Improving Antibiotic Use in Newborns

Improving Antibiotic Use in Newborns


>>Ladies and gentlemen,
thank you for standing by. Welcome to the CDC Perinatal
Quality Collaboratives Webinar Series. During the presentation,
our participants will be in a listen only mode. Afterwards, we will conduct a
question and answer session. At that time, if
you have a question, please press the star followed
by the one on your telephone. You may also enter questions at
any time throughout the webinar by using the chat
feature located in the lower left
corner of your screen. If you need to reach an
operator at any time, please press star, zero. As a reminder, this conference
is being recorded February 17th, 2017. I will now like to
turn the conference over to Dr. Zsakeba Henderson. Please go ahead.>>Good afternoon. My name is Zsakeba Henderson and
I’m an obstetrician gynecologist and medical officer
in the Division of Reproductive Health
here at CDC. I currently lead our
division’s activities in support of state-based perinatal
quality collaboratives, which provide support to six state perinatal quality
collaboratives in California, Illinois, Massachusetts, North
Carolina, New York, and Ohio. And we also provide
resources for state PQCs across the country, including
the newly launched National Network of Perinatal
Quality Collaboratives. I would like to welcome
you to today’s presentation for the CDC Perinatal Quality
Collaboratives Webinar series. Today’s webcast will be an
informative presentation of current strategies to improve
antibiotic use in newborns. Improving antibiotic use is
an important patient safety and public health issue, as
well as a national priority. This webinar will
provide an overview of CDC supported
state-based activities to prevent healthcare
associated infections, discuss improving antibiotic
use in newborn patients, and present the Perinatal
Quality Collaborative of North Carolina’s
antibiotic stewardship effort. At the end of this presentation,
you will have the opportunity to ask questions and participate in a discussion with
the presenters. As previously mentioned, you may
also submit questions via the Ready Talk chat function
throughout the presentation. A recording of this webinar
will be archived on our web page at www.cdc.gov/reproductive
health/maternalinfanthealth/pqc. Handouts were made available
with the reminder e-mail sent to all registrants
today and are cached under downloadable
files in that e-mail. Handouts will also be made
available again to registrants in a follow-up communication
after the webinar. I will be our first
speaker for this afternoon and will first give a
brief introductory overview of perinatal quality
collaboratives. Our next presenter will then
be Elizabeth Mothershed, who serves as the lead for
strategy and integration of state-based healthcare
associated infection and antibiotic resistance
activities in the Division of Healthcare Quality
Promotion here at CDC. Since 2011, Ms. Mothershed
has worked on policies and partnerships in support of
their mission to promote safety, quality, and value in
healthcare delivery systems. She has spoken on partnership
building and working with state health agencies
to promote best practices of healthcare associated
infection policy implementation for building sustainable
healthcare quality infection programs for prevention impact. The next presenter will then
be Dr. Arjun Srinivasan, who is the associate director for healthcare associated
infection prevention programs in the Division of Healthcare
Quality Promotion at CDC. Dr. Srinivasan is also a captain
in the US Public Health Service. He’s an infectious
disease specialist and oversees several
CDC programs aimed at eliminating healthcare
associated infections and improving antibiotic use. Before coming to the CDC, he
was an assistant professor of medicine in the
infectious diseases division at the Johns Hopkins
School of Medicine, where he was the
founding director of the Johns Hopkins
Antibiotic Management Program and the associate
hospital epidemiologist. He currently serves
as expert faculty for the Vermont Oxford Network
Choosing Antibiotics Wisely iNICQ Collaborative, which
is working to reduce overuse and misuse of antibiotics in
neonatal intensive care units. His presentation
will then be followed by our final presenter,
Dr. Marty McCaffrey. Dr. McCaffrey is a neonatologist
and professor of pediatrics in the Division of Neonatal
and Perinatal Medicine at the University of North
Carolina Chapel Hill. He is a retired captain from
the US Navy Medical Corps and after 20 years of service,
where he served as the director of the neonatal intensive care
at the Naval Medical Center in San Diego and as the Navy
surgeon general’s special leader for neonatology. He is a member of the National
Perinatal Information Center board of directors
and is the director of the North Carolina
Perinatal Quality Collaborative, whose mission is to make
North Carolina the best place to give birth and be born. So I’ll start by
giving a brief overview of state-based perinatal
quality collaboratives. State perinatal quality
collaboratives, or PQCs, are networks of perinatal
care providers and public health
practitioners working to improve pregnancy outcomes by advancing evidence-informed
clinical practices and continuous quality
improvement. PQC members identify
care processes that need to be improved and use
the best available methods to make changes in improved
outcomes as quickly as possible. State PQCs include key
leaders in private, public, and academic healthcare
settings with expertise in evidence-based
obstetric and neonatal care and quality improvement. The methodology that
PQCs use is based on quality improvement
principles developed and used in other disciplines and
specialties and is dependent on baseline and ongoing
collection of data and rapid return of data
to member facilities to meet objectives
to improve care. PQC strategies include use of the collaborative
learning model, use of rapid response data
for quality improvement, and providing quality
improvements via support and assistance to
hospital teams. The ultimate goal of PQCs
is to achieve improvements in population level outcomes
in maternal and infant health. Although individual institutions
and organizations have been able to achieve improvements
in perinatal care, regional PQCs serve
a unique role because they encourage
taking on the responsibility of improving outcomes
for the entire population of the region’s mothers
and infants. They also understand
the regional network of perinatal care and
collaborate among teams for both the hospital
and community. And in addition, they are able to compare performance among
hospitals that are operating within a similar
demographic, economic, and health services context. Members of a regional quality
improvement initiative represent a community of change and
this model has been shown to be successful for
rapid dissemination of evidence-based
protocols and processes. As you can see by this map, the number of state-based
PQCs has grown considerably over the past decade with an
active PQC now in various stages of development in
almost every state. The main goal of the CDC support of perinatal quality
collaboratives is to provide support for funded
states to expand current efforts within the state and to use the
experiences and knowledge gained from these successful CDC funded
PQCs to help other states, which included the
development of a resource guide to provide assistance to states
that may wish to form PQCs or that are facing challenges
with PQC development. This support also included
support for the formation of a national network of
PQCs across the country. CDC in collaboration with March of Dimes has supported
the development of the National Network
