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Weaving an Antimicrobial Safety Net

Stewards thread together new programs and protocols while trimming unwarranted tests and mislabeled allergies.

Nationwide Children’s added several threads to its antimicrobial safety net during the past year.

Josh Watson, MD, an Infectious Diseases physician and director of Antimicrobial Stewardship at Nationwide Children’s Hospital, and Terry Barber, MD, medical director of offsite Urgent Care Centers, developed a simple urinary tract infection (UTI) protocol for outpatients.

The researchers found urgent care physicians prescribed antibiotics for a high number of children with UTI symptoms but whose urine cultures later showed no infection. Now when urinalysis is negative and a clinician determines the antibiotic is unnecessary, a nurse calls the caregiver to halt treatment.

Documented follow-ups grew from 4 percent to 84 percent of cases. The number of days children took unnecessary antibiotics dropped 60 percent.

In pursuit of diagnostic stewardship, Dr. Watson and colleagues are searching for potential UTI biomarkers among antimicrobial peptides (AMPs) in urine. They found that AMPs HD5 and HNP1-3 appear to improve specificity without decreasing sensitivity of the UTI test. The researchers are studying more AMPs, to develop a test yielding fewer false-positives.

“Bacteria inevitably become resistant to antibiotics, but the more antibiotics taken, the more certain resistant bacteria will emerge.”

– Josh Watson, MD

Dipanwita Saha, MD, director of Quality Improvements in Urgent Care, and colleagues found the hospital’s centers swabbed 2,300 children’s throats per month and 74 percent of the tests came back negative for streptococcal pharyngitis.

Among those with a positive result were children who carry harmless group A streptococcus yet received an antibiotic.

Dr. Saha’s team refined the Licensed Provider Initiated Protocol swab guidance, spelling out symptoms of strep infection versus viral infection. Urgent Care Centers cut throat swabs 39 percent.

Studies show that up to 10 percent of people are labeled allergic but the real figure is less than 1 percent. The Division of Allergy and Immunology has been screening and testing children for the allergy and found almost none have it.

“Beta-lactam antibiotics, including penicillin, are among the cheapest and most effective,” says Mitchell Grayson, MD, division director. “If you can tell who’s truly allergic, it improves the ability to use the right drug.”

The division has been reaching out to general pediatricians and practitioners with a penicillin allergy information handout and decision tree, based partly on their screening experience.

Saha D, Patel J, Buckingham D, Thornton D, Barber T, Watson JR. Urine culture follow-up and antimicrobial stewardship in a pediatric urgent care network. Pediatrics. 2017 Apr;139(4) pii: e20162103.

Watson JR, Hains DS, Cohen DM, Spencer JD, Kline JM, Yin H, Schwaderer AL. Evaluation of novel urinary tract infection biomarkers in children. Pediatric Research. 2016 Jun;79(6):934-9.

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