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Indian Pediatr 2016;53: 304-306 |
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Antimicrobial Justification form for
Restricting Antibiotic Use in a Pediatric Intensive Care Unit
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Harkirat Singh Bhullar, Farhan AR Shaikh, Deepak R,
Preetham Kumar Poddutoor and Dinesh Chirla
From Department of Pediatrics, Rainbow Children’s
Hospital, Banjara Hills, Hyderabad, Andhra Pradesh, India.
Correspondence to: Dr Preetham Kumar Poddutoor,
Consultant Pediatrician, Rainbow Children’s Hospital, Vikrampuri Colony,
Secunderabad 500 034, Hyderabad, Andhra Pradesh, India.
Received: May 22, 2015;
Initial review: August 04, 2015;
Accepted: February 12, 2016.
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Objective: To study whether introduction of an ‘antimicrobial
justification form’ deters clinicians from prescribing restricted
antimicrobials and results in de-escalation of these antimicrobials.
Methods: Clinicians were asked to fill a
justification form if prescribing an antimicrobial from the
pre-identified restricted group. Antimicrobial usage pattern over next
year was compared with that in the one year preceding the introduction
of justification form.
Results: Significant overall decrease in
antimicrobial usage (40.5% vs 34.6%) was noted in the
post-intervention group along with a significant increase in the
de-escalation of antibiotics.
Conclusion: Introduction of a justification form
before prescribing antimicrobials or at the time of deferring
de-escalation can be useful in restricting usage of antimicrobials
Keywords: Antimicrobial agents, Antimicrobial resistance,
Nosocomial infections.
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N osocomial infections are very common in intensive
care unit (ICU) settings, leading to prolonged morbidity, escalation of
treatment costs, and mortality [1-5]. Antibiotic resistance increases
due to inappropriate empiric antimicrobial treatment [6].
There is evidence that early and adequate
administration of antibiotics ("Hit Hard - Hit Fast" approach) improves
survival in severe sepsis and septic shock patients [7]. Thus it becomes
difficult for a physician to balance the approach of early and
aggressive treatment against conservative approach. The antibiotic
stewardship can be done by different means – either by restraining the
prescription or switching to a narrower spectrum, or stopping
antibiotics when not needed [8, 9]. All these methods of restricting the
use of antimicrobials carry potential of creating conflict between the
treating physician and the infection control team. In this study, we
evaluated efficacy of an intervention wherein physicians were made to
fill a justification form before using selected spectrum antimicrobials.
Methods
The study was conducted in a 14-bedded pediatric
intensive care unit (PICU). All children admitted to PICU from 1st June
2013 to 31st March 2014 (post-intervention group) were enrolled in the
study, and those admitted at the same time previous year (1st June 2012
to 31st March 2013) were taken as historical (pre-intervention)
controls. The study was approved by the Institutional ethical committee.
Piperacillin-tazobactum, meropenem, linezolid,
vancomycin, colistin, tigecycline, teicoplanin, daptomycin, aztreonam,
ticarcillin, amphotericin B, fluconazole, voriconazole, and caspofungin
were classified as restricted group antimicrobials. Records of patients
admitted in PICU during pre-intervention period were retrieved and
patients who received antimicrobials from "restricted group" were
labeled as group A. The ‘Restricted antimicrobial use justification
form’ was introduced in PICU on 1st May 2013 and the staff was educated
about it for a month, and the study started from 1 st
June 2013. Admissions to PICU during this period (post-intervention
group) were prospectively analyzed and those patients who received
antimicrobials from the restricted group were labeled as group B.
The justification form had to be filled within 24
hours of starting a restricted antimicrobial. The treating consultant
was notified of the culture report within 48-72 hours by the infection
control nurse. The treating consultant was asked for a justification
form if the antibiotic was decided to be continued. This was again
reviewed on day seven, and any decision to continue the antibiotic had
to be followed by filling another justification form. Any change of
antibiotic within the restricted group also warranted filling a
justification form. Monthly review of the forms was done by the hospital
infection control committee. A sample size of 288 cases and 288 controls
was calculated to be sufficient to document a reduction in use of
restricted antimicrobials from estimated 40% to 25% with a power of 0.9
and type I error of 0.01. Student t-test and chi- square test were used
for statistical analyses.