of State Perinatal Quality Collaboratives, which
is a consultative and mentoring resource to
increase capacity in states to improve maternal
and infant health. The mission of the network
is to support the development and enhance the ability of state
perinatal quality collaboratives to make measurable improvements
in state-wide maternal and infant healthcare
and health outcomes. The network was officially
launched in November of 2016, with the goals to strengthen
existing leadership, identify and disseminate best
practices for establishing and sustaining PQCs, and to
identify and develop tools, training, and resources
necessary to foster the sharing of best practices to support a
sustainable PQC infrastructure with data driven quality
improvement processes to improve maternal and infant
health across the country. All of the state PQCs in the country came together
during the network launch in November and each state
PQC presented a poster with their current
projects on display. I wanted to highlight
some of the state PQCs that are actively working
to improve antibiotic use for newborns in Colorado,
Tennessee, Oklahoma, Wisconsin, and North Carolina,
which we’ll hear more about later in the presentation. It is our hope that the
experiences and successes gained by these PQCs in this
work will provide examples that can be shared
with other states. Finally, I would like to draw
your attention to our webpage, which contains resources
for PQCs, including the archived
presentations from this PQC webinar
series, PQC success stories, and the PQC resource
guide, in addition to a link to state-based healthcare
associated infection prevention activities. We encourage you to check this
page for additional information about PQCs, including
contact information for PQCs in your state. I would now like to
turn the presentation over to Elizabeth Mothershed.>>Thank you, Zsakeba. I’d really like to give a
special thanks to the Division of Reproductive Health
for inviting us to present on this joint webinar. The goal of presenting
together is connect the state and local healthcare
associated infection and antibiotic resistance
programs currently working on infection prevention and
antibiotic stewardship efforts with the perinatal
quality collaboratives and other existing resources
in order to maximize efforts. In some states, the HAI programs and the PQCs are already
connected, as you’ve heard, through their work previously
on CLABSI prevention. We think there’s a
great opportunity to expand the collaboration between state-based
healthcare [inaudible] infection and antibiotic resistance
programs and PQCs in the area of antibiotic stewardship
as well and to encourage connections
between the HAI/AR programs and PQCs who may not
already be working together. So first, I want to give a brief
introduction to our division, the Division of Healthcare
Quality Promotion. DHQP priorities have
not changed, but we know there is a need to
do more to protect patients. We continue to work to
prevent healthcare associated infections, including
those caused by antibiotic resistant
pathogens, and are working to eliminate device and
procedure related infections, like central line associated
bloodstream infections and catheter associated
urinary infections and surgical site infections
from all healthcare settings. We are working to reduce
transmission of infections between patients, infections
like Clostridium difficile, the carbapenem-resistant
enterobacteriaceae, and MRSA to approaches like
improving environmental cleaning and understanding how patients
move between facilities. We are keenly focused on
working on better ways to detect and contain new types
of resistant pathogens and to control outbreaks of all healthcare-associated
infections, and we’re also focused on improving antibiotic
use in every situation. For many years, CDC has been a
leader for providing education and training about
antibiotic stewardship through the Get Smart campaign. More recently, even greater
emphasis has been placed on improving antibiotic use
across all areas of healthcare and in the community as a
result of CDC sounding the alarm about antibiotic resistance. There is no doubt
that overprescribing and misprescribing
is contributing to the growing challenges
posed by Clostridium difficile and antibiotic resistant
bacterium. And studies show that
improving prescribing practices in hospitals can not
only help reduce rates of these infections, but can
also improve individual patient outcomes and reduce
healthcare costs. But of course, we don’t
do this work alone. DHQP works in close
collaboration with many partners both
within CDC and externally for implementing
proven strategies for improving antibiotic use
in all healthcare settings and for developing new
and improved strategies for special populations
and rural hospitals. We work closely with state
and local health departments and the emerging
infections program as a core public health
prevention network and we collaborate
with academic centers through the prevention
epicenters to conduct innovative infection
control and prevention research. We also work closely with our
federal partners, like CMS and others, with our public
health and healthcare partners at both the national and
local levels on practices and policies, including
payment policies that promote appropriate
antibiotic use. And we seek ongoing
input from patients and patient representatives to
bring a critical perspective and reinforce that our
purpose and our mission is to protect patients
and save lives. Last year, because of the
budget initiative CDC received for combatting antibiotic
resistance, we were able to significantly increase
support to the state and local HAI/AR programs. HAI/AR prevention programs work
at the local level with many of the partners mentioned in
the previous slide in order to implement these
prevention strategies and to improve antibiotic
prescribing across all healthcare
settings and in the community. In all 50 state health
departments and six local health
departments, we’ve expanded core
capacities to prevent HAIs, respond to outbreaks, and contain antibiotic
resistance threats, including adding funding for
enhance laboratory capacity for carbapenem-resistant
enterobacteriaceae testing. And in 28 health
departments, that’s 25 states and three major cities,
programs are working as prevention networks across
public health, healthcare, and the community to
prevent transmission of Clostridium difficile
infections an AR pathogens and to measure and
improve antibiotic use in acute care hospitals,
such as through reporting to the National Healthcare
Safety Network. It’s really undeniable that
partnership is critical to making a difference
in preventing infections, protecting patients, and
improving antibiotic use. In addition to working
with the perinatal quality collaboratives, some states
have joined the effort of the Vermont Oxford
Network, as you’ve heard, the quality collaboratives
called Choosing Antibiotics Wisely, which focuses
specifically on key components of antibiotic stewardship
programs within NICUs. The Division of Healthcare
Quality Promotion has partnered with the Vermont Oxford Network
and we’re proud to have two of our experts, Dr. Arjun
Srinivasan and Dr. Dan Pollock, working as faculty
for this effort. There are already at least five
statewide collaboratives working with VON. And in 2017, VON is working
to build additional capacity in partnership with interested
states and organizations who will help lead
and scale up local and regional antibiotic
use improvement efforts. So this can be another
great opportunity for the state HAI/AR programs
and can add to collaboration with the perinatal quality
collaboratives as well. So that’s it for me. I’ll now turn it over to Dr.
