Variability in Antibiotic Use Across PICUs

Changes in Inhaled Nitric Oxide Use Across ICUs After Implementation of a Standard Pathway

OBJECTIVES

Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator. It is expensive, frequently used, and not without risk. There is limited evidence supporting a standard approach to initiation and weaning. Our objective was to optimize the use of iNO in the cardiac ICU (CICU), PICU, and neonatal ICU (NICU) by establishing a standard approach to iNO utilization.

DESIGN

A quality improvement study using a prospective cohort design with historical controls.

SETTING

Four hundred seven-bed free standing quaternary care academic children's hospital.

PATIENTS

All patients on iNO in the CICU, PICU, and NICU from January 1, 2017 to December 31, 2022.

INTERVENTIONS

Unit-specific standard approaches to iNO initiation and weaning.

MEASUREMENTS AND MAIN RESULTS

Sixteen thousand eighty-seven patients were admitted to the CICU, PICU, and NICU with 9343 in the pre-iNO pathway era (January 1, 2017 to June 30, 2020) and 6744 in the postpathway era (July 1, 2020 to December 31, 2022). We found a decrease in the percentage of CICU patients initiated on iNO from 17.8% to 11.8% after implementation of the iNO utilization pathway. We did not observe a change in iNO utilization between the pre- and post-iNO pathway eras in either the PICU or NICU. Based on these data, we estimate 564 total days of iNO (-24%) were saved over 24 months in association with the standard pathway in the CICU, with associated cost savings.

CONCLUSIONS

Implementation of a standard pathway for iNO use was associated with a statistically discernible reduction in total iNO usage in the CICU, but no change in iNO use in the NICU and PICU. These differential results likely occurred because of multiple contextual factors in each care setting.

Antibiotic Exposure of Critically Ill Children at a Tertiary Care Paediatric Intensive Care Unit in Switzerland

Antibiotic overtreatment fosters multidrug-resistance that threatens healthcare systems worldwide as it increases patient morbidity and mortality. Contemporary data on antibiotic usage on tertiary care paediatric intensive care units for in- and external benchmarking are scarce. This was a single-centre retrospective quality control study including all patients with antibiotic treatment during their hospitalization at a paediatric intensive care unit in the time period 2019-2021. Antibiotic treatment was calculated as days of therapy (DOT) per 100 patient days (DOT/100pd). Further, the variables PIM II score, length of stay in intensive care (LOS), gender, age, treatment year, reason for intensive care unit admission, and death were assessed. Two thousand and forty-one cases with a median age of 10 months [IQR 0-64] were included; 53.4% were male, and 4.5% of the included patients died. Median LOS was 2.73 days [0.07-5.90], and PIM II score was 1.98% [0.02-4.86]. Overall, the antibiotic exposure of critically ill children and adolescents was 59.8 DOT/100pd. During the study period, the antibiotic usage continuously increased (2019: 55.2 DOT/100pd; 2020: 59.8 DOT/100pd (+8.2%); 2021: 64.5 DOT/100pd (+8.0%)). The highest antibiotic exposure was found in the youngest patients (0-1 month old (72.7 DOT/100pd)), in patients who had a LOS of >2-7 days (65.1 DOT/100pd), those who had a renal diagnosis (98 DOT/100pd), and in case of death (91.5 DOT/100pd). Critically ill paediatric patients were moderately exposed to antibiotics compared to data from the previously published literature. The current underreporting of antimicrobial prescription data in this cohort calls for future studies for better internal and external benchmarking.

Antimicrobial use among paediatric inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program, 2017/2018

BACKGROUND

Antimicrobial resistance threatens the ability to successfully prevent and treat infections. While hospital benchmarks regarding antimicrobial use (AMU) have been well documented among adult populations, there is less information from among paediatric inpatients. This study presents benchmark rates of antimicrobial use (AMU) for paediatric inpatients in nine Canadian acute-care hospitals.

