Decreasing antibiotic over-use by implementation of an antibiotic stewardship programme in preterm neonates in resource limited settings – a quality improvement initiative

ABSTRACT

Background

Antibiotics play a critical role in neonatal sepsis but excessive use is associated with adverse outcomes and the current prescribing rates of antibiotics are unacceptably high.

Aim

To reduce antibiotic over-use in preterm neonates by implementing an antibiotic stewardship programme using a quality improvement (QI) initiative.

Methods

This study was conducted at a neonatal intensive care unit in a resource-limited setting. The reasons for antibiotic over-use were analysed and an antibiotic stewardship programme was implemented by using a QI initiative. The duration of the QI was a 1-month baseline phase followed by 3 months of implementation which was undertaken in the form of Plan-Do-Study-Act (P-D-S-A) cycles. The sustainment phase was observed for 2 months. All neonates admitted to the preterm unit were included. The outcome measure was the antibiotic usage expressed as days of therapy (DOT)/1000 patient days.

Results

In the baseline phase, DOT/1000 patient days was 1464 which fell to 706, 511, and 442 DOT/1000 patient days, respectively, over 3 months, resulting in a 65% reduction in antibiotic usage. This was achieved by a combination of efforts directed towards defining the conditions for no antibiotics, revising existing antibiotic policy, stopping orders at 48 hours, de-escalation to the narrowest spectrum antibiotic, stopping prophylactic antifungal agents and limited use of broad-spectrum antibiotics. The results were achieved without an increase in culture-positive sepsis or mortality.

Conclusions

Implementation of a tailored antibiotic stewardship programme through a QI initiative was effective and safe in reducing antibiotic use in preterm neonates in a resource-limited setting.

Abbreviations

AIIMS, All India Institute of Medical Sciences; DOT, days of therapy; HIC, high-income countries; ICMR, Indian Council of Medical Research; LMIC, low- to middle-income countries; LOS, late-onset sepsis; NICU, neonatal intensive care unit; NNF, National Neonatology Forum; P-D-S-A, plan-do-study-act; QI, quality improvement; SNCU, Special newborn care unit.

KEYWORDS:

• Antibiotic stewardship
• quality improvement
• preterm neonates
• implementation

Acknowledgments

The authors sincerely thank Dr N. S. Murthy, Ex-Emeritus Medical Scientist (ICMR), Research Director (M. S. Ramaiah Medical College) and Mr Vishwanth (Bangalore Medical College and Research Institute) for statistical analysis. We are grateful for advice from Drs Swarnarekha Bhat, Karthik Nagesh, Rajath Athreya, Shivshankar Diggikar and Shrikant Kulkarni, the SNCU Mentoring Team and Drs Bharathi Balachander and Y. N. Prashantha, St John’s Medical College Hospital; and to Mr C. Santosh and Mrs M. Mamatha for SNCU data entry.

Authors’ contributions

AK, SR and SD initiated and designed the study; PV, SR, SD training the faculty, residents and nurses in the QI methodology; AK and VB collected and interpreted the data; MK, SD, BD, AK and SS implemented the QI; SD, SKL and GDC sustained the QI. All authors contributed to revision of the manuscript and accept accountability for all aspects of the work.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Anitha Kommalur

Anitha Kommalur, MD, Assistant Professor, Department of Paediatrics, BMCRI, Bengaluru, Karnataka, India

Vidyalakshmi Baddadka

Vidyalakshmi Baddadka, (MD), Junior Resident, Department of Paediatrics, BMCRI, Bengaluru, Karnataka, India

Sahana Devadas

Sahana Devadas, MD, Fellowship in Perinatal Medicine, Professor and Neonatologist, Department of Paediatrics, BMCRI, Bengaluru, Karnataka, India

Mallesh Kariyappa

Mallesh Kariyappa, DM(Cardiology), Professor and Head of the Department of Paediatrics, BMCRI, Bengaluru, Karnataka, India

B. Dakshayani

B Dakshayani, MD, Assistant Professor, Department of Paediatrics, BMCRI, Bengaluru, Karnataka, India

Shilpa Krishnapura Lakshminarayana

Shilpa Krishnapura Lakshminarayana, MD, Assistant Professor, Department of Paediatrics, BMCRI, Bengaluru, Karnataka, India

Suman P. N. Rao

Suman P.N.Rao, DM(Neonatology), Professor, Department of Neonatology, St.John's Medical College, Bengaluru, Karnataka, India

Praveen Venkatagiri

Praveen Venkatagiri, MD, MRCPCH (UK), Consultant Neonatologist, OVUM Hospital, Bengaluru, Karnataka, India.

Gayathri Devi Chinnappa

Gayathri Devi Chinnappa, MD, Associate Professor, Department of Paediatrics, BMCRI, Bengaluru, Karnataka, India

Sushma Veranna Sajjan

Sushma Veranna Sajjan, MD, Fellowship in Paediatric neurology, Assistant Professor, Department of Paediatrics, BMCRI, Bengaluru, Karnataka, India