Charge Nurses Taking Charge, Challenging the Culture of Culture-Negative Sepsis, and Preventing Central-Line Infections to Reduce NICU Antibiotic Usage
Objective We aimed to reduce our monthly antibiotic usage rate (AUR, days of treatment per 1,000 patient-days) in the neonatal intensive care unit (NICU) from a baseline of 330 (July 2015–April 2016) to 200 by December 2018.
Study Design We identified three key drivers as follows: (1) engaging NICU charge nurses, (2) challenging the culture of culture-negative sepsis, and (3) reducing central-line associated bloodstream infections (CLABSI). Our main outcome was AUR. The percentage of culture-negative sepsis that was treated with antibiotics for >48 hours and CLABSI was our process measure. We used hospital cost/duration of hospitalization and mortality as our balancing measures.
Results After testing several plan-do-study-act (PDSA) cycles, we saw a modest reduction in AUR from 330 in the year 2016 to 297 in the year 2017. However, we did not find a special-cause variation in AUR via statistical process control (SPC) analysis (u'-chart). Thereafter, we focused our efforts to reduce CLABSI in January 2018. As a result, our mean AUR fell to 217 by December 2018. Our continued efforts resulted in a sustained reduction in AUR beyond the goal period. Importantly, cost of hospitalization and mortality did not increase during the improvement period.
Conclusion Our sequential quality improvement (QI) efforts led to a reduction in AUR. We implemented processes to establish a robust antibiotic stewardship program that included antibiotic time-outs led by NICU charge nurses and a focus on preventing CLABSI that were sustained beyond the QI period.
This is a quality improvement project to reduce antibiotic usage in NICU.
Charge nurses should take charge to reduce infections in NICU.
Central line infections should be reduced to decrease antibiotic usage.
Institutional Review Board at University of Florida Health Jacksonville (UFHJ) approved this initiative as a QI project. Any sensitive health information was not shared or disclosed outside UFHJ.
Received: 03 April 2020
Accepted: 24 September 2020
03 November 2020 (online)
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- 1 Ho T, Dukhovny D, Zupancic JA, Goldmann DA, Horbar JD, Pursley DM. Choosing wisely in newborn medicine: five opportunities to increase value. Pediatrics 2015; 136 (02) e482-e489
- 2 Cotten CM, McDonald S, Stoll B, Goldberg RN, Poole K, Benjamin Jr DK. National Institute for Child Health and Human Development Neonatal Research Network. The association of third-generation cephalosporin use and invasive candidiasis in extremely low birth-weight infants. Pediatrics 2006; 118 (02) 717-722
- 3 Cotten CM, Taylor S, Stoll B. et al. NICHD Neonatal Research Network. Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for extremely low birth weight infants. Pediatrics 2009; 123 (01) 58-66
- 4 Kuppala VS, Meinzen-Derr J, Morrow AL, Schibler KR. Prolonged initial empirical antibiotic treatment is associated with adverse outcomes in premature infants. J Pediatr 2011; 159 (05) 720-725
- 5 Saiman L, Ludington E, Dawson JD. et al. National Epidemiology of Mycoses Study Group. Risk factors for Candida species colonization of neonatal intensive care unit patients. Pediatr Infect Dis J 2001; 20 (12) 1119-1124
- 6 Lee JH, Hornik CP, Benjamin Jr DK. et al. Risk factors for invasive candidiasis in infants >1500 g birth weight. Pediatr Infect Dis J 2013; 32 (03) 222-226
- 7 Cantey JB, Patel SJ. Antimicrobial stewardship in the NICU. Infect Dis Clin North Am 2014; 28 (02) 247-261
- 8 Alexander VN, Northrup V, Bizzarro MJ. Antibiotic exposure in the newborn intensive care unit and the risk of necrotizing enterocolitis. J Pediatr 2011; 159 (03) 392-397
- 9 Neu J, Pammi M. Pathogenesis of NEC: impact of an altered intestinal microbiome. Semin Perinatol 2017; 41 (01) 29-35
- 10 Ting JY, Roberts A, Sherlock R. Canadian Neonatal Network Investigators. et al. Duration of initial empirical antibiotic therapy and outcomes in very low birth weight infants. Pediatrics 2019; 143 (03) 143
- 11 Cantey JB, Baird SD. Ending the culture of culture-negative sepsis in the neonatal ICU. Pediatrics 2017; 140 (04) 140
- 12 Cantey JB, Wozniak PS, Pruszynski JE, Sánchez PJ. Reducing unnecessary antibiotic use in the neonatal intensive care unit (SCOUT): a prospective interrupted time-series study. Lancet Infect Dis 2016; 16 (10) 1178-1184
- 13 Schulman J, Dimand RJ, Lee HC, Duenas GV, Bennett MV, Gould JB. Neonatal intensive care unit antibiotic use. Pediatrics 2015; 135 (05) 826-833
- 14 Cantey JB, Milstone AM. Bloodstream infections: epidemiology and resistance. Clin Perinatol 2015; 42 (01) 1-16 , vii vii.
