Antimicrobial Stewardship Barriers and Goals in Pediatric Oncology and Bone Marrow Transplantation: A Survey of Antimicrobial Stewardship Practitioners

Wolf, Joshua; Sun, Yilun; Li, Tang; Newland, Jason G.; Gerber, Jeffrey S.; Dyke, Christie J. Van; Hymes, Saul R.; Yu, Diana; Carias, Delia; Bryant, Penelope A

doi:10.1017/ice.2015.295

Cited by 34 publications

(32 citation statements)

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“…While we did not delve into this topic, the issue of prescriber opposition was explored in a recent study about stewardship barriers and goals in pediatric oncology and HCT. 31 Our survey also showed that monitoring is not done robustly in transplant patients with the exception of C.difficile rates, followed by antimicrobial costs. According to the 2016 IDSA/SHEA guideline, every ASP should track antimicrobial utilization in order to examine overall consumption or compare usage by unit, provider, or service in the hospital.…”

Section: Discussionmentioning

confidence: 83%

Current State of Antimicrobial Stewardship at Solid Organ and Hematopoietic Cell Transplant Centers in the United States

Seo

Abbo

2016

Infect. Control Hosp. Epidemiol.

103

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Objective To assess the extent of antimicrobial stewardship programs (ASPs) at solid organ (SOT) and hematopoietic cell transplant (HCT) centers in the United States (US). Design An 18-item voluntary survey was developed by Memorial Sloan Kettering Cancer Center and University of Miami to gauge current antimicrobial stewardship practices in transplant patients, examine the availability and perceived usefulness of novel diagnostics and azole levels to guide therapy, and identify challenges for implementation of ASPs at these centers. Participants The survey was distributed electronically to Infectious Disease physicians and pharmacists at adult and pediatric SOT and HCT centers during May 1–22, 2015. Facilities were de-identified. Results After duplicate removal, 71 (56%) of 127 unique transplant centers in 32 states were analyzed. Forty-four sites (62%) performed ≥ 100 SOT annually, and forty (56%) performed ≥100 HCT annually. Top five stewardship activities encompassing transplant patients included formulary restriction, guideline development, prospective audit & feedback, education, and dose optimization. Respiratory viral panels (100%), azole levels (97%), and serum/BAL galactomannan (88%) were perceived as most useful to guide therapy. Apparent challenges to antimicrobial stewardship included: undefined duration for certain infections (90%), diagnostic uncertainty (80%), the perception that antibiotic-resistant infections required escalation (71%), prescriber opposition (69%), and costly drugs (63%). Conclusions ASP activities were performed at many adult and pediatric SOT and HCT centers in the US. Diagnostic and therapeutic uncertainty in transplant patients are challenging for ASPs. Collaborative research to examine the impact of antimicrobial stewardship practices in SOT and HCT should be explored.

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Section: Discussionmentioning

confidence: 83%

Current State of Antimicrobial Stewardship at Solid Organ and Hematopoietic Cell Transplant Centers in the United States

Seo

Abbo

2016

Infect. Control Hosp. Epidemiol.

103

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“…Yet, ASPs may result in reduced mortality [62, 63]. With continuously mounting evidence in support of improved patient outcomes due to ASPs, physicians can be further convinced of the benefit of a multidisciplinary approach to antimicrobial stewardship.…”

Section: Antibiotic Stewardshipmentioning

confidence: 99%

The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship

et al. 2017

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Purpose: To concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to the management of multidrug-resistant (MDR) bacteria, antibiotic use, and antimicrobial stewardship in the intensive care unit (ICU) setting. Methods: Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. Results: The prevalence of infection of critically ill patients by MDR bacteria is rapidly evolving. Clinical studies aimed at improving understanding of the changing patterns of these infections in ICUs are urgently needed. Ideal antibiotic utilization is another area of uncertainty requiring additional investigations aimed at better understanding of dose optimization, duration of therapy, use of combination treatment, aerosolized antibiotics, and the integration of rapid diagnostics as a guide for treatment. Moreover, there is an imperative need to develop non-antibiotic approaches for the prevention and treatment of MDR infections in the ICU. Finally, clinical research aimed at demonstrating the beneficial impact of antimicrobial stewardship in the ICU setting is essential. Conclusions: These and other fundamental questions need to be addressed over the next decade in order to better understand how to prevent, diagnose, and treat MDR bacterial infections. Clinical studies described in this research agenda provide a template and set priorities for investigations that should be performed in this field.

