94 - Standardizing Antibiotic Duration in Surgical NEC/SIP Cases, a Quality Improvement Initiative

Publication Number: 4092.94

Daniel Mohan, UPMC Childrens Hospital of Pittsburgh, Pittsburgh, PA, United States; Brighid O'Donnell, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Abeer Azzuqa, UPMC Childrens Hospital of Pittsburgh, Sewickley, PA, United States; Paul Waltz, UPMC Childrens Hospital of Pittsburgh, Pittsburgh, PA, United States; John Ibrahim, University of Texas Southwestern Medical School, Dallas, TX, United States; Toby Yanowitz, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States

Background: Prolonged antibiotic use in premature newborns is known to be associated with adverse outcomes. Although shorter antibiotic courses have proven safe, our center showed substantial variability in duration of treatment for surgical necrotizing enterocolitis (sNEC) and spontaneous intestinal perforation (SIP).

Objective: SMART

Aim: Standardize and reduce by 25% broad-spectrum antibiotic use for sNEC/SIP at a large level IV NICU from Nov 2024 to Nov 2025 and maintain for 1 year.

Design/Methods: Evidence-based multidisciplinary clinical guidelines were developed to standardize antibiotic duration for infants with sNEC/SIP, recommending an duration that is the shorter of 7d post-operation or 10d total. Data was collected retrospectively for baseline infants and prospectively post-guideline implementation. The primary outcome measure is duration of antibiotic treatment for sNEC/SIP. Process measures include compliance and documentation if deviating from guidelines. Balancing measures include surgical site infections, additional antibiotics in the 30d following completion of sNEC/SIP course, and mortality.

Results: The guideline was implemented on 11/1/24. In our baseline population (1/1/21-10/31/24.), 42 infants completed their antibiotic course (26 with sNEC, 16 with SIP). There were 8 deaths, all but one prior to finishing the antibiotic course. The mean(SD) post-operative antibiotic duration was 12.7(3.1) days. Since implementation of the guideline, 9 patients underwent surgery and survived (5 sNEC and 4 SIP). Two NEC patients died before completing antibiotic course. The 9 surviving infants had a mean(SD) post-operative antibiotic duration of 9.7(2.7) days, a 24% decrease from baseline (Figure1). However, 4 NEC patients were not in compliance (1 bacteremia, 2 with multiple laparotomies and 7d of therapy post-final laparotomy, 1 treated 7d post-single laparotomy). Post-implementation, there were no surgical site infections, 1 episode of bacteremia [compared to 8 baseline (Table)], and no increase in the 30d post-NEC/SIP antibiotic days [5.3(7.3) days pre vs 3.5(5.4) days post (Figure2)].

Conclusion(s): After implementing standardized multidisciplinary guidelines, we have seen a 24% decrease in antibiotic days for surgical NEC/SIP and no increase in additional antibiotics given in the subsequent 30 days. However, the sample size is small and more patients are needed to claim a definitive shift. There has been no increase in surgical site infection or mortality attributable to shortening the antibiotic course. The current PDS cycle will address infants who require multiple surgeries to achieve source control.

Figure 1
X-bar control chart displaying the days of antibiotics each patient received for their NEC/SIP course. Infants numbered in chronological order.

Figure 2
X-bar control chart displaying the additional days of antibiotics each patient received in the 30 days following completion of their NEC/SIP course. Infants numbered in chronological order.

Table
Demographic and clinical data of infants