American Academy of Pediatrics – Committee on Infectious Diseases and the Pediatric Infectious Diseases Society
View all recommendations from this societyNovember 12, 2018
Don’t use vancomycin or carbapenems empirically for neonatal intensive care patients unless an infant is known to have a specific risk for pathogens resistant to narrower-spectrum agents.
Antibiotics such as vancomycin and carbapenems are active against highly-antibiotic resistant bacteria unresponsive to other antibiotics. Overuse of these antibiotics can exert selection pressure and promote colonization and infection with increasingly resistant organisms, raising the specter of morbidity and mortality due to untreatable infection. Vancomycin in particular is commonly used as a first-line choice when infection is suspected in the newborn intensive care unit, despite evidence that there is no survival benefit attributed to empiric therapy for most infected infants. Guidelines have been developed that can safely limit the empiric use of vancomycin to those infants known to be colonized with MRSA.
This list from the American Academy of Pediatrics is developed with judicious use of antimicrobials in mind, however, when a patient has suddenly and inexplicably become severely ill, the short-term, empiric use of broad-spectrum antibiotics is warranted, and should be left to the discretion of the medical team.
How The List Was Created
The American Academy of Pediatrics Committee on Infectious Diseases’ Subcommittee on Antimicrobial Resistance and Stewardship identified the need to promote the judicious use of antibiotics in the inpatient setting at their strategic planning session held in October 2015. A workgroup of pediatric experts was formed with representatives from the Academy’s Committee on Infectious Diseases, Committee on Fetus and Newborn, Section on Infectious Diseases, and external partners from the Pediatric Infectious Diseases Society. A modified Delphi process was used to create the list for Choosing Wisely. Experts from the workgroup were asked to create an initial list of what practices may be included– 15 practices for inpatient antimicrobial stewardship were identified through email and conference calls.
The workgroup reviewed and ranked via survey which practices within the list of 15 were the most important to include. The survey also asked for any additional suggestions for inpatient AS practices that were not included on the list. This survey was then simultaneously sent to the Antimicrobial Resistance Stewardship workgroup, as well as, internally, to the following Executive Committees: 1. Committee on Hospital Care, 2. Committee on Fetus and Newborn, 3. Committee on Pediatric Emergency Medicine, Section on Critical Care, Section on Emergency Medicine, Section on Infectious Diseases, and Section on Neonatal-Perinatal Medicine and externally to the Pediatric Infectious Diseases Society Executive Committee and their antimicrobial stewardship workgroup. The list was edited based on the feedback received and narrowed down to a new top ten list. The workgroup reviewed the list and voted on their top five based on the following criteria: 1. Feasibility, 2. Supported by Evidence, 3. Not Duplicative, 4. Free from Harm, and 5. Truly Necessary. The list was peer reviewed by relevant expert Committee, Council and Section leadership. The AAP Executive Committee approved this publication of the list.
AAP’s disclosure and conflict of interest policy can be found at www.aap.org.
Sources
Hsieh EM, Hornik CP, Clark RH, Laughon MM, Benjamin DK Jr, Smith PB; Best Pharmaceuticals for Children Act Pediatric Trials Network. Medication use in the neonatal intensive care unit. Am J Perinatol. 2014;31(9):811-821.
Ericson JE, Thaden J, Cross HR, Clark RH, Fowler VG Jr, Benjamin DK Jr, Cohen-Wolkowiez M, Hornik CP, Smith PB; Antibacterial Resistance Leadership Group. No survival benefit with empirical vancomycin therapy for coagulase-negative staphylococcal bloodstream infections in infants. Pediatr Infect Dis J. 2015;34(4):371-375.
Thaden JT, Ericson JE, Cross H, Bergin SP, Messina JA, Fowler VG Jr, Benjamin DK Jr, Clark RH, Hornik CP, Smith PB; Antibacterial Resistance Leadership Group. Survival Benefit of Empirical Therapy for Staphylococcus aureus Bloodstream Infections in Infants. Pediatr Infect Dis J. 2015;34(11):1175-1179.
Chiu CH, Michelow IC, Cronin J, Ringer SA, Ferris TG, Puopolo KM. Effectiveness of a guideline to reduce vancomycin use in the neonatal intensive care unit. Pediatr Infect Dis J. 2011;30(4):273-278.
Holzmann-Pazgal G, Khan AM, Northrup TF, Domonoske C, Eichenwald EC. Decreasing vancomycin utilization in a neonatal intensive care unit. Am J Infect Control. 2015;43(11):1255-1257.
