Olivia Jackson, RN, Infection Control Coordinator, Elizabeth Seton Pediatric Center

The appropriate use of antibiotics has become a top priority for long-term as well as acute care healthcare facilities. Misuse of antibiotics has been shown to increase antimicrobial resistance leading to limited options for treatment of resistant bacteria, increased risk for toxicity, and harmful side effects which include an increased prevalence of Clostridium difficile infections. The administration of inappropriate antibiotics also increases pharmaceutical and costs.

In order to limit the inappropriate use of antibiotics, many healthcare facilities have implemented antimicrobial stewardship programs. The goals of ASPs include optimizing clinical outcomes by ensuring correct indication, drug, dose, duration and minimizing the unintended consequences of antimicrobial use such as toxicity and the emergence of multi-drug resistant organisms.

Our 137-bed pediatric long-term care facility in New York created a pilot antimicrobial stewardship program in April 2014 after the infection prevention team recognized that antibiotics were being prescribed for extensive durations and for non-infection indications. We therefore created a multidisciplinary antibiotic stewardship team, led by the infection control coordinator, which included prescribers, pharmacists, nursing staff and an infectious disease consulting physician. Consensus was achieved by analyzing baseline data on antibiotic use and selecting goals that were easily achievable. Our approach to stewardship started with reviewing antibiotic orders on a monthly basis and providing feedback to prescribers. The two initial target areas for improvement were to ensure all antibiotic orders had a documented indication and to decrease the use of mupirocin for non-bacterial skin infections.

When the program began, physician orders were entered in a paper record and a clinical indication for antibiotic use was not required. We saw a decrease in antibiotic orders without indication in September when we implemented an Electronic Medical Record that offered a choice of indications from a drop-down menu. Further improvement was seen when the Center implemented the ASP recommendation that indication for treatment be a required field for all antibiotic orders.

To limit the use of mupirocin for inappropriate indications, we focused our intervention on feedback to prescribers. Inappropriate indications included dermatitis, infection prevention, and skin irritation. When orders for mupirocin were received for non-infectious skin conditions, either the pharmacist or the infection control coordinator would notify the prescriber and suggest alternatives such as a non-antimicrobial ointment. Overall, our intervention of monitoring antimicrobial use and giving immediate provider feedback resulted in a significant improvement in prescribing behavior.

Following these implementations, the facility saw an 83% decrease in medication orders without a clinical indication and a 59% decrease in the use of mupirocin within a four month period in 2014. We found that certain strategies were highly effective in our ASP program. Pharmacists were empowered to engage with prescribers to discuss most appropriate antibiotic choices. During our monthly ASP meetings we resolved areas of discord such as choice of antibiotic and indication for use.  

In conclusion, antimicrobial stewardship is a team effort, particularly in pediatric long-term care. The creation of a pilot antimicrobial stewardship program and the implementation of an electronic medical record in our pediatric long term care facility had significant positive effects. Additionally, we found that it is important to set goals that are well defined and easily measured in order to ensure that they can be achieved. It is equally important to share successes frequently with the whole team to encourage further buy-in from the stakeholders, especially from prescribers.

Antimicrobial stewardship is an ongoing process, so it is necessary to provide continuous education and support.

Olivia Jackson, RN, is the infection control coordinator at Elizabeth Seton Pediatric Center in Yonkers, NY.