Unnecessary Antibiotic Exposure Research Articles

P-1479. Patterns of surgical antibiotic prophylaxis among patients undergoing Cesarean deliveries in tertiary care hospitals in Bangladesh

Abstract Background The World Health Organization recommends a single dose of a first-generation cephalosporin given 30-60 minutes prior to surgery to prevent surgical site infections (SSI) in Cesarean deliveries (C-section). Perinatal exposure to antibiotics may modulate the microbiome of mothers and newborns, favoring the persistence of drug-resistant organisms which are frequently implicated in neonatal sepsis. This study investigated the pattern of surgical antibiotic prophylaxis (SAP) among patients undergoing C-sections in Bangladeshi tertiary care hospitals Commonly prescribed antibiotics to surgery patients Commonly prescribed antibiotics to surgery patients Methods From May through December 2023, we conducted a prospective observational study in six tertiary care hospitals and enrolled 1,335 women who underwent C-sections. Information on demographics and types of prophylactic antibiotic use was collected during the preoperative, postoperative, and post-discharge phases Results The median age of enrolled participants was 26 years (IQR: 22-28) and nearly half (48.9%) had a prior C-section. Pre-operatively, ceftriaxone was the most common SAP, which was used in 88% of cases. The median time for pre-operative antibiotic administration until incision was 180 minutes (IQR: 90-270). Post-operatively, injectable antibiotics were administered to all patients, with ceftriaxone (92.6%) and metronidazole (95.3%) being the most frequently prescribed. Similarly, all patients received oral antibiotics upon discharge. Cefixime (84.6%) and metronidazole (51.0%) were the most prescribed antibiotics at hospital discharge, followed by flucloxacillin (48.4%) and amoxicillin-clavulanic acid (13.1%), for a median duration of 5 days Conclusion Patients undergoing C-sections were frequently prescribed broad-spectrum antibiotics as part of SAP with extended post-operative dosing. Extensive SAP use may suggest underlying concerns regarding patient population, local antimicrobial resistance profiles, infection prevention lapses, and a lack of local hospital-based SAP guidelines. Understanding motivations for and effects of SAP patterns is essential for mitigating unnecessary perinatal antibiotic exposure and guiding antimicrobial stewardship efforts. Additionally, the timing of pre-operative SAP administration warrants further optimization Disclosures All Authors: No reported disclosures

P-943. Adherence to Guideline-Recommended Duration of Antibiotic Treatment for Uncomplicated Cardiovascular Implantable Electronic Device Lead Infections

Abstract Background Cardiovascular Implantable Electronic Device lead infection (CIEDLI) is defined as infection involving the leads without concurrent valvular endocardial involvement. These infections are categorized as complicated when extracardiac infection is present and as uncomplicated when distant sites of infection are absent. According to the American Heart Association (AHA), uncomplicated CIEDLI due to Staphylococcus aureus should be treated for 2 to 4 weeks of antibiotic treatment, while non-S. aureus infections typically require a 2-week course. We aimed to evaluate physician adherence to AHA guidelines regarding duration of treatment for CIEDLI. Methods We retrospectively reviewed adults presenting with CIEDLI at our institution between 2015 and 2023 to identify those with uncomplicated infection. Physician recommendations regarding treatment duration for CIEDLI were examined. Patients with evidence of CIED-related endocarditis, complicated CIEDLI, and pocket infections without evidence of CIEDLI were excluded. Results Twenty-three patients met study criteria. The median age at the time of presentation was 66 years (IQR 46-75) with the majority being male (13/23, 57%) and Caucasian (12/23, 52%). Most patients had an Implantable Cardioverter Defibrillator (11/23, 48%). S. aureus was the most common causative pathogen (13/23, 56%), followed by coagulase negative staphylococci. Only 30% (7/23) of patients received therapy for the duration recommended by guidelines, while the remaining 70% were treated for longer periods, up to six weeks, despite having uncomplicated infection. Side effects to antibiotic therapy (acute kidney injury) were reported in two patients receiving prolonged treatment, whereas none were reported in the group treated according to guidelines. Conclusion Our study highlights a lack of adherence to AHA guidelines regarding the duration of antibiotic treatment for uncomplicated CIEDLI. Future efforts should focus on improving awareness and implementing evidence-based practices to optimize patient outcomes, minimize unnecessary antibiotic exposure, potentially mitigating the development of antibiotic resistance, and conserve healthcare resources. Disclosures Muhammad R. Sohail, MD, Angiodynamics: consulting fees from Medtronic, Phillips and Angiodynamics|Medtronic: Honoraria|Medtronic: Consulting fees from Medtronic, Phillips and Angiodynamics|Phillips: consulting fees from Medtronic, Phillips and Angiodynamics

