Wednesday, April 2, 2025
4/2/2025
Implementing vancomycin-sparing regimens in preterm infants - PROJECT SUMMARY/ABSTRACT Antibiotics are the most prescribed medication in neonatal intensive care units (NICU). Antibiotic stewardship efforts have reduced overall antibiotic use in the NICU, but preterm and low birth weight infants have not benefited proportionately. Preterm infants (≤35 week gestation) constitute ~45% of all NICU admissions, are admitted for extended periods, are frequently exposed to antibiotics, are at higher risk for antibiotic side effects and serve as reservoirs for multi-drug resistant pathogens. Thus, interventions to optimize antibiotic use in preterm infants can reduce unit-level selection pressure and improve patient safety. Despite recommendations from the American Academy of Pediatrics against its empirical use in the NICU, vancomycin is the most common antibiotic administered to preterm infants after 3 days of age, largely as empiric therapy for suspected late-onset sepsis (LOS). Studies by us and others demonstrate that use of vancomycin reducing protocols (VRP), designed to encourage the use of narrower spectrum antibiotics as first-line empiric and provide guidance for when vancomycin is an appropriate choice, can safely reduce vancomycin use in the NICU. Yet these regimens are not universally adopted, and when adopted are not universally applied, highlighting the need for more comprehensive strategies to implement change. Our long-term goal is to identify and promote practices that optimize antibiotic use in neonates. Our broad objective is to implement a VRP in NICUs for safe and sustained reduction of unnecessary vancomycin use in preterm infants (≤35 weeks). We hypothesize that VRP implemented by preparing local champions, educational outreach, introduction of a clinical decision support tool and providing unit-level audit and feedback will reduce vancomycin use (Aim 1); and that the use of additional external facilitation will improve fidelity and acceptability of VRP use (Aim 2). We used the updated Consolidated Framework for Implementation Research (CFIR) to design this study and simultaneously use CFIR constructs to understand barriers and facilitators of VRP use (Aim 3). We will comprehensively examine antibiotic use in the context of VRP implementation including evaluation of implementation outcomes, disparity drivers, and parent and clinician perspectives. We will conduct this study in 13 NICUs across two large healthcare networks. Our specific aims are 1) To reduce unnecessary vancomycin use in preterm infants by implementing a VRP in a quasi-experimental trial; 2) To determine the effect of external facilitation on the fidelity of using VRP and other implementation outcomes in a cluster randomized trial; and 3) To identify barriers and facilitators to implementation of the VRP across NICUs. By using an implementation science approach to reduce vancomycin in a multicenter study we will provide a road map for the broader implementation of VRP across NICUs in the United States. Additionally, our study will provide key insights into the factors influencing prescribing behavior in the NICU that can inform future antibiotic stewardship efforts in this high-risk setting.
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