Quality improvement initiative approach to decrease the unindicated usage of antibiotics in a neonatal intensive care unit of a tertiary care teaching hospital in Hyderabad, India

Antimicrobial resistance is an emerging global problem concerned with patient safety. It is even more challenging in developing countries like India. Antibiotic stewardship initiative is the best arrow in the quiver to prevent and control this antimicrobial resistance. We observed 61% of the neonates admitted to neonatal intensive care unit of Niloufer hospital, Hyderabad, India were receiving improper antibiotics with respect to choice of drug or dosage or duration. Subsequently, an antibiotic stewardship team was formed to address the antibiotic misuse. Team consisted of neonatology faculty, residents, staff nurses, infection control nurses and microbiologist. We identified problems related to staff awareness, policy issues like lack of display of the antibiotic policy and lack of antibiotic lock, process issues like low rate of documentation of indication for initiation or escalation of antibiotic and a lack of dynamic review plan regarding continuation or de-escalation. We used the Plan-Do-Study-Act cycles to test and adapt solutions to these problems. Within 10 weeks of starting our quality improvement (QI) project, the proportion of unindicated antibiotic usage decreased from 61% to 27%. Timely de-escalation of antibiotic is a neglected intervention in neonates, and yielded the maximum result in our study. We conclude that QI projects are simple, doable yet powerful effective tools to address the burning problems like antibiotic misuse. This result was very satisfying and encouraging boosting our team’s faith in the effectiveness of QI approach.

Frequency and Microbiological Profile of Catheter-Related Infections in Hemodialysis Patients Receiving Gentamicin as Antimicrobial Lock Therapy for Prophylaxis

Antibiotic lock solution (ALS) in the lumen of catheter is a mean to decrease the possibility of catheter related blood stream infection (CRBSI). We conducted this study using Gentamicin as ALS to observe the frequency of catheter related infections (CRI) including CRBSI and exit site infection in this hemodialysis patients being dialyzed through tunneled and temporary hemodialysis catheters. Methods This descriptive, cross sectional study was conducted at Dr. Ziauddin Hospital, North Campus between January 2017- December 2017. Symptomatic patients for CRBSI were included in this study. Blood culture from the catheter ports and periphery and exit site swab if pus visible were sent for culture sensitivity. Results Total 138 patients of either gender with age more than 18 years to less than 80 years were evaluated. 44.9% were male and mean age of patients was 58.79±14.05 years. 70.3% patients were diabetic for 15.61±4.61 years and 11.6% were using immunosuppressive drugs. The overall mean catheter duration was 22.27±14.39 days and mean hemodialysis duration was 25.32±44.31 weeks. Tunneled catheter was placed in 40.6% and 46.4% had femoral temporary catheters. Blood culture was done for 51 cases and 21.5% were positive. Tip culture was positive in 33.3% patients. In our study, 23.18% patients were found to have catheter related infections, out of which 61.5% were found with gentamicin resistance including colonization. Conclusion We report a high frequency of catheter related infections despite using ALS as prophylaxis, with predominant organisms being gram positives and a high incidence of gentamycin resistance.

Antibiotic Lock Therapy with Linezolid for the Treatment of Persistent Catheter-Related Infection in Children with Cancer

Objective Central venous catheter (CVC) colonization is a common problem in the pediatric oncology department. Initial colonization of CVC by coagulase-negative staphylococci (CoNS), Staphylococcus aureus, and enterococci is followed by the growth of intraluminal biofilm formation, and results in antibiotic therapy failure. The removal of the old CVC and insertion of new CVC is a difficult and expensive procedure in small children with cancer. The present article aimed to study our treatment results of antibiotic lock therapy (ALT) with linezolid in pediatric cancer patients. Methods This study was planned as retrospective presentation of case series with eight pediatric cancer patients treated with 11 courses of systemic and linezolid lock therapy. Demographic information, clinical findings, laboratory data, blood culture results, complications, and outcome were collected for each patient retrospectively and descriptive statistical methods were used. Results Prior to treatment, peripheral and CVC blood culture results showed Staphylococcus epidermidis in seven patients and Staphylococcus hominis in four patients. All pathogens were susceptible to vancomycin and teicoplanin; first-line treatment was vancomycin in six and teicoplanin in five patients. After first-line treatment, peripheral blood cultures of all patients were negative, whereas blood cultures from CVC remained positive. During second-line therapy with linezolid, microbiological eradication was achieved on the fourth day of treatment in each patient. Median catheter survival time for all patients was 14 (range: 8–30) months. No side effects were observed during the treatment and no resistant organisms were documented. Conclusion Although multicentric prospective controlled trials will be required to provide more generalizable results, we suggest that systemic antibiotics combined with linezolid lock therapy used in pediatric cancer patients may be an effective option in treating catheter-related bloodstream infection (CRBSI) and prolonging CVC survival when CoNS are identified.

Extended Experience in the Use of Antibiotic Lock for Eradication of Biofilm Bacteria on Tenckhoff Catheter

Whilst antibiotic lock is effective to eradicate biofilm bacteria on hemodialysis catheters, this adjunctive method has scarcely been tested in peritoneal dialysis (PD) patients. After our previous successful experience of its use to salvage two Tenckhoff catheters, we encountered another patient with problematic biofilm-associated PD peritonitis who strongly refused catheter removal. As a result, antibiotic lock was given once daily, initially, with continuation of the usual PD schedule. However, relapsing peritonitis could not be prevented until we administered antibiotic lock without dialysate in the abdomen, which led to successful eradication of biofilm bacteria. To investigate the significance of having “dry abdomen” during antibiotic lock treatment, we injected an equivalent amount of contrast into the Tenckhoff catheter under fluoroscopy. We observed that the catheter lock solution could be retained over a long period of time only with “dry abdomen,” whereas rapid dissipation of the lock solution occurred in the presence of dialysate. We concluded that whilst antibiotic lock in a once-daily regimen can be highly effective against biofilm bacteria on a Tenckhoff catheter, it is essential to withhold PD exchanges during the dwell of antibiotic lock to prevent it from dissolving into the surrounding dialysate.