P-663. Evaluating the Effectiveness of a Real-Time Electronic Alert to Monitor the Duration of Antibiotic Therapy in Hospitalized Pneumonia Patients in the Asian Healthcare Setting

Abstract Background Limiting the duration of antibiotic prescribing to the shortest effective period is recognized as a strategy to mitigate the risk of antibiotic resistance. This study aims to assess the impact of a Real-Time Electronic Alert system designed to monitor the duration of antibiotic therapy in hospitalized pneumonia patients, with the goal of reducing unnecessary antibiotic exposure. Methods The intervention involved the implementation of a dashboard capable of generating real-time alerts whenever hospitalized patients diagnosed with community- or hospital-acquired pneumonia received antibiotics for more than five consecutive days. The study was conducted between December 2022 and January 2024 at two medical college hospitals in South Asia. Alerts generated by the dashboard were regularly reviewed by an antibiotic stewardship (AS) team, who intervened when patients exceeded the guideline-recommended duration of antibiotic therapy for pneumonia without additional clinical indications warranting continued antibiotic use. To evaluate the effectiveness of the intervention, the inappropriate duration of antibiotic therapy was compared before and after the implementation of the dashboard. A similar hospital with comparable patient demographics served as a comparative group. Results During the intervention period, the AS team reviewed a total of 218 patients flagged by the dashboard, resulting in 117 documented interventions. Reasons for lack of intervention included the presence of additional infection diagnoses necessitating prolonged antibiotic therapy, co-infections, and delayed clinical improvement. Post-implementation, the mean excess duration of antibiotic therapy for pneumonia decreased to 0.48 days compared to the pre-implementation mean of 2.13 days. In contrast, the comparative hospital, which did not employ the alert system, experienced a post-intervention mean excess duration of 1.97 days compared to a pre-intervention mean of 2.04 days. Conclusion The pneumonia dashboard represents a potentially valuable stewardship tool for reducing unnecessary antibiotic exposure in pneumonia patients. Disclosures All Authors: No reported disclosures

P-406. Implementation of an Initial Specimen Blood Culture Diversion Device to Reduce Blood Culture Contamination: Lessons Learned

Abstract Background Blood culture (BCx) contamination (BCxC) leads to unnecessary antibiotic exposure, increased hospital stay, and cost. Despite best practices, our health system’s BCxC rates remain above the 1% benchmark. Implementation of an initial specimen diversion device (ISDD) have demonstrated reduced BCxC rates. 3,4 We assessed the impact of the Kurin Lock® ISDD on BCxC and vancomycin utilization in adult emergency departments (EDs), intensive care and step-down units (ICU/SD). Methods The Kurin Lock® was implemented in 3 Lifespan health system hospitals (The Miriam Hospital [TMH] ED October2022; Rhode Island Hospital [RIH] and Newport Hospital [NH] EDs January 2023, and in all 3 hospital’s ICU/SD units June 2023). We included adult BCx obtained by nurses (all hospitals) or phlebotomists (NH only). BCx were drawn per protocol; growth was monitored with the BioMérieux VIRTUO System. BCxC rates were calculated dividing the number of contaminated cultures (per CDC NHSN commensal list) by the total number of BCxs/month. Mean BCxC rates prior to Kurin Lock® implementation (6 months) and after implementation (subsequent months through December 2023), excluding the month of implementation, were compared using the Wilcoxon rank-sum test. An interrupted time-series analysis was performed using binomial regression models; vancomycin days of therapy (DOT) for ’bacteremia’ was analyzed using generalized linear models. Results Overall mean BCxC rates for all hospitals and locations decreased from 3% to 1.9% after ISDD implementation (P=0.009). This decline was observed in all EDs but only statistically significant in RIH ICUs/SDs. In the time-series analysis, an abrupt 65% decline in BCxC was observed immediately after implementation in all hospitals and locations (P = 0.04). Lower BCxC rates were sustained after 200 days in the ICUs/SDs and 400 days in the EDs; however, an upward trend was observed with time. Vancomycin DOT was not significantly different pre- vs. post-Kurin Lock® implementation (41/1000 patient days vs. 37/1000 patient days, P=0.9). Conclusion A sustained decline in BCxC is achievable with the Kurin Lock® ISDD in academic and community hospital settings. But consistent education on best practices is key to guarantee the efficacy and cost-effectiveness of this intervention. Disclosures Leonard Mermel, DO, ScM, Citius Pharmaceuticals: Advisor/Consultant|CorMedix Pharma: Advisor/Consultant|Destiny Pharma: Advisor/Consultant|Lightline Medical: Advisor/Consultant|Lightline Medical: Stocks/Bonds (Private Company)|Pristine Access Technologies: Advisor/Consultant|Pristine Access Technologies: Stocks/Bonds (Private Company)

Impact analysis of infant antibiotic exposure on the burden of asthma: a simulation modeling study

