ArticlesReducing unnecessary antibiotic use in the neonatal intensive care unit (SCOUT): a prospective interrupted time-series study
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.
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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
References (30)
- et al.
Prolonged initial empirical antibiotic treatment is associated with adverse outcomes in premature infants
J Pediatr
(2011) - et al.
Antibiotic exposure in the newborn intensive care unit and the risk of necrotizing enterocolitis
J Pediatr
(2011) - et al.
The relationship of early-life antibiotic use with asthma in at-risk children
J Allergy Clin Immunol
(2014) - et al.
The infant nasopharyngeal microbiome impacts severity of lower respiratory infection and risk of asthma development
Cell Host Microbe
(2015) - et al.
Antimicrobial stewardship in the NICU
Infect Dis Clin North Am
(2014) - et al.
Prevention of neonatal group B streptococcal disease: a combined intrapartum and neonatal protocol
Am J Obstet Gynecol
(2002) - et al.
Antimicrobial use metrics and benchmarking to improve stewardship outcomes: methodology, opportunities, and challenges
Infect Dis Clin North Am
(2014) - et al.
CRIB II: an update of the clinical risk index for babies score
Lancet
(2003) - et al.
Viral respiratory tract infections in the neonatal intensive care unit: the VIRIoN-I study
J Pediatr
(2014) - et al.
Reported medication use in the neonatal intensive care unit: data from a large national data set
Pediatrics
(2006)