METHODS

Acute-care hospitals participating in the Canadian Nosocomial Infection Surveillance Program submitted annual AMU data from paediatric inpatients from 2017 and 2018. All systemic antimicrobials were included. Data were available for neonatal intensive care units (NICUs), pediatric ICUs (PICUs), and non-ICU wards. Data were analyzed using days of therapy (DOT) per 1000 patient days (DOT/1000pd).

RESULTS

Nine hospitals provided paediatric AMU data. Data from seven NICU and PICU wards were included. Overall AMU was 481 (95% CI 409-554) DOT/1000pd. There was high variability in AMU between hospitals. AMU was higher on PICU wards (784 DOT/1000pd) than on non-ICU (494 DOT/1000pd) or NICU wards (333 DOT/1000pd). On non-ICU wards, the antimicrobials with the highest use were cefazolin (66 DOT/1000pd), ceftriaxone (59 DOT/1000pd) and piperacillin-tazobactam (48 DOT/1000pd). On PICU wards, the antimicrobials with the highest use were ceftriaxone (115 DOT/1000pd), piperacillin-tazobactam (115 DOT/1000pd), and cefazolin (111 DOT/1000pd). On NICU wards, the antimicrobials with the highest use were ampicillin (102 DOT/1000pd), gentamicin/tobramycin (78 DOT/1000pd), and cefotaxime (38 DOT/1000pd).

CONCLUSIONS

This study represents the largest collection of antimicrobial use data among hospitalized paediatric inpatients in Canada to date. In 2017/2018, overall AMU was 481 DOT/1000pd. National surveillance of AMU among paediatric inpatients is necessary for establishing benchmarks and informing antimicrobial stewardship efforts.

Update on Therapeutic Drug Monitoring of Beta-Lactam Antibiotics in Critically Ill Patients—A Narrative Review

Beta-lactam antibiotics remain one of the most preferred groups of antibiotics in critical care due to their excellent safety profiles and their activity against a wide spectrum of pathogens. The cornerstone of appropriate therapy with beta-lactams is to achieve an adequate plasmatic concentration of a given antibiotic, which is derived primarily from the minimum inhibitory concentration (MIC) of the specific pathogen. In a critically ill patient, the plasmatic levels of drugs could be affected by many significant changes in the patient’s physiology, such as hypoalbuminemia, endothelial dysfunction with the leakage of intravascular fluid into interstitial space and acute kidney injury. Predicting antibiotic concentration from models based on non-critically ill populations may be misleading. Therapeutic drug monitoring (TDM) has been shown to be effective in achieving adequate concentrations of many drugs, including beta-lactam antibiotics. Reliable methods, such as high-performance liquid chromatography, provide the accurate testing of a wide range of beta-lactam antibiotics. Long turnaround times remain the main drawback limiting their widespread use, although progress has been made recently in the implementation of different novel methods of antibiotic testing. However, whether the TDM approach can effectively improve clinically relevant patient outcomes must be proved in future clinical trials.

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

BACKGROUND

Antibiotics are prescribed to most pediatric intensive care unit (PICU) patients, but data describing indications and appropriateness of antibiotic orders in this population are lacking.

METHODS

We performed a multicenter point prevalence study that included children admitted to 10 geographically diverse PICUs over 4 study days in 2019. Antibiotic orders were reviewed for indication, and appropriateness was assessed using a standardized rubric.

RESULTS

Of 1462 patients admitted to participating PICUs, 843 (58%) had at least 1 antibiotic order. A total of 1277 antibiotic orders were reviewed. Common indications were empiric therapy for suspected bacterial infections without sepsis or septic shock (260 orders, 21%), nonoperative prophylaxis (164 orders, 13%), empiric therapy for sepsis or septic shock (155 orders, 12%), community-acquired pneumonia (CAP; 118 orders, 9%), and post-operative prophylaxis (94 orders, 8%). Appropriateness was assessed for 985 orders for which an evidence-based rubric for appropriateness could be created. Of these, 331 (34%) were classified as inappropriate. Indications with the most orders classified as inappropriate were empiric therapy for suspected bacterial infection without sepsis or septic shock (78 orders, 24%), sepsis or septic shock (55 orders, 17%), CAP (51 orders, 15%), ventilator-associated infections (47 orders, 14%), and post-operative prophylaxis (44 orders, 14%). The proportion of antibiotics classified as inappropriate varied across institutions (range, 19%-43%).

