Selected Podcast
Antibiotic Resistance and Use in the NICU
In this panel discussion, Barbara Warner, MD, and Jason Newland, MD, discuss antibiotic resistance and use in the NICU. They explain the state of antibiotic resistance and how doctors are monitoring the use of antibiotics to treat premature infants.
Featured Speaker:
Learn more about Barbara Warner, MD
Jason G. Newland, MD Clinical Interests; Pediatric infectious diseases, pediatric diagnostics, antimicrobial stewardship.
Learn more about Jason G. Newland, MD
Barbara Warner, MD & Jason G. Newland, MD
Barbara Warner, MD research interests include the effect of the neonatal microbiome on health and disease, with emphasis on necrotizing enterocolitis.Learn more about Barbara Warner, MD
Jason G. Newland, MD Clinical Interests; Pediatric infectious diseases, pediatric diagnostics, antimicrobial stewardship.
Learn more about Jason G. Newland, MD
Transcription:
Antibiotic Resistance and Use in the NICU
Melanie Cole (Host): Welcome. Our topic today is antibiotic resistance and use in the NICU. My guests are Dr. Jason Newland, he’s a Washington University Pediatric Infectious Disease physician at St. Louis Children’s Hospital and Dr. Barbara Warner; she’s a Washington University Neonatologist at St. Louis Children’s Hospital. Dr. Newland, I’d like to start with you. Explain a little bit about the clinical impact of antimicrobial resistant pathogens in the NICU. What’s going on today?
Jason Newland, MD (Guest): Thanks Melanie. Antimicrobial resistant bacterial, primarily bacterial pathogens are being seen more and more throughout our country in all areas of healthcare; whether it’s in our ambulatory clinics, our hospitalized patients and as well as in our NICUs. What we know regarding data in overall use or overall impact on our clinical lives or on our patients is that annually, 23,000 Americans die from an antibiotic resistant bacterial infection and another two million are infected with an antibiotic resistant bacterial infection. While this number isn’t specific to the NICU; Dr. Warner and myself and other neonatologists in pediatric infectious diseases physicians can tell you of patients that they have seen with antibiotic resistant infections in the NICU that haven’t done as well as we would like because of the difficulties that we can be faced when we are treating these infections.
Barbara Warner, MD (Guest): And I would like to add that in the NICU, specifically, the use of antibiotics has been very widespread over the decades because no one saw that there was a potential downside. If I give antibiotics; I can potentially prevent severe infection. But what we are now realizing is that there is a downside to antibiotic use. There’s definitely an upside. Antibiotics have still probably saved more babies than they have harmed; but we have to evaluate in this very critical and at-risk population the risks versus the benefits. And I think we are at a point now where we are starting to do that more clearly.
Melanie: And I thank you for that Dr. Warner because that was going to be my next question as the high rates of antibiotic use in the NICU. Can you tell us, is there evidence of clinical benefit from liberal compared with conservative antibiotic use?
Dr. Warner: Let me begin by talking a little bit about why antibiotics are used so widely or have been used so widely in the NICU. The presenting symptoms for infection overlap significantly with the presenting symptoms for prematurity and because the babies are so small; are ability to make a laboratory-based diagnosis, growing the bacteria out of the blood; is limited. We can only take so much blood. You can take maybe a quarter of a teaspoon of blood from a baby who weighs under a pound. And so those limitations have made it difficult to be able to identify the risks versus the reality of an infection. We now have some tools that enable us to look at those risks more clearly and evaluate those risks more clearly. It’s still difficult to make the diagnosis sometimes. But we have better tools that have been evaluated medically in the literature that enable us to be able to look at that information. From your question, specifically, has there been an evaluation through some type of a trial of a liberal versus a conservative approach. What we know from term babies, this is really based more on term babies; is that a conservative approach versus a liberal approach with use of antibiotics in babies that are at risk; if you use these tools, these evaluation tools, that look at what’s the maternal history, what was the perinatal factors, that the outcomes are as good in a more conservative approach and with that comes a decreased risk of development of antibiotic resistant organisms.