- 15 Dellit TH, Owens RC, McGowan Jr JE. Infectious Diseases Society of America, Society for Healthcare Epidemiology of America. et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44 (02) 159-177
- 16 Ramasethu J, Kawakita T. Antibiotic stewardship in perinatal and neonatal care. Semin Fetal Neonatal Med 2017; 22 (05) 278-283
- 17 Pollack LA, Srinivasan A. Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. Clin Infect Dis 2014; 59 (Suppl. 03) S97-S100
- 18 Charles D, Heal CF, Delpachitra M. et al. Alcoholic versus aqueous chlorhexidine for skin antisepsis: the AVALANCHE trial. CMAJ 2017; 189 (31) E1008-E1016
- 19 Maiwald M, Chan ES. The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis. PLoS One 2012; 7 (09) e44277
- 20 Chiriboga N, Cortez J, Pena-Ariet A. et al. Successful implementation of an intracranial hemorrhage (ICH) bundle in reducing severe ICH: a quality improvement project. J Perinatol 2019; 39 (01) 143-151
- 21 Mohammed MA, Panesar JS, Laney DB, Wilson R. Statistical process control charts for attribute data involving very large sample sizes: a review of problems and solutions. BMJ Qual Saf 2013; 22 (04) 362-368
- 22 Benneyan JC, Lloyd RC, Plsek PE. Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care 2003; 12 (06) 458-464
- 23 Kuzniewicz MW, Puopolo KM, Fischer A. et al. A quantitative, risk-based approach to the management of neonatal early-onset sepsis. JAMA Pediatr 2017; 171 (04) 365-371
- 24 Dhudasia MB, Mukhopadhyay S, Puopolo KM. Implementation of the sepsis risk calculator at an academic birth hospital. Hosp Pediatr 2018; 8 (05) 243-250
- 25 Carola D, Vasconcellos M, Sloane A. et al. Utility of early-onset sepsis risk calculator for neonates born to mothers with chorioamnionitis. J Pediatr 2018; 195: 48-52.e1
- 26 Arora V, Strunk D, Furqan SH. et al. Optimizing antibiotic use for early onset sepsis: A tertiary NICU experience. J Neonatal Perinatal Med 2019; 12 (03) 301-312
- 27 Nzegwu NI, Rychalsky MR, Nallu LA. et al. Implementation of an antimicrobial stewardship program in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2017; 38 (10) 1137-1143
- 28 Bizzarro MJ, Shabanova V, Baltimore RS, Dembry LM, Ehrenkranz RA, Gallagher PG. Neonatal sepsis 2004-2013: the rise and fall of coagulase-negative staphylococci. J Pediatr 2015; 166 (05) 1193-1199
- 29 Walker S, Datta A, Massoumi RL, Gross ER, Uhing M, Arca MJ. Antibiotic stewardship in the newborn surgical patient: a quality improvement project in the neonatal intensive care unit. Surgery 2017; 162 (06) 1295-1303
- 30 Bhat R, Custodio H, McCurley C. et al. Reducing antibiotic utilization rate in preterm infants: a quality improvement initiative. J Perinatol 2018; 38 (04) 421-429
- 31 Ting JY, Paquette V, Ng K. et al. Reduction of inappropriate antimicrobial prescriptions in a tertiary neonatal intensive care unit after antimicrobial stewardship care bundle implementation. Pediatr Infect Dis J 2019; 38 (01) 54-59
- 32 Flannery DD, Puopolo KM. Neonatal antibiotic use: how much is too much?. Pediatrics 2018; 142 (03) 142
- 33 Astorga MC, Piscitello KJ, Menda N. et al. Antibiotic stewardship in the neonatal intensive care unit: effects of an automatic 48-hour antibiotic stop order on antibiotic use. J Pediatric Infect Dis Soc 2019; 8 (04) 310-316
- 34 Steinmann KE, Lehnick D, Buettcher M. et al. Impact of empowering leadership on antimicrobial stewardship: a single center study in a neonatal and pediatric intensive care unit and a literature review. Front Pediatr 2018; 6: 294
- 35 Schulman J, Stricof R, Stevens TP. et al. New York State Regional Perinatal Care Centers. Statewide NICU central-line-associated bloodstream infection rates decline after bundles and checklists. Pediatrics 2011; 127 (03) 436-444
- 36 Ho T, Buus-Frank ME, Edwards EM. et al. Adherence of newborn-specific antibiotic stewardship programs to CDC recommendations. Pediatrics 2018; 142 (06) 142
- 37 Schulman J, Profit J, Lee HC. et al. Variations in neonatal antibiotic use. Pediatrics 2018; 142 (03) 142