The threat of antimicrobial resistance — the ability of organisms to defeat the very drugs designed to kill them — is well known in modern medicine. It is the reason infections are becoming harder to treat. It is one explanation for higher healthcare costs, longer hospital stays, and more than 35,000 deaths in the US alone.

Antimicrobial stewardship, a coordinated effort to promote optimal use of antimicrobials, can turn all that around, improving the health and well-being of all while also saving money, experts said.

Pediatric hospitalists have an important role in antimicrobial stewardship, according to speakers at a recent Pediatric Hospital Medicine meeting in Anaheim, California.

“We do so much antibiotic prescribing,” said Kristina Nazareth-Pidgeon, MD, inpatient medical director of general pediatrics at Duke University, Durham, North Carolina, in a post-meeting interview with Medscape Medical News. And that prescribing is not always appropriate, contributing to the threat of resistance.

The Over-Prescribing Problem

While studies have found that 30%-50% of antibiotics prescribed for hospitalized patients of all ages are inappropriate, data on pediatric patients are limited. One recent analysis looked at antibiotic prescribing at 32 US children’s hospitals and found that 1 in 3 pediatric hospital patients are given antibiotics during their stay.

For that study, researchers evaluated the hospitalized children with one or more antibiotic orders at 8 AM on one day per calendar quarter over 6 quarters from 2016 to 2017 to determine the appropriateness of the prescriptions. Antimicrobial stewardship program physicians or pharmacists used a standardized survey, collecting data on the orders and evaluating the appropriateness.

The researchers found that of the 1 in 3 receiving one or more antibiotics at any given time, one quarter were receiving suboptimal therapy, and nearly half of that was not captured by current antimicrobial stewardship program practices.

Of the 34,927 children hospitalized on survey days, 12,213 (35%) had one or more active antibiotic orders. The most common reasons for inappropriate use were a mismatch of bug to drug, surgical prophylaxis for more than 24 hours, overly broad empiric therapy, and unnecessary treatment. 

Before getting to the question of prescribing, Nazareth-Pidgeon said four areas need to be considered:

• When to test — only when clinically indicated
• What to test — most appropriate test selection
• How to test — requires proper specimen collection
• How to interpret — clinical context is crucial

Antibiotic stewardship involves giving the right drug at the right dose to the right patient for the right duration, she said. The goal is to optimize antibiotic use. 

The Value of Antibiograms

Antibiograms are important, Nazareth-Pidgeon said, and should be leveraged. Defined as an overall profile of antimicrobial susceptibility testing results of a specific microorganism to a battery of antimicrobial medications, the antibiogram profile is created by the laboratory. It uses aggregate data from a healthcare system or a hospital. 

According to Nazareth-Pidgeon, the Clinical and Lab Standards Institute is typically credited with creating the concept.

Using antibiograms effectively is critical, Nazareth-Pidgeon said. “There are studies that show patterns within a hospital can be different on different floors,” she said. “The bone marrow unit may have different patterns than the general peds wards.”

How to use antibiograms effectively? “Use as local [data] as possible,” Nazareth-Pidgeon said. Update information regularly. Keep the information pediatric-specific and unit-specific, when possible, she said.

Pediatric-Focused Information

Pediatric-specific information, not adult, “is essential for the best care of our patients,” said Laura Lemley Hampton, MD, assistant professor of pediatrics and director of pediatric quality improvement at the Children’s Hospital of Georgia at Wellstar MCG Health, Augusta, Georgia.

“Practical strategies and support do exist, even if you don’t have a pediatric infectious disease physician specialist at your hospital,” she said.

Her suggestions are to engage key stakeholders at your hospital, such as your pharmacist, your infection prevention team, and the microbiology lab. Discuss how you can embed the antimicrobial stewardship program into your quality improvement program.

Many consider those as two separate entities, she said, but she said that’s not the best approach. “Marrying the two and embedding them [both] into the quality improvement program is helpful.”

Measuring impact is critical, Lemley Hampton said. “You have to track pediatric-specific metrics to demonstrate value and improvement.” She suggests using the resources from the CDC’s National Healthcare Safety Network.

Be proactive about penicillin allergy delabeling, Nazareth-Pidgeon said. According to the CDC, 10% of the population reports a penicillin allergy, but less than 1% are truly allergic. Because of this, Nazareth-Pidgeon said, broad-spectrum antibiotics are used more. “Being proactive and delabeling patients from their penicillin allergies allows for the use of more narrow-spectrum antibiotics,” a goal to decrease antimicrobial resistance. The CDC has step-by-step suggestions on how to do so.

No Formal Program Needed

To do well with antimicrobial stewardship, “you don’t need to be an expert in terms of having an infectious disease background,” said Margaret Oates Poisson, PharmD, pediatric pharmacy specialist at Children’s Hospital of Georgia at Wellstar MCG Health and pharmacy representative to its stewardship program. Nor does a hospital need a formal program to practice stewardship, she and others said.

“Engaging key team members — pharmacy being one — when evaluating can be helpful,” Oates Poisson told Medscape Medical News.

Among the common questions she gets are how cultures are interpreted and how antibiotics are selected. “If you can engage your pharmacist, everyone can be a steward of antimicrobials.”

Practical Points

The talk had valuable takeaways for clinicians, said Aruni Gunaratne, MD, pediatric hospitalist and outpatient general pediatrician at MedStar Georgetown University Hospital, Washington, DC, who attended. She cited an audience poll question asking about the most important variable in detecting bacteremia or fungemia in a blood culture.

“It was interesting to learn during the talk that the most important variable in detecting bacteremia or fungemia is the blood culture volume,” she said. (The other choices were timing of blood draw, technique and care in obtaining the specimen, and lab detection device interpretation.)

“Sometimes, as physicians, we are not always present during the actual blood culture draw, as our role is typically to decide whether a blood culture is needed and to place the order for a blood culture to be drawn.” Learning that the blood culture volume is crucial for accurate and sensitive detection of the bacteremia or fungemia, she said, “I plan to incorporate this into my future practice.”

In one study, more clinically significant microorganisms were found when two tubes of blood were collected compared with one.

Gunaratne said she would also suggest that colleagues reevaluate the antibiotic plan during rounds for each patient, because appropriate stewardship can change daily depending on new lab results, the patient’s clinical status, and other factors.

“Discussing the antibiotic plan on rounds can help expose trainees, such as residents, medical students, and pharmacy students, to the thought process behind antibiotic stewardship discussions,” she said, which can help them when they make their own decisions in the future.

Lemley Hampton, Nazareth-Pidgeon, Oates Poisson, and Gunaratne reported having no disclosures.