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Variability in antimicrobial use in pediatric ventilator-associated events

Manjiree V Karandikar¹, Susan E Coffin², Gregory P Priebe³

¹1Department of Population Medicine,Harvard Pilgrim Health Care Institute and Harvard Medical School,Boston,Massachusetts.

Infection Control and Hospital Epidemiology

|November 10, 2018

Insights

Antimicrobial use is frequent for pediatric ventilator-associated events (VAEs), but often without clear infection evidence. This highlights opportunities for antimicrobial stewardship to optimize antibiotic use in intensive care units.

Area of Science:

Pediatric critical care medicine
Infectious diseases
Clinical pharmacology

Background:

Ventilator-associated events (VAEs) are common in critically ill children.
Antimicrobial use for VAEs varies significantly, impacting patient outcomes and resistance.
Effective antimicrobial stewardship is crucial for optimizing treatment in pediatric intensive care units (PICUs).

Purpose of the Study:

To evaluate the variability in antimicrobial prescribing for pediatric VAEs.
To examine the association between antimicrobial use and infection testing in VAEs.
To identify opportunities for antimicrobial stewardship interventions.

Main Methods:

Retrospective cohort study with a nested case-control design.
Analysis of data from 6 US hospitals across PICUs, CICUs, and NICUs.
Inclusion of children (≤18 years) ventilated for at least one day, identified using established criteria for VAEs, antimicrobial use (AVACs), and possible pneumonia (PVAP).

Main Results:

Of 9,025 ventilated children, 192 had VAEs; 79 (41%) met AVAC criteria.
Antimicrobial use (AVACs) and spectrum varied by ICU type and hospital, with CICUs and PICUs more frequently using broad-spectrum agents.
Only 39% of AVAC cases had respiratory infection testing, identifying PVAP in 15 cases; 73% of AVAC cases lacked positive diagnostic tests.

Conclusions:

Antimicrobial use is prevalent in pediatric VAEs, but often not supported by diagnostic evidence of infection.
Significant variability exists in antimicrobial prescribing practices across different pediatric intensive care settings.
The high rate of antimicrobial use without confirmed infection in AVAC cases presents a key target for antimicrobial stewardship programs.

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Abstract

Objective:

To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs).

Design:

Descriptive retrospective cohort with nested case-control study.

Setting:

Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.PatientsChildren≤18 years ventilated for≥1 calendar day.

Methods:

We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria.

Results:

Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20-67%; PICU, 0-70%; and NICU, 0-43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test.

Conclusions:

Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.

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