1. Implementation of a Hospital Paediatric Antimicrobial Stewardship Program Sydney Children’s Hospital Mostaghim M, Snelling T, McMullan B, Palasanthiran P

2. Background AMS programs are a core element of the National Safety and Quality Health Service (NSQHS) Standards. 3 Healthcare services are required to: Have an AMS program in place Provide prescribers access to Therapeutic Guidelines Monitor antimicrobial use and resistance Act to improve the effectiveness of AMS programs 2

3. Paediatric Challenges Limited consensus paediatric references to provide recommendations for optimal antimicrobial selection, dosing, route, and duration therapy. Frequent “off label” prescribing Neonates Specialties including Transplant, Haematology/Oncology and ICU Standard usage measures (e.g. DDD) are not well established. 3

4. Antimicrobial Use Point Prevalence Survey 2011 55% (70/127) inpatients on antimicrobials 15% for targeted indications 154 antibiotics prescribed 4

5. Aims 1.Optimise antimicrobial use within a tertiary paediatric hospital by implementing an AMS program aided by an electronic approval and decision support system 2. Achieve accreditation under NSQHS criteria 3.14 Antimicrobial Stewardship 5

6. Methods Risk stratification of formulary antimicrobials based on spectrum of activity, toxicity and cost: Green : Unrestricted Yellow: Restricted. Electronic approvals generated. Prospective audit and feedback model Red: Highly restricted. Infectious Diseases Consult necessary. Preauthorisation model 6 Phase 1: Risk Stratification Phase 2: Literature Review Phase 3: Consensus Building Phase 4: “Programming” Phase 5: Implementation and Governance

7. Local SCH and Network Guidelines Formulary Restriction State-wide Guidelines and Policy Directives National Therapeutic Guidelines: Antibiotic National Paediatric Guidelines and Consensus Documents Other International Paediatric References & Standard Medication texts Neonatal Recommendations Methods Phase 1: Risk Stratification Phase 2: Literature Review Phase 3: Consensus Building Phase 4: “Programming” Phase 5: Implementation and Governance

8. Methods 8 SCH Specialty Units SCHN Specialty Units Local Health District (LHD) Paediatric Units SCHN/ LHD Drug and Therapeutics Committee approval Phase 1: Risk Stratification Phase 2: Literature Review Phase 3: Consensus Building Phase 4: “Programming” Phase 5: Implementation and Governance

9. Methods 9 Approval process integrating indication specific: Dose, route, duration Management & monitoring Guidance on: IV to oral switch Escalation and de-escalation Access to endorsed guidelines When to seek consultation from Specialty Units Phase 1: Risk Stratification Phase 2: Literature Review Phase 3: Consensus Building Phase 4: “Programming” Phase 5: Implementation and Governance

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13. Methods Real time and long term collation of data and feedback ensures: System remains up-to-date and integrates with formulary changes and updates/new guidelines Ongoing optimisation of antimicrobial use Direct links to drug and therapeutics and patient safety committees and Hospital Executive 13 Phase 1: Risk Stratification Phase 2: Literature Review Phase 3: Consensus Building Phase 4: “Programming” Phase 5: Implementation and Governance

14. Methods Evaluation Framework: Appropriateness of prescribing Usage Antibiograms Clostridium difficile rates Toxicity (ADRs, local incident monitoring system) System adherence User Satisfaction 14

15. Methods 15

16. Results Approvals generated reflect hospital and AMS activity level to date and identify areas for further collaboration or refinement of system. No adverse events have resulted from the use of the system recommendations 16

17. Results Trends identified since implementation include: Improvements in antimicrobial appropriateness NSQHS accreditation with merit for 3.14. Antimicrobial Stewardship Reduced 3 rd generation cephalosporin, gentamicin and carbapenem use 17 Nov 12 SCHMay 13 SCHDec 13 SCH P value Patients on antimicrobials61/110 (56%)71/127 (56%)63/106 (59%) 0.66 Number of antimicrobials prescribed11214398NA Appropriate prescription68/109 (62%)99/137 (72%)81/96 (84%) 0.0003

18. Conclusion A comprehensive multidisciplinary paediatric AMS program was successfully implemented, performing routine evaluation and optimisation of antimicrobial use. 18 1.MacDougall C, Polk R. Antimicrobial stewardship programs in health care systems Clinical Microbiology Review 2005;18(4):638-656. 2.Dellit, T.H., et al., Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clinical Infectious Diseases, 2007. 44(2): p. 159-177. 3.Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 3: Preventing and Controlling Healthcare Associated Infections (October 2012). Sydney. ACSQHC, 2012.