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Antimicrobial Use After Implementation of Antimicrobial Stewardship Program in
Tertiary Care Centre NICU
Nikhil Tenneti, Anurag Fursule, Anup Thakur, Gunjan Mishra,
Manisha Mehta, Priyanka Karnani, Richa Mallik, Manoj Modi,
Arun Soni, Pankaj Garg, Satish Saluja, Neelam Kler
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Introduction
• Rational use of antibiotics is important for prevention of
emergence of drug resistant strains
• We implemented an antimicrobial stewardship program and
studied its impact on antibiotic usage in NICU
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Objective
Primary objective:
• To evaluate the impact of antimicrobial stewardship program on
antibiotic use in days of therapy for antibiotics (DOT) per 1000 patient-
days
Secondary objectives:
• To evaluate the impact of antimicrobial stewardship program on
episodes of culture-positive sepsis, healthcare associated infections
(HAI), necrotizing enterocolitis and mortality
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Materials and Methods
• Study design
• Prospective Observational study
• Setting
• Neonatal intensive care unit (NICU), Department of
Neonatology, Sir Ganga Ram Hospital, New Delhi.
• Study duration
• November 2018 to August 2019 ( 10 months)
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Subjects and intervention
• Antimicrobial Stewardship Program (AMSP) was started in
November 2018
• The study was done in collaboration with ICMR as part of
the “Capacity Building And Strengthening Of Hospital
Infection Control to detect and prevent antimicrobial
resistance in India” under CDC/ AIIMS
• All neonates who were initiated on intravenous antibiotics
were enrolled in the study
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• The study was divided in three epochs-first 4 months
(Preparatory phase), next 3 months (intervention phase)
and last three months (post intervention) phase
• Intervention consisted of introducing antibiograms specific
for the hospital, creation of antibiotic policy based on the
annual antibiogram, monitoring antibiotic consumption in
NICU using days of therapy and staff education in form of
one day CME for hospital staff
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• Antibiotic policy was reintroduced and updated
• Third line (Colistin, vancomycin) antibiotics use was
restricted during this period
• Days on therapy (DOT) was defined as atleast one dose of
intravenous antibiotic given on a calendar day to a patient in
the NICU
• Days on therapy (DOT) for each individual antibiotic were
recorded
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Data collection
• An antibiotic usage form was introduced which collected the
following data:
• Organ system involved
• Details of the blood culture/sensitivity
• Antibiotic to be used along with details of dose,
frequency and intended duration
• Basis of treatment given as prophylaxis, empirical or
definitive
• Specific indication for starting each antibiotic
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Reserve antibiotic
usage form
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Reserve antibiotic
usage form
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• Data was collected in a predesigned proforma and entered
in the Microsoft Excel software
• Analysis of data was done by using SPSS software
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Results
Base line characteristics Epoch 1 Epoch 2 Epoch 3
Number of neonates 317 207 240
Mean gestation (weeks)* 35.3 (3.1) 35.42 (3.6) 35.39 (3.7)
Mean Birth Weight (g)* 2367 (747) 2450 (831) 2405 (835)
Male gender (%) 204 (64.3%) 114 (55%) 150(62.5%)
Duration of stay (days)# 4 (7) 5 (8.5) 4 (7)
* Denotes data expressed as mean (SD), # denotes data expressed as median (IQR)
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Clinical outcomes
Clinical outcomes Epoch 1 Epoch 2 Epoch 3 P value
Duration of hospital stay median (IQR)
4 (7) 5 (8.5) 4 (7) 0.03
Culture positive sepsis episodes
14 17 20 0.1
Healthcare associated infection
10 8 7 0.84
NEC 4 3 6 0.5
Mortality 21 27 20 0.15
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Days of therapy
Risk factors Epoch 1 Epoch 2 Epoch 3 P value
Total DOT 405 407 416 0.31
Piperacillinmedian DOT
12.4 11.2 8.8 0.02
Colistinmedian DOT
14.4 11.2 8.8 0.05
Meropenemmedian DOT
21 22.4 23.4 0.43
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Discussion
• Antibiotic stewardship is the necessity of the hour in view of
emergence of antimicrobial resistance
• Afzal et al noted decreased use of reserve drugs after
setting up anti-microbial committee and initiation of
antimicrobial stewardship program
• Reduced use of restricted antimicrobial drugs, decreased
duration of hospital admission and reduced cost per month
were noted after initiation of antimicrobial stewardship
programme in a study done by Singh et al
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• In our study, reduction in days of therapy of piperacillin-
tazobactam and colistin were noted by 2.4/1000 patient
days
• No reduction in total days of therapy was observed and a
trend towards increase in meropenem DOT was noted
although not statistically significant
• There were no differences in episodes of culture-positive
sepsis, healthcare associated infections (HAI), necrotizing
enterocolitis and mortality
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Strengths
• This study was conducted under the aegis of ICMR with
multidisciplinary team approach
• A dedicated clinical pharmacologist along with attending
neonatologist and microbiologist ensured the adherence to
antibiotic policy and appropriateness of antibiotics given in
culture positive neonates
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Limitations
• The sample size of the study is limited
• The benefits secondary to cost saving was not evaluated in
the study
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Summary
• Colistin and piperacillin tazobactam usage decreased after
implementation of Antimicrobial Stewardship Program
• No difference in total DOT was noted after AMSP
implementation