Pediatric ASP Toolkit

Action(s) to Perform

Prospective Audit and Feedback (PAF)

PAF allows clinicians to order antibiotics and then the ASP team reviews the use of this antibiotic and when an opportunity for antibiotic optimization is identified, the stewardship team contacts the prescribing team to provide recommendations. Depending on the institution, recommendations may be documented in the medical record. Some programs have successfully augmented the recommendation process by delivering recommendations face-to-face on “stewardship rounds.”

References

Prior Approval

“Prior approval or preauthorization” refers to a policy in which antibiotic orders must be approved by the stewardship program before the pharmacy will fill the order. So-called “restrictive policies” are highly effective in producing an immediate decline in utilization of targeted antibiotics (Davey et al, 2013). Prior approval encourages careful consideration of each case at the time of initial ordering, potentially preventing any unnecessary exposure to the targeted agent.

References:

Clinical Guidelines / Protocols / Care Process Models

Standardization of care for common conditions has been an effective strategy to improve antibiotic use. Clinical guidelines/protocols/care process models are based on existing national or international practice guidelines and can be used to enhance guideline adherence. These guidelines can be adapted to best fit the particular settings and microbiologic patterns of the institutions that will utilize them.

References:

Neonatal Specific Guidelines/Resources:

Early-Onset Neonatal Sepsis

Puopolo KM, Benitz WE, Zaoutis TE, Committee on Fetus and Newborn, Committee on Infectious Diseases. Management of Neonates Born at ≥35 0/7 Weeks’ Gestation With Suspected or Proven Early-Onset Bacterial SepsisPediatrics. December 2018, 142 (6) e20182894.

Puopolo KM, Benitz WE, Zaoutis TE, Committee on Fetus and Newborn, Committee on Infectious Diseases. Management of Neonates Born at ≤34 6/7 Weeks’ Gestation With Suspected or Proven Early-Onset Bacterial SepsisPediatrics. December 2018, 142 (6) e20182896.

Neonatal Early-Onset Sepsis Calculator (https://neonatalsepsiscalculator.kaiserpermanente.org/)

Puopolo KM, Lynfield R, Cummings JJ, Committee on Fetus and Newborn, Committee on Infectious Diseases. Management of Infants at Risk for Group B Streptococcal DiseasePediatrics. August 2019, 144 (2) e20191881.

American College of Obstetrics and Gynecology Committee Opinion No. 797: Prevention of Group B Streptococcal Early-Onset Disease in Newborns: CorrectionObstet Gynecol. 2020. PMID: 32217968 https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/02/prevention-of-group-b-streptococcal-early-onset-disease-in-newborns

Late-Onset Neonatal Sepsis

There is a lack of consensus on the most appropriate antibiotic regimen to treat suspected late-onset neonatal sepsis. Empiric antibiotic regimens should be based on the most likely organisms for a particular unit and the clinical situation. Antibiotic choices should be guided by local susceptibility patterns and once an organism is identified, therapy should be tailored appropriately.

Necrotizing Enterocolitis

There is a lack of consensus of the most appropriate antibiotic regimen to treat suspected and/or confirmed necrotizing enterocolitis. In general, regimens should provide coverage for pathogens that cause late-onset sepsis and the addition of anaerobic coverage should be considered, although there is inadequate evidence to support a specific regimen. Antibiotic choices should be guided by local susceptibility patterns, and if an organism is identified, therapy should be tailored appropriately.

Health Care-Associated Infections in the NICU

Polin RA, Denson S, Brady MT, Committee on Fetus and Newborn, Committee on Infectious Diseases. Strategies for Prevention of Health Care–Associated Infections in the NICUPediatrics. May 2016, 137 (5) e20160592.

Polin RA, Denson S, Brady MT, Committee on Fetus and Newborn, Committee on Infectious Diseases. Epidemiology and Diagnosis of Health Care–Associated Infections in the NICUPediatrics. May 2016, 137 (5) e20160592.

Antibiotic Stewardship in Neonatal Intensive Care Units

Patel SJ, Saiman L. Principles and strategies of antimicrobial stewardship in the neonatal intensive care unitSemin Perinatol. 2012; 36(6): 431–436.

Cantey SB, Patel SJ. Antimicrobial stewardship in the NICUInfect Dis Clin North Am. 2014 Jun;28(2):247-61.

Mukhopadhyay S, Sengupta S, Puopolo KM. Challenges and opportunities for antibiotic stewardship among preterm infantsArch Dis Child Fetal Neonatal Ed. 2019;104:F327–F332.

Utilization of Rapid Diagnostics

The implementation of rapid diagnostic tools have had the greatest success in improving antibiotic use and patient outcomes when an ASP is involved. Examples include:

  • Matrix-Assisted Laser Desorption and Ionization Time-of-Flight (MALDI-TOF)
    • Decreased duration of unnecessary antibiotic therapy for coagulase-negative staphylococcal bloodstream contaminants
    • Marked reduction (approximately 2.5 – 4 days) in duration of time prior to initiation of optimal antibiotic therapy for gram negative bacteria
    • Reduction in overall length of inpatient hospital stay by 2-3 days
    • Hospital cost savings of ~$20,000 – $30,000 per patient diagnosed with gram-negative sepsis
  • Multiplex Polymerase Chain Reaction (PCR)/Nucleic Acid Assays
    • Reduction in duration of therapy for blood culture contaminants
    • Decreased overall length of inpatient hospital stay
    • More rapid implementation of effective therapy aimed at treatment of multidrug-resistant pathogens
    • Hospital cost savings of ~$20,000 per patient diagnosed with Staphylococcus aureus bacteremia

References:

Improving the health of children worldwide through philanthropic support of scientific and educational programs.