Standardizing the approach to late onset sepsis in neonates through antimicrobial stewardship: a quality improvement initiative.

Abstract

Antibiotics are the most prescribed medication in the neonatal intensive care unit (NICU) and there is marked variation in their use. While they are vital for treatment of infections, they put infants at risk for infections with drug resistant organisms, alteration in their microbiome and several other morbidities. Specific guidelines for neonates are often lacking and our NICU is not compliant with late onset sepsis (LOS) guidelines. By January 2019, there will be >75% compliance with our LOS bundle for any infant admitted to Tampa General Hospital's (TGH) NICU undergoing a LOS evaluation at >72 h of life. The bundle includes documented reason for LOS evaluation, appropriate initial antibiotic selection, appropriate initial evaluation considered, and appropriate de-escalation of antibiotics. The project was implemented in the NICU at TGH, the academic medical center affiliated with the University of South Florida in Tampa, FL. The multidisciplinary antimicrobial stewardship (ASP) team responsible for the project consists of a neonatology attending, three neonatology fellows, a pediatric infectious disease attending, and two NICU pharmacists. The project was started in January 2017 and all data were collected prospectively. We implemented multiple Plan-Do-Study-Act cycles in a stepwise manner; outcome measures included compliance with the LOS bundle and ASP team recommendations. Our process measures were the documented reason for sepsis evaluation, appropriate initial evaluation considered, appropriate antibiotic selection and appropriate antibiotic de-escalation. Patient length of stay was the balancing measure studied. During this 20-month initiative, there were 232 infants who underwent LOS evaluation and there were 98 true positive cultures from blood (28%), urine (35%), and cerebrospinal fluid (3%). Commonly documented rationales for treatment of culture negative sepsis were clinical pneumonia (38%) and necrotizing enterocolitis (38%). Common indications for LOS evaluations were increased respiratory support (51%) and abdominal distension (17%). There was improvement in appropriate initial antibiotic selection (70% vs. 94%); appropriate consideration of initial evaluation (63% vs. 94%, respectively); appropriate de-escalation of antibiotics (86% vs. 100%, respectively) and increase in LOS bundle compliance (44% vs. 87%, respectively). The overall antibiotic utilization rate and length of treatment did not change significantly. Developing and engaging a NICU ASP team improves compliance with late onset sepsis guidelines through the implementation of a LOS bundle of care.