Assessment of Broad-Spectrum Antibiotic Usage Following Initiation of Handshake Stewardship in a Pediatric Intensive Care Unit: A Quality Improvement Initiative
Authors: McMinn *Caleb , Clemente *Adriana Sarmiento , Vance Mary Kathryn , Maples Holly , Courtney Ashleah , Dahl Steven 
Published: January 2025

Abstract

*These authors share first authorship
Corresponding author: Caleb McMinn. One Children’s Way, Slot 304. Little Rock, Arkansas 72202, 501-364-5289, McminnCM@archildrens.org.
Alternate corresponding author: Adriana Sarmiento Clemente. One Children’s Way, Slot 512-1. Little Rock, Arkansas 72202, 501-364-1962, asarmientoclemente@uams.edu
No conflicts of interest.

Background
Antimicrobial resistance remains a major challenge in healthcare with more than 2.8 million infections and 35,000 deaths occurring yearly from resistant organisms. Due to this threat, numerous initiatives have been designed to combat antimicrobial resistance, including the CDC’s Core Elements of Hospital Antibiotic Stewardship Programs and the Joint Commission’s requirements for antibiotic stewardship programs (ASP). A unique approach to traditional ASP strategies is the implementation of handshake stewardship – the process of in-person feedback following antibiotic review. This strategy was implemented by Children’s Hospital Colorado and demonstrated significant decrease in overall antimicrobial use. We aimed to evaluate a similar approach to handshake stewardship in addition to current ASP practices at our institution.

Methods
This was a single center pre- and post-implementation study conducted at Arkansas Children’s Hospital Pediatric Intensive Care Unit (PICU). Retrospective review of antimicrobial use was performed utilizing the National Healthcare Safety Network’s (NHSN’s) Standard Antimicrobial Administration Ratios (SAARs). Handshake stewardship rounds were introduced hospital-wide in September of 2023 with a focus on the PICU. These were performed in addition to previously implemented ASP strategies including prospective audit and feedback and pre-authorization of restricted antimicrobials. Each weekday, broad spectrum and restricted antimicrobials were reviewed by a physician-pharmacist team and recommendations were given in person to PICU providers. Our inpatient ASP team consisted of two pharmacists and three physicians, with each pharmacist alternating ASP service monthly and each physician on a weekly basis. SAARS were calculated 5 months prior to implementation, during the 1- month implementation period and 5 months post implementation through NHSN’s AU reporting system with 95% confidence intervals included for each month. Each ratio utilized NHSN’s list of broad- spectrum antibiotics for hospital acquired infections (HAIs) including cefepime, piperacillin/tazobactam, and meropenem.

Results
Broad spectrum antimicrobial use significantly decreased following implementation of handshake stewardship rounds. Median SAAR from the five months preceding our intervention was 1.90, and the five months post-implementation was 1.32 (P=0.008) (Figure). Within the intervention period in September, SAAR decreased to 1.22 (22% more antibiotic use than predicted) from 1.89 in August (89% more antibiotic use than predicted), despite change in season that could result in higher antibiotic use. Of note, December of 2023 was the only month during the study period where the SAAR was not significantly higher than the goal SAAR of 1 (P = 0.2).

Conclusion
Handshake stewardship rounds in addition to current ASP strategies demonstrated a decrease in broad spectrum antibiotic usage. Future analysis of other hospital units is needed to determine hospital-wide impact. Given the potential high influence for this intervention when implemented on a regular basis, appropriate FTE support for pharmacist and physicians should be warranted.