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Am J Perinatol 2022; 39(08): 861-868
DOI: 10.1055/s-0040-1719079
Original Article

Charge Nurses Taking Charge, Challenging the Culture of Culture-Negative Sepsis, and Preventing Central-Line Infections to Reduce NICU Antibiotic Usage

Samarth Shukla
1   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
,
Josef Cortez
1   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
,
Bill Renfro
2   Department of Pharmacy, University of Florida Health, Jacksonville, Florida
,
Kartikeya Makker
3   Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Colleen Timmons
1   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
,
P. Sireesha Nandula
1   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
,
Rita Hazboun
4   Division of Neonatology, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia
,
Rima Dababneh
1   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
,
Cristina Hoopes
5   Department of Women's and Children's Nursing Services, University of Florida Health, Jacksonville, Florida
,
Jenny VanRavestein
5   Department of Women's and Children's Nursing Services, University of Florida Health, Jacksonville, Florida
,
Yvette McCarter
6   Department of Pathology and Laboratory Medicine, University of Florida Health, Jacksonville, Florida
,
Marilyn Middlebrooks
7   Department of Infection Prevention and Control, University of Florida Health, Jacksonville, Florida
,
Ma Ingyinn
1   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
,
Ana Alvarez
8   Division of Infectious Diseases and Immunology, University of Florida College of Medicine, Jacksonville, Florida
,
Mark L. Hudak
1   Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
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Abstract

Objective We aimed to reduce our monthly antibiotic usage rate (AUR, days of treatment per 1,000 patient-days) in the neonatal intensive care unit (NICU) from a baseline of 330 (July 2015–April 2016) to 200 by December 2018.

Study Design We identified three key drivers as follows: (1) engaging NICU charge nurses, (2) challenging the culture of culture-negative sepsis, and (3) reducing central-line associated bloodstream infections (CLABSI). Our main outcome was AUR. The percentage of culture-negative sepsis that was treated with antibiotics for >48 hours and CLABSI was our process measure. We used hospital cost/duration of hospitalization and mortality as our balancing measures.

Results After testing several plan-do-study-act (PDSA) cycles, we saw a modest reduction in AUR from 330 in the year 2016 to 297 in the year 2017. However, we did not find a special-cause variation in AUR via statistical process control (SPC) analysis (u'-chart). Thereafter, we focused our efforts to reduce CLABSI in January 2018. As a result, our mean AUR fell to 217 by December 2018. Our continued efforts resulted in a sustained reduction in AUR beyond the goal period. Importantly, cost of hospitalization and mortality did not increase during the improvement period.

Conclusion Our sequential quality improvement (QI) efforts led to a reduction in AUR. We implemented processes to establish a robust antibiotic stewardship program that included antibiotic time-outs led by NICU charge nurses and a focus on preventing CLABSI that were sustained beyond the QI period.

Key Points

  • This is a quality improvement project to reduce antibiotic usage in NICU.

  • Charge nurses should take charge to reduce infections in NICU.

  • Central line infections should be reduced to decrease antibiotic usage.

Keywords

antibiotic usage rate - central-line infection - quality improvement

Note

Institutional Review Board at University of Florida Health Jacksonville (UFHJ) approved this initiative as a QI project. Any sensitive health information was not shared or disclosed outside UFHJ.




