Antibiotic

stewardship in
Pediatrics
Vikram S Kumar

@vikkypaedia
 Overview
• Although antibiotic therapy has saved countless lives, their overuse
can cause harm.
• Antibiotic stewardship program( ASPs) is a practice dedicated
• to using antibiotics only when necessary ,
• when antibiotics are deemed necessary, to targeting the spectrum of activity
and using the appropriate dose, route and duration of therapy to optimize
clinical outcomes while minimizing the undesirable consequences of
antibiotic use.

@vikkypaedia
 What is the Role of ASPs
• Antibiotic stewardship has been defined as
• coordinated interventions designed to improve and measure the appropriate
use of [antibiotic] agents
• by promoting the selection of the optimal [antibiotic] drug regimen including
dosing, duration of therapy, and route of administration.
• Although most of the evidence base for antibiotic stewardship has
focused on the acute care setting, many associations have published
core elements of ASPs for
• acute care (including small and critical access hospitals),
• long-term care, and
• ambulatory care settings.
@vikkypaedia
 What are the Unintended
Consequences of Antibiotic Use
in Children?
• Adverse consequences associated with antibiotic use extend beyond
the development of resistance in targeted organisms.
• Clostridium difficile infections (CDI) is another potential consequence
of antibiotic use.
• Researchers in more recent investigations have explored the effect of
antibiotic exposure on the intestinal microbiome.
• antibiotic exposures, especially when frequent and occurring early in
life, to promote intestinal dysbiosis
• Possible effects on the development of conditions such as juvenile
idiopathic arthritis, inflammatory bowel disease, asthma, and diabetes.
@vikkypaedia
 What is the Policy Package to
Combat Antimicrobial Resistance?
• Commit to a comprehensive, financed national plan with
accountability and civil society engagement
• Strengthen surveillance and laboratory capacity
• Ensure uninterrupted access to essential medicines of assured quality
• Regulate and promote rational use of medicines, including in animal
husbandry, and ensure proper patient care· Enhance infection
prevention and control
• Foster innovations and research and development for new tools.

@vikkypaedia
 What Needs to be Done?
• Appropriate empirical antimicrobial therapy, with right dose, for right
duration and at right time.
• Delayed therapy or modifying the initial antimicrobial therapy does not
improve the outcome.
• Multidrug-resistance organism predisposes for inappropriate therapy.
• Early and accurate identification of the pathogen and susceptibility.
• Combination or mono-therapy chosen on the basis of the pathogen
identified.
• De-escalation of initial broad spectrum therapy after definitive
diagnosis (generally based on microbiology reports).
@vikkypaedia
 What Should Not be Done?

• Treat non-infectious or nonbacterial syndrome with antibiotics

@vikkypaedia
 What are the main goals of
ASPs
• Improve patient outcome: improve infection cure rate, reduce
surgical infection rate, reduce mortality and morbidity;
• Improve patient safety: reduce antimicrobial consumption without
increasing mortality or infection related readmissions; reduce C.
difficile colonization or infection by controlling the use of higher
antimicrobial;
• Reduce resistance: restrict relevant agents; and
• Reduce health care costs.

@vikkypaedia
What are the main interventions
for ASPs
• Designing and executing policies on antimicrobial "time out" which means there
should be a reassessment of the need and choice of the antibiotics started
empirically at the time of admission. This is usually done after 48 hours once
more clinical and laboratory data is available.
• Adhering to the dictum of "Prior authorization" that requires the availability of an
antibiotic expert who can review and decide the need of antibiotics before the
therapy is initiated.
• Prospective audit and feedback: This involves an external review by an antibiotic
expert regarding antibiotic therapy in very sick patients where broad spectrum
antibiotics are given. An audit is done by a team separate from the treating team.
• Regular changes from intravenous to oral treatment so that patients need less
intravenous access.
@vikkypaedia
What are the main interventions
for ASPs
• Dose adjustments in cases with organ dysfunction and dose
optimization like those with therapeutic drug monitoring, higher
doses for achieving CNS penetration, doses for highly resistant
bacteria.
• Automatic alerts to avoid unnecessary duplication of drugs which
have overlapping spectra.
• Time sensitive automatic stop orders for certain prescriptions like
antibiotics given for surgical prophylaxis.

@vikkypaedia
 What Is IAP-ICMR 4-Point Plan
to Tackle Antimicrobial
Resistance?
1. Developing and disseminating National Antibiotic Guidelines for
Children 2014 – The IAP-ICMR document
2. Educating doctors – both pediatricians and other doctors – as well
as public on rational antibiotic use
3. Developing infection control guidelines for small hospitals and
nursing homes, training the owners of such establishments and
ensuring compliance by the members
4. Collecting and collating data on antimicrobial resistance from the
clinicians
@vikkypaedia
 What are the Stewardship
Strategies in the
Inpatient Setting?
• The development and dissemination of LOCAL institutional guidelines for
diagnosing and treating common infectious syndromes,
• ASPs should determine their approach to interventions on the basis of
available resources.
• Syndrome-specific interventions target specific disease processes such as
community-acquired pneumonia or skin and soft tissue infections
• Rapid diagnostics can facilitate antibiotic de-escalation, broadening
therapy when necessary, stopping therapy, or in some cases, identifying
a viral etiology that may reduce the likelihood of a bacterial pathogen.

@vikkypaedia
 What are Outpatient ASPs?
• The vast majority of antibiotic prescribing occurs in the outpatient
setting.
• As with inpatient stewardship, effective outpatient stewardship
requires strong leadership.
• One in 5 pediatric ambulatory visits result in an antibiotic
prescription, accounting for nearly 50 million antibiotic prescriptions
annually in the US, at least half of which are considered
inappropriate.

@vikkypaedia
 What are the Stewardship
Strategies in the
Outpatient Setting?
• Stop Unnecessary Prescribing
• A strict Diagnosis Stewardship
• Antibiotic Choice: chose a narrow spectrum first line antibiotic
• Duration and Route of Therapy : Many infections need a short course
only.

@vikkypaedia
 Summary
• ASPs governing antibiotic use for children should include specialists with
pediatric expertise.
• Inpatient ASPs are ideally composed of a medical director and a clinical
pharmacist(s), both with expertise in pediatric infectious diseases and/or
antibiotic stewardship.
• Inpatient ASPs can use clinical guidelines, prior approval, and post-
prescription review and feedback as core interventions.
• Inpatient ASPs can include pharmacy-driven interventions such as dose
optimization, therapeutic drug monitoring, automatic conversion of
intravenous to oral antibiotic therapy, or dose adjustments in cases of
organ dysfunction.
@vikkypaedia
 Summary
• Inpatient ASPs can consider auditing, analyzing, and reporting local unit-
specific antibiotic prescribing data periodically to relevant stakeholders.
• Outpatient primary care practices, urgent care clinics, and emergency
departments could consider establishing standardized approaches for
antibiotic prescribing including clinical guidelines and/or decision support.
• Outpatient stewardship can focus on judicious use of antibiotics for ARTIs,
including avoidance of antibiotic prescribing for undifferentiated upper
respiratory tract infection, bronchiolitis, acute bronchitis, and
nonstreptococcal pharyngitis; refraining from prescribing antibiotics for
urinary tract infections in the absence of a urinalysis and urine culture; and
judicious diagnosis of acute otitis media, acute sinusitis, and group A
streptococcal pharyngitis.
@vikkypaedia
 Summary
• Outpatient stewardship efforts can emphasize use of the narrowest
spectrum antibiotics for the shortest duration of therapy that will
adequately treat bacterial infections.

@vikkypaedia