Decreasing​ pediatric​ antibiotic​ use​ through​ collaboration

About 60% of children are prescribed antibiotics at some point in their childhood but 1 out of every 3 antibiotic prescriptions written in the U.S. are deemed medically unnecessary.

Improper administration of these drugs can harm kids, causing diarrhea, nausea and—in extreme cases—death. Overuse of antibiotics can also lead to antimicrobial-resistant infections, such as E. coli and salmonella poisoning, which until recently were not as prevalent among children but currently are one of the largest public health issues among adults.

Dr. Sarah Parker, a pediatric infectious disease physician at Children's Hospital Colorado, said that while antibiotics can be life-saving, clinicians need to use the drugs more appropriately especially as fewer options are available.

As a first step, Children's Hospital Colorado launched an antimicrobial stewardship program that involves Parker and a pharmacist reviewing all antibiotics administered to the hospital's young patients. They look for three things: that the appropriate antimicrobial was prescribed; that the dosage corresponds with the patient's weight and age; and that the antibiotic doesn't dangerously interact with another drug the patient is taking.

Since the initiative launched in 2011, antibiotic use has dropped by 10.9% and the hospital has saved about $1 million per year. That's the result of fewer antibiotics being ordered and patients being less likely to fall ill due to adverse reactions to antibiotics, Parker said.

The program works by including forms on the hospital's electronic health record system that require clinicians to log information about antibiotics used within the last 24 hours and how the patient has reacted to the antibiotic after 48 to 72 hours.

Every day, Parker and a pharmacist review on average 50 to 100 reports related to antibiotics prescribed within the last 24 hours and about 30 to 50 reports of patients on antibiotics for up to 72 hours. About 10% of those reports are flagged for follow-up with the patient's care team. Parker and the pharmacist will discuss with the care team why an antibiotic was administered incorrectly and what can be done to fix the issue.

Parker notes that it's critical to conduct follow-up sessions in person. Most antibiotic stewardship programs will discuss concerns over email and long after the fact. The group interaction creates the opportunity for greater discussion and understanding—for both the clinicians and the patients.

"Having our team just going around has really changed the collaborative environment tremendously," Parker added.

The participating pharmacists have been able to effectively educate physicians about drug interactions, which aren't always a doctor's forte. And as an infectious disease physician, Parker can offer advice about appropriate antibiotics for certain conditions and warn about potential side effects from their administration.

Also, Parker serves as a second set of eyes while reviewing a patient's EHR and can catch errors unrelated to antibiotics—for example, if a doctor wants to figure out if a patient has a virus but didn't order the right test.

The stewardship program at Children's also involves daily rounds on units that haven't been flagged. This allows Parker to ask physicians if they have any questions or concerns related to antibiotic use. She said usually physicians take advantage of the opportunity, especially those in pediatric intensive care. That's likely because those units more often use antibiotics to help patients through complex conditions, Parker said. In fact, the pediatric ICU experienced the biggest decrease—14.5%—in antibiotic use since 2011.

The stewardship program has educated staff on antibiotics and has enabled conversations about infectious disease. It's also given the hospital an opportunity to adhere to best practices—something only a third of acute-care hospitals in the U.S. practice, according to a 2016 report. The Centers for Disease Control and Prevention estimates as many as 2 million antimicrobial-resistant infections occur in the U.S. each year, resulting in 23,000 deaths.