Inese Sviestina

Antimicrobial usage among hospitalized children in Latvia: A neonatal and pediatric antimicrobial point prevalence survey

BACKGROUND AND OBJECTIVE The point prevalence survey was conducted as part of the Antibiotic Resistance and Prescribing in European Children (ARPEC) Project. The study aimed at analyzing pediatric and neonatal antimicrobial prescribing patterns in Latvian hospitals, to identify targets for quality improvement. MATERIALS AND METHODS A one day cross-sectional point prevalence survey on antibiotic use in hospitalized children was conducted in November 2012 in 10 Latvian hospitals, using a previously validated and standardized method. The survey included all inpatient pediatric and neonatal beds and identified all children receiving an antimicrobial treatment on the day of survey. RESULTS Overall 549 patients were included in the study; 167 (39%) patients admitted to pediatric wards and 25 (21%) patients admitted to neonatal wards received at least one antimicrobial. Pediatric top three antibiotic groups were third-generation cephalosporins (55 prescriptions, 28%), extended spectrum penicillins (n=32, 16%) and first-generation cephalosporins (n=26, 13%). Eleven pediatric patients (85%) received surgical prophylaxis more than 1 day; 143 pediatric patients (86%) received antibiotics intravenously. Lower respiratory tract infections were the most common indications for antibiotic use both in pediatric (n=60, 35.9%) and neonatal patients (n=9, 36%). The most used antibiotics for neonatal patients were benzylpenicillin (n=12, 32%), and gentamicin (n=9, 24%). CONCLUSIONS We identified a few problematic areas, which need improvement: the high use of third-generation cephalosporins for pediatric patients, prolonged surgical prophylaxis, predominant use of parenteral antibiotics and an urgent need for local antibiotic guidelines.

Comparison of antimicrobial prescribing between two specialist paediatric centres in the UK and Latvia

Objective To compare the use of antibiotics among hospitalised children in the UK and Latvia at two specialist paediatric centres. Methods Two point prevalence surveys were undertaken on a single day in May and November 2011. Data collection included demographic details such as gender, age and specialty, prescribed antibiotic(s), indication, dose, frequency, route of administration and day of treatment. The data were analysed using Microsoft Excel and SPSS 20.0. Results The demographic details at the two institutions were similar. A number of differences were noted in antimicrobial prescribing. The most common groups of prescribed antibiotics were penicillin/β-lactam combinations in the UK and third-generation cephalosporins in Latvia. In both centres the most common therapeutic indication for antibiotic therapy was lower respiratory tract infection, which was predominantly treated in the UK with co-amoxiclav and in Latvia with ampicillin/amoxicillin. The intravenous route was most commonly used in both centres, but this was substantially higher in Latvia than in the UK (mean across both surveys 87.4% vs 62.6%). Conclusions A number of differences were observed in antibiotic prescribing between these two paediatric centres. By sharing audit data and antimicrobial stewardship initiatives, further changes in practice may be observed at both institutions.

A comparison of antibiotic use in three specialist paediatric hospitals in France, Latvia and the UK

Objectives This article analyses antimicrobial use in three tertiary-care paediatric hospitals with the aim of improving antimicrobial stewardship in paediatric hospitals. Methods A point prevalence survey (PPS) was undertaken during November 2012 using validated and standardised ARPEC (Antibiotic Resistance and Prescribing in European Children) methodology. The data collected contributed to the ARPEC study. Results Antimicrobials were prescribed to 116 patients (48%) in Birmingham, 114 (38%) in Paris and 128 (37%) in Riga. Respiratory tract infections were the most common indications for antibiotic use in Riga, but in Birmingham and Paris antibiotics were used most for prophylaxis in case of medical problems. The most common age group of patients receiving antimicrobials across all three sites was children aged 1–5 years old: there were 41 (35%) children in this age group in Birmingham, 37 (32%) in Paris and 36 (28%) in Riga. The most common antimicrobial used for the treatment and prophylaxis of paediatric patients was co-trimoxazole in Birmingham and Paris and ceftriaxone in Riga. Antimicrobials were mainly used parenterally: there were 100 (55%) parenteral prescriptions in Birmingham, 122 (50%) in Paris and 111 (75%) in Riga. Conclusions The PPS identified differences in antimicrobial use in the three hospitals and problem areas requiring improvement: high use of third-generation cephalosporins for paediatric patients (especially in Riga) and predominant use of parenteral antibiotics. Further collaboration between pharmacists operating at each site is needed in order to improve antimicrobial stewardship initiatives.