Arjun Srinivasan, who will talk in more detail about
improving antibiotic use in newborn patients.>>Great. Thanks so much,
Elizabeth, and thank you to all of you for joining
the call today. And as Elizabeth said, certainly
to Keba for her leadership and the leadership
of the Division of Reproductive Health
here at CDC for bringing us all
together today. I’m going to try to convince
you in the next few minutes of these fundamental facts and I don’t think my task is too
challenging because I think most of you are on the call today
because you already know and believe that most or all of
this is true, that there is room to improve antibiotic use in
our NICU and newborn settings, that improving the way we use
antibiotics will have direct benefit to our patients,
that there are ways that we can do this, and now, there is increasingly
a will to do this. We only need to find the
best ways to make it happen. There have been a number of
studies that have demonstrated that there is room
for improvement, there are opportunities
to improve antibiotic use, in NICU settings, and want to highlight a couple
of those for you. And the first is this. This is directly looking at
antibiotic use that was thought to be unnecessary, and this
was a retrospective study done in a NICU. And what they found, that about
a third, 35%, of the neonates in this unit received at
least one inappropriate course of antibiotics, mostly because
of excessive continuation of antibiotics that could
have been stopped earlier. Vancomycin was the most
commonly misused antibiotic, with about a quarter of
the days being considered to be inappropriate, and carbapenems were most
frequently used inappropriately. About 43% of all of those
carbapenem days were considered to be inappropriate. And certainly, that is a
very concerning finding given that carbapenems are one of our
kind of last resort antibiotics. We also have some very
nice data that Joe Schulman and his colleagues have
published demonstrating the incredible variation in the use
of antibiotics in a series of — number of NICUs throughout
the state of California. This is just a box and whiskers
plot showing that the rates of antibiotic use ranged from almost no neonates
getting antibiotics to almost all neonates getting
antibiotics in these 127 NICUs. And it doesn’t allow us to
comment directly on whether or not all of that use was
necessary, unnecessary, appropriate, inappropriate, but
I think those of us familiar with quality improvement know
that whenever we see a range that ranges from somewhere
between almost no one and almost everyone
getting something, there is clearly some room and
opportunity for improvement. The over use of antibiotics
wouldn’t be an issue if it didn’t have direct
consequences for our patients, and it certainly does. One of the big ones, of
course, is the growing epidemic of antibiotic resistance and,
of course, as all of you know, the newborn population and particularly our NICUs are
not being spared this problem of antibiotic resistance. This was data– the most
recent data that I could find in my literature review showing
that antibiotic resistance is, indeed, rising, and rising very
sharply in the NICU setting. And it’s not just with MRSA
and gram positive infections, but also look at ESBLs, extended
spectrum beta lactamase, producing organisms, and
even down at the very bottom, the beginning of the emergence
of carbapenem resistance in our NICUs, making
our needs to look at carbapenem use
even more important. We also know that the overuse of antibiotics has some
really direct clinical impacts on our neonates. Here, two nice studies that
looked at that and they looked at patients in NICUs who got
extended courses of antibiotics. So more than five days of empiric therapy despite
having sterile cultures. And the author said in
both of these studies that these were situations
where the use appeared to be inappropriate,
couldn’t definitively say so, and look at what they saw. If you got extended courses
of these empiric antibiotics, despite having sterile cultures,
you were at increased risk for necrotizing enterocolitis,
death, and prolonged length of stay. So some really serious clinical
impacts from the potential over use of antibiotics. And of course, we are increasingly
understanding how exposures to antibiotics greatly
impact the microbiome and we’re only beginning,
I think, to understand just how important
the microbiome is to our health and especially to the health
of our youngest patients who will be impacted potentially
for the rest of their lives by perturbations in
their microbiomes. But there’s already some studies
showing that genetic analysis of sequential samples
showing that acquisition of resistant bacteria begins
at birth and can, in fact, be driven by system
antibiotic therapy. And the authors of many of
these studies point out this is so important not just to the infant who’s
getting the antibiotics, but because of the risk of
transmission of infections within the neonatal setting,
this antibiotic exposure and this microbiome disruption
has implications for all of the patients in that
intensive care unit. [Inaudible] and there’s good
studies to support the fact that improving antibiotic use
leads to important benefits both to our individual patients
and for the larger society. And I think it’s important
to emphasize both of those. I think in the past, we’ve overemphasized
the societal benefits, the need to improve
antibiotic use for some kind of nebulous good for
society at large. And that’s important and well
and good, but as providers, we know that what’s most
important is the care of the individual patient who’s in the isolette right
in front of us. And it’s important to emphasize that improving antibiotic
use will have direct benefits for those individual patients. Improving antibiotic use can
reduce antibiotic resistance. This is data from a hospital
where they restricted the use of some really broad-spectrum
antibiotics and then looked at the susceptibilities of
pseudomonas aeruginosa before and after that restriction. And as you can see
across the board, not only did the emergence
of resistance slow, they actually had a
reversal in resistance. The isolettes in that hospital of pseudomonas actually
became more susceptible as antibiotic use
began to go down. So it shows us that we can
actually use improvements in antibiotic use to turn
back the clock on resistance. Important to emphasize,
though, that this is not just about the height of
bars in a diagram. This has direct impact
on patients. This is a study looking
at patients who got either short courses of
antibiotics, a three-day course, compared to patients in an ICU. These are adult patients who got
longer courses of antibiotics. And as you can see, the patients
who got the shorter courses of antibiotics were
significantly less likely to go on to develop an antibiotic
resistant infection during that hospitalization. And I think this does bear
direct relevance to patients in our neonatal intensive
care units who, of course, oftentimes have very
long lengths of stay and are very high risk for getting resistant infections
during the course of that stay. So reducing the antibiotic
exposure could help decrease the risk of subsequent
resistant infections. And of course, in an era when
patients are increasingly sick and increasingly complicated and
where we have more challenges with antibiotic resistant
organisms, it only makes sense that having input from experts in antibiotic use would help
improve patient outcomes, and that’s, indeed, been
shown to be the case. This was a randomized trial,
where patients were randomized to either get input from an
antibiotic stewardship program, shown in the gray bars, or to get whatever antibiotics
the providers would have normally prescribed. And as you can see, the
patients who had the input from the stewardship program
were almost three times more likely to get a guideline
recommended antibiotic, which meant that they were
almost two times more likely to have a cure of their
infection and 80% less likely to experience a treatment
