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Quality improvement report
Antibiotic stewardship in a tertiary care NICU of northern India: a quality improvement initiative
  1. Sunita Agarwal1,
  2. Jyoti Patodia2,
  3. Jaikrishan Mittal2,
  4. Yatish Singh2,
  5. Vaibhav Agnihotri2,
  6. Varun Sharma2
  1. 1Department of Microbiology, SMS Medical College, Jaipur, Rajasthan, India
  2. 2Deparment of Neonatology, Neoclinic, Jaipur, Rajasthan, India
  1. Correspondence to Dr Jyoti Patodia; jyoti_ag7{at}hotmail.com

Abstract

Background The overuse of antibiotics in newborns leads to increased mortality and morbidities. Implementation of a successful antibiotic stewardship programme (ASP) is necessary to decrease inappropriate use of antibiotics and its adverse effects.

Problem Our neonatal intensive care unit (NICU) is a tertiary referral centre of north India, consisting of all outborn babies mostly with sepsis caused by high rate of multidrug-resistant organisms (MDROs). So antibiotics are not only life-saving but also used excessively with a high antibiotic usage rate (AUR) of 574 per 1000 patient days.

Method A quality improvement (QI) study was conducted using the Plan–Do–Study–Act (PDSA) approach to reduce AUR by at least 20% from January 2019 to December 2020. Various strategies were made : such as making a unit protocol, education and awareness of NICU nurses and doctors, making check points for both starting and early stoppage of antibiotics, making specific protocol to start vancomycin, and reviewing yearly antibiotic policy as per antibiogram.

Results The total AUR, AUR (culture negative) and AUR (vancomycin) was reduced by 32%, 20% and 29%, respectively, (p<0.01). The proportion of newborns who never received antibiotics increased from 22% to 37% (p<0.045) and the proportion of culture-negative/screen-negative newborns where antibiotics were stopped within 48 hours increased from 16% to 54% (p<0.001). The compliance with the unit protocol in starting and upgrading antibiotic was 75% and 82%, respectively. In early 2020, there was a sudden upsurge in AUR due to central line-related bloodstream infection breakout. However, we were able to control it, and all the PDSA cycles were reinforced. Finally, we could reattain our goals, and also able to sustain it until next 1 year. There was no significant difference in overall necrotising enterocolitis and mortality rates.

Conclusion In a centre such as ours, where sepsis is a leading cause of neonatal deaths, restricting antibiotic use is a huge challenge. However, we have demonstrated implementation of an efficient ASP with the help of a dedicated team and effective PDSA cycles. Also, we have emphasised the importance of sustainability in success of any QI study.

  • antibiotic management
  • control charts/run charts
  • quality improvement

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2021-001470

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Contributors SA and JP designed the study and drafted the manuscript. YS and VA were involved in data collection. VS and JP did data analysis, JM critically reviewed it.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Publication of this article is made Open Access with funding from the Nationwide Quality of Care Network.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.