Antibiotic Stewardship - APSA Practice Gaps 2019

I'm going to move on now to the next section, which is the practice development committee, uh, of APSA. Um, we explained what this was last year, I'm going to explain again. So APSA, we are very proud to have as a partner of the annual update course and the what, uh, what APSA is providing is a review of what are the biggest knowledge gaps. And uh we have Dr. Liz Bierly from Alabama, Dr. Stephen Lee from UCLA, and Dr. Salim Islam from University of Florida, uh, who are going to review this year's most important knowledge gaps. Did I summarize what PDC was adequately or do you want to make a couple more comments? Did I say it? Is that accurate? Okay. So I think Liz, you're starting off, are you starting off with antibiotic stewardship? Okay. Okay. So I have this set up as a as a case vignette and then question. Perfect. So we'll start out with the vignette. Um, you have a full-term infant who is prenatally diagnosed with an Omphalocele and underwent an um, an elective delivery without uh, any problems. There was no maternal history of fever or chorioamnionitis. And on exam, the baby is stable, there's no respiratory distress. The Omphalocele is intact and covered. Um, you plan to do an abdominal wall closure in a couple of days after the work up for associated anomalies is completed. And the question is, assuming there are no signs of infection, the most appropriate antibiotic management of this patient should consist of. So what uh the PDC would like to advocate and what the data would indicate is that um preoperative antibiotic given one hour before incision and discontinued within 72 hours, uh, is uh the the most appropriate answer. Okay. Given one hour before incision. So within within one hour. One hour, yes. So, when do you usually give it? Uh, we usually give it when the baby arrives in the operating room. And the reason that we do that is because if we order it preoperatively, we have no I mean, y'all have the same kind of schedules we do. You never know when this kid's going to get to the OR, right? You could have a gunshot wound of the abdomen show up or you know, it takes them two hours to turn your room over or whatever. So we give it when the baby arrives in the operating room. In the pre-op area or in the OR actually. Correct. Yes. Okay. Um does anyone give it uh like after around the time of timeout right before the operation or does everyone give it right when the baby arrives? I was one of the one of the points about this is that the baby doesn't need antibiotics just because they showed up in the NICU. I think that there's a feeling that you know, the baby's in the NICU, they have an Omphalocele, they need antibiotics. And I think the point of the PDC, correct me if I'm wrong Liz, is that that baby doesn't need antibiotics until they go to the OR and all they need is standard prophylactic antibiotics. Correct. That's the whole point of this vignette and this scenario is um, we are probably using too much, too many antibiotics in children that don't actually need them, especially neonates. And um, you know, some of the some of the evidence that we have on the next slide would say that um, based on um, the recommendations for the AAP and for neoonatology is that um, as long as the baby is well and the mother has no signs of sepsis or Corrio, you don't need to give antibiotics for children that don't have an open abdomen. So this obviously ruptured Omphalocele, gastroschisis, those are a different ball game. Those children basically have an open abdomen and you probably should give them antibiotics. But um, you know, children that have even Dunaia, they probably don't need antibiotics if they're going to the operating room within the next 24 to 48 hours. What do you what do you do with patients that you don't bring to the operating room with Omphaloceals that you just paint and wait? We just paint and wait. No antibiotics. As long as the mom didn't have Corrio, as long as the baby doesn't have a fever, we just paint and wait. Mhm, great. The the problem is that the then the the in our face in our facility at least, the neology folks will probably start antibiotics on them. And uh they'll and I don't know what the role of measuring inflammatory markers are in that situation either. So especially in a post-op baby, they measure inflammatory markers like CRP or now um procalcitonin and because they're elevated, they will go ahead and start empiric antibiotic therapy on them. What should we do on that? Well, I guess, you know, you take a baby to the operating room, their inflammatory markers are going to go up and I don't know you know, perhaps we should base this on data. And um, you know, maybe you we maybe we maybe we need a randomized trial to look at how actually these inflammatory markers are you know, what effect they have on the use of or on whether or not we need antibiotics. That's a great idea for a study. Well, just a a comment about uh we've got the AAP telling us to cut back on our opioids and it sounds like the surgeons are telling neologists they need to cut back on antibiotics. How does the AAP help us with that? That's a great question. Um I think antibiotic stewardship is something that's uh coming up. It's uh one of those hot topics that uh which is why the uh PDC felt that it was important enough to bring to the four. Um, I think that uh we've discussed it at previous occasions when we've had a combined neology, um, pediatric surgery conference at the AAP, perhaps it should be brought up again. Is this unique to the neologist in particular because I know in my place there are loud pediatrician advocates for antibiotic stewardship and their whole programs and committees and all that. Is this something unique to the NICU? I would say at at our institution, uh, we have loud advocates both on both sides from surgery and and our pediatric colleagues and they are actually helping lead the cause of actually accusing us of giving too much antibiotics as well for patients with traheal fistulas, gastrosis and so forth. And I think the best pathway for that is really multidisciplinary conferences and and um pathways that we've developed. So that's what we've developed at our institutions for abdominal wall defects and and so forth and and dresses those issues. So nobody we we keep each other in in line for that. But I think they are our most powerful advocates is to get everybody on the same page. Yeah, I think that's a great point to um engage your colleagues in the pediatricians in the NICU and the PICU and try to come up with protocols and pathways to really streamline things. And have adherence to those pathways, so.