Up to 75% of hospitalized pediatric patients receive antibiotics,Reference Gerber, Newland and Coffin 1 and inappropriate use has been associated with unnecessary costs, avoidable adverse effects, and the development of infections with antibiotic-resistant organisms.Reference Le Saux 2 Seven years after the publication of guidelines for the development of institutional antimicrobial stewardship programs (ASPs),Reference Dellit, Owens and McGowan 3 Newland et alReference Newland, Gerber and Weissman 4 found that 42.1% of freestanding children’s hospitals in the United States had established comprehensive continuous ASPs with varying resources, structures, and approaches to stewardship. Of the remaining sites, 36% were in the process of developing a program.Reference Newland, Gerber and Weissman 4
Antimicrobial stewardship became a required organization practice (ROP) in Canada for hospital accreditation in 2013. 5 The extent to which ASPs have been implemented in children’s hospitals in Canada remains unknown. We sought to determine the team structure and resources allocated, strategies utilized, as well as quantitative and qualitative metrics utilized by ASPs in Canadian academic pediatric centers.
METHODS
Study Design
We conducted a cross-sectional survey of all 16 academic pediatric hospitals in Canada. The online survey was developed and study data were collected and managed using REDCap electronic data capture tools hosted at the Hospital for Sick Children.Reference Harris, Taylor, Thielke, Payne, Gonzalez and Conde 6 Survey links were sent to the physician and pharmacy ASP leaders at each site, and any discrepancies between responses from the same center were resolved by contacting respondents directly. The project was approved as a Quality Improvement Project by the Quality and Risk Management Department at the Hospital for Sick Children, Toronto, Canada. The survey was initially distributed in May 2015, and the results were updated on January 24, 2017.
Survey
Infectious diseases (ID) physicians and pharmacists with direct experience in ASP development and management were involved in developing and piloting the survey. Questions were guided by published surveys regarding ASP implementation and guidelines for the development of hospital-based ASPs (Supplementary Material).
The ASP leaders were asked if their site had a formal ASP (as defined by the respondent) and when it was established. The multidisciplinary team composition, as well as previous ASP-specific training and funding for each ASP member (in full-time equivalents, FTE) was ascertained. Each respondent was also asked to indicate the types of antimicrobial stewardship strategies used within their hospital. Finally, process measures and metrics that were monitored at each site were collected.
Hospital Characteristics
Of the 16 children’s hospital sites, 2 sites were freestanding hospitals, 3 hospitals were merged with a maternal health center, and the remainder were pediatric programs within larger adult medical centers. Hospital institutional information was collected from each site’s corporate website and through direct contact with the ASP leader if more details were required.
Statistical Methods
The ASP characteristics from the updated survey (2017) were summarized using descriptive statistics. Univariable analyses were conducted using the Spearman correlation coefficient for continuous variables and the χ2 or the Fisher exact test for dichotomous variables. Pearson correlations were calculated to determine the relationship between various hospital characteristics and total available FTE funding for ASPs and hospital-wide use of prospective audit and feedback (PAF). Statistical analyses were performed using SPSS Statistics for Macintosh, version 24.0 software (IBM, Armonk, NY). P values < .05 were considered statistically significant.
RESULTS
A total of 26 ASP leaders representing 15 of the 16 pediatric hospitals responded to the survey (institution response rate 94%). Respondents included ID physicians (n=17, 65%) and pharmacists (n=9, 35%), with 9 sites submitting >1 survey. Less than half of the respondents had additional training in antimicrobial stewardship: physicians (n=7, 41%) and pharmacists (n=4, 44%). Hospital sizes ranged from 38 beds to 484 beds, including neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs). All sites had a PICU and NICU; all sites performed pediatric surgeries; and 7 sites were transplant centers (Table 1).
TABLE 1 Hospital and Antimicrobial Stewardship Program (ASP) Information for Participating Sites
NOTE. ID MD, infectious disease physician; FTE, full-time equivalent; BMT, bone marrow transplant; DOT, days of therapy; N/A, not available; IT, information technology; Phm, pharmacist; RN, registered nurse; SOT, solid organ transplant.
a Strategy used in any part of the hospital.
b Monitoring of either recommendations or adherence to recommendations.
c Previous 12-month pilot program using prospective audit/feedback with 0.6 Phm FTE (not permanently funded).
d ID MD involved but not funded.
ASP Development and Implementation
All but 1 hospital (n=14, 93%) had an ASP by the time of the second survey in 2017. Among them, 3 ASPs were established between the first and second survey dates, and 5 ASPs existed prior to the implementation of the Accreditation Canada ROPs in 2013. All ASPs included an ID physician and most included both an ID physician and a dedicated pharmacist (n=9, 64%). Of all the teams, 10 ASP teams (71%) were interdisciplinary; other team members included a microbiologist (n=3, 21%), a data analyst (n=3, 21%), or information technology (IT) support (n=2, 14%). The amount of financial support for each ASP was also highly variable, with a median 0.7 FTEs (range, 0.0–1.8 FTE) being allocated overall to ASPs. Among sites reporting individual FTEs, there was a median ID physician FTE of 0.1 (range, 0.0–0.4 FTE) and median pharmacist FTE of 0.5 (range, 0–1.2 FTE). We observed a trend toward increased total combined FTE support with increasing hospital size, but this did not reach statistical significance (P=.08) (Table 1).
