Infection Control & Hospital Epidemiology (2019), 40,32–39 doi:10.1017/ice.2018.264


Original Article


Variability in antimicrobial use in pediatric ventilator-associated events


Manjiree V. Karandikar MD, MBS1,2, Susan E. Coffin MD, MPH3, Gregory P. Priebe MD4,5, Thomas J. Sandora MD, MPH5, Latania K. Logan MD, MS6, Gitte Y. Larsen MD, MPH7, Philip Toltzis MD8, James E. Gray MD, MS9,10, Michael Klompas MD, MPH1,11, Julia S. Sammons MD, MSCE3, Marvin B. Harper MD5, Kelly Horan MPH1,


Matthew Lakoma MPH1, Noelle M. Cocoros DSc, MPH1 and Grace M. Lee MD, MPH1,12 1Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, 2Division of Infectious Diseases and Global Health, Department of Pediatrics, University of California, San Francisco, San Francisco, California, 3Children’s Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, 4Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, 5Division of Infectious Diseases, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts, 6Section of Infectious Diseases, Department of Pediatrics, Rush University Medical Center, Rush Medical College, Chicago,


Illinois, 7Division of Critical Care Medicine, Department of Pediatrics, Intermountain Primary Children’s Hospital and University of Utah, Salt Lake City, Utah, 8Division of Pediatric Critical Care, Department of Pediatrics, Rainbow Babies and Children’s Hospital, Cleveland, Ohio, 9Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, 10Section of Neonatology, Children’s Hospital at Dartmouth, Lebanon, New Hampshire, 11Brigham and Women’s Hospital, Boston, Massachusetts, and 12Department of Pediatrics, Stanford University School of Medicine, Stanford, California


Abstract


Objective: To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs). Design: Descriptive retrospective cohort with nested case-control study. Setting: Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals. Patients: Children≤18 years ventilated for≥1 calendar day. Methods: We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria. Results: Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20–67%; PICU, 0–70%; and NICU, 0– 43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test. Conclusions: Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.


(Received 28 June 2018; accepted 20 September 2018; electronically published 9 November 2018)


In 2013, the National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC) replaced surveillance definitions for ventilator-associated pneumonia


Author for correspondence: Manjiree Karandikar, MD MBS, Division of Infectious


Diseases and Global Health, Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, San Francisco, CA 94158. E-mail: Manjiree.karandikar@ucsf.edu Or Grace M. Lee, MD MPH, Department of Pediatrics, 300 Pasteur Drive, G-306B, Stanford, CA 94305-5208. Email: GMLee@stanfordchildrens.org PREVIOUS PRESENTATION: Preliminary data and findings were presented at the


Society for Healthcare Epidemiology of America (SHEA) Spring Conference on March 29, 2017, in St Louis, Missouri.


Cite this article: Karandikar MV, et al. (2019). Variability in antimicrobial use in


pediatric ventilator-associated events. Infection Control & Hospital Epidemiology 2019, 40, 32–39. doi: 10.1017/ice.2018.264


© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.


(VAP) with ventilator-associated events (VAE) in adult patients. The new definitions, utilizing objective rather than subjective criteria, broadened the range of surveillance to capture both infectious and noninfectious etiologies associated with dete- rioration on the ventilator.1 In 2016, pediatric and neonatal adaptations for VAE surveillance criteria were defined.2 Similar to the adult VAE definitions, pediatric VAE consists of 3 nested definitions: (1) pediatric ventilator-associated condition (VAC), (2) pediatric AVAC (defined as pediatric VAC with antimicrobial use for≥4 days), and (3) possible VAP (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test). Patients with pediatric VAE, across all nested definitions, are at higher risk for in-hospital mortality, prolonged hospitalization,


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