Evaluation of antimicrobial use in a pediatric intensive care unit

176 Pages·2016·3.48 MB·English

University of Iowa
Iowa Research Online
Theses and Dissertations
Summer 2009
Evaluation of antimicrobial use in a pediatric
intensive care unit
Josiah Olusegun Alamu
University of Iowa
Copyright 2009 Josiah Olusegun Alamu
This dissertation is available at Iowa Research Online: https://ir.uiowa.edu/etd/277
Recommended Citation
Alamu, Josiah Olusegun. "Evaluation of antimicrobial use in a pediatric intensive care unit." PhD (Doctor of Philosophy) thesis,
University of Iowa, 2009.
https://doi.org/10.17077/etd.89yhars0
Follow this and additional works at:https://ir.uiowa.edu/etd
Part of theClinical Epidemiology Commons
EVALUATION OF ANTIMICROBIAL USE IN A PEDIATRIC
INTENSIVE CARE UNIT

by
Josiah Olusegun Alamu

An Abstract

Of a thesis submitted in partial fulfillment of the requirements
for the Doctor of Philosophy degree in Epidemiology
in the Graduate College of
The University of Iowa

July 2009

Thesis Supervisor: Professor Loreen Adele Herwaldt
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ABSTRACT
A pediatric intensivist in the University of Iowa Hospitals and Clinic’s (UIHC)
Pediatric Intensive Care Unit (PICU) was concerned about antimicrobial use in the unit.
However, no one had quantified antimicrobial use in the UIHC’s PICU or described the
patterns of antimicrobial use in this unit. To address the intensivist’s concern, the
principal investigator (PI) conducted a retrospective study to determine the percentage of
patients who received antimicrobial treatments, to determine the indications for
antimicrobial use, and to identify antimicrobial agents used most frequently in the unit.
On basis of our data, we hypothesized that empiric antimicrobial use, particularly the
duration of therapy, could be decreased.
We implemented a six-month intervention during which we asked the pediatric
intensivists to complete an antimicrobial assessment form (AA) to document their
rationale for starting antimicrobial treatments. We postulated that this documentation
process might remind physicians to review antimicrobial therapies, especially empiric
therapies, when the microbiologic data became available. In addition, we utilized the AA
form to identify factors pediatric intensivists considered when deciding to prescribe
empiric antimicrobial treatments.
Data from the AA forms suggested that pediatric intensivists in the UIHC’s PICU
often considered elevated C-reactive protein, elevated white blood cell counts, and
elevated temperatures when deciding to start empiric antimicrobial therapy. Data from
the three nested periods showed that the median duration of empiric and targeted
treatments decreased during the intervention and remained stable during the post-
intervention period. The PI estimated that 193 days of empiric antimicrobial therapy and
59 days of targeted antimicrobial therapy, respectively, may have been saved by the
decreased durations of therapy. Time series analysis assessing the trend in use of
piperacillin-tazobactam, cefepime, and ceftriaxone (measured in mg/wk) did not reveal a
significant change over time.
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On the basis of our results, an intervention strategy using an AA form alone may
not be an effective strategy for antimicrobial stewardship in PICUs. Additional measures
such as automatic stop orders and computer decision support may be useful for reducing
the duration of empiric therapy in PICUs.
Abstract Approved:
__________________________________________
Thesis Supervisor
__________________________________________
Title and Department

___________________________________________
Date
EVALUATION OF ANTIMICROBIAL USE IN A PEDIATRIC
INTENSIVE CARE UNIT

by
Josiah Olusegun Alamu

A thesis submitted in partial fulfillment of the requirements
for the Doctor of Philosophy degree in Epidemiology
in the Graduate College of
The University of Iowa

July 2009

Thesis Supervisor: Professor Loreen Adele Herwaldt
Graduate College
The University of Iowa
Iowa City, Iowa

CERTIFICATE OF APPROVAL
___________________________

PH.D. THESIS
____________

This to certify that the Ph.D. thesis of
Josiah Olusegun Alamu

has been approved by the Examining Committee for the thesis requirement for the
Doctor of Philosophy degree in Epidemiology at the July 2009 graduation.

