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Comparison of standard care versus a biomarker algorithm to guide antibiotic stewardship in pediatric intensive care
Gabriella Bottari1, Nicoletta Cembalo2, Danilo Fegatelli Alunni3
1Pediatric Intensive Care, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy. gabriella.bottari@opbg.net.
Insights
This study shows that using procalcitonin (PCT) guided reassessment in pediatric intensive care units (PICU) reduces antibiotic use in critically ill children. This approach was safe and feasible, lowering antibiotic exposure without increasing adverse outcomes.
Area of Science:
- Pediatric intensive care
- Antimicrobial stewardship
- Biomarker-guided therapy
Background:
- Antimicrobial stewardship programs (AMS) are crucial for reducing antibiotic resistance in pediatric intensive care units (PICUs).
- Procalcitonin (PCT) has shown promise in guiding antibiotic discontinuation in adults, but its use in pediatric decision-making is less explored.
Purpose of the Study:
- To assess the effectiveness and safety of an integrated antimicrobial stewardship approach in critically ill children with suspected infections in a PICU.
- To evaluate the impact of procalcitonin (PCT)-guided decision-making combined with clinical and microbiological assessments on antibiotic duration.
- To explore the utility of pancreatic stone protein (PSP) and C-reactive protein (CRP) in antibiotic de-escalation.
Main Methods:
- A prospective observational cohort study with a historical control group in a tertiary PICU.
- Assessed PCT and pediatric Sequential Organ Failure Assessment (p-SOFA) scores at multiple time points.
- Utilized microbiological samples and multidisciplinary reassessment based on PCT thresholds, clinical status, and microbiological findings for antibiotic decisions.
- Measured PSP and CRP levels.
Main Results:
- Fifty-three children were enrolled; median antibiotic days of therapy (DOT) were significantly lower (10 days) compared to the historical cohort (16 days).
- No increase in short-term adverse outcomes was observed; 7.1% experienced antibiotic restarts or PICU readmission within 7 days.
- PCT levels effectively differentiated between confirmed and non-confirmed bacterial infections (p=0.001) and guided antibiotic de-escalation/discontinuation.
- CRP and PSP did not show significant discriminatory capacity.
Conclusions:
- Implementing a structured PCT-guided reassessment algorithm within an antimicrobial stewardship framework is feasible in PICUs.
- This approach effectively reduced antibiotic exposure in critically ill children without compromising safety.
- PCT serves as a valuable biomarker for guiding antibiotic management decisions in pediatric intensive care settings.
Abstract:
The purpose of this study is to evaluate the effectiveness and safety of an integrated antimicrobial stewardship approach in critically ill children with suspected infection admitted to a pediatric intensive care unit (PICU). The approach combined procalcitonin (PCT)-guided decision-making with serial clinical and microbiological assessment to reduce antibiotic duration. Secondary aims included evaluating additional biomarkers, such as pancreatic stone protein (PSP) and C-reactive protein (CRP) in the context of antibiotic de-escalation. This prospective observational cohort study with historical control was conducted in a tertiary PICU. PCT and pediatric Sequential Organ Failure Assessment (p-SOFA) scores were assessed at baseline, 48-72 h, and 5-7 days. Microbiological samples were obtained before initiation of empirical antibiotic therapy and repeated when clinically indicated. Antibiotic decisions were made through multidisciplinary reassessment and were based on predefined PCT thresholds integrated with microbiological findings and clinical status. PSP and CRP were measured. Fifty-three children were prospectively enrolled. Median days of therapy (DOT) were lower compared with the historical cohort (10 days [IQR 5-16] vs. 16 days [IQR 7-29]). No increase in short-term adverse outcomes was observed. Restart of intravenous antibiotics or PICU readmission within 7 days occurred in 7.1% of cases. PCT levels differed significantly between confirmed and nonconfirmed bacterial infections (p = 0.001) and were associated with decisions regarding antibiotic de-escalation or discontinuation. CRP and PSP did not demonstrate statistically significant discriminatory capacity.
Conclusion:
Implementation of a structured PCT-guided reassessment algorithm within an antimicrobial stewardship framework was feasible and associated with reduced antibiotic exposure without apparent safety concerns.
What Is Known:
• Antimicrobial stewardship programs (AMS) are essential to reduce unnecessary antibiotic use and prevent antimicrobial resistance, especially in pediatric intensive care settings. • Although procalcitonin (PCT) has been validated in adult studies to guide antibiotic discontinuation, its integration into pediatric clinical decision-making remains poorly explored.
What Is New:
• This study evaluates a real-world implementation of a PCT-based reassessment algorithm in a tertiary PICU in critically ill children. • An integrated, biomarker-guided algorithm using procalcitonin, alongside clinical and microbiological evaluation was associated with reduced antibiotic exposure without short-term safety signals.