failure. So improving antibiotic use has
a number of important benefits, but how do we make
those improvements? Well, again, here we are able to
turn to some specific examples from the NICU setting showing
us a variety of different ways that people have made measurable
improvements in antibiotic use. The first was a focus
on vancomycin. As I showed you earlier,
vancomycin was one of the most commonly used
antibiotics in a couple of those NICUs where
it’s been looked at. This was a study where there
was a lot of vancomycin use and so they implemented
some guidelines. They came together and
made consensus guidelines for how they would use
vancomycin and, as you can see, the number of patients who were
started on vancomycin dropped and the number of
starts decreased as well. So significant reductions
in vancomycin use. Another NICU took that
same idea and said well, let’s not just apply
this to vancomycin. Let’s look at all of our
broad-spectrum antibiotic use. And in fact, when they looked at
broad-spectrum antibiotic use, they had seen a sharp
increase in that use. They, again, got their
experts together, developed consensus
guidelines, an agreement, for how they were going to use
these broad-spectrum antibiotics in their NICU, and you
can see that the use of these targeted broad-spectrum
antibiotics dropped by 61% and total antibiotic use in
that NICU dropped by 18%. Through a lot of the work
that you heard a little bit about from Elizabeth
that’s been going on through the Vermont Oxford
Network’s iNICQ Collaborative on antibiotic use, we’ve
seen a tremendous focus on early onset sepsis. A lot of folks are fundamentally
revisiting the management of this condition and
beginning to ask this question, does every neonate with
potential signs and symptoms of sepsis need the
same approach? It’s one that had taken
historically and I think it’s to their credit that
they’re beginning to revisit and challenge that
assumption that we needed to do this the same
way in every situation. A number of hospitals,
NICUs in this collaborative, have been implementing a
variety of different measures and new risk assessments
and changing the way that they approach
neonatal sepsis. And the results have
been really encouraging, drops in antibiotic
exposure and even reductions in hospitalizations, allowing
newborns to stay at home with their families rather
than being in the hospital. Some really exciting
results there. This is a really critical time for improving the way
we use antibiotics for antibiotic stewardship
in the NICU setting. Certainly, we are
confronted by the threat of antibiotic resistance
and we do feel like we are at a critical point in
trying to get on top of this problem before it
becomes even more significant. And antibiotic stewardship
is now a requirement for all hospitals
that are accredited by the Joint Commission,
which probably applies to most of the hospitals that have
neonatal intensive care units. And so, there is now a
requirement that hospitals, including the NICUs, take steps to improve the way
they use antibiotics. So the question, I think, is not whether we should
do this, but how we do it. And we’re seeking to answer
some really important questions. First of all, how do we
implement effective antibiotic stewardship in NICUs? There is a lot of published
literature looking at this in adult and even in
pediatric populations, but less in the NICU. So we need to figure that
out in the NICU setting. We know that it’s going to
look different from hospital to hospital, and we
think in every hospital, it can be a partnership between
the experts in neonatology and the NICU staff,
the NICU nurses, and the antibiotic
stewardship team. We’re also considering how we
best monitor antibiotic use in NICUs to provide
data for action. CDC, as you have
heard, is partnering with the Vermont Oxford Network
on this iNICQ collaborative and our goal really
is to find the ways to implement opportunities
to improve antibiotic use for all newborns and the
collaborative is also providing us an opportunity to
answer that second question. What data on antibiotic use,
and resistance, frankly, is going to really drive
the important actions in our newborn population? As Elizabeth mentioned,
there are several states that are now all in, and I
think Madge has even chatted that we’ve got a couple
of other states, Georgia and West Virginia, that
have come on board with all of their NICUs, and that’s
obviously been very exciting. We think that in many states, there have been some really nice
opportunities for collaborations between the state healthcare
associated infection prevention programs and the
perinatal community, and we are having this webinar to answer this important
question. Are there more opportunities
to connect these groups to advance the care of newborns? I’m going to close by saying
that we know from our experience in healthcare associated
infections and you all know from your experience in
perinatal quality collaboratives that these state-based efforts
can be incredibly effective in improving care. And we would like now
to harness the power of these state collaboratives to
try and improve antibiotic use in newborns and we are eager to
learn from you what we can do to help with that effort. And I’m going to conclude
there and turn it over to Marty to talk a little bit about antibiotic stewardship
and neonatal sepsis. Marty?>>Hey, thanks so much,
Arjun, and thank you all for the opportunity
to speak with you. Good afternoon and good
morning wherever you are. I’m not going to beat
to death the data that Arjun has already
well presented, but I think it’s just
worth reiterating a couple of pieces of information here. This, again, is back to the
study that Arjun presented, Joe Schulman’s work and the
work of the folks at the CPQCC, and it’s really interesting
that, really, some of the seminal work that
has been done in the area of antibiotic stewardship
in newborn and NICU care has been done by the perinatal
quality collaboratives and with CPQCC leading
the way in this. What I want to call your
attention to is the graph on the right-hand side,
which shows the variation in antibiotic use rates that
you find in different types of NICUs, so similar types of
care, whether they be regional, intermediate, community, or non-CCS California
certified NICUs. And the tremendous
variation that you see there, the variation depending on the
NICU type, is anywhere from 7 to 41-fold in antibiotic
use rates. And the outcomes
are no different within those certain
types of NICUs. So when the outcomes
are no different and we’re all doing
something so differently, we can’t all be right,
and Arjun is right on. He’s made the case well
and the data is out there and the case has been
made that we need to be doing something
about our practice. The discussion to this point
has really focused on the NICU, however, and I think
if we do that, we miss an enormous opportunity,
perhaps the biggest opportunity. Once babies get to the NICU, as we know in perinatal
quality collaborative work at the state level, you’ve
missed huge opportunities to improve care, whether
it be on the maternal side or on the newborn side. And so, I want to draw some
attention to what’s going on in newborn nurseries as well. This is work that comes from
Karen Puopolo and her group in looking at what happens
with antibiotic prescribing for a cohort of babies that
she looked at over two epics, looking specifically at
different CDC guidelines, which changed in the years
2002 and then in the years 2010 in terms of what we did with
babies with group B strep. What’s important to note
is in the CDC 2010 epic, where we still and
currently are in an era where we’re evaluating babies
whose moms are diagnosed with corneal amniotis. And what you see in
this later epic is 6.8% of asymptomatic infants
are evaluated for sepsis in this facility and 5.2% of asymptomatic newborns are
treated with antibiotics. That is a huge proportion,
a huge burden of antibiotics being imposed on
babies who ultimately are going to have negative cultures. So the decision for