BackgroundInfant antibiotic use is associated with increased risk of asthma. We examined the population impact of antibiotic exposure in the first year of life on the burden of pediatric asthma in British Columbia, Canada, using simulation modeling.MethodsWe performed a Bayesian meta-analysis of empirical studies to construct dose-response equations between antibiotic exposure in the first year of life and pediatric (<19 years of age) asthma. We used administrative health data to document trends in infant (<1 year of age) antibiotic use in British Columbia during 2001 and 2018 (the study period). An independently developed microsimulation model of asthma was utilized to estimate asthma-related outcomes under three scenarios pertaining to the trends in antibiotic use during the study period: (1) observed trends, (2) flat trend in which the prescription rate remained at the 2001 value, and (3) intermediate trends midway between these two. We reported cumulative person-years with asthma, cumulative asthma incidence, and cumulative asthma exacerbations among the pediatric population during the study period.ResultsThere were 773,160 live births during the study period, with an average antibiotic prescription rate of 523 per 1,000 infants in the first year of life. The prescription rate decreased by 71.5% during the study period. In Scenario 1, there were 1,982,861 person-years with asthma, 183,392 asthma incident cases, and 383,072 exacerbations. Had the antibiotic exposure remained at the 2001 values (Scenario 2), there would have been additional 37,213 person-years with asthma, 10,053 asthma incident cases, and 23,280 exacerbations. Had the decline been half of the observed trend (Scenario 3), there would have been additional 20,318 person-years with asthma, 5,486 asthma incident cases, and 12,728 exacerbations. At least 80% of the excess burden in each outcome was attributable to the younger pediatric population of <10 years of age.ConclusionsThe decline in infant antibiotic exposure has resulted in a substantial reduction in the burden of asthma in British Columbia. Such benefits should be considered when evaluating the value proposition of initiatives aimed at reducing unnecessary antibiotic exposure in early life.

The Critical Lens: It is time to start using the right test for febrile young infants.

Fever among infants in the first months of life is a common clinical conundrum facing all clinicians who treat children. Most well-appearing febrile young infants have viral illnesses. However, it is critical to identify those at risk of invasive bacterial infections, specifically bacteremia and bacterial meningitis. Clinicians must balance the risks of missing these infections against the harms of over-investigation. Procalcitonin testing is currently the best diagnostic test available to help guide management, and the Canadian Paediatric Society Position Statement on the management of febrile young infants recommends procalcitonin-based risk stratification. However, in many clinical settings, procalcitonin is either unavailable or has a turnaround time that is too long to aid decision-making. Clinicians who care for febrile young infants must have rapid access to procalcitonin results to provide best-evidence, guideline-adherent care. The wider availability of this test is essential to reduce unnecessary invasive testing, hospitalizations, and antibiotic exposure and could reduce system-wide resource utilization.

Linking clinical manifestations and causative organisms may provide clues for the treatment of peritoneal dialysis-associated peritonitis

IntroductionDifferent initial manifestations of peritoneal dialysis-associated peritonitis (PDAP) may depend on the type of pathogenic organism. We investigated the association between the clinical characteristics of PDAP and susceptibility to vancomycin and investigated the possibility of using vancomycin monotherapy alone as an initial treatment regimen for some PDAP patients to avoid unnecessary antibiotic exposure and secondary infection.MethodsPatients with culture-positive PDAP were retrospectively analyzed and divided into two groups: peritonitis with only cloudy effluent (PDAP-cloudy) or with cloudy effluent, abdominal pain and/or fever (PDAP-multi). The bacterial culture of PD effluent and antibiotic sensitivity test results were compared between groups. Logistic regression was used to investigate factors predicting susceptibility to vancomycin.ResultsOf 162 episodes of peritonitis which had a positive bacterial culture of PD fluid, 30 peritonitis were in the PDAP-cloudy group, and 132 peritonitis were in the PDAP-multi group. Thirty (100%) peritonitis in the PDAP-cloudy group had gram-positive bacterial infections, which was significantly greater than that in the PDAP-multi group (51.5%) (P < 0.001). Twenty-nine (96.7%) peritonitis in the PDAP-cloudy group were susceptible to vancomycin, compared to 67 (50.8%) in the PDAP-multi group (P < 0.001). The specificity of PDAP-cloudy for vancomycin-sensitive peritonitis was 98.48%. Only one patient (3.3%) in the PDAP-cloudy group experienced vancomycin-resistant peritonitis caused by Enterococcus gallinarum, which could neither be covered by vancomycin nor by the initial antibiotic regimen recommended by the current ISPD guidelines. The presence of only cloudy effluent was an independent predictor of susceptibility to vancomycin according to multivariate analysis (OR = 27.678, 95% CI 3.191-240.103, p = 0.003), in addition to PD effluent WBC counts (OR = 0.988, 95% CI 0.980–0.996, p = 0.004), diabetes mellitus (OR = 3.646, 95% CI 1.580–8.416, p = 0.002), first episode peritonitis (OR = 0.447, 95% CI 0.207–0.962, p = 0.039) and residual renal creatinine clearance (OR = 0.956, 95% CI 0.918–0.995, p = 0.027). Addition of these characteristics increased the AUC to 0.813 (95% CI 0.0.749–0.878, P < 0.001). The specificity of presenting with only cloudy effluent for vancomycin-sensitive peritonitis was 98.48%.ConclusionsCloudy dialysate, as the only symptom at PDAP onset, was an independent predictor of vancomycin-sensitive PDAP, which is an important new insight that may guide the choice of initial antibiotic treatment.

