Indication-based Antimicrobial Derestriction: Ceftazidime Derestriction for Febrile Neutropenia
Febrile neutropenia (FN) is a common condition in children receiving chemotherapy. The University of Chicago Comer Children’s Hospital has a rigorous antimicrobial restriction and prior authorization policy overseen by the Antimicrobial Stewardship Program (ASP). Ceftazidime (CTZ), our agent of choice for FN, is restricted. Use requires calling Infectious Diseases (ID) on call for approval, followed by ID calling pharmacy with authorization, leading to a potential delay in order processing.
Recognizing FN as a time-sensitive disease state with a clear indication for CTZ use, we revised the FN clinical pathway, removing the need for prior approval (“derestriction”). Along with derestriction, we implemented prospective CTZ auditing to assess the appropriateness of therapy and adjust therapy as needed.
To evaluate the change in CTZ use, we collected and aggregated monthly data, before and after derestriction. Information collected includes: indication for CTZ use, time to administration of 1stdose, number of CTZ days, time to appropriate discontinuation, rate of positive blood cultures, and patient outcomes. Total number of patient-days and ID consults were also collected.
Comparison of the first month after derestriction (January 2014) to the same month the year prior (January 2013) without derestriction, shows no statistical difference in CTZ use (mean of 6 CTZ days/FN patient vs 5 CTZ days/FN patient, [P=0.76]) or the rate of positive blood cultures (P=1.0). There was no statistical difference in the times to administration of the 1st CTZ dose (mean of 53 min vs 54 min, [P=0.92]), both less than the goal of <60 minutes. The total number of patient-days (2067 vs 2070, [P=0.48]) and ID consults (71 vs 78, [P=0.28]) remained stable. The number of CTZ approvals for FN appropriately declined to zero after derestriction. No patient deaths occurred during the study period.
Indication-based antibiotic ordering and derestriction can be successfully implemented in an ASP with a historically restriction-based system, without significant change in the appropriate use of the derestricted agent, change in the rate of bloodstream infections or patient outcomes. Future efforts will be directed towards evaluating additional factors affecting time to antibiotic administration.
C. B. Nash,
A. H. Bartlett, None