Paediatric Antimicrobial Stewardship - Improving Evidence-Based Prescribing and Reducing Costs

Background:

Few reports of successful pediatric stewardship programs have been published. Our 250 bed tertiary pediatric hospital experienced ongoing (MRSA, ESBL) and emerging (VRE, carbapenemase) problems with multiply resistant organisms (MROs) in units with high broad-spectrum antibiotic use. We spent $US 2.5 million annually on antimicrobials, disproportionately high when benchmarked against similar paediatric hospitals. The hospital had no processes for monitoring, reviewing or auditing the use of antibiotics.  While drug committee protocols for the use of certain agents existed, there was no supervision of adherence to these protocols.

Objective: We aimed to develop an effective, sustainable, and acceptable mechanism for improving antimicrobial prescribing, reducing excessive use, and reducing drug acquisition costs

Methods:

We surveyed our clinicians: 95% of respondents agreed that stewardship was reasonable to ensure appropriate antimicrobial use and prevent resistance. Only 15% felt their clinical autonomy would be infringed, and 9% that stewardship might adversely affect patient care. Respondents expressed strong preference for a pager-based system. Restricted antimicrobials were prioritised based on resistance potential and cost. High priority drugs required pre-approval via a pager, and lower priority agents were logged via the intranet within 24 hours of prescribing. Explicit support from the Hospital Drug Committee and Executive were obtained. The stewardship team included two IDP's, a microbiologist and a senior pharmacist. Pre-implementation consultation with ‘high use’ units allowed dialogue regarding accepted indications. The program was launched with presentations, targeted education, all-user emails, and laminated flyers. Noncompliance was managed through hospital governance processes.

Results: The impact was accurately quantifiable since no previous stewardship program existed. In the first year, antimicrobial expenditure fell by $US 415,000 (16%). In the second six months, as the program established credibility, a mean monthly cost reduction of $US 70,000 (31%) was achieved, and sustained into the second year for an annual saving of $US 790,000 between the 6^th and 18^th month. A rise in the IV penicillin to cephalosporin use ratio was observed after program commencement, indicating increased narrow-spectrum therapy. There was no change in in-hospital mortality (p=0.96) or length of stay (p=0.89) of patients with Gram-negative bacteremia, and no other adverse outcomes were observed. Intangible benefits included TDM initiatives, education, and input into unit-specific antimicrobial protocols.

Conclusions:

A multidisciplinary team approach ensured the effectiveness, sustainability and safety of a novel stewardship program in a tertiary pediatric hospital. Substantial cost savings have been achieved without adverse clinical outcomes.