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Reducing Second Gram-Negative Antibiotic Therapy on Pediatric Oncology and Hematopoietic Stem Cell Transplantation Services

  • Rachel L. Wattier (a1), Emily R. Levy (a2), Amit J. Sabnis (a3), Christopher C. Dvorak (a4) and Andrew D. Auerbach (a5)...

Abstract

OBJECTIVE

To evaluate interventions to reduce avoidable antibiotic use on pediatric oncology and hematopoietic stem cell transplantation (HSCT) services.

DESIGN

Interrupted time series.

SETTING

Academic pediatric hospital with separate oncology and HSCT services.

PARTICIPANTS

Children admitted to the services during baseline (October 2011–August 2013) and 2 intervention periods, September 2013–June 2015 and July 2015–June 2016, including 1,525 oncology hospitalizations and 301 HSCT hospitalizations.

INTERVENTION

In phase 1, we completed an update of the institutional febrile neutropenia (FN) guideline for the pediatric oncology service, recommending first-line β-lactam monotherapy rather than routine use of 2 gram-negative agents. Phase 2 included updating the HSCT service FN guideline and engagement with a new pediatric antimicrobial stewardship program. The use of target antibiotics (tobramycin and ciprofloxacin) was measured in days of therapy per 1,000 patient days collected from administrative data. Intervention effects were evaluated using interrupted time series with segmented regression.

RESULTS

Phase 1 had mixed effects–long-term reduction in tobramycin use (97% below projected at 18 months) but rebound with increasing slope in ciprofloxacin use (+18% per month). Following phase 2, tobramycin and ciprofloxacin use on the oncology service were both 99% below projected levels at 12 months. On the HSCT service, tobramycin use was 99% below the projected level and ciprofloxacin use was 96% below the projected level at 12 months.

CONCLUSIONS

Locally adapted guidelines can facilitate practice changes in oncology and HSCT settings. More comprehensive and ongoing interventions, including follow-up education, feedback, and engagement of companion services may be needed to sustain changes.

Infect Control Hosp Epidemiol 2017;38:1039–1047

Copyright

Corresponding author

Address correspondence to Rachel L. Wattier, MD, MHS, 550 16th St 4th Floor Box 0434, San Francisco, CA, 94143-0434 (rachel.wattier@ucsf.edu).

Footnotes

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PREVIOUS PRESENTATION. This work was presented in part as a poster at the 7th Annual Pediatric Antimicrobial Stewardship Conference in Kansas City, Missouri, on June 3, 2016, and at the UCSF Health Improvement Symposium in San Francisco, California, on September 22, 2016.

Footnotes

References

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