us as neonatologists and as newborn care providers and having been a general
pediatrician out there sitting in a newborn nursery with a tachypneic baby
has always been do I treat or not treat? And that is the question
that Arjun poses here today and I think it’s one that we all
have to confront very clearly and seriously as providers. Arjun has made the case for
how serious this problem is and we have to decide if we
are in a situation where when in doubt, it’s best to treat. That’s the way I was raised. If a baby looked like they had
signs that might be subtle signs of infection, the
risk was really that the baby might be infected
and if you did not treat them, what might happen to that child? And the thought process that
I was raised with, 15, 20, 25 years ago at this
point, I hesitate to say, was that there was really no
down side to a couple of days of amp and gent or even
a week of amp and gent. And we know that
is not the case. So Arjun has hit these, but
I’m going to repeat them. Antibiotic resistance
is a huge problem. Morbidity and mortality
associated with extended antibiotic courses
is absolutely there in terms of NEC, fungal, sepsis, death,
advanced length of stay. We know that infants treated with antibiotics now
experience a decrease in the genetic diversity
of their microbiome. And the problem there is not
just that the organisms change, but that the signaling
from the gut changes. And we know now and are just
beginning to understand, we are in the infancy barely,
probably in the fetal stage, of understanding the impact of
signaling from the intestine into what may happen later
on, years down the road, in terms of programming
development for an individual. And autoimmune disorders
certainly are something that’s potentially problematic and
being looked at very heavily now when we go in and alter the
microbiome, which may happen with even just 48
hours of antibiotics. The acquisition of resistant
bacteria does begin at birth, can be driven by that
system antibiotic therapy, and there are issues regarding
separation of moms and babies when we go ahead and we
decide that we will treat with antibiotics, and that
may impact breastfeeding and bonding in the family. So should we just treat
if we’re not sure? Well, this is just recent data
that came out of Puopolo’s group as well, looking at what
happens with sepsis evaluations across the national
network of nurseries, and this was published
in PEEDs this month. This is looking at 81
nurseries in 33 states. Typically, the obstetric
diagnosis of chorio is the most
common factor used to identify treatment for
risk for early onset sepsis. And 51 of the 79 sites in this
study ultimately were using the American Academy of
Pediatrics guidelines. Eleven used the published
sepsis risk calculator alone, which I will mention
briefly in a minute here. And there was separation that
occurred and they detailed what that separation actually
was in some of their data. What you’ll see in the middle with the red circles here is are
early onset sepsis procedures conducted in a location
separate from the mother’s room? Yes, in 76% of cases. If IV antibiotics are started
on a well appearing newborn, can newborn room in with mother? No in 40% of cases. If IV antibiotics are started
on well appearing newborn and newborn cannot room
in with the mother, where is the newborn cared for? NICU special care
nursery in 75% of cases. So there’s clearly issues
related to the separate of mom and baby at this point and
with our focus on breastfeeding and in the incredible benefits
that we know that we get from that, this is something that we should all
be considering. So as in anything, with quality
improvement you can have the best protocol in the world and
the best evidence in the world, but what is required is
dealing with the culture war that is going on in your unit,
whether it’s a newborn nursery or it’s a neonatal
intensive care unit. And it’s not necessarily
that people are probiotics or antibiotics, but it is
that people are worried about what will happen to a baby
that they may not treat and it’s that training and that culture
which has to be overcome with reasonable evidence
to say that it’s safe not to necessarily default
to the practices that we’ve taken in the past. Because they potentially
do cause real harm and can cause injury that we
really have begun to appreciate over the last 5 to
10 to 15 years. The simple fact is
the collateral damage of antibiotic overuse is huge. The only treatment that we use
and prescribe in a hospital that can not only cause harm to the patient we’re prescribing
it for, but kill the patient in the next bed, is antibiotics. And I think we have to really
start understanding that and appreciating that. And I think in the past, I will say I have not been
someone who’s really thought much about that and
appreciated that. But certainly, work of the
folks on the phone here and some of the research that we
presented and Arjun has spoken about have opened my eyes
to what we really need to be thinking about in how we
prescribe these medications. So I’ll talk a little bit about
what’s going on with our group in North Carolina as one of the state perinatal quality
collaborators trying to focus on antibiotic stewardship. What we have developed is
a state-wide initiative that includes not only NICUs, but newborn nursery
units, mother-baby units. We are promoting
collaborative teams at hospitals that include both newborn
and NICU care areas. Currently in our project
that’s ongoing on, just recently launched
last month, we have 41 centers
participating, 20 of those centers have
not only newborn nurseries participating, but
NICUs as well. We’ve also got at this point
three states participating. Hawaii, Illinois,
and Virginia have representative institutions. We’re also partnered with
Italy and we’re looking forward to our site visit there. The structure of our project,
this sort of is a little bit of the formula that
we use for all of our quality improvement
collaborative teams and initiatives that we form. But just like any good
PDSA organization, we’re constantly changing this. But ASNS, we start out
with an expert team. For us, this includes 54 members
who are nurses, physicians, hospital ID consultants,
parents, payers, Department of Public
Health representatives, our Get Smart folks from
the state of North Carolina, all participating in webinar
calls and face-to-face meetings to develop an aim
statement, an action plan, and identify the key measures. And those measures are both
process and outcome measures. The workhorses for this work
are the perinatal quality improvement teams at
the hospital level. It’s a requirement that
we have a nurse, a doc, a family partner, and a
front office administrative representative in that group. We put out prework. We do snapshot surveys
and we lead an action plan through the PQCNC team working with those local perinatal
quality improvement teams. We partner across nursery
and newborn care areas, and this has been
fascinating for us to go out and do site visits at
multiple institutions and bring NICU teams and
newborn teams into the same room and speak with them and get
them on the same page as far as antibiotic practice. We are introducing
different elements for the different
practices in those units and the different
patient populations, but what we feel is critical in this is not only doing a
superb antibiotic stewardship project, but also
promoting collaboration and the development of quality
capacity for these facilities down the road to participate with their state perinatal
quality collaboratives in future work. And facilitating all of this
is the PQCNC core team, which– what I’m describing here is
similar to what you will find in most of the state perinatal
quality collaboratives who are on the line here, who certainly
are working within CDC, and who are now growing
members of the National Network of Perinatal Quality
Collaboratives. But there’s a core team that
basically facilitates the work of teams in the field. What we at PQCNC do and