EFFICACY OF EARLY-ONSET SEPSIS CALCULATOR IN THE PREDICTION OF ANTIBIOTICS USAGE AMONG NEONATES: A LOCAL SETTING STUDY

Early-onset sepsis (EOS) in neonates is a critical condition that requires timely diagnosis and appropriate management to prevent adverse outcomes. However, overuse of antibiotics in neonates can lead to complications, including antimicrobial resistance. The EOS calculator is a clinical tool designed to assess the risk of sepsis in neonates, helping to guide antibiotic use. Its efficacy in predicting antibiotic administration in high-risk neonates needs further evaluation. Objective: To evaluate the efficacy of the EOS calculator in predicting the use of antibiotics in neonates admitted to the neonatal intensive care unit (NICU) at a tertiary care hospital. Methods: This comparative cross-sectional study was conducted in the Pediatrics Department of Combined Military Hospital, Peshawar, from August 2020 to June 2022. A total of 982 neonates admitted to the NICU due to a high risk of infection were included. Upon admission, the attending clinician applied the EOS calculator to each neonate. However, the results were kept confidential, and routine management, including antibiotic administration, was carried out based on clinical signs and relevant investigations. The use of antibiotics within 72 hours of admission was compared to the recommendations of the EOS calculator. Statistical analysis used chi-square tests to assess the association between antibiotic use and the EOS calculator's recommendations. Results: Out of the 982 neonates included, 590 (60.1%) were male, and 392 (39.9%) were female, with a mean age of 1.38±4.53 days. Within 72 hours of admission, 562 (57.2%) neonates did not receive antibiotics according to local protocols. A statistically significant association was observed between the clinical use of antibiotics and the recommendations of the EOS calculator (p-value &lt;0.001), demonstrating that the calculator could effectively predict antibiotic needs. Conclusion: The EOS calculator proved to be an effective tool in predicting the likelihood of sepsis in neonates at high risk of infection. Its use can guide clinicians in making informed decisions about antibiotic administration, reducing unnecessary antibiotic exposure while ensuring timely treatment for those who need it. Incorporating the EOS calculator into neonatal sepsis management protocols can enhance patient outcomes and help prevent the overuse of antibiotics in neonates.

Effectiveness of A Nurse-Led Multimodal Intervention in Preventing Blood Culture Contamination: A Before-and-After Study.

Blood culture is crucial for accurate and timely bacteremia diagnosis and guide antibiotic therapy. However, during culture sampling, contamination can occur, resulting in misdiagnosis, unnecessary antibiotic exposure, and prolonged hospitalization. This before-and-after intervention study aimed to evaluate the effectiveness of a multimodal intervention in preventing blood culture contamination. The study was conducted in a 170-bed hospital in Portugal and included a total of 23,566 blood cultures. Contamination rates were assessed in two phases: Phase 1 (before intervention, month 0) included 10,928 cultures, and Phase 2 (after intervention, month 6) included 12,638 cultures. During the study period, a multimodal intervention targeting the nursing staff was implemented, consisting of training actions, guideline updates, regular data monitoring and feedback, and introduction of a blood culture pack. Following the intervention, blood culture contamination decreased from 6.8% (Phase 1) to 3.9% (Phase 2). A comparative analysis revealed that the risk of contamination before the intervention was nearly four times higher in first culture, OR = 3.97 (CI 2.86-5.49). Our findings suggest that the multimodal intervention enhanced nurses' adherence to recommended practices, resulting in a reduced risk of blood culture contamination, earlier identification of infectious agents, and improved accuracy of antibiotic therapy.

Assessment of De-Escalation of Empirical Antimicrobial Therapy in Medical Wards with Recognized Prevalence of Multi-Drug-Resistant Pathogens: A Multicenter Prospective Cohort Study in Non-ICU Patients with Microbiologically Documented Infection.

