of Antimicrobial Stewardship Programs at Freestanding Children’s Hospitals in the United States. Newland JG, Gerber JS, Weissman SJ, et al. Infect Control Hosp Epidemiol. 2014;35(3):265–271 Variability in Antibiotic Use at Children’s Hospitals. Gerber JS, Newland JG, Coffin SE, et al. Pediatrics. 2010;126(6):1067–1073.
The Centers for Diseases Control and Prevention estimate that more than 2 million antibiotic-resistant infections occur annually in the United States, with at least 23,000 people dying each year as a result. The ability of microorganisms to develop resistance to antibiotics predates the discovery of antimicrobial agents and is an inevitable consequence of bacterial evolution. However, this process is accelerated with the use of antibiotics. A study of 40 children’s hospitals in the United States indicates that approximately 60% of hospitalized children receive antibiotics during their inpatient stay, with almost 50% of inpatient antibiotic use estimated to be inappropriate. The overuse and misuse of antibiotics have resulted in an unprecedented selection pressure that has made almost all disease-causing bacteria resistant to some of the antibiotics commonly used to treat them. Pharmaceutical development that previously kept us ahead of antibiotic resistance has significantly decelerated. Currently, no antibiotics are in the advanced stages of development that will have activity against some of our most highly drug-resistant gram-negative organisms, including certain types of carbapenem-resistant Enterobacteriaceae, multidrugresistant Pseudomonas aeruginosa, and multidrug-resistant Acinetobacter baumannii. This means we cannot sit idly waiting for new antibiotics to become available. Instead, maintaining the effectiveness of currently available agents should be a national priority. An antimicrobial stewardship program (ASP) is “a program or series of interventions to monitor and direct antimicrobial use at a health care institution, thus providing a standard, evidence-based approach to judicious antimicrobial use.” (1) ASPs are increasingly being developed in pediatric health care institutions and are generally composed of a physician and pharmacist knowledgeable about antimicrobials, with institution-dependent variability in personnel, depending on available local resources. The members of the ASP assist practitioners with evidence-based recommendations to optimize antibiotic use. The goals of pediatric ASPs are to ensure that every child who requires antibiotic therapy receives the right antibiotic by the right route, at the right dose, and for the right duration. Ultimately, this leads to improved clinical outcomes and decreases the unintended consequences of antibiotic use, including the emergence of antibiotic resistance. Patients infected with antibiotic-resistant organisms have repeatedly been found to have poorer outcomes than those infected with more susceptible isolates. ASPs are vital to improving the safety of our patients. Although antibiotics can be life saving when used appropriately, they can have some concerning untoward effects, including subsequent Clostridium difficile infections, fungal infections, hepatotoxicity, nephrotoxicity, anaphylaxis, dermatologic manifestations, neuromuscular
Vol. 36 No. 1 Downloaded from http://pedsinreview.aappublications.org/ at McGill University Library on January 6, 2015
JANUARY 2015
39
toxic effects, and myelosuppression. By decreasing unnecessary antibiotic exposure with the assistance of ASPs, the numbers of these adverse events will naturally be reduced. Although not the primary goal, an additional benefit of ASPs is the cost savings they generate. ASPs have been associated with an annual reduction in drug-purchasing costs in the range of $200,000 to $900,000 per year per institution. Currently, approximately 40% of freestanding children’s hospitals have an established ASP (more than half implemented after 2008), and another 35% are in the planning stages of implementing an ASP. The members of an ASP are always eager to answer patient-specific treatment questions and look for opportunities to provide topic-specific education to improve trainee and faculty knowledge of antibiotic use. There are a number of additional strategies used by ASPs to promote optimal antibiotic use: 1. Developing institution-specific guidelines that assist practitioners with the selection of appropriate empiric and culture-directed antibiotic therapy. 2. Collaborating with the microbiology laboratory staff to incorporate rapid diagnostics assays to promote the early use of optimal therapy. 