Thesis Committee: __________________________________________________
Loreen Herwaldt, Thesis Supervisor
__________________________________________________
Stanley Perlman
__________________________________________________
Elizabeth Chrischilles
__________________________________________________
Michael Jones
__________________________________________________
Kung-Sik Chan
__________________________________________________
James Torner
I dedicate this project to Dr. Loreen Herwaldt, without her this project could not
have been possible.

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ACKNOWLEDGEMENTS
I wish to thank Drs. Herwaldt, Loreen A; Torner, James C; Chrischilles, Elizabeth
A; Jones, Michael P; Smith, Tara; Perlman, Stanley; and Chan, Kung-Sik for their
unflinching support during the course of this project. I appreciate all the advice and
words of encouragement this incredible committee have provided me while carrying out
this research.
I would like to acknowledge the tremendous support of Dr. (Davis) Volk, Paige
who coordinated the intervention part of this project from the Pediatric Intensive Care
Unit (PICU). In addition, my appreciation goes to the attending physicians, residents,
fellows, nurse practitioners, pharmacists, and auxiliary staff of the PICU for supporting
this project. I would like to thank the infectious disease specialists Drs. Ziebold, Christine
S; and Gomez, Oscar G for their valuable contributions.
My gratitude also goes to Dr. Diekema, Daniel for his expert advice on culture
results, Ms. Leder, Laurie who helped with data entry, Ms. Seidel Jennifer who helped
with literature searches; Ms. Von Behren, Sandra and Dr. Helms, Charles M who
provided much needed letters of support when I applied for a grant from the Association
for Professionals in Infection Control and Epidemiology (APIC); and to all the staff of
the Program of Hospital Epidemiology for their support and encouragement. My sincere
appreciation also goes to Ms. Anderson, Marilyn and Ms. Colbert, Kathy who helped
with scheduling meetings with my committee.
I am highly indebted to my lovely wife Ms. (Sykes) Alamu, Chenoa Annette for
her spiritual support. She cared for our two small children and made the home front a
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congenial atmosphere for me while I was busy with this project. I am indebted to my two
jolly children, Victoria and Jonathan who were born after I started this project and who
never complained about not seeing their daddy. They are a blessing to me. I will not
forget the support of my in-laws, Mrs. (also known as Mama) Sykes, Lue; Ms. Sykes,
Lori; and Mr. Sykes, Brian for their persistent prayers for my success.
I would like to thank Dr. Lafollette, Sharron, Head, Department of Public Health
University of Illinois at Springfield, for supporting my PhD candidacy. She helped with
proofreading and editing.
Finally, I would like to thank APIC’s scientific council for providing grant for the
intervention stage of this project.
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TABLE OF CONTENTS
LIST OF TABLES vii
LIST OF FIGURES ix
CHAPTER 1 ANTIMICROBIAL USE 1
1.1 Introduction 1
1.2 Infections in Intensive Care Units (ICUs) 1
1.3 Antimicrobial use in ICUs 4
1.4 Antimicrobial Stewardship Strategies 9
1.5 Significance of the Problem 12
1.6 Statement of the Problem 16

CHAPTER 2 EVALUATION OF ANTIMICROBIAL USE
IN A PEDIATRIC INTENSIVE CARE UNIT 19

2.1 Introduction 19
2.2 Methods 20
2.3 Results 23
2.4 Discussion 28

CHAPTER 3 FACTORS THAT PEDIATRIC
INTENSIVISTS CONSIDER WHEN
DECIDING TO START ANTIMICROBIAL
AGENTS 46

3.1 Introduction 46
3.2 Methods 47
3.3 Results 53
3.4 Discussion 58

CHAPTER 4 INTERVENTION TO IMPROVE
ANTIMICROBIAL STEWARDSHIP IN
A PEDIATRIC INTENSIVE CARE UNIT 76

4.1 Introduction 76
4.2 Methods 78
4.3 Results 87
4.4 Discussion 96

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