Antimicrobial resistance poses a major threat to human health worldwide and the implementation of antimicrobial stewardship programs (ASPs), including antimicrobial de-escalation (ADE), is a multifaceted tool for minimizing unnecessary or inappropriate antibiotic exposure. This was a prospective observational study of 142 non-Intensive Care Unit (ICU) patients with microbiologically documented infection who were initially administered empirical antimicrobial therapy and admitted to the medical wards of 6 tertiary-care hospitals in Greece from January 2017 to December 2018. Patients were divided into two groups, the ADE and non-ADE group, based on whether ADE was applied or not, respectively. Exploratory end-points were ADE feasibility, safety and efficacy. ADE was applied in 76 patients at a median time of 4 days (IQR: 3, 5). An increased likelihood of ADE was observed in patients with urinary tract (OR: 10.04, 95% CI: 2.91, 34.57; p < 0.001), skin and soft tissue (OR: 16.28, 95% CI: 1.68, 158.08; p = 0.016) and bloodstream infections (OR: 2.52, 95% CI: 1, 6.36; p = 0.05). Factors significantly associated with higher rates of ADE were clarithromycin administration, diagnosis of urinary tract infection (UTI), isolation of E. coli, age and symptoms type on admission. Mortality was lower in the ADE group (18.4% vs. 30.3% p < 0.1) and ADE was not significantly associated with the probability of death (p = 0.432). ADE was associated with favorable clinical outcomes and can be performed even in settings with high prevalence of multi-drug resistant (MDR) pathogens without compromising safety.

Reducing Blood Culture Contamination in Adult Patients with Cancer Presenting to the Emergency Department

Background: Infection is one of the most common complications of cancer and cancer treatment. Most patients admitted for fever or infection come through the Emergency Department (ED), which is a primary site for blood culture collection. Contamination of blood cultures complicates the diagnoses, compromises quality of care, leads to unnecessary antibiotic exposure and increases financial burdens. It may also lead to unnecessary removal of central venous access devices or delay of critical therapy or procedures. At our institution, the contamination rate of blood cultures drawn in the ED was over twice that of the remainder of the hospital (2.8 versus 0.8), prompting this quality improvement project. Unlike on hospital floors, nurses, instead of phlebotomists, draw most blood cultures due to the urgency of managing suspected sepsis. Our aim was to decrease the ED contamination rate by 20 percent after the first PDSA cycle, and ultimately bring it on par with the remainder of the hospital. Methods: First, we compared ED contamination rates versus other hospital inpatient floors and outpatient centers over a three-month period. We then evaluated the contamination rates of ED nurses versus ED phlebotomists and peripheral versus central line blood draws. Process mapping and fishbone analysis helped identify practices contributing to higher contamination rates. Key drivers of these practices were diagrammed, and potential interventions were ranked on a prioritization matrix. Results: We identified use of alcohol rather than chlorhexidine swabs for peripheral disinfection and inconsistent techniques of blood draw by nurses as critical contributors to increased contamination rates in the ED. Our intervention was creating premade blood culture kits promoting the use of chlorhexidine swabs through availability and easy access in the fast-paced ED environment. Ten cubic centimeter (cc) syringes in the kits encouraged withdrawal of adequate blood samples in compliance with the 7-10 cc guideline. Designated nursing team leaders checked off ED nurses at the bedside, implementing education and adherence in using the blood culture collection kits. The average number of blood cultures in the emergency department was 1,400. A reduction in blood culture contamination from 2.46 percent to 1.89 percent was seen after two months. Conclusions: A guideline-driven, standardized blood culture collection process followed by ED nurses is vital to reducing blood culture contamination. Chlorhexidine is necessary to maintain the lowest contamination rates. Readily available premade blood culture kits improve compliance with materials and techniques associated with best practices.

Evaluating a Modified Use of the Kaiser Permanente Early-onset Sepsis Risk Calculator to Reduce Antibiotic Exposure: a Retrospective Study

BackgroundEarly-onset neonatal sepsis (EONS) remains an important disease entity due to very serious adverse outcomes if left untreated. Lack of diagnostic tools in identifying healthy from diseased neonates, and clinicians’...

Antibiotic Resistance Mechanisms and Strategies for Combating Resistance in Germany