Observational Study of Antibiotic Usage at the Children’s Clinical University Hospital in Riga, Latvia

Background and objectives: Many pediatric patients have been treated with antibiotics during their hospitalization. There is a need to improve antibiotic prescribing for pediatric patients because many of these prescriptions are inappropriate. Antibiotic consumption analysis was conducted at the Children’s Clinical University Hospital to identify targets for quality improvement. Materials and Methods: A one day cross-sectional point prevalence survey (PPS) was conducted in May and November 2011–2013 using a previously validated and standardized method. The survey included all inpatient pediatric and neonatal beds and identified all children receiving an antibiotic treatment on the day of survey. Total consumption of systemic antibiotics belonging to the ATC J01 class (except amphenicols (J01B) and a combination of antibacterials (J01R)) was also analyzed by using a defined daily dose (DDD) approach and antibiotic drug utilization (90%DU) for the period 2006–2015. Results were compared with results in 2017 using the DDD and 90%DU methodology. Results: The most commonly used antibiotic group in all PPS, except in May and November 2011, was other β-lactam antibiotics (J01D): 42 (40%) prescriptions in May 2013 and 66 (42%) and November 2011. In 2006–2015 and also in 2017, the most commonly used antibiotic groups were penicillins (J01C) and other β-lactam antibiotics (J01D)—76% (90%DU) of the total antibiotic consumption registered in 2006, 73% in 2015 and 70% in 2017. Starting in 2008, amoxicillin was the most commonly used antibiotic at the hospital. The usage of ceftriaxone increased from 3% in 2006 to 13% in 2015, but decreased in 2017 (7%). Conclusions: Study results from 2006–2015 showed that there was a need to establish a stronger antibiotic prescribing policy in the hospital reducing the use of broad-spectrum antibiotics (especially 3rd generation cephalosporins) and increasing the use of narrower spectrum antibiotics. It was partly achieved in 2017 with some reduction in ceftriaxone use.

Prescription of antibiotics in Riga and Vilnius tertiary children's hospitals

Objectives The aim of this study was to compare the use of antibiotics among hospitalised children in Riga (Latvia) and in Vilnius (Lithuania) at two tertiary paediatric centres. Methods A point prevalence survey (PPS) was conducted using validated and standardised Antibiotic Resistance and Prescribing in European Children (ARPEC) project methodology during November 2012. All inpatients less than 18 years old were included in the study. All data were recorded for patients with active antimicrobial prescriptions at 8 am on the day of the survey. Data were entered into the ARPEC-webPPS programme and were validated online for accuracy. Results The proportion of patients receiving antimicrobial therapy was statistically different: 128 (37.0%) patients in Riga and 83 (26.3%) in Vilnius. The most common age group in Riga and Vilnius was 1–5 years. The most commonly used antibiotic classes for the treatment and prophylaxis of infection were third-generation cephalosporins (38; 25.5% prescriptions) in Riga and second-generation cephalosporins (16; 19.8%) in Vilnius. Parenteral use of antimicrobials was higher in Riga than in Vilnius: 111 (74.5%) prescriptions to paediatric patients in Riga and 45 (55.6%) prescriptions in Vilnius. Conclusions The PPS identified differences in antibiotic use in both hospitals and problem areas for improvement: high use of third-generation cephalosporins for paediatric patients (in Riga) and predominant use of parenteral antibiotics. Further collaboration between both centres is needed because sharing audit data and antimicrobial stewardship initiatives may encourage further changes in practice at both institutions.

A retrospective and observational analysis of harmful excipients in medicines for hospitalised neonates in Latvia

Background Medicines used in neonates contain different excipients, which may not be safe in this age group. Objective To analyse the frequency at which hospitalised neonates are exposed to harmful excipients (HEs) and to identify substitution possibilities for medicines containing HEs. Materials and methods Retrospective, observational study at a university paediatric hospital from 1 September 2015 till 29 February 2016. All hospitalised neonates who received a prescription for medicines containing an HE were included. Neonates were divided into four groups according to gestational age (<28 weeks; 28 to <32 weeks; 32 to <37 weeks and ≥37 weeks). The following excipients were analysed: parabens, polysorbate 80, propylene glycol, benzoates, saccharin sodium, sorbitol, ethanol and benzalkonium chloride. Excipients were identified from the Summaries of Product Characteristics. Results 296 (102(34.5%) preterm) neonates included in the study received 1472 prescriptions for 106 medicines. The most often used formulations were intravenous (48/106; 45.3%) and oral solid formulations (20; 18.9%). The total number of different excipients was 169. In total, 29/106 (27.4%) medicines contained at least one HE. In total 82/102 (80.4%) preterm and 118/194 (60.8%) term neonates received medications with at least one HE. Substitution was possible for 9/29 (31.0%) HE-containing medicines. Conclusions Use of HEs can be reduced by using HE-free products available on the European market. However, medicine substitution was possible in only a small number of cases. Therefore the main focus should be on information and education of the hospital specialists about HEs used in medicines and their adverse reactions.