we see is our duty is to build web-based
reporting systems for all of our initiatives,
including ASNS. For ASNS, we have e-mails,
calls, and site visits to recruit participating
facilities. We weekly contact and
facilitate the PQITs, the perinatal quality
improvement teams. And then, again, weekly
e-mail newsletters, webinars, and quarterly face-to-face
learning sessions are critical structural elements for
how we carry out this plan. Specifically for ASNS, what
we are looking at as far as our aim, and we have to throw
down a measurable objective aim that we expect to be able to
demonstrate, shows success for this initiative
at the end of it, is that we will show a
decrease of 20% in the number of patients exposed to any
antibiotic and a decrease of 20% in the duration of antibiotic
administration past the first 48 hours of life with a
negative blood or CSF culture. So we are focusing
on acute infection. We feel that to try and bite
off all infection certainly in NICUs is a very difficult, challenging, and
daunting project. We feel that the outcomes
are much more measurable if we focus initially
on acute infection. We have no doubt that there will
be spillover from this project into antibiotic practices
for the development and identification and
treatment of late onset sepsis, but we are focused acutely
right now on the acute process. We anticipate in future
phases that this could go in several directions that
might include surgical babies and surgical prophylaxis,
that might include treatment of late onset sepsis
in antibiotic courses, antibiotic selection as well. The current action plan, I will
highlight just three elements in there that we have as
far as recommendations. One includes the recommendation
to consider the Kaiser/Puopolo, I like to call it,
sepsis calculator, the Antibiotic Timeout,
and partnership with patients and families. The Puopolo sepsis
calculator, for those of you who have not seen this, is
available on the Internet. Pardon me, I don’t
have the link on there. But if you plug in the
Kaiser sepsis calculator, you will be brought
to it on the Internet. What the Kaiser sepsis
calculator does is do away with looking at just a
straight up diagnosis of chorio, which has become very
subjective, and brings lots of babies into the realm
of the antibiotic world, and it includes a
number of factors, including what your sepsis
rate is at your facility, gestational age of the
baby, mom’s temperature, rupture of membranes,
maternal GBS status, and type of antibiotic treatment
that was received intrapartum. So there are a number of
continuous variables in here, which really add additional
power to the Puopolo calculator because the risk certainly
for maternal temperature and for gestational age, really,
depending on the continuation of the variable, heightens
your risk for infection, and this is picked
up by the calculator. This is conducted and
calculated as far as the number of sepsis risk score
that then is correlated with the clinical
exam of the baby. So no one is saying that you
can just plug in a number and go ahead and
figure out whether or not a baby should be treated,
what the temperature was, what the gestation
was, et cetera. You have to correlate this
with a clinical exam and to sit and talk in a whole
lot of detail about the calculator would
require a little bit more time. We can certainly
handle some of that in the question and
answer period. But this is something that
we’re recommending folks and it’s something that’s
been used in several of our sites in North Carolina. The sepsis calculator in
action, I can show you here. And this is from the work done by our general pediatric
group here at UNC. The neonatologists had
nothing to do with this. This is Carl Seashore
and his incredible band of pediatric nurse practitioners
putting this to work. And several of the centers now in North Carolina
are picking this up. But what you can see is looking
at our exposure to antibiotics, we’re sitting about
7.2% of babies until the intervention was made, which is the orange
arrow pointing down, which was the introduction
of the Puopolo calculator. And what we see is a reduction of antibiotic exposure
to 2% of newborns. So we have seen at UNC a 73%
reduction overall in exposure of newborn babies to antibiotics and we have seen no babies
being missed at this point. When you look at the
number needed to treat, the calculations that were done in putting together the
calculator, when you’re looking at babies who are well,
who have a reasonable exam and are relatively low risk, but who might otherwise have
been chorio, the number needed to treat for those babies would
be somewhere around 1 in 9,000, to actually pick up one baby, and I don’t think there are too
many therapies that we undertake that are 1 in 9,000 necessarily. The other interventions
that we’re undertaking in this initiative
and really trying to promulgate are the
antibiotic timeout. So what we’re trying to incorporate is
culture change here. What we hope to do is
on every baby who’s on antibiotics every
day in this initiative, people will discuss
the five rights of antibiotic administration. Is the baby on the right
drug for the right bug with the right dose
with the right duration with the right levels? And every day, we want
folks to be doing this. We don’t want them doing
it every other day, we don’t want them
doing it after 48 hours. We believe this has to
become part of how we think about antibiotics and
it’s only going to happen if we do it every
day and make it part of our personal rounding
experience. We’re also partnering
closely with parents in antibiotic stewardship and newborn sepsis
in North Carolina. We developed a number
of educational materials that we’re using with parents
to prompt them with questions that they can ask
their providers. We’re also offering logs for
parents in terms of accounting for the numbers of
antibiotic doses that their babies have received. And what we’re requesting that
individual units be doing is that at the bedside, they
actually post where babies are in their antibiotic
dose, not days, but dose, and when the dosing the
course is expected to end. We’re asking that on rounds,
that parents be included in the rounds and this
be talked about on rounds with the families so that
they be engaged in the process of antibiotic exposure. We feel this is a real
opportunity, perhaps, to start off families
with an understanding when their baby is young of the
potential risk for antibiotics and the double edged
sword that they present. Yes, antibiotics can
do wonderful things and there are certainly
indications for them. But you don’t hope for antibiotics every time
you go to a physician. And so, this maybe will get
us down the road to starting to do some education in
the outpatient environment, where patients might have a
little bit of a different view of the antibiotic world
in the office setting. The potential impact of
ASNS in North Carolina, 122,000 some odd births
in Carolina in 2016. We’ve got 70% of birth hospitals
or 70% of births accounted for in our current ASNS project. That’s about 85,000 infants
who are potentially going to be impacted by this
project with the hospitals that are participating. And if you use — a reasonable
estimate is about 7.5% of infants, newborn infants, are currently being
exposed to antibiotics. That’s about 6,442 babies. If we look at what we’ve seen
with the experience published with the Puopolo calculator
as well as with the experience from a couple of our sites,
including UNC and PQCNC, we expect that we can
avoid antibiotic exposure for 1,288 babies. Looking at that 20% mark,
we think its actually going to be much higher based on the
UNC experience, and it may be as many as 3,000 babies
a year in North Carolina who will avoid 48 hours
of antibiotic exposure in the newborn nursery. So state PQCs and antibiotic
stewardship are a unique opportunity and bad
on us if we miss it. The NICU is important. That’s where I live. But we’re missing a great
opportunity on the newborn side and we need to engage this. The organizations that have led
