Editorial
Are We Stewards for Our Patients? Debbie Fraser, MN, RNC-NIC, Editor-in-Chief
Debbie Fraser, MN, RNCNIC, Athabasca University, 1 University Drive , Athabasca, AB, Canada, T9S 3A3. E-mail: [email protected] Debbie Fraser, MN, RNCNIC, is an associate professor and the director of the Nurse Practitioner program in the Faculty of Health Disciplines at Athabasca University. She holds an appointment in the Department of Pediatrics, Faculty of Medicine, and the Faculty of Nursing at the University of Manitoba. Debbie maintains an active practice in the NICU at St. Boniface General Hospital and is the Editor-in-Chief of Neonatal Network: The Journal of Neonatal Nursing.
I
recently had the opportunity to give
a
talk on antibiotic stewardship. Digging into the literature on the harmful effects of antibiotics reinforced for me that, despite our best intentions, there is much we have to learn about the potential harm of some of our treatments. A famous quote from George Santayana, “Those who cannot remember the past are condemned to repeat it,” bears remembering. Neonatology is fraught with examples of good intentions gone wrong. Dr. William Silverman, one of the pioneers of randomized controlled trials in neonatal medicine, wrote an eloquent memoir outlining his experiences in examining the evidence supporting early neonatal interventions.1 In particular, he reminds us about our history in the treatment of respiratory distress and the subsequent epidemic of blindness in the 1940s and 50s. 2 Other examples abound: chloramphenicol resulting in “gray baby syndrome,” benzyl alcohol preservatives causing gasping syndrome, and postnatal steroids increasing the risk of poor neurodevelopmental outcomes. For a full discussion of iatrogenesis in neonatology, I encourage you to read Alex Robertson’s historical series.3–5 There are several lessons that we can take away from our history as a specialty: what we know today to be the right thing to do may turn out to be the opposite; each and every therapeutic choice that we make from how we position a baby to what we feed them to what drugs we administer must be done with a view to understanding the evidence that supports our practice; we must embrace a lifelong sense of inquiry and passion to understand that evidence; and we must always ask whether this is the right treatment at the right time for our patient. Whether it is at morning rounds, afternoon teaching sessions, or family conferences, that sense of
rational inquiry needs to underpin each and every decision we make in providing care. Merriam-Webster defines stewardship as “the conducting, supervising, or managing of something; especially: the careful and responsible management of something entrusted to one’s care.”6 This perfectly describes our role as care providers in the NICU and speaks to why the term stewardship is applied to antibiotic therapy. Antibiotics are the most commonly prescribed medications and with vitamins make up the majority of medication use in the NICU. The Centers for Disease Control and Prevention estimates that up to 50 percent of antibiotic use in the United States is inappropriate. Last week, the World Health Organization warned that antibiotic resistance is a “major threat to public health.” According to the Infectious Diseases Society of America, the rate of bacterial resistance is outpacing the development of new antimicrobials.7 In order to protect not only neonates but the global community from the crisis of antimicrobial resistance, we need to act now to rethink our approach to antibiotic therapy. The concern rega rd i ng resista nce, however, is only one of the reasons why we need a more considered approach to antibiotic therapy in the NICU. These drugs are not innocuous: they can cause renal and liver toxicity as well as ototoxicity, predispose the neonate to candida infections, and, as with all medications, can lead to harm as a result of a drug error. For neonates, there is mounting evidence that antibiotic exposure increases the risk of necrotizing enterocolitis8 and late-onset sepsis and increases the overall risk of death as the length of antibiotic exposure increases.9,10 For all of these reasons, there is now a lot of attention being given to finding ways to limit the use of antibiotics in all patients, including in the NICU.
