Infection Control & Hospital Epidemiology
Table 2. Variation in VAC, AVAC, and Respiratory Diagnostic Testing Rates Across ICU Type by Hospital Hospital
CICU 1 CICU 2 CICU 3
Total CICU
PICU 1 PICU 2 PICU 3 PICU 4 PICU 5
Total PICU
NICU 1 NICU 2 NICU 3 NICU 4 NICU 5
Total NICU Grand Total
No. of VAC Cases AVAC (% of VAC) 24 5
14 43
25 8 3 1
33 70
10 11 7 4
47 79
192
16 (67) 1 (20) 8 (57)
25 (58)
15 (60) 3 (38) 1 (33) 0 (0)
17 (51) 36 (51)
3 (30) 1 (9)
3 (43) 0 (0)
11 (23) 18 (23)
79 (41)
Respiratory Diagnostic Testing in VAC (% VAC)
9 (38) 1 (20) 2 (14)
12 (28)
12 (48) 4 (50) 0 (0)
1 (100) 6 (18)
23 (33)
3 (30) 3 (27) 3 (43) 0 (0)
13 (28) 22 (28)
57 (30)
not available. aInvasive diagnostic testing was obtained in 4 AVAC cases in the PICU and 1 AVAC case in the NICU.
AVAC was identified in 79 VAC cases (41%), 25 CICU cases
(58%), 36 PICU cases (51%), and 18 NICU VAC cases (23%). Across all ICU types, patients who met VAC criteria were more likely to receive a new antimicrobial compared with matched con- trols whodid not meetVACcriteria. There was significant variation in the proportion ofAVACcases between hospitals and byICUtype (Table 2). In the PICU, AVAC cases with underlying immuno- suppression accounted for 11 of 20 PICU VAC cases (55%).
Variability in new antimicrobial use, spectrum, and duration by ICU type
New antimicrobials were more commonly administered for VAC cases in the CICU (58%) and PICU (51%) than in the NICU (23%). AVAC antimicrobial use varied by ICU type (Fig. 1). Vancomycin was the most common antimicrobial adminis- tered in AVAC cases in the CICU (40%) and PICU (58%), compared with the NICU (5%). Fluconazole, by contrast, was the most common antimicrobial administered in AVAC cases in the NICU. AVAC cases in the CICU (72%) and PICU (83%) were on
antimicrobials prior to the VAE window more often compared with the NICU (39%). Accordingly, broad-spectrumantimicrobials (categories 4 and 5) were initiated more commonly in the CICU
and PICU compared with the NICU. In antimicrobial-naïve patients, narrow-spectrum antimicrobials were more likely to be given across ICU types (Fig. 1). Notably, 57% of first-generation cephalosporin use in the CICU was associated with recent surgical procedures. AVAC cases received antifungals more often in the NICU (67%) than in the CICU (28%) or PICU (36%). Despite initiation and prolonged use of antifungals (4 or more days) in 32 AVAC cases (7 CICU, 13 PICU, and 12 NICU), only 3 patients (2 PICU, 1 NICU) had associated positive fungal cultures (1 respiratory culture with Aspergillus, 2 urine cultures with Candida). The mean duration of individual new antimicrobials administered for AVAC patients was 9 days: CICU, 10.7±13.5 days; PICU, 8.8±11.5 days; and NICU, 6.6±4.8 days. The median duration and interquartile ranges of individual anti- microbials varied across ICU types (Fig. 2).
Respiratory diagnostic testing by ICU type
Any diagnostic testing for respiratory infections was performed in 57 of 192 VAC cases (30%) with minimal variation in the pro- portion of those tested across ICUs (CICU, 28%; PICU, 33%; and NICU, 28%), and in 31 of 79 AVAC cases (39%) (CICU, 36%; PICU, 42%; and NICU 39%) (Table 2). When comparing rates of diagnostic testing across hospitals by ICU type, however, we did
6 (38)
1 (100) 2 (25) 9 (36)
8 (53) 2 (67) 0 (0) N/A
5 (29) 15 (42) 0 (0)
1 (100) 1 (33) N/A
5 (45) 7 (39)
31 (39)
35
Respiratory Diagnostic Testing in AVAC (% AVAC)
Invasive Diagnostic
Testing in VAC (% VAC)a 0 0
1 (7) 1 (2)
1 (4)
1 (13) 0 0
3 (9) 5 (7)
0 0
1 (14) 0 0
1 (1) 7 (4)
PVAP (% VAC) 3 (13) 0 0
3 (7)
3 (12) 1 (13) 0 0
3 (9) 7 (10) 0 1 (9)
1 (14) 0
3 (6) 5 (6)
15 (8) NOTE: CICU, cardiac intensive care unit; PICU, pediatric intensive care unit; NICU, neonatal intensive care unit; VAC, ventilator-associated condition; AVAC, VAC with antimicrobial use; N/A,
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