Articles
Reducing unnecessary antibiotic use in the neonatal intensive care unit (SCOUT): a prospective interrupted time-series study

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Summary

Background

Antibiotics are used frequently in the neonatal intensive care unit. We aimed to inform antibiotic stewardship strategies in a level 3 neonatal intensive care unit by surveillance and assessment of all antibiotic use during a 14-month period, identifying scenarios where antibiotic use can be reduced, and implementing interventions while monitoring safety.

Methods

The SCOUT study is an observational study in the level 3 neonatal intensive care unit at Parkland Hospital, Dallas, TX, USA. All antibiotic use in infants admitted to the neonatal intensive care unit between March 1, 2012, and Nov 30, 2012 (9 months), was monitored and analysed. After the baseline period (Oct 3, 2011, to Nov 30, 2012), continuation of empirical antibiotic therapy for ruled-out sepsis courses beyond 48 h, pneumonia, and “culture-negative” sepsis were selected as targets for antibiotic stewardship interventions. During the intervention period (Oct 1, 2013, to June 30, 2014), empirical antibiotic therapy was set to discontinue after 48 h in the electronic medical record and the duration of therapy for pneumonia and culture-negative sepsis was limited to 5 days. Antibiotic use, defined as days of therapy per 1000 patient-days, was compared between the baseline and intervention periods. The primary outcome was the change in total antibiotic days of therapy per 1000 patient-days between the baseline and intervention periods. Safety outcomes measured were instances in which infants received 5 or more days of therapy and subsequently had antibiotic therapy reinstituted within 14 days for any indication; a composite of late-onset sepsis, necrotising enterocolitis (modified Bell stage ≥2), or death in infants 32 weeks' gestation or younger; prevalence of multidrug-resistant organism colonisation; and length of hospital stay.

Findings

2502 infants were admitted to the neonatal intensive care unit during the two study periods (1607 in the baseline period and 895 in the intervention period). Antibiotic use declined from 343·2 days of therapy per 1000 patient-days during the baseline period to 252·2 days of therapy per 1000 patient-days in the intervention period (p<0·0001), representing an overall decrease of 27%. No difference in safety outcomes was observed between the intervention and baseline periods.

Interpretation

Thorough assessment of antibiotic consumption in a neonatal intensive care unit can inform high-yield stewardship targets tailored to the individual centre. Effective interventions to reduce antibiotic use can then be designed and implemented in a collaborative manner.

Funding

The Gerber Foundation.

Introduction

Antibiotics are the most prescribed medications in neonatal intensive care units in the USA.1, 2 The beneficial effects of antibiotic therapy when indicated are unquestioned. However, the overuse of antibiotics in neonatal intensive care units has been associated with adverse outcomes, including increased risk for infection with multidrug-resistant organisms, invasive candidosis, bronchopulmonary dysplasia, necrotising enterocolitis, late-onset sepsis, and death.3, 4, 5, 6, 7, 8, 9 Early antibiotic exposure has also been associated with asthma and obesity in later childhood,10, 11 potentially related to disruption of the normal intestinal and lung microbiome.12 For these reasons, there is universal consensus about the need for antibiotic stewardship in the neonatal intensive care unit.13 To implement stewardship successfully, prospective surveillance is needed to establish the clinical decisions driving antibiotic use locally.14 Currently, data for why and how antibiotics are used in the neonatal intensive care unit are limited to retrospective observational studies that suggest inappropriate or unnecessary antibiotic use might be common.15 Therefore, the aim of the Surveillance and Correction of Unnecessary Antibiotic Therapy (SCOUT) study was to inform antibiotic stewardship strategies in a level 3 neonatal intensive care unit by surveillance and assessment of all antibiotic use during a 14-month period, determining areas where antibiotic use could be reduced safely, and then implementing interventions while monitoring for safety.

Section snippets

Study design and participants

The neonatal intensive care unit at Parkland Hospital, Dallas, TX, USA, is a level 3C, 90-bed, predominantly inborn unit with approximately 1400 admissions annually. The unit is staffed by neonatologists from the University of Texas Southwestern Medical Center, along with neonatology fellows, neonatal nurse practitioners, and paediatric junior doctors. We did prospective surveillance of all antibiotics provided to every infant who was admitted to the neonatal intensive care unit from March 1,

Results

Overall, 2502 infants were admitted to the neonatal intensive care unit during the baseline (n=1607) and intervention periods (n=895; table 1). No infants were excluded. Infant characteristics and antibiotic consumption during the retrospective and prospective baseline phases did not differ significantly and thus the data were combined into one baseline period.19 Comparison of the baseline and the intervention periods showed no significant differences in maternal or infant characteristics,

Discussion

This study shows that prospective surveillance of all antibiotic use in the neonatal intensive care unit can inform effective antibiotic stewardship processes. By thoroughly assessing all antibiotic use, we were able to establish which clinical scenarios were most amenable to stewardship interventions, design specific interventions to target those areas, and then track both subsequent antibiotic use and safety outcomes. The interventions resulted in both a 27% decrease in total antibiotic use

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