3. Assisting with prior authorization for certain toxic, broadspectrum, or excessively costly antimicrobial agents. 4. Contacting practitioners as soon as certain cultures (eg, blood cultures and cerebrospinal fluid cultures) indicate bacterial growth to ensure children receive early appropriate therapy. 5. Assisting practitioners with tailoring antimicrobial therapy for their patients 48 to 72 hours after antibiotic therapy is initiated when more clinical and microbiological results are available. 6. Assisting with early conversion of intravenous antibiotics to equivalent bioavailable oral agents to decrease complications associated with intravenous catheters. Antibiotic resistance threatens the remarkable health benefits achieved with antibiotics. With the increase in antibiotic-resistant infections and the limited new agents
40
in the foreseeable future, the implementation of ASPs at all health care facilities needs to be prioritized. ASPs should be viewed as an extension of existing patient safety initiatives because their existence exemplifies “first do no harm.” COMMENTS: There are national initiatives and guidelines to assist pediatricians in limiting inappropriate antibiotic use. Some examples include the American Academy of Pediatrics Choosing Wisely campaign, which states that children with viral upper respiratory tract infections should not be treated with antibiotics; Safety Net antibiotic prescriptions for children 2 years or older with otitis media but no toxic effects to help limit antibiotic use to children who do not improve on their own; and point-of-care testing for streptococcal pharyngitis to initiate antibiotic therapy in children most likely to benefit. However, ASPs go beyond this by assisting pediatricians at an institutional level to ensure that children who need antibiotics receive the 4 R’s: the right (1) antibiotic, (2) route, (3) dose, and (4) duration. In the cohort study of the 40 freestanding children’s hospitals that Larru and Tamma mentioned, 60% of the children received at least 1 antibiotic during hospitalization, yet the proportion of children exposed to antibiotics varied from 37% to 72%. Hospitals that used more antibiotics tended to use a higher proportion of broadspectrum antibiotics. The variability revealed that children at some institutions were 44% more likely to receive antibiotics when controlling for disease severity. ASPs help practitioners provide more standardized care with appropriate selection of antibiotics, guide choices by use of institutionspecific antibiograms to provide local sensitivities, and assist monitoring of antibiotic use by individuals and staff at academic sites and community practices to ensure the safety of patients. I have found this to be an incredibly helpful resource for patient care. – Janet Serwint, MD Consulting Editor
To view Reference list for this article, visit https://pedsinreview. aappublications.org and click on the “In Brief” link.
Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ at McGill University Library on January 6, 2015
Antimicrobial Stewardship: A National Priority Beatriz Larru and Pranita D. Tamma Pediatrics in Review 2015;36;39 DOI: 10.1542/pir.36-1-39
Updated Information & Services
including high resolution figures, can be found at: http://pedsinreview.aappublications.org/content/36/1/39
References
This article cites 3 articles, 1 of which you can access for free at: http://pedsinreview.aappublications.org/content/36/1/39#BIBL
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pedsinreview.aappublications.org/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: http://pedsinreview.aappublications.org/site/misc/reprints.xhtml
Downloaded from http://pedsinreview.aappublications.org/ at McGill University Library on January 6, 2015
Antimicrobial Stewardship: A National Priority Beatriz Larru and Pranita D. Tamma Pediatrics in Review 2015;36;39 DOI: 10.1542/pir.36-1-39
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/36/1/39
Data Supplement at: http://pedsinreview.aappublications.org/content/suppl/2014/12/23/36.1.39.DCSupplementary_Data.htm l
Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.
Downloaded from http://pedsinreview.aappublications.org/ at McGill University Library on January 6, 2015
Antimicrobial Stewardship: A National Priority Beatriz Larru, MD, PhD The Children’s Hospital of Philadelphia, Philadelphia, PA. Pranita D. Tamma, MD, MHS Charlotte Bloomberg Children’s Center, The Johns Hopkins University School of Medicine, Baltimore, MD.
AUTHOR DISCLOSURE Drs Larru and Tamma have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/ device.
