International Pediatric Antimicrobial Stewardship

Briefly describe your daily role as an antimicrobial stewardship pharmacist      

My typical day starts by attending a morning meeting with the pediatric team of residents, specialists and consultants from different specialties including infectious disease. In this meeting, we discuss overnight admissions. It includes detailed discussions on each patient’s presentation, history, assessment, lab workup, differential diagnosis and management. I have an essential role in formulating the final management plan, especially antimicrobials.

More detailed discussions for each patient are done during multidisciplinary team rounds where we do prospective audit and feedback on antimicrobial use. Here we review the appropriateness of agent selection, dosing, duration, efficacy, safety, monitoring parameters and de-escalation or escalation of therapy.

In addition to these daily antimicrobial stewardship roles, I enjoy being a member of the Pharmacy and Therapeutics Committee. The committee is responsible for approval of new antimicrobials and use restrictions. In our antimicrobial stewardship (AMS) committee meetings, we discuss and plan about the trend of prophylactic antibiotic use, HAP and VAP rates, antibiotic recycling, consumption of selected antibiotics and antibiogram changes over the previous 6 months. The decisions made in these committees have a direct role on our daily antimicrobials use.

What international stewardship initiative or antibiotic awareness effort are you most proud of that you have participated in or led?

Urinary tract infections are one of the most common infections in the pediatric population and hold a significant share in health care burden. Unlike the generally benign course of urinary tract infection (UTI) in the adult population, UTI in the pediatric population is well recognized as a cause of acute morbidity and chronic medical conditions, such as hypertension and renal insufficiency in adulthood. As E. coli is the most common cause of UTIs, empiric ceftriaxone is recommended as initial therapy in pediatric patients.

Our institutional guidelines recommend empiric use of ceftriaxone with a dose of 50-75mg per kg in 1 to 2 divided doses for pediatric UTIs. Over the past few years, the initial response to ceftriaxone in UTI cases was variable. With the help of our microbiology department, we learned that the susceptibility of ceftriaxone against E. coli was variable ranging from 63% to 70% in 2 years data. The issue was raised in AMS committee meetings and pediatric departmental meetings.

In the end, we revisited our institutional practice and agreed to allow dose increases of ceftriaxone to 100 mg per kg per day in 1 to 2 divided doses for select, severe UTI cases per Indian national guidelines. In addition to ceftriaxone, single consolidating dose of gentamicin can be considered for patients who are clinically ill at the time of presentation. 

What actions can pharmacists take to optimize antibiotic use across the globe?

Pharmacists should take more leading roles in antimicrobial stewardship programs in hospitals and on regional and global levels. Leadership roles may include developing and maintaining antimicrobial guidelines and promoting compliance with national standards for AMS. On a daily basis, pharmacists can be instrumental by participating in stewardship rounds and providing expert advice to clinicians, patients and caregivers.

In hospitals, pharmacists are in the best position to do medication reconciliation, especially upon discharge. This area carries a huge potential of improvement particularly in pediatrics as the doses are weight-based. Here are some useful points taken from the CDC flyer, “Be antibiotic aware at hospital discharge”.

1. Use the most targeted and safe antibiotic

2. Use the shortest effective antibiotic duration

3. Document and communicate a structured and timely discharge summary

4. Educate patients and caregivers

(https://www.cdc.gov/antibiotic-use/pdfs/BAA-Hospital-Discharge-Flowchart-P.pdf)

Additionally, participation in different campaigns for awareness can lead to better understanding of antibiotics. One such campaign which I am a part of and I believe every pharmacist should look upon is U.S. Antibiotic Awareness Week (USAAW) which is observed every year in November.

(https://www.cdc.gov/antibiotic-use/week/index.html)

What does "Being Antibiotics Aware" mean to you?

Rationalizing your decision for initiation of antimicrobial therapy, having a plan for duration, and monitoring the therapy for efficacy and adverse effect of antimicrobials.

What is one pearl you have for all pharmacists to help them be antibiotic stewards?

A fundamental pearl is to complete continuous education in antimicrobial stewardship field and networking initiatives within the hospital and outside the institution. By following this lifelong approach, clinical pharmacists can enhance their competency in the field of antimicrobial stewardship. Consequently, clinical pharmacists can empower patients by giving them and their caregivers precise instructions on antibiotic use. In this way, patients/caregivers/parents will be in the best position to give feedback to the therapy as they are the end consumers of antibiotics. 

Sohail Azam, PharmD, BCIDP

Clinical Pharmacist

Department of Inpatient Pharmacy

Dr. Sulaiman Al Habib Hospital, Riyadh, KSA