Antimicrobial stewardship programs decreased antibiotic use in children's hospitals

Since the Infectious Diseases Society of America published guidelines promoting antimicrobial stewardship programs in 2007, average antibiotic use has decreased significantly in children’s hospitals, according to study findings in Pediatrics.

“Antibiotics are prescribed during more than 50% of hospitalizations for children, often unnecessarily,” study researcher Adam L. Hersh, MD, PhD, of the University of Utah, and colleagues wrote. “This misuse contributes to avoidable adverse events and costs and is an important driver of antibiotic resistance, which is a growing global health and economic threat.”

Adam L. Hersh

Using data from the Pediatric Health Information System, researchers retrospectively evaluated the impact of antimicrobial stewardship programs on antibiotic use from 2004 to 2012 among hospitalized children from 31 children’s hospitals. Nine of the hospitals had an antimicrobial stewardship programs.

The researchers used days of therapy per 1,000 patient-days (DOT) to measure and evaluate trends in antibiotic use.

Evaluation included all antibiotics administered intravenously, orally and intramuscularly and intravenous vancomycin, carbapenems (meropenem, imipenem, and ertapenem) and linezolid.

“We used an interrupted time series design,” study researcher Samir S. Shah, MD, MSCE, of Cincinnati Children’s Hospital Medical Center and an Infectious Diseases in Children Editorial Board member, told Infectious Diseases in Children. “In this approach, data are aggregated over regular periods, in this case monthly before and after intervention. We used pre-intervention data to predict what antibiotic use would have been without the antimicrobial stewardship program intervention. We also examined antibiotic use at hospitals without antimicrobial stewardship programs to account for temporal trends or factors other than antimicrobial stewardship programs that may have also influenced antibiotic use. This approach allowed us to quantify the benefit of the program.”

Samir S. Shah

After the IDSA guidelines were released, there was an overall decline in all antibiotic use in hospitals with and without antimicrobial stewardship programs, according to researchers. Before then, antibiotic DOT was not significantly different between hospitals with and without programs (775 vs. 771). After the 2007 release, hospitals with antimicrobial stewardship programs had a greater decline in use of all antibiotics vs. hospitals without programs (11% vs. 8%; P=.04).

Before 2007, use of select antibiotics (vancomycin, carbapenems and linezolid) was very similar among hospitals with and without stewardship programs (115 vs. 114 DOT). After the release of IDSA guidelines, hospitals with programs experienced a 4% decline in select antibiotic use to an average of 110 DOT (P=.06); while hospitals without programs experienced little change (115 DOT).

“Relative to trends before program initiation and accounting for concurrent secular trends, overall antibiotic use declined more than was expected in nearly 90% of hospitals after starting an antimicrobial stewardship program, with an average reduction of 6% relative to previous antibiotic use patterns,” according to Hersh and colleagues. “This decline was greater for a select group of antibiotics (vancomycin, carbapenems and linezolid).”

It is important to note a significant finding of a previous study, from which the current study utilized data, said study researcher Jason G. Newland, MD, MEd, of Children’s Mercy Hospital in Kansas City, Mo., who conducted the previous investigation.

Jason G. Newland

In that study, researchers categorized hospitals as having an antimicrobial stewardship program or not, regardless of whether hospitals considered themselves to have a formal program, defined by researchers as continuously monitoring antimicrobials and providing full-time equivalents.

“We found that hospitals with a ‘formal program’ were no different than the hospitals who said they did not have a program,” Newland told Infectious Diseases in Children. “They did not differ regarding prospective audit feedback, prior restriction or use of clinical guidelines. The only difference was that those with formal programs were more likely to monitor outcomes.

“So, taking that into consideration with the current study results, where we are looking at the outcome of antimicrobial use, even though the programs do not differ, those who said they had formal programs had better outcomes.”

The study findings highlight several issues regarding such programs, according to Wilbert Mason, MD, MPH, and Kanokporn Mongkolrattanothai, MD, of Children’s Hospital Los Angeles. They include the impact of full-time equivalents, or health care professionals dedicated to the stewardship program, the need for improved metrics to measure program performance and optimal study design methods.

“Although progress has been made in some areas, we continue to struggle in others,” Mason and Mongkolrattanothai wrote in an accompanying editorial. “Progress is urgently needed in the areas of global leadership and coordination of antimicrobial use, economic incentives for new drug development, continued use of antibiotics to enhance food production, and inappropriate use of antibiotics in the treatment of viral infections and other noninfectious conditions.” – by Amanda Oldt

For more information:

Hersh AL. Pediatrics. 2015;doi:10.1542/peds.2014-2579.

Mason W. Pediatrics. 2015;doi:10.1542/peds.2014-3501.

Disclosure: Hersh, Weissman, Gerber and Newland report financial ties with Pfizer/Joint Commission. The other researchers report no relevant financial disclosures.