Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA.
Departments of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA.
Clin Infect Dis. 2024 Jan 25;78(1):15-23. doi: 10.1093/cid/ciad518.
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.
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.
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.
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.
在为接受造血细胞移植 (HCT) 的患者选择抗生素治疗时，医护人员必须在有效经验性治疗与毒性风险和附带损害之间取得平衡。由于担心治疗潜在感染不足，HCT 期间的抗菌药物管理干预措施常常具有挑战性。
为了减少我们儿科中心接受 HCT 的患者不必要的碳青霉烯类药物暴露，我们实施了个体化抗生素方案 (IAP)，为植入前中性粒细胞减少症预防、发热性中性粒细胞减少症的经验性治疗以及血流动力学不稳定的经验性治疗提供建议。我们比较了 IAP 实施前后两个 3 年期间每 1000 个患者日调整的碳青霉烯类、抗假单胞菌头孢菌素和所有抗生素的每月抗生素治疗日数 (DOT)，以衡量 IAP 对处方行为的影响。还比较了两组之间血流感染 (BSI) 和艰难梭菌 (CD) 阳性检测率。最后，对提供者进行了调查，以评估他们在抗生素决策中使用 IAP 的经验。
IAP 实施后，总体抗生素使用量减少（每月减少 19.6 个 DOT/1000 患者日；P =.004），IAP 实施后碳青霉烯类药物的使用持续下降。BSI 和 CD 阳性率保持不变。超过 90%的提供者认为 IAP 对他们的实践非常有价值或非常有价值。
在这种高危 HCT 人群中实施 IAP 可减少总体抗生素使用量，而不会增加 BSI 或 CD 检测阳性率。该方案得到了提供者的好评。