the way with this have been PQCs and the PQCs, perinatal
quality collaboratives, include multiple state partners who can support stewardship
efforts. It includes payers,
purchasers, Medicaid, DPH, and a host of others. And every PQC is a
little bit different. They have different partners
and different stakeholders that they’ve engaged, but all of
these folks are able to engage and push on different
pressure points to help produce in a reasonable manner
some good end results. And that is one of the
real powerful advantages of state PQCs. The PQCs doing this work
are conducting the work in the continuum of care in
which hospital care is provided within the state, between
state nurseries and NICUs. This is the natural environment
of care and the natural go-to for a collaboration
and a partnership to do this work absolutely
should be the state PQCs. Stewardship also very
importantly offers an opportunity for us to
look down the road. With Stewardship, there’s
a great opportunity to build collaboration
between the well newborn side, providers, practitioners,
families, administrators on those sites, with folks on
the NICU side, within hospitals and across the state, and
that will build collaborative capacity for future projects. Future directions for
PQCs, for us at this point, what we’ve talked about
include antibiotic prophylaxis for C-sections, neonatal
surgical antibiotic prophylaxis, and the treatment of
later onset sepsis, which we’ve mentioned earlier. So PQCNC ASNS at this
point include several state and international groups. It’s a unique opportunity
for PQCs to engage providers. Our project has an aim
statement action plan and data reporting
system that’s built. The advantage for most of the
state PQC projects and certainly for PQCNC’s ASNS
project is there’s no fee for participation, and that is
extremely limiting for a number of state PQCs and facilities. Maintenance of certification
is available free of charge to participants in these efforts and we would welcome the
opportunity to partner with other state PQC leaders
or any other hospitals. It’s — once this
system is built, the systems that
we build are able to accommodate multiple other
participants once the initial work is done. And I’ve just put some
contacts up there for folks if they’re interested in
considering joining us in the North Carolina project. I think it’s important
that state PQCs and now the National Network of Perinatal Quality
Collaboratives really think broadly in terms of the national
work that we can be doing. We have an example of this. We did this back in the early
2010, 2011, into 2012 period. We ran a project called NCABSI. NCABSI was a partnership
between ARC, AHA, and HRET. PQCNC led that, but we were nine
states that were in partnership, nine state perinatal
quality collaboratives. We had over 100 NICUs that
were engaged in that project. We had state PQC leaders
who led those projects within their states. Then, the action plans
and measures were adopted to those states and they were
executed within the states. We developed strong partnerships with the state hospital
associations. We incorporated CUSP, comprehensive unit safety
training, into those programs through the hospital
associations. We saw an overall reduction
of 48% in CLABSI rates in that project with
nine states. And the other critical element
is that money and funding that came to that project
went to state PQCs. What folks need to realize, and
I hope the CDC will realize, they’ve made a big investment
in the state PQC project. The opportunity with the newborn and NICU antibiotic
stewardship work is to help support state PQCs
in a much larger respect. And what could happen, and
Arjun asked, how can CDC help? My hope would be people
on the infection side and the stewardship side at CDC
antibiotic stewardship group, would say these are just
natural collaborative partners who we can help and we can
support, and not only help them and support them in doing work
in antibiotic stewardship, but in the meantime, build
collaborative organizations at the state level that can
do great work down the road. So the thought about a
national project is one that we have talked about
within the NNPQC and we talked about this at our
national meeting back in Texas during the
end of last year. The impact of this potential
project would be huge if you’re looking at newborn
nurseries and the NICUs. Just some really quick
numbers to think about. If you’re looking nationally,
the possibility exists to avoid antibiotic exposure for
almost 150,000 newborns annually if there is adoption and reasonable agreement upon
the Kaiser sepsis calculator. If you look at the PQCNC
goal of a 20% reduction in antibiotic use or even
take VON’s 25% reduction that they’ve reported for
their group, antibiotic days in the NICU could be avoided
for 62,000 to 70,000 patients, and this would be a
tremendous benefit. It represents a tremendous
opportunity. I think that CDC has been
very serious about trying to support state perinatal
quality collaboratives. We have all said as a group
within the NNPQC that we want to make this nation the best
place to give birth and be born. This is what we’re
doing in North Carolina and I think there’s a huge
opportunity now for the CDC and the infectious disease folks and the antibiotic stewardship
group to partner with state PQCs and really make this
happen nationally. Thank you very much.>>Thank you so much, Marty. We appreciate your presentation. At this time, we’re going to
open up the line for questions. Amber?>>Ladies and gentlemen,
if you would like to register a question,
please press the star followed by the one on your
telephone keypad. If your question has been
answered and you would like to withdraw
your registration, please press the pound. One moment for your
first question.>>While we’re waiting
for audio questions, we’ll start with the
questions that were sent in through the chat function. And the first question
is from Barbara Clarke. Has there been research
into the question of how much litigation
avoidance is driving positions of providers to opt for
antibiotic use in ICUs or in NICUs in the
United States?>>Yeah. We’ve — I’ll take
that Ke-, but this is Marty. I am not aware of a study
that has looked at that, but we’ve had this conversation and my strong belief is it’s
not necessarily litigation that drives people in this. And I may be naive in
this, but I don’t think so. The people that I know
who are neonatologists and general pediatricians and
family practitioners dealing with these babies, it isn’t so much necessarily
the litigation issue, it’s that they truly do worry
about what happens to the baby if I don’t treat him
and he’s really sick? And you’ve been raised with
what the potential signs of sepsis are and the baby’s
tachypneic at four hours. My threshold is he’s
going to get treat. And I don’t think it’s so much
a litigation issue at that point as it is really just a fear
that you might miss something. That’s my own personal opinion. Others might have others.>>Okay. Any other
responses to that question? If not, we’ll move
on to the next. Okay. The next questions
from Heather Hastings. Does the evaluation of
success include cost savings from reduced antibiotic use? And I’m assuming
this is referring to the success described in the
presentation in North Carolina.>>Yeah. So we’re
trying to — yeah. It’s a great question. We’re trying to determine
how we might get to that because it would
be very powerful to put some meaningful
numbers on this. There has been some
literature put out there from the Puopolo group
looking at this in terms of the cost for treatment. The numbers are fair. I mean, the cost — they can
demonstrate the cost savings related to antibiotic
administration, pharmacy cost, nursing cost, blood drawing,
all host of things probably that you’re thinking about
as you wrote that question. So there is one article out
there and I didn’t put it in my slides, but we can make
that available to you all. But there isn’t — there hasn’t
been a great assessment of that, other than the only