CONCLUSIONS

Most PICU patients receive antibiotics. Based on our study, we estimate that one-third of antibiotic orders are inappropriate. Improved antibiotic stewardship and research focused on strategies to optimize antibiotic use in critically ill children are needed.

Variability in antimicrobial use among infants born at <33 weeks gestational age

Excessive antimicrobial use is associated with adverse neonatal outcomes. In our cohort of 27,163 infants born at <33 weeks gestational age, the first week after birth accounted for the highest rates of antimicrobial use, and variability across sites persisted after adjustment for patient characteristics correlated with illness severity.

Antimicrobial Stewardship Programs in PICU Settings: A Systematic Review

OBJECTIVES

Development of antimicrobial stewardship programs (ASPs) is strategy for prevention and management of emergence of antimicrobial-resistant organisms. In this study, we systematically reviewed the literature on antimicrobial stewardship interventions in PICUs and analyzed approaches, structure, implementation, and outcomes of the ASPs.

DATA SOURCES

PubMed and Scopus databases were systematically searched for studies published from January 1, 2007, to December 31, 2020, reporting interventions on judicious use of antimicrobials in PICUs (last search performed February 28, 2021).

DATA SELECTION

Studies that evaluated an intervention in a PICU setting or both in PICU and other settings and reported separate results for PICU were eligible for full-text review. Studies that had implemented stewardship in the entire hospital, including the PICU, but without presenting dedicated PICU data were excluded from the analysis.

DATA EXTRACTION

The strategy of intervention, structure of ASP team, implementation, and outcomes were assessed with a checklist tool for all studies included in the analysis. Risk of bias was assessed with the Cochrane Risk-of-Bias in Nonrandomized studies of Interventions tool.

DATA SYNTHESIS

Thirteen articles were found: 11 that applied ASP in PICUs, and two at hospital level. All PICU-dedicated ASPs applied a multimodal intervention combining strategies simultaneously; audit with feedback (6/11) and facility-specific clinical practice guidelines (7/11) were the most common strategies. A multidisciplinary team was formulated in all ASPs except for three biomarker-based interventions. Six of 11 studies included techniques to enhance behavior change and one implemented a behavior-based intervention. Antibiotic consumption was evaluated in all ASPs, cost in three of 11, antibiotic resistance in one of 11, length of hospitalization in six of 11, and mortality in eight of 11. All hospital-wide ASPs used audit with feedback in addition to facility-specific clinical practice guidelines and assessed antimicrobial consumption, expenditures, length of stay, and mortality.

CONCLUSIONS

The prevalence of ASPs in PICUs is limited, and few programs follow all of the currently available recommendations.

A Pediatric Intensive Care Checklist for Interprofessional Rounds: The R-PICniC Study

BACKGROUND

The use of checklists in the pediatric intensive care unit can help improve the quality of care and patient safety.

OBJECTIVES

To build and validate a checklist for use in interprofessional rounds in a pediatric intensive care unit.

METHODS

This methodological study was conducted in a 20-bed pediatric intensive care unit serving children up to 14 years old. A checklist prototype was constructed through review of the literature and achievement of consensus among the professionals providing care in the unit. Content validation was performed using a modified Delphi technique involving specialists with more than 5 years of experience in pediatric intensive care, methodological studies, and patient safety. Content validity ratios were calculated for the elements of the checklist, which were considered valid when they reached values greater than 0.78. The checklist was tested for usability, application time, and effects on patient care, and feedback was obtained from potential users.

