Ventilator-Associated Pneumonia in Neonatal and Pediatric Intensive Care Unit Patients

SUMMARY Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection among pediatric intensive care unit (ICU) patients. Empiric therapy for VAP accounts for approximately 50% of antibiotic use in pediatric ICUs. VAP is associated with an excess of 3 days of mechanical ventilation among pediatric cardiothoracic surgery patients. The attributable mortality and excess length of ICU stay for patients with VAP have not been defined in matched case control studies. VAP is associated with an estimated $30,000 in attributable cost. Surveillance for VAP is complex and usually performed using clinical definitions established by the CDC. Invasive testing via bronchoalveolar lavage increases the sensitivity and specificity of the diagnosis. The pathogenesis in children is poorly understood, but several prospective cohort studies suggest that aspiration and immunodeficiency are risk factors. Educational interventions and efforts to improve adherence to hand hygiene for children have been associated with decreased VAP rates. Studies of antibiotic cycling in pediatric patients have not consistently shown this measure to prevent colonization with multidrug-resistant gram-negative rods. More consistent and precise approaches to the diagnosis of pediatric VAP are needed to better define the attributable morbidity and mortality, pathophysiology, and appropriate interventions to prevent this disease.

Download Full-text

1134. Antibiotic Indications and Appropriateness in the Pediatric Intensive Care Unit: A 10 Center Point Prevalence Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.998 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S403-S404

Author(s):

Kathleen Chiotos ◽

Jennifer Blumenthal ◽

Juri Boguniewicz ◽

Debra Palazzi ◽

Emily Berkman ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Pediatric Intensive Care Unit ◽

Tertiary Care ◽

Pediatric Intensive Care ◽

Antibiotic Use ◽

Empiric Therapy ◽

Point Prevalence ◽

Prevalence Study ◽

Point Prevalence Study

Abstract Background Antibiotics are prescribed in up to 80% of pediatric intensive care unit (PICU) patients, but multicenter studies systematically evaluating antibiotic indications and appropriateness in this high-utilizing population are lacking. Methods A multicenter point prevalence study was conducted at 10 geographically diverse tertiary care US children’s hospitals. All PICU patients < 21 years of age who were receiving systemic antibiotics at 8:00 AM on each study day were included. Study days occurred in February and March 2019. Data were abstracted by critical care and/or infectious diseases trained clinicians using standardized data collection forms and definitions of antibiotic appropriateness. Results 408 of 732 PICU patients (56%) received 618 antibiotics on the two study days. Empiric therapy for suspected bacterial infections without sepsis was the most common indication for antibiotics (22%), followed by treatment of community-acquired pneumonia and empiric therapy for septic shock (12% each, Figure 1). Overall, 194 antibiotic orders (32%) were classified as inappropriate and 158 patients (39%) received at least one inappropriate antibiotic. Vancomycin, cefepime, and ceftriaxone were the antibiotics most often inappropriately prescribed (Figure 2). Antibiotics prescribed inappropriately for the top 5 indications shown in Figure 1 accounted for 77% of all inappropriate antibiotic use. Prolonged ( >4 days) empiric therapy and prolonged ( >24 hours) post-operative prophylaxis were the most common reasons antibiotics prescribed for these indications were classified as inappropriate. Pneumonia and ventilator-associated infections were the most common infections for which antibiotics were prescribed inappropriately (46%). Reasons for inappropriate antibiotic use included lack of evidence supporting a bacterial infection (no radiographic infiltrate or significant increase in respiratory support) and use of unnecessarily broad antibiotics (Table 1). Conclusion Inappropriate antibiotic use is common in the PICU, particularly for pneumonia. Studies focused on defining optimal treatment strategies, as well as improved diagnostic approaches to curtail prolonged courses of empiric therapy, should be prioritized. Disclosures All authors: No reported disclosures.

Download Full-text

Implementation of Five-element, Interprofessional Ventilator-associated Pneumonia Prevention Bundle in the Pediatric Intensive Care Unit

10.1542/peds.141.1_meetingabstract.118 ◽

2018 ◽

Author(s):

Joanne E. Natale ◽

Cheryl McBeth ◽

Amy Powne ◽

Rosa Montes ◽

Eunice Butler ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Pediatric Intensive Care Unit ◽

Pediatric Intensive Care ◽

Ventilator Associated Pneumonia

Download Full-text

Implementation of a Pragmatic Biomarker-Driven Algorithm to Guide Antibiotic Use in the Pediatric Intensive Care Unit: the Optimizing Antibiotic Strategies in Sepsis (OASIS) II Study

Journal of the Pediatric Infectious Diseases Society ◽

10.1093/jpids/piy113 ◽

2018 ◽

Vol 9 (1) ◽

pp. 36-43 ◽

Cited By ~ 2

Author(s):

Kevin J Downes ◽

Julie C Fitzgerald ◽

Emily Schriver ◽

Craig L K Boge ◽

Michael E Russo ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Bacterial Infection ◽

Pediatric Intensive Care Unit ◽

Bacterial Infections ◽

Pediatric Intensive Care ◽

Antibiotic Use ◽

Antibiotic Administration ◽

Period 2 ◽

Rate Ratios

Abstract Background Biomarkers can facilitate safe antibiotic discontinuation in critically ill patients without bacterial infection. Methods We tested the ability of a biomarker-based algorithm to reduce excess antibiotic administration in patients with systemic inflammatory response syndrome (SIRS) without bacterial infections (uninfected) in our pediatric intensive care unit (PICU). The algorithm suggested that PICU clinicians stop antibiotics if (1) C-reactive protein <4 mg/dL and procalcitonin <1 ng/mL at SIRS onset and (2) no evidence of bacterial infection by exam/testing by 48 hours. We evaluated excess broad-spectrum antibiotic use, defined as administration on days 3–9 after SIRS onset in uninfected children. Incidence rate ratios (IRRs) compared unadjusted excess length of therapy (LOT) in the 34 months before (Period 1) and 12 months after (Period 2) implementation of this algorithm, stratified by biomarker values. Segmented linear regression evaluated excess LOT among all uninfected episodes over time and between the periods. Results We identified 457 eligible SIRS episodes without bacterial infection, 333 in Period 1 and 124 in Period 2. When both biomarkers were below the algorithm’s cut-points (n = 48 Period 1, n = 31 Period 2), unadjusted excess LOT was lower in Period 2 (IRR, 0.53; 95% confidence interval, 0.30–0.93). Among all 457 uninfected episodes, there were no significant differences in LOT (coefficient 0.9, P = .99) between the periods on segmented regression. Conclusions Implementation of a biomarker-based algorithm did not decrease overall antibiotic exposure among all uninfected patients in our PICU, although exposures were reduced in the subset of SIRS episodes where biomarkers were low.

Download Full-text