Dr. Newland: Yeah and I would like to add this – I think these studies that have really – should be I think the folks in the NICU and the neonatologists like Dr. Warner who have started to use these tools, have really bought in to understanding that this use maybe as was mentioned earlier, isn’t always necessary. So, we have from my perspective working with antibiotics and seeing and watching rates of antibiotics; we have seen dramatic decreases across the country in the use of antibiotics in the NICUs and we’ve also continued to hear stories and continue to see publications that this reduction in use has not been met with an increase in negative consequences such as worse outcomes that would include being in the hospital longer and even as the concerns can be dying of what would say of untreated bacterial infections.
Melanie: Dr. Newland, tell us a little bit about infection control strategies aimed at reducing the acquisition and transmission of these antimicrobial resistant pathogens in the NICU and when you are speaking about this, kind of cover education of the frontline staff or identification of some of these resistant pathogens. Give us some of the strategies that you are looking to.
Dr. Newland: Well I think to talk about infection prevention strategies we have to talk about the tired and true that has been demonstrated since the 1800s and that’s of hand hygiene. We know that focusing and being the best at hand hygiene is one of the most important infection prevention strategies that we all have to do, and we all have to do better. We all have to be cognizant and mindful of washing our hands when it’s obviously appropriate and not only just to say we are washing our hands, but to do it correctly, meaning that we are using soap and water or we are using the hand gel and we are not just putting it in our hands and going quickly to the next thing, but also making sure that we use friction and get all the places that need to be washed or have covered on our hands.
I think the second thing is continuing to just understand our hygiene and understand when we do have resistant organisms, that we are taking the appropriate measures necessary to prevent that contact or prevent transmitting it to others and whether that’s following our appropriate protections that might include gowning and gloving and maybe putting a mask on; those sorts of things and being cognizant and mindful to do that the best that we can; will help reduce the transmission of these antibiotic resistant infections.
And lastly, as a pediatric infectious diseases provider, I cannot be on a program without mentioning vaccinations and while we talk about it you can wonder why he is talking about vaccinations. Well, we know that in this day and age if we vaccinate, we reduce bacterial infections. We also reduce viral infections and today, we are in the season coming up of influenza; we stress and now you see hospitals mandate we all get influenza vaccine and that is essential in helping us prevent infections that then lead to use of antibiotics, that then lead to overuse and then we can see these other negative consequences.
Dr. Warner: And I would strongly advocate that because prevention in the NICU starts particularly during the winter season with prevention in the community. We have the highest risk babies and the truth is that while we try very hard to prevent infections from coming in; organisms don’t follow the same boundaries that we have, and they will come into the NICU through the community and so having vaccinations, the flu vaccine, I would say everyone please go out and get your flu vaccine. It will help my babies in the NICU.
Melanie: Dr. Warner, and this is such an important discussion that we are having today and as this is one of the more important issues facing the medical community and how you can potentially curtail the unnecessary use of antibiotics, we hear about antibiotic stewardship and all of these things are coming out now, but in the NICU, as you have stated, some of these diseases really raise the mortality rate of these tiny babies. Tell us about some of the challenges that you might have in the implementation of some of the strategies and the containment of these resistant pathogens.
Dr. Warner: It’s a really good question and it’s a really difficult position to be in as a physician and as a provider for these babies. Because the risk for our preterm infants and for infants who have medical issues is that we don’t identify early an infection and so I don’t want to give anyone the impression that we are not using antibiotics or that antibiotics are a bad thing. Antibiotics are life-saving. They are life-saving for our population. But as I mentioned before, there is – as with everything in life that is good, there is always a risk associated with it. And so, the strategies that we have to try to minimize the risks associated with unneeded antibiotics are related to many of the things that Jason has brought in and his team in terms of antibiotic stewardship. How long do we really need to treat this potential infection? How quickly can we move toward a diagnosis? Are there a subset of babies that we don’t need to treat because their profile would indicate that the symptoms that we are seeing are not infectious symptoms, they are more likely related to their prematurity?
So, very practical kinds of things. We now put in hard stop dates for antibiotics. Sometimes, the duration of antibiotics would leak over because they didn’t get stopped in the orders or someone didn’t realize that the antibiotic would continue until tomorrow or the day after. So, hard stop dates. Reevaluation every day on rounds what are the antibiotics. How long have they been on? Do we need to continue them? All those kinds of practical hands-on things have really improved our ability to restrict the antibiotics. And then finally, to use antibiotics that are as narrow in spectrum as we can. So, we are considered kind of old fogies in the NICU because the antibiotics that we use tend to not be the newest and the most robust and that’s because it’s safer to narrow the spectrum as soon as we can. Sometimes, we can’t. Sometimes we can’t use a narrow spectrum antibiotic, but to try to use those antibiotics that are as narrow in spectrum and fit the disease process that we are trying to treat. And I would say that the antibiotic stewardship program has really helped us as physicians stay on task for those kinds of very practical hands-on. We round every day together and so that really keeps our feet to the fire.
