Suboptimal antimicrobial discharge prescriptions at a tertiary referral children's hospital.

Objective: To determine the rate of and factors associated with suboptimal discharge antimicrobial prescribing at a tertiary referral children's hospital. Design: Retrospective cohort. Setting: Tertiary referral children's hospital. Population: All enteral antimicrobial discharge prescriptions at Lucile Packard Children's Hospital Stanford from January 1st, 2021 through December 31st, 2021. Method: All enteral discharge antimicrobials are routinely evaluated by our antimicrobial stewardship program within 48 hours of hospital discharge. Antimicrobials are determined to be optimal or suboptimal by an antimicrobial stewardship pharmacist after evaluating the prescribed choice of antimicrobial, dose, duration, dosing frequency, and formulation. The rate and factors associated with suboptimal antimicrobial discharge prescribing were evaluated. Results: Of 2,593 antimicrobial prescriptions ordered at discharge, 19.7% were suboptimal. Suboptimal prescriptions were due to incorrect duration (72.2%), dose (31.0%), dose frequency (23.3%), drug choice (6.5%), or formulation (5.7%). In total, 87.2% of antimicrobials for perioperative prophylaxis and 13.5% of treatment antimicrobials were suboptimal. Antimicrobials with the highest rate of suboptimal prescriptions were amoxicillin-clavulanate (40.7%), clindamycin (36.6%), and cephalexin (36.6%). Conclusion: Suboptimal antimicrobial discharge prescriptions are common and present an opportunity for antimicrobial stewardship programs during hospital transition of care. Factors associated with suboptimal prescriptions differ by antimicrobial and prescribed indication, indicating that multiple stewardship interventions may be needed to improve prescribing.

Leveraging antimicrobial stewardship programs in response to the coronavirus disease 2019 (COVID-19) public health emergency.

The coronavirus disease 2019 (COVID-19) pandemic has strained antimicrobial stewardship programs (ASPs) but offered new opportunities. This review summarizes the impact of the COVID-19 pandemic on ASPs, review the contributions ASPs have made in the pandemic response, and highlight the potential role of ASPs in future pandemics.

Advancing pediatric antimicrobial stewardship: Has pharmacodynamic dosing for gram-negative infections taken effect?

Objective: To characterize pharmacodynamic dosing strategies used at children's hospitals using a national survey. Design: Survey. Setting: Children's hospitals. Participants: Volunteer sample of antimicrobial stewardship program (ASP) respondents. Methods: A nationwide survey was conducted to gain greater insight into the current adoption of nontraditional dosing methods and monitoring of select ß-lactam and fluoroquinolone antibiotics used to treat serious gram-negative infections in pediatric populations. The survey was performed through the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative. Results: Of the 75 children's hospitals that responded, 68% of programs reported adoption of pharmacodynamically optimized dosing using prolonged ß-lactam infusions and 35% using continuous ß-lactam infusions, although use was infrequent. Factors including routine MIC monitoring and formal postgraduate training and board certification of ASP pharmacists were associated with increased utilization of pharmacodynamic dosing. In addition, 60% of programs reported using pharmacodynamically optimized ciprofloxacin and 14% reported using pharmacodynamically optimized levofloxacin. Only 20% of programs monitored ß-lactam levels; they commonly cited lack of published guidance, practitioner experience, and laboratomory support as reasons for lack of utilization. Less physician time dedicated to ASP programs was associated with lower adoption of optimized dosing. Conclusions: Use of pharmacodynamic dosing through prolonged and continuous infusions of ß-lactams have not yet been routinely adopted at children's hospitals. Further guidance from trials and literature are needed to continue to guide pediatric pharmacodynamic dosing efforts. Children's hospitals should utilize these data to compare practices and to prioritize further research and education efforts.

Impact of Direct From Blood Culture Identification of Pathogens Paired With Antimicrobial Stewardship Interventions in a Pediatric Hospital.

OBJECTIVE: Identification of organisms directly from positive blood culture by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) has the potential for improved clinical outcomes through earlier organism identification and shorter time to appropriate clinical intervention. The uses of this technology in pediatric patients and its impact in this patient population have not been well described. METHODS: Direct from positive blood culture organism identification via MALDI-TOF was implemented in September 2019. A quality improvement project was performed to assess its impact on admissions for contaminant blood cultures and time to effective and optimal antimicrobials and clinical decision-making. A pre- and post-implementation retrospective review for consecutive September through February time periods, was conducted on patients with positive monomicrobial blood cultures. Statistics were evaluated using Mann-Whitney U and χ2 tests. RESULTS: One hundred nineteen patients with 131 unique blood cultures (65 in pre- and 66 in post-implementation) were identified. Time to identification was shorter, median 35.4 hours (IQR, 22.7-54.3) versus 42.3 hours (IQR, 36.5-49) in post- and pre-groups, respectively (p = 0.02). Patients were less likely to be admitted for a contaminated blood culture in the post-implementation, 26% versus 11% in the pre-implementation (p = 0.03) group. In patients treated for bacteremia, there was a shorter time to optimal therapy from Gram stain reporting in the post-implementation (median 42.7 hours [IQR, 27.2-72]) versus pre-implementation (median 60.8 hours [IQR, 42.9-80.6]) (p = 0.03). CONCLUSIONS: Direct from positive blood culture identification by MALDI-TOF decreased time to effective and optimal antimicrobials and decreased unnecessary admission in pediatric patients for contaminated blood cultures.