Antimicrobial Stewardship Programs in PICU Settings: A Systematic Review

Abstract

Development of antimicrobial stewardship programs (ASPs) is strategy for prevention and management of emergence of antimicrobial-resistant organisms. In this study, we systematically reviewed the literature on antimicrobial stewardship interventions in PICUs and analyzed approaches, structure, implementation, and outcomes of the ASPs. DATA SOURCES: PubMed and Scopus databases were systematically searched for studies published from January 1, 2007, to December 31, 2020, reporting interventions on judicious use of antimicrobials in PICUs (last search performed February 28, 2021).DATA SELECTION: Studies that evaluated an intervention in a PICU setting or both in PICU and other settings and reported separate results for PICU were eligible for full-text review. Studies that had implemented stewardship in the entire hospital, including the PICU, but without presenting dedicated PICU data were excluded from the analysis. DATA EXTRACTION:The strategy of intervention, structure of ASP team, implementation, and outcomes were assessed with a checklist tool for all studies included in the analysis. Risk of bias was assessed with the Cochrane Risk-of-Bias in Nonrandomized studies of Interventions tool.DATA SYNTHESIS: Thirteen articles were found: 11 that applied ASP in PICUs, and two at hospital level. All PICU-dedicated ASPs applied a multimodal intervention combining strategies simultaneously; audit with feedback (6/11) and facilityspecific clinical practice guidelines (7/11) were the most common strategies. A multidisciplinary team was formulated in all ASPs except for three biomarkerbased interventions. Six of 11 studies included techniques to enhance behavior change and one implemented a behavior-based intervention. Antibiotic consumption was evaluated in all ASPs, cost in three of 11, antibiotic resistance in one of 11, length of hospitalization in six of 11, and mortality in eight of 11. All hospitalwide ASPs used audit with feedback in addition to facility-specific clinical practice guidelines and assessed antimicrobial consumption, expenditures, length of stay, and mortality. CONCLUSIONS:The prevalence of ASPs in PICUs is limited, and few programs follow all of the currently available recommendations.

A nationwide survey of Antimicrobial Stewardship in Pediatric Intensive Care Unit: implementation notes from the Brazilian underground

“…On the other hand, scientific literature indicates that the presence of ASP in PICUs is limited, and only a few programs adhere to all of the existing recommendations. 10 …”

Evaluation of Hospital Antimicrobial Stewardship Programs: Implementation, Process, Impact, and Outcomes, Review of Systematic Reviews

“…When comparing enablement objectives with or without ASP interventions, there were no observed mortality differences [ 20 ]. Efficacy without compromising safety has been similarly observed in vulnerable populations at critical care units, in both adult and pediatric settings, through effective program interventions such as prescribing audits, feedback, education, and persuasion [ 20 , 21 , 39 ].…”

“…The feared prime concerns were understandably directed towards critical care, where the highest levels of hospital antimicrobial consumption are usually reported, combined with the critical nature of the patients’ cohort. Nevertheless, SRs in such important aspects affirmed safety and efficacy, although the evidence is more pronounced for adult when compared to pediatric populations because of limited data [ 21 , 39 , 59 , 74 ]. However, the picture is not fully clear, since there is a counterargument that restricting antimicrobials at critical care settings might be protective through limiting unfavorable adverse events or might be confounded by the plausible practice of reducing interventions in less critical patients [ 74 ].…”

Editor’s Choice Articles for August

“…My final Editor's Choice article returns to the topic of QI in the PICU (1). Over 2021 to 2023, the QI themes of antibiotic stewardship (21)(22)(23), bacterial investigations (24,25), and diagnostic accuracy (26,27), have had extended coverage in PCCM, and all this material is worth reviewing. Now, in this latest QI report (20), the authors follow PCCM's guidance on reporting QI studies (28,29) and describe their pre-versus postimplementation findings (4,290 versus 2,843) of an algorithm for PICU patients with new fever or clinical instability.…”