Purpose: The aim of the study was to explore antibiotic resistance mechanisms and strategies for combating resistance in Germany Methodology: This study adopted a desk methodology. A desk study research design is commonly known as secondary data collection. This is basically collecting data from existing resources preferably because of its low cost advantage as compared to a field research. Our current study looked into already published studies and reports as the data was easily accessed through online journals and libraries. Findings: antibiotic resistance represents a complex and evolving challenge to public health in Germany. Mechanisms such as efflux pumps, mobile genetic elements, and enzymatic degradation contribute to the resilience of bacteria against antibiotics. However, strategic interventions have been identified to combat resistance effectively. Exploration of alternative therapies like bacteriophage therapy offers promising avenues for addressing antibiotic-resistant infections, especially in light of increasing resistance rates. Unique Contribution to Theory, Practice and Policy: Evolutionary theory of antibiotic resistance &amp; Game Theory in Antibiotic Stewardship may be used to anchor future studies on antibiotic resistance mechanisms and strategies for combating resistance in Germany. Implement antimicrobial stewardship programs across healthcare settings to optimize antibiotic use. These programs should involve prescriber education, antibiotic guidelines, and regular audits to promote appropriate prescribing practices and minimize unnecessary antibiotic exposure. Prioritize infection prevention measures, including hand hygiene, environmental cleaning, and infection control protocols, to reduce the spread of resistant pathogens within healthcare facilities and communities. Enact policies to regulate the use of antibiotics in human health, veterinary medicine, and agriculture. This includes restrictions on antibiotic use in food production, bans on over-the-counter antibiotic sales, and incentives for the development of new antibiotics.

Laboratory approaches to determining blood culture contamination rates: an ASM Laboratory Practices Subcommittee report.

Blood culture contamination (BCC) is the presence of specific commensal and environmental organisms cultivated from a single blood culture set out of a blood culture series and that do not represent true bacteremia. BCC can impact quality of care and lead to negative outcomes, unnecessary antibiotic exposure, prolonged hospital stays, and substantial costs. As part of the laboratory's quality management plan, microbiology laboratory personnel are tasked with monitoring BCC rates, preparing BCC rate reports, and providing feedback to the appropriate committees within their healthcare system. The BCC rate is calculated by the laboratory using pre-set criteria. However, pre-set criteria are not universally defined and depend on the individual institution's patient population and practices. This mini-review provides practical recommendations on elaborating BCC rate reports, the parameters to define for the pre-set criteria, how to collect and interpret the data, and additional analysis to include in a BCC report.

Tailored Approach to Evaluation and Management of Early Onset Neonatal Sepsis in a Safety-Net Teaching Hospital in Northeast Florida.

Objective Early onset neonatal sepsis (EONS) remains a significant cause of morbidity and mortality in newborns in the immediate postnatal period. High empiric antibiotic use in well-appearing infants with known risk factors for sepsis led the American Academy of Pediatrics (AAP) to revise its 2010 guidelines for the evaluation and management of EONS to avoid overuse of antibiotics. In this recent clinical report, the AAP provided a framework that outlined several evidence-based approaches for sepsis risk assessment in newborns that can be adopted by institutions based on local resources and structure. One of these approaches, the sepsis risk calculator (SRC) developed by Kaiser Permanente, has been widelyvalidated for reducing unnecessary antibiotic exposure and blood work in infants suspected of having EONS. In order to determine the utility and safety of modifying our institution's protocol to the SRC, we implemented a two-phased approach to evaluate the use of SRC in our newborn nursery. Phase 1 utilized a retrospective review of cases with SRC superimposition. If results from Phase 1 were found to be favorable, Phase 2 initiated a trial of the SRC for a six-month period prior to complete implementation. Methods Phase 1 consisted of retrospectively applying the SRCto electronic medical records (EMR) of infants ≥ 35 weeks' gestational age admitted to the newborn nursery with risk factors for EONS between June 2016 and May 2017. We compared actual antibiotic use as determined by the unit's EONS protocol for evaluation and management based on 2010 Centers for Disease Control and Prevention (CDC) and AAP guidelines to SRC-recommended antibiotic use. We used EMR to determine maternal and infant data, blood work results, and antibiotic usage as well asused daily progress notes by the clinical team to determine the clinical status of the infants retrospectively. Based on the projected reduction in blood work and antibiotics use with the retrospective superimposition of SRC on this cohort of infants and identification of our high-risk patient subset, we developed a novel, hybrid EONS protocol that we implemented and assessed throughout Phase 2, a six-month period from August 2018 to January 2019, as a prospective observational study. Results Phase 1 (SRC superimposition) demonstrated that the use of the SRC would have reduced empiric antibiotic use from 56% to 13% in the study cohort when compared with 2010 CDC/AAP guidelines. However, these same findings revealed use of the SRC would have resulted in delayed evaluation and initiation of antibioticsin 2 of 4 chorioamnionitis-exposed infants with positive blood cultures. During Phase 2 (n=302), with the implementation of our tailored approach (SRC implementation with additional blood culture in chorioamnionitis-exposed infants), 12 (4%) neonates received empiric antibiotic treatment compared to nine (3%) neonates who would have been treated per strict adherence to SRC recommendations. No neonate had culture-positive EONS. Continued use of 2010 CDC/AAP guidelines would have led to empiric antibiotic use in 38 (12.6%) infants in this cohort. Conclusion We developed a novel hybrid approach to the evaluation and management of neonates at increased risk of EONS by tailoring SRC recommendations to our safety-net population. Our stewardship effort achieved a safe and significant reduction in antibiotic usage compared to prior usage determined using CDC/AAP guidelines.