CP-015 Potentially harmful excipients in medicines for hospitalised neonates

Background Medicines used in neonates contain different excipients, which may not be safe in this age group. Purpose To analyse the frequency that hospitalised neonates are exposed to potentially harmful excipients (HE) and to identify possible substitutes for medicines containing HE. Material and methods This was a retrospective observational study at a university paediatric hospital. All hospitalised neonates were included. Neonates were divided into four groups according to gestational age (<28 weeks; 28 to <32 weeks; 32 to <37 weeks; and >37 weeks). The study period was from 1 September 2015 to 29 February 2016. All medicines and food supplements, except blood products, glucose and electrolyte solutions, vaccines, parenteral nutrition products and contrast agents, were analysed. The following excipients were analysed: parabens, polysorbate 80, propylene glycol, benzoates, saccharin sodium, sorbitol, ethanol and benzalkonium chloride. Excipients were identified from the Summaries of Product Characteristics. Substitutions were analysed according to Nellis et al (Paediatr Drugs 2016, Product substitution study). Results 327 neonates were hospitalised during the study period. Of these, 296 (102 (35%) preterm) included in the study received 1472 prescriptions for 106 medicines. The most often used formulations were intravenous (48/106; 45%), oral solid formulations (20; 19%) and topical formulations (16; 15%). The total number of different excipients was 169. In total, 29/106 (27%) medicines contained at least one HE. 82/102 (80%) preterm and 118/194 (61%) term neonates received medications with at least one HE. Substitution was possible for 9/29 (31%) HE containing medicines. Therefore, the clinical pharmacist prepared leaflets and recommendations in the hospital intranet warning doctors about currently used medicines with HE. There was also information about the HE that these products contain and the possible adverse reactions. Conclusion Usage of HE can be reduced by using HE-free products available on the European market. However, substitution was possible in only a small number of cases. Therefore, the main focus should be on information and education of hospital specialists on which HE are present in medicines, what adverse reactions they may cause and how to avoid usage of these medicines. No conflict of interest

CP-016 Analysis of antibiotic prescriptions for surgical prophylaxis in patients with upper and lower extremity injuries at the paediatric surgery clinic

Background There are numerous audits performed in order to evaluate the appropriateness of the use of antibiotics (AB) in surgical prophylaxis in adult populations, but there is still a shortage of data regarding paediatric surgery. Purpose To analyse prescribed AB and AB doses to patients with upper and lower extremity injuries before and after introduction of hospital recommendations for surgical prophylaxis (HR) at the paediatric surgery clinic (PSC) and to evaluate the usefulness of the AB electronic prescription form. Material and methods Retrospective study. Patients aged <18 years hospitalised at the PSC were included in the study. Study period: 2011–2014. All data on patients were obtained from the patients’ medical records (2011–2013), as well as from the hospital software (2014). The HR (accepted in September 2013) and the summary of the product characteristic (SPC) were used as information resources for analysis of dosing errors. The cefazolin dose in the HR was 25 mg/kg but in SPC it was 25–50 mg/kg. AB prescriptions were analysed before the introduction of the HR (201–013) and after (2014). Results 743 (66%) patients had AB prophylaxis in 201–013. In 2014, there were 367 electronically filled AB prescription forms. 546 (73%) patients had the correct duration of AB prophylaxis (1 dose) in 201–013 but in 2014, 254 (69%) patients. In 2011–2013, AB choice (cefazolin) was correct in 377 (51%) cases compared with 361 (98%) cases in 2014. In 2011–2013, AB doses were wrong in 217 (59%) prescriptions according to HR compared with 268 (74%) prescriptions in 2014. According to SPC, AB doses were wrong in 120 (33%) prescriptions in 2011–2013 and in 34 (9%) prescriptions in 2014. Conclusion Although the guidelines were discussed and accepted by surgeons only a few positive trends (eg, the correct AB choice) were observed with AB treatment guidelines not having a major impact on AB use. The electronic AB prescription form did not improve the situation either. There is a need for new ways of promoting adherence to guidelines and appropriate antibiotic use. References and/or Acknowledgements Ciofi Degli Atti M, et al. Eur J Clin Pharmacol 2015;71:483-8 Formaini N, et al. J Pediatr Orthop 2012;32:737-40 No conflict of interest.