N E O N A T A L N E T W O R K V O L . 3 3 , N O . 4 , J U LY / A U G U S T 2 0 1 4 © 2014 Springer Publishing Company183 http://dx.doi.org/10.1891/0730-0832.33.4.183
The use of antibiotics in neonates poses unique difficulties: our patients are immunologically compromised, they received limited immunoglobulins in utero, infection is implicated as a cause of preterm delivery, and we have few tests to accurately predict which neonates are septic. Even gathering adequate samples for culture can be a challenge in a compromised newborn. Because of the aggressive nature of the pathogens affecting the neonate, it is necessary to start antibiotic therapy in any patient where sepsis is suspected. In fact, Nash and colleagues reported that an average of 30–40 percent of patients in their NICU were receiving antibiotics on any given day.11 Given the frequency of antibiotic use in our units, we need to ensure that these drugs are used appropriately and, more importantly, discontinued as quickly as possible. Antibiotic stewardship programs (ASPs) are intended as a tool to help monitor and advise practitioners on the use of antimicrobial drugs. The CDC highlighted stewardship as one of the primary interventions to reduce the risk of antimicrobial resistance.12 Do you have a program in place in your facility? How often are you collecting data about the length of antibiotic exposure for the neonates in your unit? Do you have access to the antibiograms for the organisms commonly responsible for infections in your NICU? Do pharmacists and infectious-diseases specialists regularly participate in reviews of antibiotic prescriptions? These are a few strategies that comprise an antibiotic stewardship program for neonatal patients.13 This editorial includes homework: if you don’t have an ASP in your NICU, look at the SHEA/IDSA Guidelines (www.shea-online.org/ PriorityTopics/CompendiumofStrategiestoPreventHAIs. aspx) and get started. 1 12/16/13 11:33 AM Page 1 NeoNatalPubAd2_Layout
REFERENCES
1. Silverman WA. Personal reflections on lessons learned from randomized trials involving newborn infants, 1951 to 1967. http://www.jameslind library.org/essays/cautionary/silverman.html. Published 2003. 2. Silverman WA. A cautionary tale about supplemental oxygen: the albatross of neonatal medicine. Pediatrics. 2004;113:394-396. 3. Robertson AF. Reflections on errors in neonatology: I. the ‘hands-off’ years, 1920-1950. J Perinatol. 2003;23:48-55. 4. Robertson AF. Reflections on errors in neonatology: II. the ‘heroic’ years, 1950-1970. J Perinatol. 2003;23:154-161. 5. Robertson AF. Reflections on errors in neonatology: III. the ‘experienced’ years, 1970-2000. J Perinatol. 2003;23:240-249. 6. Merriam-Webster Dictionary. Stewardship. http://www.merriamwebster.com/dictionary/stewardship. Accessed June 6, 2014. 7. Infectious Diseases Society of America (IDSA) IDSA Public Policy. Combating antimicrobial resistance: policy recommendations to save lives. Clin Infect Dis. 2011;52(suppl 5):S397-S428. 8. Alexander VN, Northrup V, Bizzarro MJ. Antibiotic exposure in the newborn intensive care unit and the risk of necrotizing enterocolitis. J Pediatr. 2011;159(3):392-397. 9. Cotten CM, Taylor S, Stoll B, et al.; NICHD Neonatal Research Network. Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for extremely low birth weight infants. Pediatrics. 2009;123(1):58-66. 10. Kuppala VS, Meinzen-Derr J, Morrow AL, Schibler KR. Prolonged initial empirical antibiotic treatment is associated with adverse outcomes in premature infants. J Pediatr. 2011;159(5):720-725. 11. Nash C, Simmons E, Bhagat P, Bartlett A. Antimicrobial stewardship in the NICU: lessons we’ve learned. NeoReviews. 2014;15(4):e116-e122. 12. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. http://www.cdc.gov/drugresistance/threatreport-2013/ 13. Patel SJ, Saiman L. Principles and strategies of antimicrobial stewardship in the neonatal intensive care unit. Semin Perinatol. 2012;36(6):431-436.