RESULTS

Before content validation, the checklist contained 11 domains, 32 items, and 6 daily goals. The invitation to validate content was sent to 86 specialists, and content validity was achieved after 2 rounds of evaluation, with the checklist elements having content validity ratios ranging from 0.94 to 0.97. The mean application time of the checklist was 5 minutes. The final version consisted of 11 domains, 33 items, and 8 daily goals.

CONCLUSIONS

This study resulted in a useful and valid instrument for application in interprofessional rounds that was tailored to the needs of local health care professionals.

Uncovering Discrepancies in IV Vancomycin Infusion Records between Pump Logs and EHR Documentation

BACKGROUND

Infusion start time, completion time, and interruptions are the key data points needed in both area under the concentration-time curve (AUC)- and trough-based vancomycin therapeutic drug monitoring (TDM). However, little is known about the accuracy of documented times of drug infusions compared with automated recorded events in the infusion pump system. A traditional approach of direct observations of infusion practice is resource intensive and impractical to scale. We need a new methodology to leverage the infusion pump event logs to understand the prevalence of timestamp discrepancies as documented in the electronic health records (EHRs).

OBJECTIVES

We aimed to analyze timestamp discrepancies between EHR documentation (the information used for clinical decision making) and pump event logs (actual administration process) for vancomycin treatment as it may lead to suboptimal data used for therapeutic decisions.

METHODS

We used process mining to study the conformance between pump event logs and EHR data for a single hospital in the United States from July to December 2016. An algorithm was developed to link records belonging to the same infusions. We analyzed discrepancies in infusion start time, completion time, and interruptions.

RESULTS

Of the 1,858 infusions, 19.1% had infusion start time discrepancy more than ± 10 minutes. Of the 487 infusion interruptions, 2.5% lasted for more than 20 minutes before the infusion resumed. 24.2% (312 of 1,287) of 1-hour infusions and 32% (114 of 359) of 2-hour infusions had over 10-minute completion time discrepancy. We believe those discrepancies are inherent part of the current EHR documentation process commonly found in hospitals, not unique to the care facility under study.

CONCLUSION

We demonstrated pump event logs and EHR data can be utilized to study time discrepancies in infusion administration at scale. Such discrepancy should be further investigated at different hospitals to address the prevalence of the problem and improvement effort.

Antimicrobial stewardship programs in European pediatric intensive care units: an international survey of practices

Antibiotic therapy represents one of the most common interventions in pediatric intensive care units (PICUs). This study aims to describe current antimicrobial stewardship programs (ASP) in European PICUs. A cross-sectional survey distributed to European pediatric intensive care physicians through the European Society of Neonatal and Pediatric Intensive Care (ESPNIC) Infection, Inflammation, and Sepsis Section, to members of the Spanish Society of Pediatric Intensive Care, of the Pediatric Reanimation and Emergency Care French Group, and to European physicians known to be involved in antimicrobial stewardship programs. Responses from 60 PICUs across 12 countries were analyzed. Fifty three (88%) stated that ASP was implemented. The main interventions considered as ASP were the pharmacokinetic monitoring of antimicrobials (n = 41, 77%) and the development of facility-specific clinical practice guidelines (n = 40, 75%). The most common team composition of antimicrobial stewardship program included a pediatric infectious disease physician, a pharmacist, and a microbiologist (n = 11, 21%).

CONCLUSION

 Although ASP practices were reported to be widely implemented across European PICUs, this survey observed a large heterogeneity in terms of activities and modalities of intervention.

WHAT IS KNOWN

• Antibiotic therapy represents one of the most common interventions in pediatric intensive care units. • The role and subsequent success of antimicrobial stewardship programs has largely been reported in the adult population but scarcely in the pediatric population.

WHAT IS NEW

• Antimicrobial stewardship programs were reported to be widely implemented across European pediatric intensive care units. • We observed a large heterogeneity in terms of activities and modalities of intervention.

