Antibiotic Indications and Appropriateness in the Pediatric Intensive Care Unit: A 10-Center Point Prevalence Study

Abstract

Background Antibiotics are prescribed to most pediatric intensive care unit (PICU) patients, but data evaluating indications and appropriateness of antibiotic orders in this population are lacking. Methods We performed a multicenter point prevalence study including children admitted to 10 geographically diverse PICUs over four study days in 2019. Antibiotic orders were reviewed for indication, and appropriateness was assessed using a standardized rubric. Results Of 1462 patients admitted to participating PICUs, 843 (58%) had at least one antibiotic order. A total of 1277 antibiotic orders were reviewed. Common indications were empiric therapy for suspected bacterial infections without sepsis or septic shock (260 orders, 21%), non-operative prophylaxis (164 orders, 13%), empiric therapy for sepsis or septic shock (155 orders, 12%), community acquired pneumonia (CAP) (118 orders, 9%), and post-operative prophylaxis (94 orders, 8%). Appropriateness was assessed for 985 orders for which an evidence-based rubric for appropriateness could be created. Of these, 331 (34%) were classified as inappropriate. Indications with the most orders classified as inappropriate were empiric therapy for suspected bacterial infection without sepsis or septic shock (78 orders, 24%), sepsis or septic shock (55 orders, 17%), CAP (51 orders, 15%), ventilator-associated infections (47 orders, 14%), and post-operative prophylaxis (44 orders, 14%). The proportion of antibiotics classified as inappropriate varied across institutions (range: 19%-43%). Conclusions Most PICU patients receive antibiotics, and based on our study, we estimate that one-third of antibiotic orders are inappropriate. Improved antibiotic stewardship and research focused on strategies to optimize antibiotic use in critically ill children are needed.

Incidence of and Risk Factors for Third-Generation Cephalosporin-Resistant Escherichia coli Bloodstream Infections in Children

“… 2 However, as the antibiotic administration time window for BSIs has been emphasized in recent years, 3 , 4 overtreatment may be also be an urgent problem for clinicians. 5 …”

“…2 However, as the antibiotic administration time window for BSIs has been emphasized in recent years, 3,4 overtreatment may be also be an urgent problem for clinicians. 5 Third-generation cephalosporins are among the most frequently used broad-spectrum antimicrobial agents in critical patients with gram-negative bacterial infections. 6 The emergence of third-generation cephalosporin-resistant (3GC-R) isolates may worsen the prognosis, 7 especially in areas with limited medical resources.…”

Establishing a paediatric critical care core quality measure set using a multistakeholder, consensus-driven process

“…1 , 2 Staff and resource shortages, 3 , 4 limitations in adverse event monitoring systems, 5 , 6 combined with the proliferation of quality measures collected, 7 , 8 make measurement challenging. Critically ill children have increased risk of healthcare-associated harm 9 due to the invasive nature of medical treatment and patient factors such as pre-existing organ failure. [10] , [11] , [12] While some progress has been made, lack of alignment across paediatric critical care quality programs has contributed to challenges for clinicians and facilities when it comes to prioritising quality measures that are meaningful to patients, families, and clinicians.…”

A Novel Comprehensive Algorithm for Evaluation of PICU Patients With New Fever or Instability*

“…However, culturing and antibiotic treatment practices vary substantially, and many clinicians have a low threshold to obtain bacterial cultures in febrile ICU patients (3–7). Unintended consequences of this can include avoidable antibiotic treatment, delayed diagnosis of alternative causes of fever, additional diagnostics, extended lengths of stay (LOS), and inflation of healthcare costs (8–11).…”