Hospital-Level Variability in Broad-Spectrum Antibiotic Use for Children With Acute Leukemia Undergoing Hematopoietic Cell Transplantation

Abstract

OBJECTIVETo explore the prevalence and drivers of hospital-level variability in antibiotic utilization among hematopoietic cell transplant (HCT) recipients to inform antimicrobial stewardship initiatives.DESIGNRetrospective cohort study using data merged from the Pediatric Health Information System and the Center for International Blood and Marrow Transplant Research.SETTINGThe study included 27 transplant centers in freestanding children's hospitals.METHODSThe primary outcome was days of broad-spectrum antibiotic use in the interval from day of HCT through neutrophil engraftment. Hospital antibiotic utilization rates were reported as days of therapy (DOTs) per 1,000 neutropenic days. Negative binomial regression was used to estimate hospital utilization rates, adjusting for patient covariates including demographics, transplant characteristics, and severity of illness. To better quantify the magnitude of hospital variation and to explore hospital-level drivers in addition to patient-level drivers of variation, mixed-effects negative binomial models were also constructed.RESULTSAdjusted hospital rates of antipseudomonal antibiotic use varied from 436 to 1121 DOTs per 1,000 neutropenic days, and rates of broad-spectrum, gram-positive antibiotic use varied from 153 to 728 DOTs per 1,000 neutropenic days. We detected variability by hospital in choice of antipseudomonal agent (ie, cephalosporins, penicillins, and carbapenems), but gram-positive coverage was primarily driven by vancomycin use. Considerable center-level variability remained even after controlling for additional hospital-level factors. Antibiotic use was not strongly associated with days of significant illness or mortality.CONCLUSIONAmong a homogenous population of children undergoing HCT for acute leukemia, both the quantity and spectrum of antibiotic exposure in the immediate posttransplant period varied widely. Antimicrobial stewardship initiatives can apply these data to optimize the use of antibiotics in transplant patients.Infect Control Hosp Epidemiol 2018;797-805.

Meropenem Use in Pediatric Oncology – Audit on Indication, Appropriateness and Consumption Comparing Patient Derived and Pharmacy Dispensing Data

“…Due to the severity of the patientsʼ underlying disease and immunosuppression, high administration rates of antibiotics have been documented in pediatric cancer patients [6,10], including carbapenems [9]. The appropriateness of carbapenem use in pediatric cancer patients has been addressed by a few recent publications describing retrospective consumption data and antibiotic stewardship (ABS) initiatives [1,13,14,19,20].…”

Density of antibiotic use and infectious complications in pediatric allogeneic hematopoietic cell transplantation

“…In the pediatric allo‐HCT population, little is known about antibiotic prescription and specific practice recommendations for AMS programs are needed 43 . Internationally, analyses of registry data reveal wide variation in antibiotic prescription practices in early HCT between centers, though the use of broad‐spectrum antipseudomonal agents often until neutrophil recovery is commonplace 44,45 . Here we illustrate hospital‐specific antibiotic prescription practices and hence fill an important gap in the literature.…”

“…43 Internationally, analyses of registry data reveal wide variation in antibiotic prescription practices in early HCT between centers, though the use of broad-spectrum antipseudomonal agents often until neutrophil recovery is commonplace. 44,45 Here we illustrate hospital-specific antibiotic prescription practices and hence fill an important gap in the literature. Our results demonstrate heavy use of broad-spectrum anaerobic antibiotics and indicate prescribing inconsistent with previously reported goals of AMS, thus providing opportunities to intervene in order to improve outcomes for our allo-HCT patients.…”

The Impact of Proactive Gastrostomy Tube Placement on Treatment-related Outcomes in Young Children With High-grade Central Nervous System Tumors

“…Further, despite the rate of GT cellulitis, there was no significant difference in antibiotic utilization days overall or when adjusted for person-time at risk. This lack of difference in utilization is of significant clinical importance when considering recommendations for the type of enteral tube placement given the high risk for infection in children with cancer and increasing antibiotic resistance 13 …”

“…This lack of difference in utilization is of significant clinical importance when considering recommendations for the type of enteral tube placement given the high risk for infection in children with cancer and increasing antibiotic resistance. 13 Anecdotally, the benefits of GT placement include decreased hospitalization times, decreased TPN use, improved nutrition, and an alternative for oral medication administration. While the results of this study support modest improvements in nutrition and hydration status with GT placement, there seems to be no significant benefit in the limited objective resource utilization measures analyzed, such as inpatient duration and TPN use.…”