Publikationsverlauf

Eingereicht: 03. April 2020

Angenommen: 24. September 2020

Artikel online veröffentlicht:
03. November 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Ho T, Dukhovny D, Zupancic JA, Goldmann DA, Horbar JD, Pursley DM. Choosing wisely in newborn medicine: five opportunities to increase value. Pediatrics 2015; 136 (02) e482-e489
    CrossrefPubMedSuche in Google Scholar
  • 2 Cotten CM, McDonald S, Stoll B, Goldberg RN, Poole K, Benjamin Jr DK. National Institute for Child Health and Human Development Neonatal Research Network. The association of third-generation cephalosporin use and invasive candidiasis in extremely low birth-weight infants. Pediatrics 2006; 118 (02) 717-722
    CrossrefPubMedSuche in Google Scholar
  • 3 Cotten CM, Taylor S, Stoll B. et al; NICHD Neonatal Research Network. Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for extremely low birth weight infants. Pediatrics 2009; 123 (01) 58-66
    CrossrefPubMedSuche in Google Scholar
  • 4 Kuppala VS, Meinzen-Derr J, Morrow AL, Schibler KR. Prolonged initial empirical antibiotic treatment is associated with adverse outcomes in premature infants. J Pediatr 2011; 159 (05) 720-725
    CrossrefPubMedSuche in Google Scholar
  • 5 Saiman L, Ludington E, Dawson JD. et al; National Epidemiology of Mycoses Study Group. Risk factors for Candida species colonization of neonatal intensive care unit patients. Pediatr Infect Dis J 2001; 20 (12) 1119-1124
    CrossrefPubMedSuche in Google Scholar
  • 6 Lee JH, Hornik CP, Benjamin Jr DK. et al. Risk factors for invasive candidiasis in infants >1500 g birth weight. Pediatr Infect Dis J 2013; 32 (03) 222-226
    CrossrefPubMedSuche in Google Scholar
  • 7 Cantey JB, Patel SJ. Antimicrobial stewardship in the NICU. Infect Dis Clin North Am 2014; 28 (02) 247-261
    CrossrefPubMedSuche in Google Scholar
  • 8 Alexander VN, Northrup V, Bizzarro MJ. Antibiotic exposure in the newborn intensive care unit and the risk of necrotizing enterocolitis. J Pediatr 2011; 159 (03) 392-397
    CrossrefPubMedSuche in Google Scholar
  • 9 Neu J, Pammi M. Pathogenesis of NEC: impact of an altered intestinal microbiome. Semin Perinatol 2017; 41 (01) 29-35
    CrossrefPubMedSuche in Google Scholar
  • 10 Ting JY, Roberts A, Sherlock R. Canadian Neonatal Network Investigators. et al. Duration of initial empirical antibiotic therapy and outcomes in very low birth weight infants. Pediatrics 2019; 143 (03) 143
    PubMedSuche in Google Scholar
  • 11 Cantey JB, Baird SD. Ending the culture of culture-negative sepsis in the neonatal ICU. Pediatrics 2017; 140 (04) 140
    CrossrefPubMedSuche in Google Scholar
  • 12 Cantey JB, Wozniak PS, Pruszynski JE, Sánchez PJ. Reducing unnecessary antibiotic use in the neonatal intensive care unit (SCOUT): a prospective interrupted time-series study. Lancet Infect Dis 2016; 16 (10) 1178-1184
    Suche in Google Scholar
  • 13 Schulman J, Dimand RJ, Lee HC, Duenas GV, Bennett MV, Gould JB. Neonatal intensive care unit antibiotic use. Pediatrics 2015; 135 (05) 826-833
    CrossrefPubMedSuche in Google Scholar
  • 14 Cantey JB, Milstone AM. Bloodstream infections: epidemiology and resistance. Clin Perinatol 2015; 42 (01) 1-16 , vii vii.
    CrossrefPubMedSuche in Google Scholar
  • 15 Dellit TH, Owens RC, McGowan Jr JE. Infectious Diseases Society of America, Society for Healthcare Epidemiology of America. et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44 (02) 159-177
    CrossrefPubMedSuche in Google Scholar
  • 16 Ramasethu J, Kawakita T. Antibiotic stewardship in perinatal and neonatal care. Semin Fetal Neonatal Med 2017; 22 (05) 278-283
    CrossrefPubMedSuche in Google Scholar
  • 17 Pollack LA, Srinivasan A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clin Infect Dis 2014; 59 (Suppl. 03) S97-S100
    CrossrefPubMedSuche in Google Scholar
  • 18 Charles D, Heal CF, Delpachitra M. et al. Alcoholic versus aqueous chlorhexidine for skin antisepsis: the AVALANCHE trial. CMAJ 2017; 189 (31) E1008-E1016
    CrossrefPubMedSuche in Google Scholar