Results
There were 872 patients in the pre-intervention
period out of which 353 (40.5%) received one of the restricted
antimicrobials (Group A). There were 821 patients in the
post-intervention cohort, of which 284 (34.6%) received one of the
restricted antimicrobials (Group B) (P=0.01). The population of
children in both study periods was comparable in terms of mortality and
the average duration of PICU stay (Table I). Children in
group B were significantly sicker with higher number of ventilated
patients (112 vs 83, P<0.001) and higher mean PRISM scores
(6.9 vs 5.2, P=0.001) in comparison to Group A. There was also a
reduction in the number and average duration of use of most
antimicrobials with significant de-escalation in group B (Table
II).
TABLE I Demographic and Morbidity Profile Before and After Introduction of the Justification Form
Parameter |
Before |
After |
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(n=353) |
(n=284) |
Male gender, n (%) |
229 (64.9) |
192 (67.6) |
Age (y), mean (SD) |
3.39 (4) |
3.36 (3.8) |
Infants, n (%) |
151 (42.8) |
113 (39.8) |
Ventilated* n (%) |
83 (23.5) |
112 (39.4) |
PRISM Score,# Mean(SD) |
5.2 (6.3) |
6.9 (5.1) |
Morbidity pattern, n |
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Respiratory |
116 |
101 |
Neurology |
33 |
25 |
GIT and Hepatobiliary |
14 |
17 |
Oncology |
6 |
4 |
Sepsis |
100 |
78 |
Post surgical and trauma |
18 |
17 |
Infections (Viral,protozoal,etc.) |
54 |
30 |
Miscellaneous (metabolic, nephro) |
12 |
12 |
*P=<0.001; #P=0.001; PRISM= Pediatric risk of mortality |
TABLE II Antibiotic Usage Before and After Introduction of Antibiotic Justification Form
Antibiotic
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Initial No. (%)
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De- escalation Mean (SD)
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Duration of antibiotic
(days)No. (%)
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Group A |
Group B |
P value |
Group A |
Group B |
P value |
GroupA |
Group B |
P value |
Piperacillin-Tazobactum |
220 (62.3) |
193 (68) |
0.2 |
58 (26.4) |
89 (46.1) |
<0.001 |
5.4 (3.2) |
4.8 (2.9) |
0.04 |
Meropenem |
123 (34.8) |
108 (38) |
0.45 |
14 (11.4) |
30 (27.8) |
0.002 |
7.4 (3.4) |
6 (3.7) |
0.003 |
Linezolid |
82 (23.2) |
122 (43) |
0.001 |
12 (14.6) |
51(41.8) |
<0.001 |
7.4 (3.9) |
5.5 (3.7) |
0.001 |
Vancomycin |
60 (17) |
11 (3.8) |
<0.001 |
24 (40) |
5 (45.5) |
0.75 |
6.1 (4.9) |
6.3 (5.8) |
0.8 |
Group A: Pre-intervention; Group B: Post-intervention. |
Discussion
In this study, we observed that introduction of
‘antimicrobial justification form’ in a PICU has the potential of
restricting use, and de-escalation of selected antimicrobial agents. As
both the groups were comparable in terms of demographic profile, and
disease spectrum and severity, the reduction in the initial usage and
later de-escalation of these antimicrobials can be attributed to the
awareness created by the justification form.
Few other studies also have shown similar impact. An
earlier study from Pakistan documented reduction in use of carbapenems
and antifungals with the introduction of a ‘reserve antibiotic indent
form’ [10]. A study by Ozkurt, et al. [11] concluded that
enforcement of restriction policy decreased consumption of restricted
antibiotics by 40%. Himmelberg, et al. [12] found that removal of
antimicrobial restriction policy resulted in increased use and higher
expenditures for previously restricted agents, along with an
inappropriate usage of at least one agent.
The main limitation of this study is a historical
control rather than a randomized controlled design. Also, we did not
compare overall use of antibiotics as our study aimed to evaluate the
impact of justification form on selected antimicrobials. Other factors
potentially affecting antimicrobial usage were also not adjusted for in
the statistical analysis.
We conclude that introduction of ‘antimicrobial
justification form’ has the potential of restricting the use of selected
antimicrobials in a PICU. Well-designed cluster-randomized trials
evaluating similar policies need to be conducted in various settings
where antibiotic abuse may be a problem.
Contributors: HSB: study design, collection of
data, data entry, drafting of article; FARS: designing the study, data
analysis, drafting of article; PKP: designing the study, data analysis,
statistical analysis, revision of article; DR: data collection, data
analysis, drafting of article; DC: designing the study, data analysis,
drafting of article. All authors approved the final version.
Funding: None; Competing interests: None stated.
What This Study Adds?
•
Introduction of a justification
form before prescribing antimicrobials or at the time of
deferring de-escalation can be useful in antibiotic stewardship.
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