Individualized Antibiotic Plans as a Quality Improvement Initiative to Reduce Carbapenem Use for Hematopoietic Cell Transplant Patients at a Freestanding Pediatric Hospital

Adam W Brothers; Daniel J Pak; Nicole M Poole; Matthew P Kronman; Brendan Bettinger; Jennifer J Wilkes; Paul A Carpenter; Janet A Englund; Scott J Weissman

doi:10.1093/cid/ciad518

Individualized Antibiotic Plans as a Quality Improvement Initiative to Reduce Carbapenem Use for Hematopoietic Cell Transplant Patients at a Freestanding Pediatric Hospital

Clin Infect Dis. 2024 Jan 25;78(1):15-23. doi: 10.1093/cid/ciad518.

Authors

Affiliations

¹ Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA.
² Departments of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA.
³ Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Washington, Seattle, Washington, USA.
⁴ Department of Clinical Analytics, Seattle Children's Hospital, Seattle, Washington, USA.
⁵ Department of Pediatrics, Division of Hematology/Oncology, University of Washington, Seattle, Washington, USA.
⁶ Ben Towne Center for Childhood Cancer Research, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA.
⁷ Division of Clinical Research, Fred Hutchinson Cancer Center, Seattle, Washington, USA.
⁸ Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA.

PMID: 37647637
DOI: 10.1093/cid/ciad518

Abstract

Background: Providers must balance effective empiric therapy against toxicity risks and collateral damage when selecting antibiotic therapy for patients receiving hematopoietic cell transplant (HCT). Antimicrobial stewardship interventions during HCT are often challenging due to concern for undertreating potential infections.

Methods: In an effort to decrease unnecessary carbapenem exposure for patients undergoing HCT at our pediatric center, we implemented individualized antibiotic plans (IAPs) to provide recommendations for preengraftment neutropenia prophylaxis, empiric treatment of febrile neutropenia, and empiric treatment for hemodynamic instability. We compared monthly antibiotic days of therapy (DOT) adjusted per 1000 patient-days for carbapenems, antipseudomonal cephalosporins, and all antibiotics during two 3-year periods immediately before and after the implementation of IAPs to measure the impact of IAP on prescribing behavior. Bloodstream infection (BSIs) and Clostridioides difficile (CD) positivity test rates were also compared between cohorts. Last, providers were surveyed to assess their experience of using IAPs in antibiotic decision making.

Results: Overall antibiotic use decreased after the implementation of IAPs (monthly reduction of 19.6 DOT/1000 patient-days; P = .004), with carbapenems showing a continuing decline after IAP implementation. BSI and CD positivity rates were unchanged. More than 90% of providers found IAPs to be either extremely or very valuable for their practice.

Conclusions: Implementation of IAPs in this high-risk HCT population led to reduction in overall antibiotic use without increase in rate of BSI or CD test positivity. The program was well received by providers.

Keywords: antimicrobial stewardship; carbapenem; handshake stewardship; hematopoietic cell transplant; individualized antibiotic plan.

MeSH terms

Anti-Bacterial Agents*
Carbapenems / therapeutic use
Child
Hematopoietic Stem Cell Transplantation* / adverse effects
Hospitals, Pediatric
Humans
Quality Improvement

Substances

Anti-Bacterial Agents
Carbapenems