Quality improvement initiative approach to decrease the unindicated usage of antibiotics in a neonatal intensive care unit of a tertiary care teaching hospital in Hyderabad, India.

Antimicrobial resistance is an emerging global problem concerned with patient safety. It is even more challenging in developing countries like India. Antibiotic stewardship initiative is the best arrow in the quiver to prevent and control this antimicrobial resistance. We observed 61% of the neonates admitted to neonatal intensive care unit of Niloufer hospital, Hyderabad, India were receiving improper antibiotics with respect to choice of drug or dosage or duration. Subsequently, an antibiotic stewardship team was formed to address the antibiotic misuse. Team consisted of neonatology faculty, residents, staff nurses, infection control nurses and microbiologist. We identified problems related to staff awareness, policy issues like lack of display of the antibiotic policy and lack of antibiotic lock, process issues like low rate of documentation of indication for initiation or escalation of antibiotic and a lack of dynamic review plan regarding continuation or de-escalation. We used the Plan-Do-Study-Act cycles to test and adapt solutions to these problems. Within 10 weeks of starting our quality improvement (QI) project, the proportion of unindicated antibiotic usage decreased from 61% to 27%. Timely de-escalation of antibiotic is a neglected intervention in neonates, and yielded the maximum result in our study. We conclude that QI projects are simple, doable yet powerful effective tools to address the burning problems like antibiotic misuse. This result was very satisfying and encouraging boosting our team's faith in the effectiveness of QI approach.

Clinical Profile and Outcome of Children with Congenital Obstructive Uropathy.

OBJECTIVES: To study the etiology and clinical profile of congenital obstructive uropathy in children, renal status and growth at diagnosis and at follow-up and to determine the predictors for development of chronic kidney disease (CKD). METHODS: An observational (retrospective-prospective) study was conducted at a tertiary care hospital in South India from September 2014 through September 2016. Sixty children diagnosed to have congenital obstructive uropathy with a minimum follow-up period of 5 y were included and followed up prospectively for 2 more years during the study period. The data of the children at admission and follow-up was obtained from the medical records and analyzed. RESULTS: Congenital uretero-pelvic junction obstruction followed by Posterior urethral valve were the most common etiologies identified. Male preponderance (88.3%) was observed with poor urinary stream being the most common presentation (36.6%). Forty percent of the population had elevated creatinine. Fifteen percent were hypertensive and 25% had growth failure at diagnosis. However, there was a reduction in the number of children with poor estimated glomerular filtration rate (eGFR), hypertension and growth faltering during follow-up. Among the risk factors, hypertension at diagnosis [O.R-12.8 (2.21-74.22) and p value <0.05] and frequent urinary tract infection (UTI) [O.R-14.06 (2.32-85.42) and p value <0.05] were the most important factors for CKD progression. Children with low eGFR (< 60 ml/min/1.73m2) had more height faltering and hypertension at follow-up (p value <0.05). CONCLUSIONS: Hypertension and frequent UTI were observed to be strongly associated with progression of CKD. Estimated GFR was found to be significantly associated with faltering of height and hypertension. Preserving the renal function prevents growth faltering and development of hypertension at follow-up thereby ensuring a better quality of life.

Acute severe monarthritis: a rare manifestation of scrub typhus.

Scrub typhus caused by Orientia tsutsugamushi is an important cause for fever of unknown origin in endemic areas including India. The vasculitis associated with the disease leads to a variety of clinical manifestations. However, the joint involvement is quite rare and not reported in children. We present severe arthritis of hip joint associated with scrub typhus causing a diagnostic and management challenges in a 4-year-old girl.