What clinical audit can be completed within a week in the pediatric or Neonatal Intensive Care Unit (NICU) to assess antibiotic use in patients with conditions such as premature birth, low birth weight, or congenital anomalies?

Rapid One-Week Clinical Audit: Antibiotic Prescribing Appropriateness in NICU

Conduct a prospective audit of empirical antibiotic prescribing for suspected late-onset sepsis in your NICU, comparing actual prescribing patterns against WHO-recommended first-line regimens and local antibiograms over a 7-day period. This audit can be completed within one week and provides actionable data for antimicrobial stewardship 1, 2.

Audit Design and Methodology

Data Collection Period

• Capture all new antibiotic starts for suspected late-onset sepsis over 7 consecutive days 3
• Include all neonates admitted to your NICU during this period, with particular focus on premature infants (<37 weeks gestation) and low birth weight infants (<2000g) who have the highest antibiotic exposure rates 4

Key Data Points to Collect

Patient Demographics:

• Gestational age at birth, current postnatal age, and birth weight 4
• Presence of congenital anomalies or comorbidities 1
• Previous antibiotic exposure within the current hospitalization 5

Prescribing Details:

• Specific antibiotics prescribed (drug, dose, frequency, route) 6
• Clinical indication documented in medical record 7
• Time from clinical suspicion to first antibiotic dose 1, 5
• Whether blood cultures were obtained before antibiotic administration 1

Appropriateness Criteria:

• Compare prescribed regimen against WHO-recommended first-line therapy (ampicillin plus gentamicin for early-onset sepsis; local guidelines for late-onset sepsis) 1, 8
• Assess dosing accuracy against weight-based recommendations 8, 6
• Evaluate whether empirical coverage matches local resistance patterns from your institution's antibiogram 1

Specific Audit Questions to Answer

Question 1: Empirical Regimen Selection

• What percentage of neonates received WHO-recommended first-line antibiotics (ampicillin plus gentamicin or ceftazidime)? 1, 8
• Document deviations: Are clinicians using broad-spectrum agents (vancomycin, carbapenems, third-generation cephalosporins) as first-line therapy? 4
• The most common deviation in low-resource settings is use of meropenem as empirical therapy (15.9% of regimens), which may reflect local resistance patterns but warrants scrutiny 1

Question 2: Dosing Accuracy

• Calculate the proportion of prescriptions with correct weight-based dosing 6
• For ampicillin: Should be 150 mg/kg/day divided every 8 hours for infants under 6 months 8
• For gentamicin: Should be 4 mg/kg/dose every 24 hours with therapeutic drug monitoring 1, 8
• Inappropriate dose selection is the most common reason for guideline non-adherence in pediatric respiratory infections (adherence rate only 27.6%), and this likely applies to NICU settings 6

Question 3: Time to First Dose

• Measure time from documented clinical suspicion of sepsis to antibiotic administration 1, 5
• Target: Within 1 hour for suspected septic shock 1, 5
• Target: Within 3 hours for other severe infections 1

Question 4: Culture Practices

• What percentage of patients had blood cultures drawn before antibiotic administration? 1
• This is a critical antimicrobial stewardship measure that enables de-escalation 1, 5

Practical Implementation Steps

Day 1-2: Setup

• Create a simple data collection form (paper or electronic) with the audit questions above 1
• Brief NICU nursing staff and physicians about the audit to ensure cooperation 3
• Identify your data sources: medication administration records, laboratory systems, and medical charts 6, 7

Day 3-7: Active Data Collection

• Review all new antibiotic orders daily 3
• Capture prescribing in real-time or within 24 hours of initiation 3
• Document the prescriber's level of experience (years in NICU practice), as this predicts appropriate prescribing 7

Day 8: Analysis and Reporting

• Calculate your key metrics:
  • Percentage adherence to recommended first-line regimens 1
  • Percentage with correct dosing 6
  • Mean time to first antibiotic dose 1
  • Percentage with pre-treatment cultures 1
• Compare your findings to benchmarks: In one study, only 23% of neonates globally received WHO-recommended antibiotics 1

Common Pitfalls and How to Avoid Them

Pitfall 1: Incomplete capture of antibiotic starts

• Solution: Cross-reference pharmacy dispensing records with NICU admission logs to ensure no patients are missed 1

Pitfall 2: Lack of documented indication

• Solution: If indication is unclear from chart review, directly ask the prescriber within 24 hours while the clinical context is fresh 7

Pitfall 3: Confusing prophylactic vs. therapeutic use

• Solution: Clearly categorize each antibiotic course as empirical therapy for suspected infection, targeted therapy for confirmed infection, or prophylaxis (e.g., post-surgical) 7

Pitfall 4: Not accounting for local resistance patterns

• Solution: Obtain your institution's most recent antibiogram before starting the audit to properly assess appropriateness of empirical choices 1

Expected Outcomes and Next Steps

This audit will reveal:

• Your unit's baseline antibiotic utilization rate (calculate as days of therapy per 1000 patient-days) 3
• Specific targets for antimicrobial stewardship intervention (e.g., excessive vancomycin use, which was the most commonly used antibiotic in one NICU study at 143 LOT/1000 patient-days) 4
• Whether prescribing varies by provider experience level 7

The audit findings should directly inform prospective audit and feedback interventions, which have demonstrated 20% reductions in antibiotic use in pediatric cardiac ICUs without increasing length of stay or mortality 3.

Alternative Rapid Audits (If Primary Audit Not Feasible)

Option 2: Duration of Therapy Audit

• Measure actual duration of antibiotic courses for culture-negative sepsis evaluations 4
• Target: Should be discontinued at 48-72 hours if cultures negative and clinical improvement 5
• One study found mean duration was 10.8 days, revealing substantial overuse 4

Option 3: Therapeutic Drug Monitoring Compliance

• Audit whether aminoglycoside peak and trough levels are being obtained appropriately 1, 8
• Peak should be measured 30 minutes after first dose 1
• This audit requires only reviewing laboratory orders and can be completed in 3-4 days 1