Antibiotic Stewardship in NICU

Dr Padmesh
• DEFINITION: Defined by the Infectious Diseases Society of
America (IDSA):
“Interventions targeted toward the improvement and
monitoring of appropriate antimicrobial use by selecting
the most optimal drug regimen, including the type of drug
used, dose, duration of therapy, and route of
administration.”
• AIM:
• Antimicrobial stewardship efforts strive to :
– achieve clinical Cure,
– limit Toxicity and adverse events,
– reduce Cost.
– decrease Health-care–associated infections
– reduce the development of Resistant organisms.
• Antimicrobial stewardship programs (ASP) :
• TEAM:
• Infectious diseases physician
• Clinical pharmacist
• Microbiologist
• Infection preventionist (eg, infection control nurse)
• Hospital epidemiologist,
• Information systems specialist.
• Antibiotic Stewardship in NICU:
• CORNERSTONES:
– Importance of optimal Diagnostic strategies (eg, use of
biomarkers),
– Empiric antibiotic selection based on local Antibiogram
characteristics and risk factors,
– Constant Reevaluation of the antimicrobial regimen,
– Monitoring of Toxicity, and
– Consideration of Shorter antimicrobial courses
• Antibiotic Stewardship in NICU:
• Broad spectrum antibiotic exposure  emergence of multi-
drug resistant gram-negative bacilli and development of
invasive candidiasis.
• Prolonged duration of empiric antibiotic therapy for early
onset sepsis in ELBW  increased risk of death and
necrotizing enterocolitis.
• Antibiotics  adverse events such as nephrotoxicity,
hepatoxicity.
• Biomarkers may be useful to identify infants with true
infection and reduce unnecessary antibiotic use.
(measuring interleukin-8 and C reactive protein (CRP))
• Antibiotic Stewardship in NICU:
• Suggested tactics include obtaining two blood
cultures of at least 0.5 mL of blood in the initial
evaluation of late-onset sepsis (LOS) for improved
recovery of organisms.
• Obtaining 2 blood cultures may help clinicians
differentiate between contamination or
colonization and infection, particularly if CoNS are
isolated.
• Avoid concurrent use of redundant coverage (eg,
meropenem and metronidazole) for the treatment
of necrotizing enterocolitis (NEC).
• Antibiotic Stewardship in NICU:
• 2 MAIN STEPS:
–1.Infection prevention
–2.Optimal drug
• 1. INFECTION PREVENTION:
• 1. CLABSI prevention: appropriate insertion, maintenance,
and timely removal of central venous catheters (CVCs),
• 2. Prevention of colonization and decolonization of
potential pathogens,
• 3. Microbiology laboratory surveillance
• 4. Local antibiogram use,
• 5. Containment of isolated infections.
• 6. Continued staff education
• 7. Hand hygiene,
• 8. Appropriate isolation precautions to prevent outbreaks.
• 2. OPTIMAL DRUG:
• 1. Selecting Appropriate Empiric Antibiotics
– Based on antibiogram of NICU (at least annual audit of
antibiogram)
• 2. Tailoring/Changing antibiotics based on culture report
• 3. Appropriate dosing
• 4. Appropriate route of administration (Change from IV to
Oral route whenever possible)
• 5. Limiting Antibiotic Duration
• 6. Maximizing Safety and Efficacy
• 7. Adhering to Unit Protocols
• OUTCOME MEASURES:
• 1. Hospital length of stay
• 2. Readmission rates
• 3. Number of patients with infection due to
multidrug-resistant organisms
• 4. Mortality due to infection
• 5. C. difficile infection rates (hospital acquired
versus all)
• STEWARDSHIP PROGRAM METRICS:
• 1. Monitoring of outcome measures:
– Recovery
– Days in hospital
– MDR organisms
– Adverse effects
– Deaths
– Readmission rates
– Cost
• 2. Increasing awareness
• 3. Feedback to the Team & Audit
THANK YOU