one publication I know from Karen on the topic. And it does show cost
savings, by the way, and it’s reasonably significant.>>Okay. Thank you. And while you’re talking, Marty,
is another question for you from Ben Chan, for
Dr. McCaffrey. I’m wondering the reason for
not including pharmacists on the PQYTs. For antibiotic source
of activities, pharmacists are key partners.>>Yeah. So in terms of what
we’re absolutely requiring, this is our generic requirement
for any team that we put down in a hospital for a
quality improvement team. So we want at least a doc,
a nurse, a family member, and a front office
representative. For all of our teams, pharmacy
has been critically involved in all of them and our
expert team has included — at this point, it’s got three
pharmacists on it right now. So it’s a great point. Yeah. It’s an oversight
that I didn’t put that down. But absolutely. Pharmacists have to
be involved in this. They are going to drive this,
by the way, and especially — a lot of this can be driven sort
of with computerized order entry and sort of the way you sort of
change practice based on that, and they are key in that.>>Okay. The next question
is from Kelsey Everson. Using the Kaiser calculator,
it recommends not to treat. Is there a recommended
observation period?>>No. So there isn’t a period. It will tell you if there is
a baby that you don’t treat, but it will pop up
in there, observe, and it will tell you that. But if a baby falls out
and they say no treatment, there isn’t a recommendation
just to fall back just because there is a diagnosis of
chorioamnionitis, for instance, where you say, well, I’ll just
watch him for 24 or 48 hours. So the calculator directs you
fairly well and the — it’s — if you haven’t seen it, it’s worth really sitting
down and looking at. I think they’ve done a
really good job at looking at a huge amount of data. This was a calculator
derived on over 600,000 babies in the Kaiser and the Brigham
systems, where they looked at data, did multiple
regressions to sort this out, and pulled out the
continuous variables. I mean, it’s something that
most of us will — a lot — none of us will ever
be able to replicate. But what is critical is
your exam in conjunction with that sepsis score. And then, what lights up in the
box on the calculator is what at least the Puopolo calculator
absolutely recommends. You could do whatever you
want, obviously, and a number of the places that
are picking this up in our collaborative,
they’re saying, yeah. We’re going to recommend it, but
everyone isn’t going to do it. Well, I mean, as we do
in quality work, then, if you don’t want to
do it, that’s fine, but we’ll just track your data and see what things
look like thereafter.>>Okay. The next
question I believe can go to any of the speakers. Would these programs seek to
reduce the use of antibiotic use of erythromycin specifically?>>This is Arjun. Marty might want to comment
on — I don’t know that — I don’t think that erythromycin
has been a specific focus of any of the efforts at least that
I’ve reviewed literature on. They’ve focused on — a
lot of them on vancomycin, on broad-spectrum antibiotics, and obviously the
sepsis ones tend to focus on penicillin and gentamicin. So I’m not aware of a
focus on erythromycin. Marty?>>Yeah. And I’m
not sure, is this — I’m not sure if it’s a question
related to [inaudible] or — I mean, some, certainly
preterm labor, we see a lot of erythromycin get
thrown around. Right, Arjun? I mean, not so much erythro. I guess [inaudible]. No. So I haven’t heard any —
[inaudible], yes, eye ointment. I have not heard
anyone really talk much about eye ointment prophylaxis. Madge is jumping
in now and said she and their initiative is not
counting topical erythromycin for eye prophylaxis as an
antibiotic and certainly, we’re not either
in North Carolina. It’s an interesting
thought, though.>>Okay. Fantastic. Okay. The next question
is from Munish Gupta. Is there a growing consensus that the Kaiser risk
calculator is a better approach than the CDC guidelines
for deciding antibiotics for well appearing
infants at risk for sepsis? Is there a plan to
modify the CDC guidelines? If so, when?>>Yeah. I don’t — Munish,
I don’t sit on the Committee of the Fetus and Newborn,
but some of my sources there, some of who are on
the line here, have hinted that that
is going to be the case. I don’t know when exactly
that’s going to happen, but people have been saying
for months now that any day, there’s going to be a
new statement coming out on how we treat early onset
sepsis and evaluate for that and certainly focus on chorio. But the word on the street
from folks in the know is that there will be
something coming where probably the Kaiser
sepsis calculator is going to be recognized
as an acceptable and reasonable practice.>>Okay. Thank you. And then, the next question
from the chat box is to Arjun. If you’re willing to share
the vision of NHSN data on AUAR in the future?>>Yes. That was from Madge, and
Madge, thank you so much for all of your helpful comments and questions throughout
the webinar and the chat. One of the things that we have
recognized in our partnership with the Vermont Oxford Network
and all of the facilities that we’ve been working
within in the collaborative is that the current
categories that we have for measuring antibiotic
use don’t work very well in the NICU setting. And we are now embarking on an
effort to assemble some experts from the neonatal community and
begin to have some discussions to try and determine,
well, what are the measures of antibiotic use that
are most meaningful in the NICU population? What data is going to
motivate improvement actions? How do you want to
look at this data? Are there individual
agents that we need to pull out that are the most important? Are there combinations, like
ampicillin and gentamicin that we could put
together and express? And so, we’re just really
now beginning that work, but that is one of the things
that we’re very focused on in this upcoming year
of the collaborative, is building on measurement
experience. And so, certainly interested
in hearing thoughts and ideas on that because I think
it really is a very important issue. It’s a nascent one for all
of the work that we’re doing in the antibiotic
use and certainly, we have very little
experience on that in the NICU and newborn setting.>>Okay. Can we check to see if there are any
questions on the phone line?>>Again, just a
reminder, if you would like to register a question,
please press star, one.>>You can also use this line if
you have any particular comments for the speakers or a question.>>And there are no
questions at this time.>>I don’t know if Madge
has been very active. I don’t know, Madge, if
there’s anything you wanted to comment on specifically?>>Yes. This would
be a good time — oh, she said she doesn’t –>>Have a phone line. Okay. Well, thank you
for all your chats.>>Yes. We appreciate
your participation. So if we don’t have any other
questions, I’m just going to check to make sure
they’re not on chat –>>And there are no audio
questions, Dr. Henderson.>>Okay. In that case, we
would like to thank all of our presenters for such
an informative presentation on improving antibiotic
use in newborns. We’d also like to thanks
all of you for participating in this webinar and we’d like to
invite you to provide feedback about this presentation
and the webinar series. We’ll be contacting you after
this webinar for your input. We hope that our web page and this webinar series
will facilitate exchange of information and
promote visibility of perinatal quality improvement
activities throughout the country. You may also visit our web page at www.cdc.gov/reproductive
health/maternalinfanthealth/pqc to learn more about CDC support of perinatal quality
improvement collaboratives. Again, if you would like
handouts for this presentation, they were attached to your
reminder e-mail at the beginning of the presentation
and will be sent again in the reminder e-mail. Thank you again for
participating and have a wonderful afternoon.

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