CP-070 The impact of hospital antibiotic guidelines on surgical prophylaxis in paediatric patients suffering upper and lower extremity injuries

Background Infliximab (INF) is a chimeric immunoglobulin antibody to tumour necrosis factor (A-TNF) approved for the treatment of Crohn’s disease and ulcerative colitis. Guidelines recommend a 5 mg/kg dose given as induction regimen in weeks 0, 2 and 6, followed by a maintenance regimen of 5 mg/kg every 8 weeks. However, a significant rate of patients with an initial response, later experience the return of the active disease despite ongoing INF maintenance treatment. International guidelines suggest intensifying the INF regimen if the treatment fails, by increasing the dose to 10 mg/kg, or decreasing the interval to 5 mg/kg every 6 weeks. Purpose To analyse the different intensification strategies used in a tertiary university hospital, and their results. Material and methods Single-centre, retrospective, observational study. Information was obtained from both the Farmatools application and clinical histories. Fifty-five patients were included in our study; all of them started INF treatment between 2005 and 2013. Results Out of 55 patients enrolled: 60% (33) were responders, 9% (5) were non-responders, 27% (15) loss of response, and (4%) 2 didn’t tolerate INF. The treatment of the 22 patients who didn’t respond satisfactorily was modified: in 73% (16) the interval was shortened, 9% (2) stepped up to 10 mg and 5% (1) the interval were shortened and the dose stepped up to 10 mg. The other 14% (3) were moved to another A-TNF. In our study, shortening the interval was effective in 52% of cases (9/16), stepping up to 10 mg in 100% (2/2), and the combination of the two strategies in 100% (1/1). Conclusion INF induces remission in most of the patients following the usual maintenance regimen. In our hospital the favourite intensification strategy is to shorten the interval. The use of another A-TNF is reserved for hypersensitivity reactions or for failure of the previous intensification. Both intensification strategies were effective, though more information is required to choose the best strategy. References and/or Acknowledgements No conflict of interest.

DI-100 Comparison of antibiotic prescribing for paediatric lower respiratory tract infections in three paediatric hospitals in the UK, France and Latvia

Background The most common indications for antibiotic use in hospitalised children are lower respiratory tract infections (LRTI). The point prevalence survey (PPS) allows targets to be identified for quality improvement. Comparing antibiotic use between different countries may help identify successful initiatives that further rationalise treatment. Purpose To compare antibiotic use for LRTI between three paediatric centres in the UK, France and Latvia to identify strategies to optimise treatment. Materials and methods This PPS was a part of the Antibiotic Resistance and Prescribing in European Children project (ARPEC). It was conducted at three tertiary-care children’s hospitals in Birmingham (UK), Paris (France) and Riga (Latvia) using ARPEC methodology during November 2012. Results LRTI accounted for 19/211 (9.0%) of antibiotic prescriptions in Birmingham, 29/245 (11.8%) in Paris and 43/168 (26%) in Riga. The most common age group of patients with LRTI across all three sites was under 5 years making up 14/19 (74%) patients in Birmingham, 14/29 (48%) in Paris and 22/39 (56%) in Riga. 7 different antibiotics were prescribed for LRTI in Birmingham, 14 in Paris and 9 in Riga. The most commonly prescribed antibiotics were co- amoxicillin/clavulanic acid 5 (28% of prescriptions) and piperacillin/tazobactam 5 (28%) in Birmingham, amoxicillin 5 (17%) and amoxicillin/clavulanic acid 6 (21%) in Paris and, amoxicillin 13 (30%) and ceftriaxone 9 (21%) in Riga. In Birmingham 13 (68%) antibiotic prescriptions were for community acquired infections, in Paris 24 (83%) and 42 (98%) in Riga. Antibiotics were predominantly prescribed intravenously: 11 (58%) prescriptions in Birmingham, 16 (55%) in Paris and 36 (84%) in Riga. Conclusions The PPS identified differences in antibiotic use in 3 hospitals and the high use of parenteral antibiotics in all hospitals. Further studies are required to determine the appropriateness of the choice of antibiotics in LRTI, the diversity of agents prescribed and the use of broad-spectrum antibiotic treatment. No conflict of interest.