Use of Antimicrobials in a Tertiary Children’s Hospital

BACKGROUND AND OBJECTIVES Rational use of antimicrobials is paramount due to increasing bacterial resistance and a lack of novel antimicrobials. Investigating the clinical use and consumption of antimicrobials aids in the prudent use of these drugs in a tertiary paediatric hospital. The purpose of this study was to obtain detailed information on the use of antimicrobials in a tertiary Children’s Hospital, Helsinki University Hospital, in order to support prudent, safe and efficient use of antimicrobials. The objectives were the following: 1) To evaluate the appropriateness of antimicrobial therapy (AMT) in children with blood culture positive infections (Study I), 2) To investigate the consumption of antimicrobials in the hospital in Defined Daily Doses (Study II), 3) To record the prevalence of off-label use of antimicrobials in neonates (Study III) and last, 4) To analyse the occurrence of antimicrobial medication errors in children (Study IV). MATERIALS AND METHODS The Children’s Hospital, University of Helsinki, is a tertiary hospital in Finland. In Study I, data on 149 children (0–17 years) with blood culture positive hospital infections between 2005 and 2012 were collected. In Study II, the consumption of antimicrobials in Defined Daily Doses (DDDs according to the Anatomical Therapeutic Chemical (ATC)/DDD index) was investigated retrospectively between 2003 and 2013. In Study III, the prevalence of off-label use of antimicrobials was investigated in three different paediatric cohorts. The largest cohort consisted of premature NICU patients (450–2000g) with blood culture positive infections and antimicrobial therapy given between 2005 and 2014 (N=282). In Study IV, the types of documented antimicrobial errors were analysed. The errors were reported by healthcare professionals using a voluntary web-based error reporting system, HaiPro between 2009-2014. Overall, different types of methods were used regarding quantitative and qualitative analysis and retrospective reviews of electronic patient records and registry data. RESULTS The AMT was inappropriate in 17% (26/149) of patients with blood culture positive infections (Study I). Three of these patients received antimicrobials that were totally ineffective according to in vitro data. During 2003 and 2013, the use of many beta-lactam antimicrobials increased. The most notable change was in the use of carbapenems, which increased by 110% during the study period (Study II). A total of 18% (51/282) of premature neonates with blood culture positive infection received at least one off-label antimicrobial (Study III). An increase in birth weight was found to statistically significantly decrease the probability of off-label usage (odds ratio=0.85 for 100g increase in birth weight, p-value < 0.001). In Study IV, there were 157 antimicrobial errors reported in 149 patients from four wards (GEN, NICU, HEM-ONC and INF). Two errors were reported as clinically significant (2/149, 1%). Most of the errors occurred with drugs with high consumption, such as cefuroxime (15/157, 10%) and penicillin G (15/157, 10%). CONCLUSIONS These studies gave a useful overall picture regarding AMT and the use of antimicrobials at the Children’s Hospital. More attention should be paid to appropriate AMT, and training of prescribers should be provided. This thesis provides a window into issues that undermine the quality of care regarding hospital infections in paediatrics and aids the launch of an antimicrobial stewardship program (ASP) in the Children’s Hospital.