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Development of an Antibiotic Guideline for Children With Suspected Ventilator-Associated Infections
Steven L Shein1, Oliver Karam2, Andrew Beardsley3
1Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, Cleveland, OH.
Insights
This study developed a guideline to help decide when to stop antibiotics in children with suspected ventilator-associated infections. The new scoring system aims to reduce antibiotic use while monitoring patient outcomes.
Area of Science:
- Pediatric critical care medicine
- Infectious disease management
- Antibiotic stewardship
Background:
- Ventilator-associated infections (VAI) are a significant concern in pediatric intensive care units (PICUs).
- Optimal duration of antibiotic therapy for suspected VAI in children remains a challenge.
- Current practices may lead to overuse or underuse of antibiotics, impacting patient outcomes and antimicrobial resistance.
Purpose of the Study:
- To develop a clinical guideline for antibiotic decision-making at 48-72 hours in children with suspected VAI.
- To create a scoring system to guide the continuation or discontinuation of antibiotics.
- To potentially reduce antibiotic exposure in pediatric patients.
Main Methods:
- Prospective, multicenter observational data collection in 22 PICUs.
- Development of a guideline scoring system by an expert panel using consensus and literature review.
- Retrospective application of the scoring system to collected patient data.
Main Results:
- A scoring system was developed, correlating with antibiotic duration and disease severity (eGFR2 scores).
- Recommendations were made: stop antibiotics for scores ≤2, continue for scores ≥6.
- No recommendation was made for intermediate scores (3-5).
Conclusions:
- A novel scoring system and guideline were developed to aid antibiotic management in pediatric VAI.
- The guideline aims to optimize antibiotic duration, balancing efficacy and stewardship.
- Prospective validation in Phase 3 is planned to assess the impact on antibiotic use and patient outcomes.
Objectives:
To develop a guideline for the decision to continue or stop antibiotics at 48-72 hours after their initiation in children with suspected ventilator-associated infection.
Design:
Prospective, multicenter observational data collection and subsequent development of an antibiotic guideline.
Setting:
Twenty-two PICUs.
Patients:
Children less than 3 years old receiving mechanical ventilation who underwent clinical testing and initiation of antibiotics for suspected ventilator-associated infection.
Interventions:
None.
Measurements And Main Results:
Phase 1 was a prospective data collection in 281 invasively ventilated children with suspected ventilator-associated infection. The median age was 8 months (interquartile range, 4-16 mo) and 75% had at least one comorbidity. Phase 2 was development of the guideline scoring system by an expert panel employing consensus conferences, literature search, discussions with institutional colleagues, and refinement using phase 1 data. Guideline scores were then applied retrospectively to the phase 1 data. Higher scores correlated with duration of antibiotics (p < 0.001) and higher PEdiatric Logistic Organ Dysfunction 2 scores (p < 0.001) but not mortality, PICU-free days or ventilator-free days. Considering safety and outcomes based on the phase 1 data and aiming for a 25% reduction in antibiotic use, the panel recommended stopping antibiotics at 48-72 hours for guideline scores less than or equal to 2, continuing antibiotics for scores greater than or equal to 6, and offered no recommendation for scores 3, 4, and 5. The acceptability and effect of these recommendations on antibiotic use and outcomes will be prospectively tested in phase 3 of the study.
Conclusions:
We developed a scoring system with recommendations to guide the decision to stop or continue antibiotics at 48-72 hours in children with suspected ventilator-associated infection. The safety and efficacy of the recommendations will be prospectively tested in the planned phase 3 of the study.
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