N E O N A T A L N E T W O R K 184
J U LY / A U G U S T 2 0 1 4 , V O L . 3 3 , N O . 4
Are We Stewards for Our Patients? Debbie Fraser, MN, RNC-NIC, Editor-in-Chief
Debbie Fraser, MN, RNCNIC, Athabasca University, 1 University Drive , Athabasca, AB, Canada, T9S 3A3. E-mail: [email protected] Debbie Fraser, MN, RNCNIC, is an associate professor and the director of the Nurse Practitioner program in the Faculty of Health Disciplines at Athabasca University. She holds an appointment in the Department of Pediatrics, Faculty of Medicine, and the Faculty of Nursing at the University of Manitoba. Debbie maintains an active practice in the NICU at St. Boniface General Hospital and is the Editor-in-Chief of Neonatal Network: The Journal of Neonatal Nursing.
I
recently had the opportunity to give
a
talk on antibiotic stewardship. Digging into the literature on the harmful effects of antibiotics reinforced for me that, despite our best intentions, there is much we have to learn about the potential harm of some of our treatments. A famous quote from George Santayana, “Those who cannot remember the past are condemned to repeat it,” bears remembering. Neonatology is fraught with examples of good intentions gone wrong. Dr. William Silverman, one of the pioneers of randomized controlled trials in neonatal medicine, wrote an eloquent memoir outlining his experiences in examining the evidence supporting early neonatal interventions.1 In particular, he reminds us about our history in the treatment of respiratory distress and the subsequent epidemic of blindness in the 1940s and 50s. 2 Other examples abound: chloramphenicol resulting in “gray baby syndrome,” benzyl alcohol preservatives causing gasping syndrome, and postnatal steroids increasing the risk of poor neurodevelopmental outcomes. For a full discussion of iatrogenesis in neonatology, I encourage you to read Alex Robertson’s historical series.3–5 There are several lessons that we can take away from our history as a specialty: what we know today to be the right thing to do may turn out to be the opposite; each and every therapeutic choice that we make from how we position a baby to what we feed them to what drugs we administer must be done with a view to understanding the evidence that supports our practice; we must embrace a lifelong sense of inquiry and passion to understand that evidence; and we must always ask whether this is the right treatment at the right time for our patient. Whether it is at morning rounds, afternoon teaching sessions, or family conferences, that sense of
rational inquiry needs to underpin each and every decision we make in providing care. Merriam-Webster defines stewardship as “the conducting, supervising, or managing of something; especially: the careful and responsible management of something entrusted to one’s care.”6 This perfectly describes our role as care providers in the NICU and speaks to why the term stewardship is applied to antibiotic therapy. Antibiotics are the most commonly prescribed medications and with vitamins make up the majority of medication use in the NICU. The Centers for Disease Control and Prevention estimates that up to 50 percent of antibiotic use in the United States is inappropriate. Last week, the World Health Organization warned that antibiotic resistance is a “major threat to public health.” According to the Infectious Diseases Society of America, the rate of bacterial resistance is outpacing the development of new antimicrobials.7 In order to protect not only neonates but the global community from the crisis of antimicrobial resistance, we need to act now to rethink our approach to antibiotic therapy. The concern rega rd i ng resista nce, however, is only one of the reasons why we need a more considered approach to antibiotic therapy in the NICU. These drugs are not innocuous: they can cause renal and liver toxicity as well as ototoxicity, predispose the neonate to candida infections, and, as with all medications, can lead to harm as a result of a drug error. For neonates, there is mounting evidence that antibiotic exposure increases the risk of necrotizing enterocolitis8 and late-onset sepsis and increases the overall risk of death as the length of antibiotic exposure increases.9,10 For all of these reasons, there is now a lot of attention being given to finding ways to limit the use of antibiotics in all patients, including in the NICU.
