Background

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.

Objective

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.

Study design

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.

Results

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.

Conclusions

Developing and engaging a NICU ASP team improves compliance with late onset sepsis guidelines through the implementation of a LOS bundle of care.

中文翻译：

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通过抗菌药物管理标准化治疗新生儿迟发性败血症的方法：一项质量改进计划

背景

抗生素是新生儿重症监护病房 (NICU) 中处方最多的药物，其使用存在显着差异。虽然它们对于治疗感染至关重要，但它们使婴儿面临感染耐药生物、改变微生物组和其他几种疾病的风险。通常缺乏针对新生儿的具体指南，而且我们的新生儿重症监护室不符合迟发性脓毒症 (LOS) 指南。

客观的

到 2019 年 1 月，对于任何在坦帕综合医院 (TGH) NICU 接受 LOS 评估并在其生命 > 72 小时内接受 LOS 评估的婴儿，我们的 LOS 捆绑包将有 >75% 的依从性。该捆绑包包括记录的 LOS 评估原因、适当的初始抗生素选择、考虑的适当初始评估以及抗生素的适当降级。

学习规划

该项目在佛罗里达州坦帕市南佛罗里达大学附属的学术医疗中心 TGH 的新生儿重症监护室实施。负责该项目的多学科抗菌药物管理 (ASP) 团队由一名新生儿科主治医师、三名新生儿科研究员、一名儿科传染病主治医师和两名 NICU 药剂师组成。该项目于 2017 年 1 月启动，所有数据都是前瞻性收集的。我们以逐步的方式实施了多个计划-实施-学习-行动周期；结果测量包括遵守 LOS 捆绑包和 ASP 团队建议。我们的过程措施是记录脓毒症评估的原因、考虑的适当初始评估、适当的抗生素选择和适当的抗生素降级。患者住院时间是研究的平衡措施。

结果

在这 20 个月的计划中，有 232 名婴儿接受了 LOS 评估，血液 (28%)、尿液 (35%) 和脑脊液 (3%) 培养结果为 98 个真阳性。治疗培养阴性脓毒症的常见依据是临床肺炎（38%）和坏死性小肠结肠炎（38%）。LOS 评估的常见适应症是增加呼吸支持 (51%) 和腹胀 (17%)。适当的初始抗生素选择有所改善（70% 对 94%）；适当考虑初步评估（分别为 63% 和 94%）；抗生素的适当降级（分别为 86% 和 100%）并提高 LOS 束依从性（分别为 44% 和 87%）。总体抗生素利用率和治疗时间没有显着变化。

结论

开发和参与 NICU ASP 团队通过实施 LOS 捆绑护理来提高对迟发性脓毒症指南的遵从性。