antimicrobial use after implementation of antimicrobial ... · for the hospital, creation of...

Antimicrobial Use After Implementation of Antimicrobial Stewardship Program in

Tertiary Care Centre NICU

Nikhil Tenneti, Anurag Fursule, Anup Thakur, Gunjan Mishra,

Manisha Mehta, Priyanka Karnani, Richa Mallik, Manoj Modi,

Arun Soni, Pankaj Garg, Satish Saluja, Neelam Kler

Introduction

• Rational use of antibiotics is important for prevention of

emergence of drug resistant strains

• We implemented an antimicrobial stewardship program and

studied its impact on antibiotic usage in NICU

Objective

Primary objective:

• To evaluate the impact of antimicrobial stewardship program on

antibiotic use in days of therapy for antibiotics (DOT) per 1000 patient-

days

Secondary objectives:

• To evaluate the impact of antimicrobial stewardship program on

episodes of culture-positive sepsis, healthcare associated infections

(HAI), necrotizing enterocolitis and mortality

Materials and Methods

• Study design

• Prospective Observational study

• Setting

• Neonatal intensive care unit (NICU), Department of

Neonatology, Sir Ganga Ram Hospital, New Delhi.

• Study duration

• November 2018 to August 2019 ( 10 months)

Subjects and intervention

• Antimicrobial Stewardship Program (AMSP) was started in

November 2018

• The study was done in collaboration with ICMR as part of

the “Capacity Building And Strengthening Of Hospital

Infection Control to detect and prevent antimicrobial

resistance in India” under CDC/ AIIMS

• All neonates who were initiated on intravenous antibiotics

were enrolled in the study

• The study was divided in three epochs-first 4 months

(Preparatory phase), next 3 months (intervention phase)

and last three months (post intervention) phase

• Intervention consisted of introducing antibiograms specific

for the hospital, creation of antibiotic policy based on the

annual antibiogram, monitoring antibiotic consumption in

NICU using days of therapy and staff education in form of

one day CME for hospital staff

• Antibiotic policy was reintroduced and updated

• Third line (Colistin, vancomycin) antibiotics use was

restricted during this period

• Days on therapy (DOT) was defined as atleast one dose of

intravenous antibiotic given on a calendar day to a patient in

the NICU

• Days on therapy (DOT) for each individual antibiotic were

recorded

Data collection

• An antibiotic usage form was introduced which collected the

following data:

• Organ system involved

• Details of the blood culture/sensitivity

• Antibiotic to be used along with details of dose,

frequency and intended duration

• Basis of treatment given as prophylaxis, empirical or

definitive

• Specific indication for starting each antibiotic

Reserve antibiotic

usage form

Reserve antibiotic

usage form

• Data was collected in a predesigned proforma and entered

in the Microsoft Excel software

• Analysis of data was done by using SPSS software

Results

Base line characteristics Epoch 1 Epoch 2 Epoch 3

Number of neonates 317 207 240

Mean gestation (weeks)* 35.3 (3.1) 35.42 (3.6) 35.39 (3.7)

Mean Birth Weight (g)* 2367 (747) 2450 (831) 2405 (835)

Male gender (%) 204 (64.3%) 114 (55%) 150(62.5%)

Duration of stay (days)# 4 (7) 5 (8.5) 4 (7)

* Denotes data expressed as mean (SD), # denotes data expressed as median (IQR)

Clinical outcomes

Clinical outcomes Epoch 1 Epoch 2 Epoch 3 P value

Duration of hospital stay median (IQR)

4 (7) 5 (8.5) 4 (7) 0.03

Culture positive sepsis episodes

14 17 20 0.1

Healthcare associated infection

10 8 7 0.84

NEC 4 3 6 0.5

Mortality 21 27 20 0.15

Days of therapy

Risk factors Epoch 1 Epoch 2 Epoch 3 P value

Total DOT 405 407 416 0.31

Piperacillinmedian DOT

12.4 11.2 8.8 0.02

Colistinmedian DOT

14.4 11.2 8.8 0.05

Meropenemmedian DOT

21 22.4 23.4 0.43

Discussion

• Antibiotic stewardship is the necessity of the hour in view of

emergence of antimicrobial resistance

• Afzal et al noted decreased use of reserve drugs after

setting up anti-microbial committee and initiation of

antimicrobial stewardship program

• Reduced use of restricted antimicrobial drugs, decreased

duration of hospital admission and reduced cost per month

were noted after initiation of antimicrobial stewardship

programme in a study done by Singh et al

• In our study, reduction in days of therapy of piperacillin-

tazobactam and colistin were noted by 2.4/1000 patient

days

• No reduction in total days of therapy was observed and a

trend towards increase in meropenem DOT was noted

although not statistically significant

• There were no differences in episodes of culture-positive

sepsis, healthcare associated infections (HAI), necrotizing

enterocolitis and mortality

Strengths

• This study was conducted under the aegis of ICMR with

multidisciplinary team approach

• A dedicated clinical pharmacologist along with attending

neonatologist and microbiologist ensured the adherence to

antibiotic policy and appropriateness of antibiotics given in

culture positive neonates

Limitations

• The sample size of the study is limited

• The benefits secondary to cost saving was not evaluated in

the study

Summary

• Colistin and piperacillin tazobactam usage decreased after

implementation of Antimicrobial Stewardship Program

• No difference in total DOT was noted after AMSP

implementation

Thank You!!!