Infection Control & Hospital Epidemiology
reflect concerns about risk of obtaining respiratory samples, par- ticularly in neonates and young infants,14 the presence of systemic infection in the absence of pneumonia, or noninfectious etiologies leading to VAC (eg, fluid overload, atelectasis). Furthermore, positive findings on a respiratory sample did not always trigger antimicrobial use, which may have been appropriate.15 For example, 8 VAC cases had positive cultures (respiratory and nonrespiratory) yet did not receive additional antimicrobials surrounding the VAC event, particularly in the NICU. Previous studies have highlighted the discordance between pedia- tric PVAP and previously defined NHSN VAP surveillance defi- nitions.5 In a retrospective single-center study inGreece, application of the adult VAE criteria to a pediatric population showed poor concordance between the 2 definitions.16 Limited overlap has also been described for adult VAP and adult VAE definitions, pre- sumably due to the subjectivity of VAP definitions and the wide range of noninfectious conditions associated with VAE.17 Our study has certain limitations given the retrospective nat-
ure and small sample size. First, we are unable to speak to the appropriateness of the antimicrobial regimens or diagnostic testing given the lack of concomitant clinical data and lack of data on microbiologic resistance patterns of organisms in different institutions. Second, dosing intervals in neonates could result in inaccurate classification of AVAC cases due to misclassification as a new antimicrobial, such as the use of fluconazole prophylaxis in NICUs (typically dosed twice weekly). Similarly, in children with concomitant renal or hepatic failure, the degree to which dosing modifications due to end-organ dysfunction may play a role in inappropriately triggering or missing AVAC remains to be elu- cidated. Small sample size limited our capacity to draw firm conclusions. Due to lack of power, we are only able to describe qualitiative differences in variability in antimicrobial use amongst hospitals and ICU types. We were unable to collect overall institution specific rates of antibiotic utilization among ICUs. Therefore, our study population may not reflect the full range of llness severity and practice variability in antimicrobial pre- scribing seen in other US hospitals, especially in light of the increased presence of antimicrobial stewardship interventions in recent years. In conclusion, we have documented wide variability in the rate
of antimicrobial utilization between ICU types and within ICU types across 6 hospitals. In addition, diagnostic testing for respiratory infections was performed in <50% of AVAC cases, with PVAP and other infectious etiologies representing only 27% of AVAC cases. The new pediatric VAE definitions, proposed to release as early as January 2019,18 allow for identification of a subset of patients in whom antimicrobial use may be further evaluted. Although initiation of prolonged use of antimicrobials may be unrelated to VAC, such as postsurgical prophylaxis or fluconazole prophylaxis, opportunities for de-escalation remain with regard to duration and/or antimicrobial spectrum. These findings can provide a foundation for interhospital comparisons, and they suggest potential focus areas for antimicrobial stew- ardship programs.
Acknowledgments. We are grateful to our colleagues who contributed to this study. We also wish to thank our Pediatric VAC Advisory Members.
Financial support. This research was funded by the Agency for Healthcare Research and Quality (AHRQ R18 grant no. 1R18HS021636) to Dr. Lee.
Conflicts of interest. The authors have indicated they have no financial relationships relevant to this article to disclose. Dr. Sammons received grant
39
funding fromthe CDC Epicenters Program. Dr. Priebe has received grants from AHRQ. Dr. Klompas received grant support from this study and support from AHRQ for studies on VAE surveillance and prevention. Dr. Gray has received grants from Beth Isreal Deaconess Medical Center, and received payment for consulting with Vermont-Oxford Network. Dr. Cocoros received grant funding for AHRQ. Dr. Toltzis has received payment through the University Hospitals Cleveland Medical Center. Dr. Coffin has received payment for medical legal consultation, employment through the Philadelphia Department of Public Health, and grant support form AHRQ, NIH, and the CDC.
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