P0755 - Reducing antibiotic usage rate in a level 4 regional neonatal intensive care unit (NICU)

Background:
Extremely premature and hospitalized neonates are exposed to a large amount of antibiotics during their NICU stay due to their immature immune systems, need for central lines, endotracheal tubes, and surgical procedures. Frequent exposure to antibiotics leads to antibiotic resistance, change in microbiome, and increased risk of necrotizing enterocolitis.

Objective:
The baseline antibiotic utilization rate in our NICU as of January 2018 was 195 antibiotic days/1000 patient days. Our initial goal was to reduce our antibiotic utilization rate by 10% to 180 antibiotic days/1000 patient days by December 2018.

Methods:
We developed a multidisciplinary team as part of the Vermont Oxford Network iNIQ 2018-2019 Choosing Antibiotics Wisely Collaborative, incorporating NICU nurses, NICU APNs, neonatologists, NICU pharmacists, ID specialists, pediatric surgeons, and infection control. Multiple PDSA cycles were completed for each major intervention. Major interventions included: 1. Development of center specific early onset sepsis (EOS) guidelines for infants < 34 weeks and those >/= 34 weeks at birth. 2. Development of guidelines for surgical prophylaxis by wound classification. 3. Development of late onset sepsis (LOS) guidelines to standardize the evaluation and treatment for specific conditions (pneumonia, urinary tract infection, bacteremia, culture negative sepsis, meningitis, necrotizing enterocolitis, spontaneous intestinal perforation). 4. Modification of early onset sepsis guidelines for infants >/= 34 weeks at birth.

The major outcome measure was monitoring of the monthly antibiotic utilization rate. Process measures included monitoring compliance with the developed guidelines and balancing measures included measuring the rate of late onset bacteremia and cases of missed or inadequately treated culture positive sepsis.

Results:
Since January 2018, we successfully decreased the antibiotic utilization rate by 45% to 108 antibiotic days/1000 patient days with no increase in the rate of late onset bacteremia and have sustained this change over the last 9 months. There was 1 case of late onset bacteremia which was not promptly identified or treated during the time period, however this was not due to change in unit guidelines. Complete compliance with guidelines has ranged from 59-84% since implementation.

Conclusion:
We surpassed our initial aim and significantly reduced antibiotic usage rates in the unit. Monitoring both process measures and balancing measures were essential to sustain improvement and improve group buy-in. Next steps include maintaining the decreased antibiotic usage rate and reducing cases of late onset sepsis due to central line blood stream infection.