Antibiotic Resistance Threats. Atlanta, GA: US Dept of Health and Human Services, Centers for Diseases Control and Prevention; 2013. http://www.cdc.gov/drugresistance/ threatreport-2013. Accessed May 30, 2014 Antimicrobial Stewardship in Pediatrics: How Every Pediatrician Can Be a Steward. Hyun DY, Hersh AL, Namtu K, et al. JAMA Pediatr. 2013;167(9):859–866 Prevalence and Characteristics of Antimicrobial Stewardship Programs at Freestanding Children’s Hospitals in the United States. Newland JG, Gerber JS, Weissman SJ, et al. Infect Control Hosp Epidemiol. 2014;35(3):265–271 Variability in Antibiotic Use at Children’s Hospitals. Gerber JS, Newland JG, Coffin SE, et al. Pediatrics. 2010;126(6):1067–1073.
The Centers for Diseases Control and Prevention estimate that more than 2 million antibiotic-resistant infections occur annually in the United States, with at least 23,000 people dying each year as a result. The ability of microorganisms to develop resistance to antibiotics predates the discovery of antimicrobial agents and is an inevitable consequence of bacterial evolution. However, this process is accelerated with the use of antibiotics. A study of 40 children’s hospitals in the United States indicates that approximately 60% of hospitalized children receive antibiotics during their inpatient stay, with almost 50% of inpatient antibiotic use estimated to be inappropriate. The overuse and misuse of antibiotics have resulted in an unprecedented selection pressure that has made almost all disease-causing bacteria resistant to some of the antibiotics commonly used to treat them. Pharmaceutical development that previously kept us ahead of antibiotic resistance has significantly decelerated. Currently, no antibiotics are in the advanced stages of development that will have activity against some of our most highly drug-resistant gram-negative organisms, including certain types of carbapenem-resistant Enterobacteriaceae, multidrugresistant Pseudomonas aeruginosa, and multidrug-resistant Acinetobacter baumannii. This means we cannot sit idly waiting for new antibiotics to become available. Instead, maintaining the effectiveness of currently available agents should be a national priority. An antimicrobial stewardship program (ASP) is “a program or series of interventions to monitor and direct antimicrobial use at a health care institution, thus providing a standard, evidence-based approach to judicious antimicrobial use.” (1) ASPs are increasingly being developed in pediatric health care institutions and are generally composed of a physician and pharmacist knowledgeable about antimicrobials, with institution-dependent variability in personnel, depending on available local resources. The members of the ASP assist practitioners with evidence-based recommendations to optimize antibiotic use. The goals of pediatric ASPs are to ensure that every child who requires antibiotic therapy receives the right antibiotic by the right route, at the right dose, and for the right duration. Ultimately, this leads to improved clinical outcomes and decreases the unintended consequences of antibiotic use, including the emergence of antibiotic resistance. Patients infected with antibiotic-resistant organisms have repeatedly been found to have poorer outcomes than those infected with more susceptible isolates. ASPs are vital to improving the safety of our patients. Although antibiotics can be life saving when used appropriately, they can have some concerning untoward effects, including subsequent Clostridium difficile infections, fungal infections, hepatotoxicity, nephrotoxicity, anaphylaxis, dermatologic manifestations, neuromuscular
Vol. 36 No. 1 Downloaded from http://pedsinreview.aappublications.org/ at McGill University Library on January 6, 2015
JANUARY 2015
39
toxic effects, and myelosuppression. By decreasing unnecessary antibiotic exposure with the assistance of ASPs, the numbers of these adverse events will naturally be reduced. Although not the primary goal, an additional benefit of ASPs is the cost savings they generate. ASPs have been associated with an annual reduction in drug-purchasing costs in the range of $200,000 to $900,000 per year per institution. Currently, approximately 40% of freestanding children’s hospitals have an established ASP (more than half implemented after 2008), and another 35% are in the planning stages of implementing an ASP. The members of an ASP are always eager to answer patient-specific treatment questions and look for opportunities to provide topic-specific education to improve trainee and faculty knowledge of antibiotic use. There are a number of additional strategies used by ASPs to promote optimal antibiotic use: 1. Developing institution-specific guidelines that assist practitioners with the selection of appropriate empiric and culture-directed antibiotic therapy. 