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Antimicrobial review is a key component of inpatient antimicrobial stewardship programs (ASPs). Prospective audit and feedback, especially handshake stewardship, may be the most effective method to reduce excess antibiotic use.
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The development of guidelines and decision-support tools can improve appropriate prescribing and foster collaboration with frontline providers.
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Diagnostic stewardship is emerging as an opportunity for ASPs to impact upstream steps that influence antimicrobial prescribing.
The Current State and Future Directions of Inpatient Pediatric Antimicrobial Stewardship
Section snippets
Key points
History of antimicrobial stewardship
When antibiotics were first discovered and came into clinical use in the 1940s, they were hailed as miracle drugs and some predicted the end of infectious diseases (ID). However, it was not long before clinicians began to identify some of the problems associated with antimicrobials. Negative side effects were noted early, including rashes, drug fever, and anaphylaxis.1 At least as troubling, clinicians noticed that rather than eliminating ID, the widespread use of antibiotics led to a shift in
Rationale for antimicrobial stewardship
More than 60 years after Finland first lamented the near universal use of antibiotics, the problem of excess antimicrobial use persists. Antibiotic use across children's hospitals is highly variable, with 38% to 72% of children receiving antibiotics during their admission.11 About half of this use is likely unnecessary and 21% is considered to be suboptimal.12 Prophylactic antibiotic use remains problematic as well, with 33% of surgical prophylaxis considered inappropriate in a recent
Antibiotic stewardship program team composition
The 2019 update to the CDC Core Elements of Hospital Antimicrobial Stewardship Programs highlights the importance of joint physician/pharmacist leadership of ASPs, which is in line with recommendations from IDSA.8,9 This reflects recent trends in pediatric ASPs: in 2017 88% of surveyed hospital ASPs reported having a pharmacist devoted to their program compared with only 34% in 2011.10 Pharmacists offer a unique perspective and skillset that is critical to the success of an ASP. Their
Antimicrobial stewardship actions
The CDC Core Elements of Antimicrobial Stewardship identify a number of different actions that stewardship programs should pursue.9 These include different methods to oversee antibiotic use, facility-specific guidelines, and targeted interventions for common infections (such as community-acquired pneumonia (CAP) and urinary tract infections) or high-risk prescribing (such as outpatient parenteral antibiotic therapy). They also identify the importance of interventions that are directed at
Reporting and outcomes of interest
Regardless of the methods used, all ASPs should regularly track and report the outcomes of their interventions to stakeholders, including prescribers, pharmacists, nurses, and hospital leadership. ASPs commonly track process measures, including types of recommendations made by the ASP and their acceptance by frontline providers. They should also assess and report adherence to local guidelines and overall antibiotic use (generally reported as days of therapy per thousand patient days) and the
Education
At its core, antimicrobial stewardship has always focused on the education of frontline providers with the goal of empowering them to make optimal antibiotic choices for their patients. This education can take many forms, including didactics, dedicated rotations for trainees, or case-based teaching focused on specific prescribing choices during interactions around prior authorization or prospective audit and feedback of antimicrobials. All interactions can benefit from using a consistent
Summary
Antibiotic use in hospitalized children is highly variable and often unnecessary, which puts children at risk of antibiotic-associated harms, including adverse drug events, the development of antibiotic resistance, and long-term chronic health problems. Antimicrobial stewardship programs are effective in reducing unnecessary antibiotic use and related costs. Antimicrobial review, pre or postprescription, is central to inpatient ASPs and prospective audit and feedback, especially handshake
Clinics care points
Inpatient pediatric antimicrobial stewardship programs (ASPs) should be co-led by a physician and pharmacist. Ideally leaders should have infectious diseases (ID) training; in settings where this is not possible, there are many resources for non-ID-trained leaders to gain the knowledge and skills required to build a successful ASP. ASPs should conduct antimicrobial review by either prospective audit and feedback, prior authorization, or a combination of the two. Handshake stewardship is an
Disclosure
The author has nothing to disclose.
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