N E O N A T A L N E T W O R K V O L . 3 3 , N O . 4 , J U LY / A U G U S T 2 0 1 4 © 2014 Springer Publishing Company183 http://dx.doi.org/10.1891/0730-0832.33.4.183
The use of antibiotics in neonates poses unique difficulties: our patients are immunologically compromised, they received limited immunoglobulins in utero, infection is implicated as a cause of preterm delivery, and we have few tests to accurately predict which neonates are septic. Even gathering adequate samples for culture can be a challenge in a compromised newborn. Because of the aggressive nature of the pathogens affecting the neonate, it is necessary to start antibiotic therapy in any patient where sepsis is suspected. In fact, Nash and colleagues reported that an average of 30–40 percent of patients in their NICU were receiving antibiotics on any given day.11 Given the frequency of antibiotic use in our units, we need to ensure that these drugs are used appropriately and, more importantly, discontinued as quickly as possible. Antibiotic stewardship programs (ASPs) are intended as a tool to help monitor and advise practitioners on the use of antimicrobial drugs. The CDC highlighted stewardship as one of the primary interventions to reduce the risk of antimicrobial resistance.12 Do you have a program in place in your facility? How often are you collecting data about the length of antibiotic exposure for the neonates in your unit? Do you have access to the antibiograms for the organisms commonly responsible for infections in your NICU? Do pharmacists and infectious-diseases specialists regularly participate in reviews of antibiotic prescriptions? These are a few strategies that comprise an antibiotic stewardship program for neonatal patients.13 This editorial includes homework: if you don’t have an ASP in your NICU, look at the SHEA/IDSA Guidelines (www.shea-online.org/ PriorityTopics/CompendiumofStrategiestoPreventHAIs. aspx) and get started. 1 12/16/13 11:33 AM Page 1 NeoNatalPubAd2_Layout
REFERENCES
1. Silverman WA. Personal reflections on lessons learned from randomized trials involving newborn infants, 1951 to 1967. http://www.jameslind library.org/essays/cautionary/silverman.html. Published 2003. 2. Silverman WA. A cautionary tale about supplemental oxygen: the albatross of neonatal medicine. Pediatrics. 2004;113:394-396. 3. Robertson AF. Reflections on errors in neonatology: I. the ‘hands-off’ years, 1920-1950. J Perinatol. 2003;23:48-55. 4. Robertson AF. Reflections on errors in neonatology: II. the ‘heroic’ years, 1950-1970. J Perinatol. 2003;23:154-161. 5. Robertson AF. Reflections on errors in neonatology: III. the ‘experienced’ years, 1970-2000. J Perinatol. 2003;23:240-249. 6. Merriam-Webster Dictionary. Stewardship. http://www.merriamwebster.com/dictionary/stewardship. Accessed June 6, 2014. 7. Infectious Diseases Society of America (IDSA) IDSA Public Policy. Combating antimicrobial resistance: policy recommendations to save lives. Clin Infect Dis. 2011;52(suppl 5):S397-S428. 8. Alexander VN, Northrup V, Bizzarro MJ. Antibiotic exposure in the newborn intensive care unit and the risk of necrotizing enterocolitis. J Pediatr. 2011;159(3):392-397. 9. Cotten CM, Taylor S, Stoll B, et al.; NICHD Neonatal Research Network. Prolonged duration of initial empirical antibiotic treatment is associated with increased rates of necrotizing enterocolitis and death for extremely low birth weight infants. Pediatrics. 2009;123(1):58-66. 10. Kuppala VS, Meinzen-Derr J, Morrow AL, Schibler KR. Prolonged initial empirical antibiotic treatment is associated with adverse outcomes in premature infants. J Pediatr. 2011;159(5):720-725. 11. Nash C, Simmons E, Bhagat P, Bartlett A. Antimicrobial stewardship in the NICU: lessons we’ve learned. NeoReviews. 2014;15(4):e116-e122. 12. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. http://www.cdc.gov/drugresistance/threatreport-2013/ 13. Patel SJ, Saiman L. Principles and strategies of antimicrobial stewardship in the neonatal intensive care unit. Semin Perinatol. 2012;36(6):431-436.
N E O N A T A L N E T W O R K 184
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