2. Collaborating with the microbiology laboratory staff to incorporate rapid diagnostics assays to promote the early use of optimal therapy. 3. Assisting with prior authorization for certain toxic, broadspectrum, or excessively costly antimicrobial agents. 4. Contacting practitioners as soon as certain cultures (eg, blood cultures and cerebrospinal fluid cultures) indicate bacterial growth to ensure children receive early appropriate therapy. 5. Assisting practitioners with tailoring antimicrobial therapy for their patients 48 to 72 hours after antibiotic therapy is initiated when more clinical and microbiological results are available. 6. Assisting with early conversion of intravenous antibiotics to equivalent bioavailable oral agents to decrease complications associated with intravenous catheters. Antibiotic resistance threatens the remarkable health benefits achieved with antibiotics. With the increase in antibiotic-resistant infections and the limited new agents
40
in the foreseeable future, the implementation of ASPs at all health care facilities needs to be prioritized. ASPs should be viewed as an extension of existing patient safety initiatives because their existence exemplifies “first do no harm.” COMMENTS: There are national initiatives and guidelines to assist pediatricians in limiting inappropriate antibiotic use. Some examples include the American Academy of Pediatrics Choosing Wisely campaign, which states that children with viral upper respiratory tract infections should not be treated with antibiotics; Safety Net antibiotic prescriptions for children 2 years or older with otitis media but no toxic effects to help limit antibiotic use to children who do not improve on their own; and point-of-care testing for streptococcal pharyngitis to initiate antibiotic therapy in children most likely to benefit. However, ASPs go beyond this by assisting pediatricians at an institutional level to ensure that children who need antibiotics receive the 4 R’s: the right (1) antibiotic, (2) route, (3) dose, and (4) duration. In the cohort study of the 40 freestanding children’s hospitals that Larru and Tamma mentioned, 60% of the children received at least 1 antibiotic during hospitalization, yet the proportion of children exposed to antibiotics varied from 37% to 72%. Hospitals that used more antibiotics tended to use a higher proportion of broadspectrum antibiotics. The variability revealed that children at some institutions were 44% more likely to receive antibiotics when controlling for disease severity. ASPs help practitioners provide more standardized care with appropriate selection of antibiotics, guide choices by use of institutionspecific antibiograms to provide local sensitivities, and assist monitoring of antibiotic use by individuals and staff at academic sites and community practices to ensure the safety of patients. I have found this to be an incredibly helpful resource for patient care. – Janet Serwint, MD Consulting Editor
To view Reference list for this article, visit https://pedsinreview. aappublications.org and click on the “In Brief” link.
Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ at McGill University Library on January 6, 2015
Antimicrobial Stewardship: A National Priority Beatriz Larru and Pranita D. Tamma Pediatrics in Review 2015;36;39 DOI: 10.1542/pir.36-1-39
Updated Information & Services
including high resolution figures, can be found at: http://pedsinreview.aappublications.org/content/36/1/39
References
This article cites 3 articles, 1 of which you can access for free at: http://pedsinreview.aappublications.org/content/36/1/39#BIBL
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pedsinreview.aappublications.org/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: http://pedsinreview.aappublications.org/site/misc/reprints.xhtml
Downloaded from http://pedsinreview.aappublications.org/ at McGill University Library on January 6, 2015
Antimicrobial Stewardship: A National Priority Beatriz Larru and Pranita D. Tamma Pediatrics in Review 2015;36;39 DOI: 10.1542/pir.36-1-39
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pedsinreview.aappublications.org/content/36/1/39
Data Supplement at: http://pedsinreview.aappublications.org/content/suppl/2014/12/23/36.1.39.DCSupplementary_Data.htm l
Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.
Downloaded from http://pedsinreview.aappublications.org/ at McGill University Library on January 6, 2015
