Antibiotic stewardship in the newborn surgical patient: A quality improvement project in the neonatal intensive care unit

doi:10.1016/j.surg.2017.07.021

Surgery

Volume 162, Issue 6, December 2017, Pages 1295-1303

https://doi.org/10.1016/j.surg.2017.07.021 Get rights and content

Background

There is significant diversity in the utilization of antibiotics for neonates undergoing surgical procedures. Our institution standardized antibiotic administration for surgical neonates, in which no empiric antibiotics were given to infants with surgical conditions postnatally, and antibiotics are given no more than 72 hours perioperatively.

Methods

We compared the time periods before and after implementation of antibiotic protocol in an institution review board–approved, retrospective review of neonates with congenital surgical conditions who underwent surgical correction within 30 days after birth. Surgical site infection at 30 days was the primary outcome, and development of hospital-acquired infections or multidrug-resistant organism were secondary outcomes.

Results

One hundred forty-eight infants underwent surgical procedures pre-protocol, and 127 underwent procedures post-protocol implementation. Surgical site infection rates were similar pre- and post-protocol, 14% and 9% respectively, (P = .21.) The incidence of hospital-acquired infections (13.7% vs 8.7%, P = .205) and multidrug-resistant organism (4.7% vs 1.6%, P = .143) was similar between the 2 periods.

Conclusion

Elimination of empiric postnatal antibiotics did not statistically change rates of surgical site infection, hospital-acquired infections, or multidrug-resistant organisms. Limiting the duration of perioperative antibiotic prophylaxis to no more than 72 hours after surgery did not increase the rate of surgical site infection, hospital-acquired infections, or multidrug-resistant organism. Median antibiotic days were decreased with antibiotic standardization for surgical neonates.

Section snippets

Available knowledge

Guidelines have been published previously regarding preoperative antibiotic prophylaxis by the Centers for Medicare & Medicaid Services, the Joint Commission, the Centers for Disease Control and Prevention, and the Surgical Care Improvement Project (SCIP) to aid in decreasing rates of surgical site infection (SSI) in other patient populations.2, 3 These guidelines give recommendations on when to administer preoperative parenteral antibiotics, which preoperative antibiotics to administer, and

Rationale

With regard to postnatal antibiotic administration, we used the 2011 guidelines put forth by the American Academy of Pediatrics regarding GBS prophylaxis.⁸ We also referred to general guidelines put forth by SCIP in terms of perioperative antibiotic protocols.⁹ We recognized that SCIP guideline recommendations do not cover patients younger than 1 year of age. In the neonate literature, no one antimicrobial option has been proven better than another for empiric perioperative coverage. Therefore,

Specific aims

Our specific aims were to create a standardized antibiotic practice in the NICU commensurate with the antibiotic stewardship guidelines by administering postnatal antibiotics only when a specific need exists and standardizing the type and duration of antibiotics given to surgical neonates in the perioperative setting.

Context

Children's Hospital of Wisconsin is a 298-bed tertiary children's hospital affiliated with the Medical College of Wisconsin with a 70-bed level IV NICU, with 750 admissions per year. Approximately 50 to 60 index surgical procedures are on the diagnoses of interest annually. A single group of surgeons and a single group of neonatologists care for patients. Both groups were engaged in the development of this quality improvement project. The number of NICU admissions and surgical cases did not

Results

The timeline of the development and implementation in the protocol is outlined in Fig 1. It took approximately 6 months to formulate the intervention and present it to all stakeholder groups before implementation.

Discussion

Neonatal infections and sepsis may present insidiously, yet cause a significant morbidity and mortality.10, 13, 14, 15 Thus, physicians and providers are obliged to treat neonates with antimicrobial agents at the first suspected signs of sepsis, making antimicrobials the most commonly used medications in NICUs.¹⁶ A review of antibiotic usage in 29 NICUs in the United States from 1999 to 2000 found that each patient received a median of 2 antibiotics at any one time.¹⁷ A study by Schulman et al.

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Cited by (32)