Melanie: Dr. Newland last word to you. Speak about the antibiotic stewardship program and when Dr. Warner discusses rounding and making sure the dosage and the timing of these antibiotics is all recorded and very carefully watched. What do you want the listeners and other providers to take away from this as far as what you see happening in the future for antibiotics and the stewardship programs?
Dr. Newland: Yes, thank you. I think I’ve – I think the keys of this are setting up a system or a program that really believes in the communication and collaboration around making sure that we are using our antimicrobials appropriately. As you have heard from Dr. Warner and all the great work they have done in the NICU; this has been a partnership. They have driven the work and we have been there to help with that work because we all believe and know that there is that negative consequence to using antibiotics. And so, for us, we spend our time from our antimicrobial stewardship program, we spend our time with our frontline providers.
And so, for the listeners, I think the key is that being open and collaborative and understanding or working together with those who spend their days trying to figure out ways to better use our antibiotics is key. And I think we are learning more and more and the more data and the more work we can do together to demonstrate these risks such as the risk of necrotizing enterocolitis; we are starting to see if you receive more antibiotics early on in life and not – maybe we need to learn now as we reduce our antibiotic use; are we seeing a reduction in that risk. So, that we can continue to learn and strive to make our babies have the best opportunities to live. And the live healthily and to thrive. I think as Barb said earlier, antibiotics are life-saving. They have changed healthcare. I would argue without antibiotics, we don’t have as many babies under one pound that survive and thrive that we do in 2018. However, without working together, without these stewardship programs that work alongside our wonderful frontline clinicians; we will, and we could possibly have an era where we no longer have antibiotics. Which then would send us back to an era of before we even could safely care for a lot of these sick patients including our NICU babies.
Melanie: Dr. Warner do you have anything you’d like to add as we finish up?
Dr. Warner: I would say one of the remaining questions that we have about antibiotics and antibiotic resistance is what happens after the NICU? How long does the antibiotic resistant organisms stay around? I think those are questions that the infectious disease people here at Washington University are starting to look at along with the providers. What does that mean in the long-term? Those are answers we don’t know yet.
Melanie: Thank you both so much for being with us today. What a fantastic segment and so inspiring and informative, really, really great. Thank you so much for joining us. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital you can go to www.stlouischildrens.org, that’s www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.
Antibiotic Resistance and Use in the NICU
Melanie Cole (Host): Welcome. Our topic today is antibiotic resistance and use in the NICU. My guests are Dr. Jason Newland, he’s a Washington University Pediatric Infectious Disease physician at St. Louis Children’s Hospital and Dr. Barbara Warner; she’s a Washington University Neonatologist at St. Louis Children’s Hospital. Dr. Newland, I’d like to start with you. Explain a little bit about the clinical impact of antimicrobial resistant pathogens in the NICU. What’s going on today?
Jason Newland, MD (Guest): Thanks Melanie. Antimicrobial resistant bacterial, primarily bacterial pathogens are being seen more and more throughout our country in all areas of healthcare; whether it’s in our ambulatory clinics, our hospitalized patients and as well as in our NICUs. What we know regarding data in overall use or overall impact on our clinical lives or on our patients is that annually, 23,000 Americans die from an antibiotic resistant bacterial infection and another two million are infected with an antibiotic resistant bacterial infection. While this number isn’t specific to the NICU; Dr. Warner and myself and other neonatologists in pediatric infectious diseases physicians can tell you of patients that they have seen with antibiotic resistant infections in the NICU that haven’t done as well as we would like because of the difficulties that we can be faced when we are treating these infections.
Barbara Warner, MD (Guest): And I would like to add that in the NICU, specifically, the use of antibiotics has been very widespread over the decades because no one saw that there was a potential downside. If I give antibiotics; I can potentially prevent severe infection. But what we are now realizing is that there is a downside to antibiotic use. There’s definitely an upside. Antibiotics have still probably saved more babies than they have harmed; but we have to evaluate in this very critical and at-risk population the risks versus the benefits. And I think we are at a point now where we are starting to do that more clearly.
