38


Table 3. Positive Microbiologic Data in AVAC Patients by ICU Type ICU


(Total AVAC) CICU (n=25)


PICU (n=36)


Patient 1 2 3 4 5 1 2 3 4 5 6 7


NICU (n=18)


8 1 2 3 4 5 6 7 8


PVAP Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes


No Yes Yes Yes Yes Yes No No No


Test Type


Sputum: Pseudomonas aeruginosa Sputum: Escherichia coli Sputum: P. aeruginosa


Blood culture: Staphylococcus epidermidis


Wound culture, peritoneal fluid, catheter tip: Klebsiella pneumoniae Tracheal aspirate: Parainfluenza 2


Endotracheal aspirate: Haemophilus influenzae Endotracheal aspirate: Rhinovirus, Enterovirus Bronchial alveolar lavage: Streptococcus pneumoniae


Endotracheal aspirate: Methicillin-resistant Staphylococcus aureus Tracheal aspirate: P. aeruginosa, Aspergillus fumigatus


Sputum culture: P. aeruginosa Urine culture: Candida albicans


Blood PCR: Adenovirus


Endotracheal aspirate: Proteus mirabilis Endotracheal aspirate: Acinetobacter baumanii Endotracheal aspirate: Enterobacter aerogenes


Bronchial alveolar lavage: Delftia acidovorans (Comamonas)


Blood culture, peritoneal fluid culture, sputum culture: Klebsiella pneumoniae Peritoneal fluid culture: K. pneumoniae Blood culture: P. aeruginosa


Urine culture: C. albicans Tissue culture (mediastinum): Mycobacterium avium complex


NOTE: CICU, cardiac intensive care unit; PICU, pediatric intensive care unit; NICU, neonatal intensive care unit; AVAC, VAC with antimicrobial use; PVAP: possible ventilator-associated pneumonia; PCR, polymerase chain reaction.


in adult patients reported variability in infection-related ventilator- associated complications (IVAC) across ICU types, ranging from 31% in the medical ICU to 46% in the thoracic ICU.10 Further- more, PVAP or other concomitant infections occurred in only 15% of VAC cases, highlighting previous literature attesting that most VACs are noninfectious and the potential overutilization of sus- tained courses of antimicrobials (ie, at least 4 calendar days). While there is likely variability in the case mix among hos-


pitals and ICU types in our study that can explain some variation in rates of antimicrobial use, cultural differences in prescribing practices by ICU type or by hospital may also contribute to underlying variation. For example, despite higher total rates of VAC in the NICU, rates of AVAC were proportionately lower when compared with the PICU and CICU presumably reflecting baseline pulmonary comorbidities secondary to prematurity leading to deterioration on the ventilator. Additionally, neona- tologists have made substantial efforts to minimize unnecessary antimicrobial use due to potential concerns for necrotizing enterocolitis, bronchopulmonary dysplasia, emergence of resis- tant pathogens, and/or emergence of invasive candidiasis.11–13


Nonetheless, additional studies to understand patient-specific versus ICU-specific risk factors may aid our ability to optimize antimicrobial use in these patients. We also noted variability in the spectrum of AVAC anti-


microbials used by ICUs and by hospitals. AVAC antimicrobials tended to be more broad spectrum, and antifungals were more likely to be initiated in certain ICUs, which may be due in part to higher rates of antimicrobial use prior to the VAC event in those units. While further characterization of antimicrobial spectrum was limited due to small sample size, this is a potential focus area of interhospital antimicrobial stewardship programs. Finally, we note potential variability among hospitals in the


frequency of respiratory diagnostic testing in VAC cases across ICU types, though interpretation of these results is limited due to the small sample size. Differences in the use and stewardship of diagnostic testing for infection in neonates and children may directly impact the rate of pediatric PVAP, which in turn may impact antimicrobial use, suggesting that diagnostic stewardship initiatives may be important in reducing unnecessary antimicrobial use. The low rates of PVAP observed in our study (7.8%) may


Manjiree V. Karandikar et al


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