Health care-associated infections in neonatology
2024, Anales de Pediatria
Las infecciones relacionadas con la asistencia sanitaria (IRAS) son frecuentes en neonatología, pero no existe un consenso en sus definiciones. Esto dificulta la comparación de incidencias entre distintas unidades o la valoración de la eficacia de los paquetes de prevención. Por ello, es que consideramos muy importante lograr un acuerdo en las definiciones y diagnóstico de una de las morbilidades más recurrentes de los neonatos hospitalizados. El presente documento pretende unificar estas definiciones en relación con las infecciones más comunes como son la bacteriemia relacionada con el catéter (BRC), la neumonía vinculada a la ventilación mecánica (NAV) y la infección de la herida quirúrgica (IHQ), así como su abordaje diagnóstico-terapéutico.
Health care-associated infections are common in neonatology, but there is no consensus on their definitions. This makes it difficult to compare their incidence or assess the effectiveness of prevention bundles. This is why we think it is very important to achieve a consensus on the definitions and diagnostic criteria for one of the most frequent causes of morbidity in hospitalised neonates. This document aims to standardise the definitions for the most frequent health care-associated infections, such as catheter-associated bloodstream infection, ventilator-associated pneumonia and surgical wound infection, as well as the approach to their diagnosis and treatment.
Incidence and risk factors of bacterial sepsis and invasive fungal infection in neonates and infants requiring major surgery: an Italian multicentre prospective study
2022, Journal of Hospital Infection
Limited data are currently available on the incidence rates and risk factors for bacterial sepsis and invasive fungal infections (IFIs) among neonates and infants undergoing major surgery.
To assess the incidence of bacterial sepsis and IFI, fungal colonization, risk factors for sepsis, and mortality in neonates and infants aged <3 months undergoing major surgery.
A multicentre prospective study was conducted involving 13 level-3 neonatal intensive care units in Italy, enrolling all infants aged ≤3 months undergoing major surgery.
From 2018 to 2021, 541 patients were enrolled. During hospitalization, 248 patients had a bacterial infection, and 23 patients had a fungal infection. Eighty-four patients were colonized by fungal strains. Overall, in-hospital mortality was 2.8%, but this was higher in infected than in uninfected infants (P = 0.034). In multivariate analysis, antibiotic exposure before surgery, ultrasound-guided or surgical placement of vascular catheters, vascular catheterization duration, and gestational age ≤28 weeks were all associated with bacterial sepsis. The risk of IFI was markedly higher in colonized infants (odds ratio (OR): 8.20; P < 0.001) and was linearly associated with the duration of vascular catheterization. Fungal colonization in infants with abdominal surgery increased the probability of IFI 11-fold (OR: 11.1; P < 0.001).
Preventive strategies such as early removal of vascular catheters and the fluconazole prophylaxis should be considered to prevent bacterial and fungal sepsis in infants undergoing abdominal surgery, and even more so in those with fungal colonization.
The incidence of abdominal surgical site infections after abdominal birth defects surgery in infants: A systematic review with meta-analysis
2021, Journal of Pediatric Surgery
: Surgical site infections (SSI) are a frequent and significant problem understudied in infants operated for abdominal birth defects. Different forms of SSIs exist, namely wound infection, wound dehiscence, anastomotic leakage, post-operative peritonitis and fistula development. These complications can extend hospital stay, surge medical costs and increase mortality. If the incidence was known, it would provide context for clinical decision making and aid future research. Therefore, this review aims to aggregate the available literature on the incidence of different SSIs forms in infants who needed surgery for abdominal birth defects.
: The electronic databases Pubmed, EMBASE, and Cochrane library were searched in February 2020. Studies describing infectious complications in infants (under three years of age) were considered eligible. Primary outcome was the incidence of SSIs in infants. SSIs were categorized in wound infection, wound dehiscence, anastomotic leakage, postoperative peritonitis, and fistula development. Secondary outcome was the incidence of different forms of SSIs depending on the type of birth defect. Meta-analysis was performed pooling reported incidences in total and per birth defect separately.
: 154 studies, representing 11,786 patients were included. The overall pooled percentage of wound infections after abdominal birth defect surgery was 6% (95%-CI:0.05–0.07) ranging from 1% (95% CI:0.00–0.05) for choledochal cyst surgery to 10% (95%-CI:0.06–0.15) after gastroschisis surgery. Wound dehiscence occurred in 4% (95%-CI:0.03–0.07) of the infants, ranging from 1% (95%-CI:0.00–0.03) after surgery for duodenal obstruction to 6% (95%-CI:0.04–0.08) after surgery for gastroschisis. Anastomotic leakage had an overall pooled percentage of 3% (95%-CI:0.02–0.05), ranging from 1% (95%-CI:0.00–0.04) after surgery for duodenal obstruction to 14% (95% CI:0.06–0.27) after colon atresia surgery. Postoperative peritonitis and fistula development could not be specified per birth defect and had an overall pooled percentage of 3% (95%-CI:0.01–0.09) and 2% (95%-CI:0.01–0.04).
: This review has systematically shown that SSIs are common after correction for abdominal birth defects and that the distribution of SSI differs between birth defects.
Antibiotic Stewardship for the Neonatologist and Perinatologist
2021, Clinics in Perinatology
Citation Excerpt :