ASP Strategies
The most common ASP strategies used hospital-wide were clinical guidelines (n=14, 93%), order sets (n=12, 80%), and formulary restriction (n=11, 73%). These 3 strategies were also the most commonly used in the PICU and NICU settings. Prospective audit and feedback (PAF) was used in at least 1 area in 8 hospitals (53%), including 5 sites using this strategy hospital-wide. We found no association between the number of hospital beds (P=.29), year of ASP inception (P=.12), total ASP FTE support (P=.22), ID physician FTE support (P=.78), or pharmacist FTE support (P=.25) and implementation of hospital-wide PAF (Figure 1).
FIGURE 1 Summary of ASP Strategies/Models Across All Sites (N=15)
ASP Metrics
In this study, 12 ASPs (86%) monitored antimicrobial usage using days of therapy (DOT) and/or cost (n=12, 86%). Most programs monitored antimicrobial resistance (AMR) or had an antibiogram. All ASPs monitored Clostridium difficile infections (CDI), and 5 sites monitored additional antibiotic-related infections including methicillin-resistant Staphylococcus aureus (n=3), vancomycin-resistant Enterococcus (n=2), carbapenem-resistant Enterobacteriaceae (n=1), and Stenotrophomonas (n=1). Moreover, 8 sites (57%) monitored the documentation of ASP recommendations and/or adherence to ASP recommendations, and 11 ASPs (79%) had data management systems in place to track various metrics and process measures (Table 1).
DISCUSSION
To our knowledge, this survey is the first to document the implementation of ASPs and the current status of antimicrobial stewardship across Canadian academic pediatric centers. Four years after the implementation of Accreditation Canada standards to establish hospital ASPs, we found that 93% of hospitals represented by survey respondents had a formal ASP in place, but we detected significant variability in team composition, strategies used, and metrics monitored. Our results provide essential benchmarking information for centers planning to establish or expand programs, and they emphasize the need for standardized metrics for comparing antimicrobial use and the effects of ASPs between centers.
We observed significant variability in the amount of personnel support for the ASPs in our survey. The median overall total combined 0.7 FTE remained unchanged compared to 2015 when fewer formal ASPs existed. Our results indicated that more funding was generally available for pharmacists (median FTE, 0.5) than for physicians (median FTE, 0.1). Similarly, Newland et alReference Newland, Gerber and Weissman 4 also reported that almost all established ASP teams included both a physician and a pharmacist. Furthermore, the median number of total FTE allotted to a program was 0.63 (range, 0.1–1.8 FTE), with physicians having a median FTE of 0.25 (range, 0.1–0.5 FTE), while pharmacists had a median FTE of 0.5 (range, 0.1–1.5 FTE).Reference Newland, Gerber and Weissman 4
Overall, Canadian children’s hospitals utilized at least 1 core recommended strategy (ie, prospective audit with intervention and feedback, formulary restriction, and preauthorization),Reference Dellit, Owens and McGowan 3 , Reference Barlam, Cosgrove and Abbo 7 including one-third of sites that implemented hospital-wide PAF. In contrast, among surveyed US freestanding children’s hospitals, these core strategies were implemented among 87% of hospitals, of which 21 sites used PAF.Reference Newland, Gerber and Weissman 4 The drivers influencing the adoption of certain strategies remain unclear. Our logistic regression analysis did not reveal any correlation between the use of hospital-wide PAF and hospital size or various characteristics of the ASPs.
Identification of measurable performance indicators that can be used to evaluate processes and outcomes of an ASP is an essential component of a successful ASP. In adults, commonly used ASP metrics include DOT, defined daily doses, antimicrobial costs, AMR, adverse events, and CDI.Reference Wagner, Filice and Drekonja 8 However, some metrics may be less meaningful in the pediatric setting. We found significant variation in the metrics collected and monitored by pediatric ASPs across Canada. As such, there is a necessity for both a description of the best metrics to assess the impact of pediatric ASPs and publication of these findings for benchmarking and quality improvement initiatives.
Our high institutional response rate provides a broad overview of the pediatric inpatient ASP landscape in Canada, covering major metropolitan areas and representing a variety of hospital funding models. However, our findings may not reflect the scenario for a substantial proportion of Canadian children admitted to other pediatric wards within adult hospitals, where stewardship practices may differ significantly. In addition to identifying optimal strategies and metrics for pediatric-specific antimicrobial stewardship, future studies need to assess the impact of Canadian pediatric ASPs and determine whether they are in line with emerging pediatric and adult literature that demonstrate improved prescribing patterns and patient outcomes (eg, institutional resistance patterns, fewer adverse events, and decreased antimicrobial costs).Reference Wagner, Filice and Drekonja 8 – Reference Smith, Gerber and Hersh 10
ACKNOWLEDGMENTS
We would like to thank the members of the Groupe Antibiothérapie en Pédiatrie Canada Alliance for Stewardship of Antimicrobials in Pediatrics (GAP Can ASAP) for their participation and support.
Financial support: No financial support was provided relevant to this article.
Potential conflicts of interest: All authors report no conflicts of interest relevant to this article. Dr Science reports grants from Canadian Institutes of Health Research during the conduct of the study, and grants from Physician Services, Inc, outside the submitted work.
SUPPLEMENTARY MATERIAL
To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2017.292