Melanie: And I thank you for that Dr. Warner because that was going to be my next question as the high rates of antibiotic use in the NICU. Can you tell us, is there evidence of clinical benefit from liberal compared with conservative antibiotic use?
Dr. Warner: Let me begin by talking a little bit about why antibiotics are used so widely or have been used so widely in the NICU. The presenting symptoms for infection overlap significantly with the presenting symptoms for prematurity and because the babies are so small; are ability to make a laboratory-based diagnosis, growing the bacteria out of the blood; is limited. We can only take so much blood. You can take maybe a quarter of a teaspoon of blood from a baby who weighs under a pound. And so those limitations have made it difficult to be able to identify the risks versus the reality of an infection. We now have some tools that enable us to look at those risks more clearly and evaluate those risks more clearly. It’s still difficult to make the diagnosis sometimes. But we have better tools that have been evaluated medically in the literature that enable us to be able to look at that information. From your question, specifically, has there been an evaluation through some type of a trial of a liberal versus a conservative approach. What we know from term babies, this is really based more on term babies; is that a conservative approach versus a liberal approach with use of antibiotics in babies that are at risk; if you use these tools, these evaluation tools, that look at what’s the maternal history, what was the perinatal factors, that the outcomes are as good in a more conservative approach and with that comes a decreased risk of development of antibiotic resistant organisms.
Dr. Newland: Yeah and I would like to add this – I think these studies that have really – should be I think the folks in the NICU and the neonatologists like Dr. Warner who have started to use these tools, have really bought in to understanding that this use maybe as was mentioned earlier, isn’t always necessary. So, we have from my perspective working with antibiotics and seeing and watching rates of antibiotics; we have seen dramatic decreases across the country in the use of antibiotics in the NICUs and we’ve also continued to hear stories and continue to see publications that this reduction in use has not been met with an increase in negative consequences such as worse outcomes that would include being in the hospital longer and even as the concerns can be dying of what would say of untreated bacterial infections.
Melanie: Dr. Newland, tell us a little bit about infection control strategies aimed at reducing the acquisition and transmission of these antimicrobial resistant pathogens in the NICU and when you are speaking about this, kind of cover education of the frontline staff or identification of some of these resistant pathogens. Give us some of the strategies that you are looking to.
Dr. Newland: Well I think to talk about infection prevention strategies we have to talk about the tired and true that has been demonstrated since the 1800s and that’s of hand hygiene. We know that focusing and being the best at hand hygiene is one of the most important infection prevention strategies that we all have to do, and we all have to do better. We all have to be cognizant and mindful of washing our hands when it’s obviously appropriate and not only just to say we are washing our hands, but to do it correctly, meaning that we are using soap and water or we are using the hand gel and we are not just putting it in our hands and going quickly to the next thing, but also making sure that we use friction and get all the places that need to be washed or have covered on our hands.
I think the second thing is continuing to just understand our hygiene and understand when we do have resistant organisms, that we are taking the appropriate measures necessary to prevent that contact or prevent transmitting it to others and whether that’s following our appropriate protections that might include gowning and gloving and maybe putting a mask on; those sorts of things and being cognizant and mindful to do that the best that we can; will help reduce the transmission of these antibiotic resistant infections.
And lastly, as a pediatric infectious diseases provider, I cannot be on a program without mentioning vaccinations and while we talk about it you can wonder why he is talking about vaccinations. Well, we know that in this day and age if we vaccinate, we reduce bacterial infections. We also reduce viral infections and today, we are in the season coming up of influenza; we stress and now you see hospitals mandate we all get influenza vaccine and that is essential in helping us prevent infections that then lead to use of antibiotics, that then lead to overuse and then we can see these other negative consequences.
Dr. Warner: And I would strongly advocate that because prevention in the NICU starts particularly during the winter season with prevention in the community. We have the highest risk babies and the truth is that while we try very hard to prevent infections from coming in; organisms don’t follow the same boundaries that we have, and they will come into the NICU through the community and so having vaccinations, the flu vaccine, I would say everyone please go out and get your flu vaccine. It will help my babies in the NICU.
