Why We Need to Be Antimicrobial Stewards

Published on in Children's Doctor

Antibiotics, the most common form of antimicrobial drugs, are by far the most common prescription drugs given to children. In the United States, more than 60% of hospitalized children receive antibiotics, and roughly 75 million antibiotic prescriptions are given to children each year in the ambulatory setting, accounting for one-fourth of all medication use in this age group.

Unfortunately, we don’t use these drugs very well. In fact, studies suggest that about 50% of antibiotic use is inappropriate. This includes not only antibiotic prescribing for conditions for which these drugs are not indicated, such as for viral infections, but also when children receive the wrong type of antibiotic, the wrong dose, or the wrong duration of therapy.

Inappropriate prescribing of antibiotics might not be especially problematic if antibiotics had no harmful side effects—but they do. Harmful effects of antibiotic exposure include both drug-related adverse effects and the promotion of antibiotic resistance. More than 140 000 emergency department visits occur annually in the United States for antibiotic-related adverse effects, comprising almost 20% of all ED visits for drug-related adverse effects. In fact, rates of antibiotic-related adverse events were 3 times higher than rates of adverse drug events attributable to the most high-risk medicines, including anticoagulant and antiplatelet agents (eg, aspirin and clopidogrel), oral hypoglycemics (eg, metformin), and narrow therapeutic index agents (eg, phenytoin and lithium).

In addition to this direct patient harm, the public health implications of inappropriate antibiotic use are profound. Antibiotic overuse is the key driver of antibiotic resistance, which has been described by the World Health Organization (WHO) as “1 of the 3 greatest threats to human health.” Infections with resistant bacteria increase patient morbidity and mortality, and greatly increase the cost of medical care; the Institute of Medicine estimated that we spend roughly $20 billion per year to treat antibiotic-resistant infections.

So What Can We Do?

To address the overuse of antibiotics, the Centers for Disease Control and Prevention (CDC) and other leading healthcare authorities have called for hospitals to implement antimicrobial stewardship programs (ASPs). Most notably, the need for antibiotic stewardship has been recognized in the National Action Plan for Combating Antibiotic- Resistant Bacteria issued by the White House in March 2015. This plan calls for establishment of ASPs in all acute care hospitals by 2020 and for the Centers for Medicare & Medicaid Services (CMS) to issue a Condition of Participation that participating hospitals develop ASPs. Expansion of stewardship activities to ambulatory surgery centers, dialysis centers, nursing homes, and other long-term care facilities, and ED and outpatient settings is also recommended.

What Is Antimicrobial Stewardship?

Simply put, ASPs are designed to optimize antimicrobial use. They are coordinated, quality-improvement interventions designed to improve and measure appropriate use of antibiotic agents by promoting the selection of the optimal antibiotic drug regimen including dosing, duration of therapy, and route of administration. The benefits of antimicrobial stewardship include improved patient outcomes, including hospital length of stay; reduced adverse events such as Clostridium difficile infection (CDI) and complications of central lines; improvement in rates of antibiotic susceptibilities to targeted antibiotics; and substantial cost savings.

CHOP was one of the first children’s hospitals to build and implement an ASP, created by Paul Offit, MD, and Theo Zaoutis, MD, almost 2 decades ago. The ASP, housed in CHOP’s Office of Safety and Medical Operations, consists of a medical director, 2 infectious diseases-trained clinical pharmacists, and 9 pediatric infectious diseases fellows. This core team works closely with and relies on the support of several clinical groups—including all departments and divisions, microbiology and virology laboratories, informatics, nursing, pharmacy, and infection prevention and control—to optimize antimicrobial use across the institution. In addition, the CHOP ASP also receives critical support from Hospital administration, which has provided the resources necessary to conduct a comprehensive ASP in one of the largest children’s hospitals in the nation. Without this collaboration, the ASP could not be successful.

The CHOP ASP leverages a variety of guideline-recommended strategies to help improve antimicrobial use. It also constantly seeks to develop new partners for improving antimicrobial use across the institution, building upon successful initiatives led by physicians, pharmacists, nurse practitioners, and nurses in the PICU, NICU, oncology, hematology, and across many surgical divisions, to name a few.

CHOP's Antimicrobial Stewardship Program

Examples of the multifaceted program include:

  • Electronic health record-facilitated prior authorization for broad-spectrum antimicrobials reserved for severe or life-threatening infections
  • Support of a variety of clinical pathways for conditions requiring antimicrobial use
  • Surveillance of all positive microbiologic cultures to remedy bug-drug mismatch
  • Review of opportunities for IV to PO conversion of select antimicrobials
  • Education of frontline providers regarding ASP initiatives
  • Partnering with primary care physicians in the CHOP Care Network in recognition that most antimicrobial use occurs in ambulatory settings

Antimicrobials are a precious resource that can save children’s lives. In order to preserve the effectiveness of these drugs, however, we must use them judiciously. ASPs are dedicated to getting the right antimicrobial at the right time at the right dose for the right duration—goals that should be applied to all medications given to all children.

Referral Information

For information or to refer a patient to the Division of Infectious Diseases, call 215-590-2549. Information can be found at www.chop.edu/infectious-diseases.

The Vaccine Education Center at CHOP has a wealth of information for physicians and patient families. Please visit vaccine.chop.edu for information on all vaccines and for resources to use with families (print materials, videos, mobile app and more).