antibiotic stewardship in the nicu: an...
TRANSCRIPT
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Antibiotic Stewardshipin the NICU: An Overview
David Braun, MD
Regional Perinatal Coordinator
Kaiser Permanente, Southern California
May 20, 2016
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What is Antibiotic Stewardship?Definition
– Coordinated interventions designed to improve and measure the appropriate use of antibiotics
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Antibiotic StewardshipOverview Topics
1. The Microbial World
2. Bacteria are bad
3. Antibiotics are good
4. Bacteria are good
5. Antibiotics are bad
6. The need for a better balance
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1. We’re Just a Little Part of a Big WorldMost of Its Inhabitants are Microbes
4 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.May 18, 2016
Us
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2. Bacteria are BadWe’re Understandably Afraid of them
5 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.May 18, 2016
Necrotizing Enterocolitis
Pneumonia
Sepsis
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3. Antibiotics are goodHave Saved Many Lives (50 fold drop)
6 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.May 18, 2016
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But The Drop in Infection Is Only Partly From Antibiotics
7 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.May 18, 2016
Pre-antibiotic era Antibiotic era
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Current ImbalanceLow Neonatal Infection rate, High Antibiotic Use
Early Onset Sepsis incidence: <0.05%
Blood Cultures: 15%
Antibiotics : 10%
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Others Side Effects of ImbalanceMaternal Complications from NICU
• Disruption of mother-baby bonding
• Disruption of breast feeding initiation
• Elevated maternal postpartum depression risk
• Vulnerable child syndrome risk
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4. Bacteria are goodOur (Internal) Microbiome Promotes Health
10 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.May 18, 2016
• Examples
• Suppress pathogenic bacteria
• Encourage immunological homeostasis
• Support GI physiology
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5. Antibiotics are BadThey Disrupt the Microbiome, Causing Harm
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Antibiotics are BadThey Cause Antibiotic Resistance
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New Antibiotic Development Can’t Keep UpDevelopment Slowing, Deaths Rising
10 fold drop in new antibiotics since 1980s 10 fold increase in deaths
from antibiotic resistance by 2050?
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Antibiotic Stewardship Striking a Better Balance of Benefit and Risk
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Antibiotic Stewardship It Can Work
Meta-analysis (Lancet 2016)
– N=145 studies
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Intervention Mortaltiy (RR)
Guideline Driven Choice of Initial
Antibiotics
35% less
Guideline driven de-escalation of
antibiotics
64% less
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Antibiotic StewardshipHuge Area of Interest
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Antibiotic Stewardship Legally Mandated
California
– Senate Bill 739 (2006)
– Senate Bill 1311
Federal
– CMS Executive Order (2015)
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Antibiotic Stewardship Demonstrated Deficiency in California NICUs
Schulman 2015
– N=127 California NICUs
– Measure:
% patient days with one or more iv antibiotics
– Results
2% to 97%!
– Unrelated to:
Proven infection
NICU level
NEC
Surgical volume
Mortality
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Antibiotic Stewardship Overview Thanks!
Thanks to
– Nami Jhaveri, MD
– Carol Glaser, MD
– My colleagues in CPQCC and KP
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Antibiotic Stewardship Striking a Better Balance of Benefit and Risk
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