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“…Physician or hospital practices may reflect local antibiograms, institutional stew-ardship initiatives, hospital formulary choices, or the reliance of transplant groups on historical practice outside the influence of a stewardship program. 26 Data regarding physician- or hospital-specific practice patterns were not available in this dataset so this hypothesis could not be evaluated. However, it should be considered in future investigations.…”

Section: Discussionmentioning

confidence: 99%

“…No specific recommendations exist for stewardship in transplant units. 26 Options for intervention recommended by the 2016 IDSA guidelines include prospective audit of antibiotic prescriptions with feedback to individual prescribers and formulary restriction. 27 Both strategies have been successfully implemented in an adult hematology/oncology and transplant units.…”

Section: Discussionmentioning

confidence: 99%

Hospital-Level Variability in Broad-Spectrum Antibiotic Use for Children With Acute Leukemia Undergoing Hematopoietic Cell Transplantation

Elgarten

Arnold

et al. 2018

Infect. Control Hosp. Epidemiol.

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OBJECTIVETo explore the prevalence and drivers of hospital-level variability in antibiotic utilization among hematopoietic cell transplant (HCT) recipients to inform antimicrobial stewardship initiatives.DESIGNRetrospective cohort study using data merged from the Pediatric Health Information System and the Center for International Blood and Marrow Transplant Research.SETTINGThe study included 27 transplant centers in freestanding children's hospitals.METHODSThe primary outcome was days of broad-spectrum antibiotic use in the interval from day of HCT through neutrophil engraftment. Hospital antibiotic utilization rates were reported as days of therapy (DOTs) per 1,000 neutropenic days. Negative binomial regression was used to estimate hospital utilization rates, adjusting for patient covariates including demographics, transplant characteristics, and severity of illness. To better quantify the magnitude of hospital variation and to explore hospital-level drivers in addition to patient-level drivers of variation, mixed-effects negative binomial models were also constructed.RESULTSAdjusted hospital rates of antipseudomonal antibiotic use varied from 436 to 1121 DOTs per 1,000 neutropenic days, and rates of broad-spectrum, gram-positive antibiotic use varied from 153 to 728 DOTs per 1,000 neutropenic days. We detected variability by hospital in choice of antipseudomonal agent (ie, cephalosporins, penicillins, and carbapenems), but gram-positive coverage was primarily driven by vancomycin use. Considerable center-level variability remained even after controlling for additional hospital-level factors. Antibiotic use was not strongly associated with days of significant illness or mortality.CONCLUSIONAmong a homogenous population of children undergoing HCT for acute leukemia, both the quantity and spectrum of antibiotic exposure in the immediate posttransplant period varied widely. Antimicrobial stewardship initiatives can apply these data to optimize the use of antibiotics in transplant patients.Infect Control Hosp Epidemiol 2018;797-805.

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Antimicrobial Stewardship Barriers and Goals in Pediatric Oncology and Bone Marrow Transplantation: A Survey of Antimicrobial Stewardship Practitioners

Cited by 34 publications

References 10 publications

Current State of Antimicrobial Stewardship at Solid Organ and Hematopoietic Cell Transplant Centers in the United States

Current State of Antimicrobial Stewardship at Solid Organ and Hematopoietic Cell Transplant Centers in the United States

The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship

Hospital-Level Variability in Broad-Spectrum Antibiotic Use for Children With Acute Leukemia Undergoing Hematopoietic Cell Transplantation

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