  • 19 Maiwald M, Chan ES. The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis. PLoS One 2012; 7 (09) e44277
    CrossrefPubMedSuche in Google Scholar
  • 20 Chiriboga N, Cortez J, Pena-Ariet A. et al. Successful implementation of an intracranial hemorrhage (ICH) bundle in reducing severe ICH: a quality improvement project. J Perinatol 2019; 39 (01) 143-151
    CrossrefPubMedSuche in Google Scholar
  • 21 Mohammed MA, Panesar JS, Laney DB, Wilson R. Statistical process control charts for attribute data involving very large sample sizes: a review of problems and solutions. BMJ Qual Saf 2013; 22 (04) 362-368
    CrossrefPubMedSuche in Google Scholar
  • 22 Benneyan JC, Lloyd RC, Plsek PE. Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care 2003; 12 (06) 458-464
    CrossrefPubMedSuche in Google Scholar
  • 23 Kuzniewicz MW, Puopolo KM, Fischer A. et al. A quantitative, risk-based approach to the management of neonatal early-onset sepsis. JAMA Pediatr 2017; 171 (04) 365-371
    CrossrefPubMedSuche in Google Scholar
  • 24 Dhudasia MB, Mukhopadhyay S, Puopolo KM. Implementation of the sepsis risk calculator at an academic birth hospital. Hosp Pediatr 2018; 8 (05) 243-250
    CrossrefPubMedSuche in Google Scholar
  • 25 Carola D, Vasconcellos M, Sloane A. et al. Utility of early-onset sepsis risk calculator for neonates born to mothers with chorioamnionitis. J Pediatr 2018; 195: 48-52.e1
    CrossrefPubMedSuche in Google Scholar
  • 26 Arora V, Strunk D, Furqan SH. et al. Optimizing antibiotic use for early onset sepsis: A tertiary NICU experience. J Neonatal Perinatal Med 2019; 12 (03) 301-312
    CrossrefPubMedSuche in Google Scholar
  • 27 Nzegwu NI, Rychalsky MR, Nallu LA. et al. Implementation of an antimicrobial stewardship program in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2017; 38 (10) 1137-1143
    CrossrefPubMedSuche in Google Scholar
  • 28 Bizzarro MJ, Shabanova V, Baltimore RS, Dembry LM, Ehrenkranz RA, Gallagher PG. Neonatal sepsis 2004-2013: the rise and fall of coagulase-negative staphylococci. J Pediatr 2015; 166 (05) 1193-1199
    CrossrefPubMedSuche in Google Scholar
  • 29 Walker S, Datta A, Massoumi RL, Gross ER, Uhing M, Arca MJ. Antibiotic stewardship in the newborn surgical patient: a quality improvement project in the neonatal intensive care unit. Surgery 2017; 162 (06) 1295-1303
    Suche in Google Scholar
  • 30 Bhat R, Custodio H, McCurley C. et al. Reducing antibiotic utilization rate in preterm infants: a quality improvement initiative. J Perinatol 2018; 38 (04) 421-429
    CrossrefPubMedSuche in Google Scholar
  • 31 Ting JY, Paquette V, Ng K. et al. Reduction of inappropriate antimicrobial prescriptions in a tertiary neonatal intensive care unit after antimicrobial stewardship care bundle implementation. Pediatr Infect Dis J 2019; 38 (01) 54-59
    CrossrefPubMedSuche in Google Scholar
  • 32 Flannery DD, Puopolo KM. Neonatal antibiotic use: how much is too much?. Pediatrics 2018; 142 (03) 142
    Suche in Google Scholar
  • 33 Astorga MC, Piscitello KJ, Menda N. et al. Antibiotic stewardship in the neonatal intensive care unit: effects of an automatic 48-hour antibiotic stop order on antibiotic use. J Pediatric Infect Dis Soc 2019; 8 (04) 310-316
    CrossrefPubMedSuche in Google Scholar
  • 34 Steinmann KE, Lehnick D, Buettcher M. et al. Impact of empowering leadership on antimicrobial stewardship: a single center study in a neonatal and pediatric intensive care unit and a literature review. Front Pediatr 2018; 6: 294
    CrossrefPubMedSuche in Google Scholar
  • 35 Schulman J, Stricof R, Stevens TP. et al. New York State Regional Perinatal Care Centers. Statewide NICU central-line-associated bloodstream infection rates decline after bundles and checklists. Pediatrics 2011; 127 (03) 436-444
    CrossrefPubMedSuche in Google Scholar
  • 36 Ho T, Buus-Frank ME, Edwards EM. et al. Adherence of newborn-specific antibiotic stewardship programs to CDC recommendations. Pediatrics 2018; 142 (06) 142
    Suche in Google Scholar
  • 37 Schulman J, Profit J, Lee HC. et al. Variations in neonatal antibiotic use. Pediatrics 2018; 142 (03) 142
    Suche in Google Scholar