Inpatient pediatric antimicrobial use for respiratory infections during the RSV surge

Background: In the United States, pneumonia causes &gt;100,000 pediatric hospitalizations annually. On November 4, 2022, the CDC issued a Heath Advisory concerning an upcoming surge of respiratory illnesses including SARS-CoV-2, influenza, and respiratory syncytial virus (RSV). Differentiating between viral and bacterial causes is challenging and can lead to antimicrobial overuse. Currently, tools are being developed to distinguish between viral and bacterial pneumonia. The VALS-DANCE Pneumonia Etiology Predictor (PEP) provides clinical scoring criteria (Fig. 1) to determine probable cause of pneumonia with 93.1% sensitivity for bacterial pneumonia. Scores &gt;11 have a &gt;25% likelihood of having bacterial etiology. Given that antimicrobial exposure increases resistance rates, disrupts natural flora, and increases the risk of side effects, a core goal of researchers is to develop ways to promote stewardship and reduce inappropriate use. We assessed the patterns of use for antimicrobials in pediatric patients admitted with pneumonia at our institution. Methods: This retrospective review included pediatric cases admitted to an urban safety-net community hospital from July 22, 2022, to December 16, 2022. A daily list of all patients receiving antimicrobials was reviewed, and pediatric patients with diagnosis of a respiratory infection were included. Patients with additional indications for antimicrobial therapy, diagnosis of bronchitis, incomplete records, or without complete information were excluded from the scoring criteria. The primary objective was to assess the appropriateness of antimicrobial use for pneumonia, defined as use consistent with PEP scoring recommendations. Results: Of 53 patients reviewed, 37 met inclusion criteria. Of 37 patients, 22 (59.5%) met study criteria for appropriate therapy. The 15 patients (40.5%) who were inappropriate for treatment received an average of 4.67 ± 1.91 days of antibiotics. Of these 15 patients, 11 (73.3%) also had a positive viral test, further increasing the likelihood of a viral etiology. This subgroup had an average antibiotic exposure of 4.27 ± 1.79 days. Documented rationale for therapy included severity of illness (4 of 11), radiograph consolidation (4 of 11), and provider disagreement with radiograph interpretation (3 of 11). Conclusions: Pediatric respiratory infections represent a significant opportunity for antimicrobial stewardship. In this study, as many as 40% of pediatric patients may have received unnecessary antibiotic exposure. Use of the VALS-DANCE criteria may help clinicians identify patients with low likelihood of bacterial infection and reduce antimicrobial use. The national surge of viral infections serves to highlight the vital importance of appropriate diagnostic stewardship.Disclosure: None

Broad- Versus Narrow-Spectrum Perioperative Antibiotics and Outcomes in Pediatric Congenital Heart Disease Surgery: Analysis of the Vizient Clinical Data Base.

Despite guidelines recommending narrow-spectrum perioperative antibiotics (NSPA) as prophylaxis for most children undergoing congenital heart disease (CHD) surgery, broad-spectrum perioperative antibiotics (BSPA) are variably used, and their impact on postoperative outcomes is poorly understood. We used administrative data from U.S. hospitals participating in the Vizient Clinical Data Base. Admissions from 2011 to 2018 containing a qualifying CHD surgery in children 0-17 years old were evaluated for exposure to BSPA versus NSPA. Propensity score-adjusted models were used to compare postoperative length of hospital stay (PLOS) by exposure group, while adjusting for confounders. Secondary outcomes included subsequent antimicrobial treatment and in-hospital mortality. Among 18 088 eligible encounters from 24 U.S. hospitals, BSPA were given in 21.4% of CHD surgeries, with mean BSPA use varying from 1.7% to 96.1% between centers. PLOS was longer for BSPA-exposed cases (adjusted hazard ratio 0.79; 95% confidence interval [CI]: 0.71-0.89, P < .0001). BSPA was associated with higher adjusted odds of subsequent antimicrobial treatment (odds ratio [OR] 1.24; 95% CI: 1.06-1.48), and there was no significant difference in adjusted mortality between exposure groups (OR 2.06; 95% CI: 1.0-4.31; P = .05). Analyses of subgroups with the most BSPA exposure, including high-complexity procedures and delayed sternal closure, also did not find (but could not exclude) a measurable benefit from BSPA on PLOS. BSPA use was common in high-risk populations, and varied substantially between centers. Standardizing perioperative antibiotic practices between centers may reduce unnecessary broad-spectrum antibiotic exposure and improve clinical outcomes.