There is no clear evidence that antibiotics need to be continued beyond 24 hours postoperatively, with 1 single-center, retrospective study finding no difference in the rates of SSI within 30 days of procedure, between neonates who received 24 hours or less of postoperative antibiotics versus those who received more than 24 hours of antibiotics after abdominal surgery.47 A multidisciplinary effort at 1 hospital led to the creation of a standardized approach to perioperative antibiotics, including a single preoperative dose of piperacillin-tazobactam within 1 hour before the surgical incision and prompt discontinuation of antibiotics within 72 hours postoperatively.46 Infants with perinatally recognized surgical conditions did not receive postnatal antibiotics unless there was evidence of or risk factors for infection, and empiric antibiotics were discontinued if cultures were negative at 48 hours.
Expanding antimicrobial stewardship strategies for the NICU: Management of surgical site infections, perioperative prophylaxis, and culture negative sepsis
2020, Seminars in Perinatology
Citation Excerpt :
A typical regimen for gastrointestinal organisms could include ampicillin (for enterococcus), gentamicin (for gram- negative organisms) and metronidazole (for anaerobes). Piperacillin-tazobactam – a beta-lactam-beta lactamase inhibitor has been suggested as another option for NICUs with higher rates of gram-negative SSIs.14 The use of a broad-spectrum agent such as piperacillin-tazobactam has to be balanced against the emergence of resistant organisms such as Enterobacter and Serratia (e.g., AmpC beta-lactamase producers).
Objective: To review antibiotic stewardship strategies for neonatal intensive care units (NICU) in the areas of management of surgical site infections, perioperative prophylaxis and culture negative late onset sepsis. Finding: Review of local microbiology, stratification of surgical procedures by risk of contamination of the surgical site, and adherence to evidence-based principles of perioperative antibiotic administration (targeted therapy, effective dosing, appropriate timing and limiting duration post-operatively) can help to minimize unnecessary antibiotic use for neonatal surgery. Creating a late onset sepsis case definition, appropriate collection and interpretation of blood cultures, and instituting antibiotic time-outs can minimize the overuse of antibiotics for culture negative sepsis. Conclusion: Effective implementation of these antimicrobial stewardship strategies in the NICU can reduce unnecessary antimicrobial use and limit the emergence of resistant pathogens.
Establishment of an antimicrobial stewardship strategy on the surgical NICU at Cairo University specialized pediatric hospital
2020, Journal of Pediatric Surgery
Citation Excerpt :
Culture and sensitivity results from the current study revealed a decrease in extended and multidrug resistant organisms when comparing pre-implementation and ASP periods: 74% and 57.8% respectively. Similarly, a study conducted on a neonatal intensive care unit showed a decrease in multidrug-resistant organisms between two periods with percentages of 4.7% and 1.6% respectively [19]. One of the essential elements of an ASP is to study how laboratory technologists can provide the fast and accurate results to the physicians as reference for antibiotic prescription.
Antimicrobial resistance is a major concern that we are facing nowadays. This is due to antibiotic misuse and bacteria developing resistance to the commonly used antibiotics. This may lead to increased mortality and consumption of country resources. Implementation of an antimicrobial stewardship program [ASP] can limit the use of unnecessary antibiotics and subsequently decrease the infection rates with better patient outcome. We aimed to control antibiotic misuse, reduce infection rate, decrease drug costs, and reduce length of hospital stay in the ICU.
We conducted a prospective study on the surgical neonatal ICU [SNICU] over a period of 6 months divided into pre-implementation phase, followed by an ASP phase, in which we applied the antibiotic guidelines approved by the ASP committee. Data were collected in the two phases and analyzed for demographics, compliance with guidelines, prescribed antibiotics, lab investigations, surgical site infection [SSI], length of stay and patient outcome.
Compliance to the guidelines was encountered in 86% and SSI rate decreased to 20%. Days of Therapy (DOT) per 1000 patient days showed a significant decrease in Ampicillin Sulbactam by 296 (p = 0.024), Imipenem by 220.34 (p = 0.024) and Vancomycin by 287.34 (p = 0.048). Drug cost showed a 1185.97 EGP decrease in the ASP period compared to the pre-implementation period (p = 0.714). Average LOS decreased in the ASP period by a mean difference of 2.5 (p = 0.027).
ASP implementation can control antibiotic misuse, decrease the medical care expenses and improve patient outcome.
Clinical research paper.
Level one.

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Pediatric SurgeryPresented at the Academic Surgical Congress 2017Antibiotic stewardship in the newborn surgical patient: A quality improvement project in the neonatal intensive care unit

Background

Methods

Results

Conclusion

Section snippets

Available knowledge

Rationale

Specific aims

Context

Results

Discussion

Am J Surg

J Pediatr

J Pediatr Surg

J Pediatr Surg

12-step program to prevent antimicrobial resistance in health care settings

MMWR

Clinical practice guidelines for antimicrobial prophylaxis in surgery

Surg Infect (Larchmt)

National variability and appropriateness of surgical antibiotic prophylaxis in US children's hospitals

JAMA Pediatr

Potential NICU environmental influences on the neonate's microbiome: a systematic review

Adv Neonatal Care

Ameican Academy of Pediatrics policy statement – recommendations for the prevention of perinatal group B streptococcal (GBS) disease

Pediatrics

Pediatric Surgery
Presented at the Academic Surgical Congress 2017
Antibiotic stewardship in the newborn surgical patient: A quality improvement project in the neonatal intensive care unit