Melanie: Dr. Warner, and this is such an important discussion that we are having today and as this is one of the more important issues facing the medical community and how you can potentially curtail the unnecessary use of antibiotics, we hear about antibiotic stewardship and all of these things are coming out now, but in the NICU, as you have stated, some of these diseases really raise the mortality rate of these tiny babies. Tell us about some of the challenges that you might have in the implementation of some of the strategies and the containment of these resistant pathogens.
Dr. Warner: It’s a really good question and it’s a really difficult position to be in as a physician and as a provider for these babies. Because the risk for our preterm infants and for infants who have medical issues is that we don’t identify early an infection and so I don’t want to give anyone the impression that we are not using antibiotics or that antibiotics are a bad thing. Antibiotics are life-saving. They are life-saving for our population. But as I mentioned before, there is – as with everything in life that is good, there is always a risk associated with it. And so, the strategies that we have to try to minimize the risks associated with unneeded antibiotics are related to many of the things that Jason has brought in and his team in terms of antibiotic stewardship. How long do we really need to treat this potential infection? How quickly can we move toward a diagnosis? Are there a subset of babies that we don’t need to treat because their profile would indicate that the symptoms that we are seeing are not infectious symptoms, they are more likely related to their prematurity?
So, very practical kinds of things. We now put in hard stop dates for antibiotics. Sometimes, the duration of antibiotics would leak over because they didn’t get stopped in the orders or someone didn’t realize that the antibiotic would continue until tomorrow or the day after. So, hard stop dates. Reevaluation every day on rounds what are the antibiotics. How long have they been on? Do we need to continue them? All those kinds of practical hands-on things have really improved our ability to restrict the antibiotics. And then finally, to use antibiotics that are as narrow in spectrum as we can. So, we are considered kind of old fogies in the NICU because the antibiotics that we use tend to not be the newest and the most robust and that’s because it’s safer to narrow the spectrum as soon as we can. Sometimes, we can’t. Sometimes we can’t use a narrow spectrum antibiotic, but to try to use those antibiotics that are as narrow in spectrum and fit the disease process that we are trying to treat. And I would say that the antibiotic stewardship program has really helped us as physicians stay on task for those kinds of very practical hands-on. We round every day together and so that really keeps our feet to the fire.
Melanie: Dr. Newland last word to you. Speak about the antibiotic stewardship program and when Dr. Warner discusses rounding and making sure the dosage and the timing of these antibiotics is all recorded and very carefully watched. What do you want the listeners and other providers to take away from this as far as what you see happening in the future for antibiotics and the stewardship programs?
Dr. Newland: Yes, thank you. I think I’ve – I think the keys of this are setting up a system or a program that really believes in the communication and collaboration around making sure that we are using our antimicrobials appropriately. As you have heard from Dr. Warner and all the great work they have done in the NICU; this has been a partnership. They have driven the work and we have been there to help with that work because we all believe and know that there is that negative consequence to using antibiotics. And so, for us, we spend our time from our antimicrobial stewardship program, we spend our time with our frontline providers.
And so, for the listeners, I think the key is that being open and collaborative and understanding or working together with those who spend their days trying to figure out ways to better use our antibiotics is key. And I think we are learning more and more and the more data and the more work we can do together to demonstrate these risks such as the risk of necrotizing enterocolitis; we are starting to see if you receive more antibiotics early on in life and not – maybe we need to learn now as we reduce our antibiotic use; are we seeing a reduction in that risk. So, that we can continue to learn and strive to make our babies have the best opportunities to live. And the live healthily and to thrive. I think as Barb said earlier, antibiotics are life-saving. They have changed healthcare. I would argue without antibiotics, we don’t have as many babies under one pound that survive and thrive that we do in 2018. However, without working together, without these stewardship programs that work alongside our wonderful frontline clinicians; we will, and we could possibly have an era where we no longer have antibiotics. Which then would send us back to an era of before we even could safely care for a lot of these sick patients including our NICU babies.
Melanie: Dr. Warner do you have anything you’d like to add as we finish up?
Dr. Warner: I would say one of the remaining questions that we have about antibiotics and antibiotic resistance is what happens after the NICU? How long does the antibiotic resistant organisms stay around? I think those are questions that the infectious disease people here at Washington University are starting to look at along with the providers. What does that mean in the long-term? Those are answers we don’t know yet.
Melanie: Thank you both so much for being with us today. What a fantastic segment and so inspiring and informative, really, really great. Thank you so much for joining us. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital you can go to www.stlouischildrens.org, that’s www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.