Risk Stratification to Support Antibiotic Stewardship and Breastfeeding Exclusivity in a Military Treatment Facility

ObjectiveTo safely reduce unnecessary antibiotic exposure in neonates exposed to chorioamnionitis and inadequately treated Group B Streptococcus (GBS) using the early-onset sepsis (EOS) calculator for risk stratification and a 36-hour antibiotic duration. DesignEvidence-based quality improvement initiative. Setting/Local ProblemObstetric service at a midsized military treatment facility with approximately 2,000 births annually and no standard process for neonatal EOS risk assessment. ParticipantsClinical nurse specialist, physicians, nursing leadership, unit-level nursing champions, and nurses assigned to the mother–baby and labor and delivery units. Intervention/MeasurementsAn interdisciplinary working group created a protocol to institute an EOS risk assessment calculator, a note for the electronic heath record, and interdisciplinary education for all staff providing care to neonates in our facility. ResultsBefore implementation of the EOS calculator, 97.6% of neonates exposed to chorioamnionitis or inadequate maternal GBS treatment received antibiotics; after implementation, the mean rate dropped to 32%. Exclusive breastfeeding rates before discharge in neonates exposed to chorioamnionitis or inadequate maternal GBS treatment also increased during this time, from 40% to a mean of 89%. After implementation, there were no readmissions to our institution for culture-proven sepsis within 14 days of discharge. ConclusionMultidisciplinary team-led implementation of the EOS calculator and of shortened antibiotic duration were associated with safely reduced antibiotic exposure in well-appearing neonates exposed to chorioamnionitis and GBS. In addition, dramatically improved rates of exclusive breastfeeding at discharge were observed in this population.

A Quality Improvement Project to Reduce Antibiotic Exposure in Premature Neonates.

Overuse of antibiotics in NICUs is a problem worldwide. Unnecessary antibiotic exposure leads to resistance, changes in the microbiome, and increases the risk of bronchopulmonary dysplasia, retinopathy of prematurity, periventricular leukomalacia, necrotizing enterocolitis, late-onset sepsis (LOS), and mortality in neonates. We aimed to safely reduce the antibiotic usage rate (AUR) in our level IV unit by 10% by December 2018. A multidisciplinary quality improvement project took place as part of a Vermont Oxford Network initiative in 2018. Multiple interventions took place, including identification of variations in practices and subsequent standardization through the creation of early onset and LOS guidelines, mass education, improved visibility of the guidelines, and standardized documentation. The main outcome measure for this project was the AUR for infants born <35 weeks' gestation expressed as antibiotic doses per 1000 patient days. The AUR decreased from a mean of 524 to 394, for a decrease of 24.8%. Results have been sustained for 3 years. Main contributors that led to the sustained success include decreasing the overall use of antibiotics for early onset sepsis, as well as the duration when cultures are negative. The number of LOS courses also decreased slightly. We noted no cases of inadequately treated sepsis resulting in subsequent positive cultures. Creation of guidelines with mass education and ongoing feedback/monitoring can result in a safe reduction of AUR in the NICU.

Can Presepsin Be Valuable in Reducing Unnecessary Antibiotic Exposure after Birth?

Due to a lack of rapid, accurate diagnostic tools for early-onset neonatal sepsis (EOS) at the initial suspicion, infants are often unnecessarily given antibiotics directly after birth. We aimed to determine the diagnostic accuracy of presepsin for EOS before antibiotic initiation and to investigate whether presepsin can be used to guide clinicians' decisions on whether to start antibiotics. In this multicenter prospective observational cohort study, all infants who started on antibiotics for EOS suspicion were consecutively included. Presepsin concentrations were determined in blood samples collected at the initial EOS suspicion (t = 0). In addition to this, samples were collected at 3, 6, 12 and 24 h after the initial EOS suspicion and from the umbilical cord directly after birth. The diagnostic accuracy of presepsin was calculated. A total of 333 infants were included, of whom 169 were born preterm. We included 65 term and 15 preterm EOS cases. At the initial EOS suspicion, the area under the curve (AUC) was 0.60 (95% confidence interval (CI) 0.50-0.70) in the term-born infants compared to 0.84 (95% CI 0.73-0.95) in the preterm infants. A cut-off value of 645 pg/mL resulted in a sensitivity of 100% and a specificity of 54% in the preterm infants. The presepsin concentrations in cord blood and at other time points did not differ significantly from the concentrations at the initial EOS suspicion. Presepsin is a biomarker with an acceptable diagnostic accuracy for EOS (culture-proven and clinical EOS) in preterm infants and might be of value in reducing antibiotic exposure after birth when appended to current EOS guidelines. However, the small number of EOS cases prevents us from drawing firm conclusions. Further research should be performed to evaluate whether appending a presepsin-guided step to current EOS guidelines leads to a safe decrease in antibiotic overtreatment and antibiotic-related morbidity.