Machine Learning Approach to Predicting Absence of Serious Bacterial Infection at PICU Admission

BACKGROUND AND OBJECTIVES

Serious bacterial infection (SBI) is common in the PICU. Antibiotics can mitigate associated morbidity and mortality but have associated adverse effects. Our objective is to develop machine learning models able to identify SBI-negative children and reduce unnecessary antibiotics.

METHODS

We developed models to predict SBI-negative status at PICU admission using vital sign, laboratory, and demographic variables. Children 3-months to 18-years-old admitted to our PICU, between 2011 and 2020, were included if evaluated for infection within 24-hours, stratified by documented antibiotic exposure in the 48-hours prior. Area under the receiver operating characteristic curve (AUROC) was the primary model accuracy measure; secondarily, we calculated the number of SBI-negative children subsequently provided antibiotics in the PICU identified as low-risk by each model.

RESULTS

A total of 15 074 children met inclusion criteria; 4788 (32%) received antibiotics before PICU admission. Of these antibiotic-exposed patients, 2325 of 4788 (49%) had an SBI. Of the 10 286 antibiotic-unexposed patients, 2356 of 10 286 (23%) had an SBI. In antibiotic-exposed children, a radial support vector machine model had the highest AUROC (0.80) for evaluating SBI, identifying 48 of 442 (11%) SBI-negative children provided antibiotics in the PICU who could have been spared a median 3.7 (interquartile range 0.9-9.0) antibiotic-days per patient. In antibiotic-unexposed children, a random forest model performed best, but was less accurate overall (AUROC 0.76), identifying 33 of 469 (7%) SBI-negative children provided antibiotics in the PICU who could have been spared 1.1 (interquartile range 0.9-3.7) antibiotic-days per patient.

CONCLUSIONS

Among children who received antibiotics before PICU admission, machine learning models can identify children at low risk of SBI and potentially reduce antibiotic exposure.

Improving Vancomycin Stewardship in Critically Ill Children

BACKGROUND AND OBJECTIVES

Inappropriate vancomycin use is common in children's hospitals. We report a quality improvement (QI) intervention to reduce vancomycin use in our tertiary care PICU.

METHODS

We retrospectively quantified the prevalence of infections caused by organisms requiring vancomycin therapy, including methicillin-resistant Staphylococcus aureus (MRSA), among patients with suspected bacterial infections. Guided by these data, we performed 3 QI interventions over a 3-year period, including (1) stakeholder education, (2) generation of a consensus-based guideline for empiric vancomycin use, and (3) implementation of this guideline through clinical decision support. Vancomycin use in days of therapy (DOT) per 1000 patient days was measured by using statistical process control charts. Balancing measures included frequency of bacteremia due to an organism requiring vancomycin not covered with empiric therapy, 30-day mortality, and cardiovascular, respiratory, and renal organ dysfunction.

RESULTS

Among 1276 episodes of suspected bacterial infection, a total of 19 cases of bacteremia (1.5%) due to organisms requiring vancomycin therapy were identified, including 6 MRSA bacteremias (0.5%). During the 3-year QI project, overall vancomycin DOT per 1000 patient days in the PICU decreased from a baseline mean of 182 DOT per 1000 patient days to 109 DOT per 1000 patient days (a 40% reduction). All balancing measures were unchanged, and all cases of MRSA bacteremia were treated empirically with vancomycin.

CONCLUSION

Our interventions reduced overall vancomycin use in the PICU without evidence of harm. Provider education and consensus building surrounding indications for empiric vancomycin use were key strategies.

Diagnostic Stewardship in the Pediatric Intensive Care Unit

In the pediatric intensive care unit (PICU), clinicians encounter complex decision making, balancing the need to treat infections promptly against the potential harms of antibiotics. Diagnostic stewardship is an approach to optimize microbiology diagnostic test practices to reduce unnecessary antibiotic treatment. We review the evidence for diagnostic stewardship of blood, endotracheal, and urine cultures in the PICU. Clinicians should consider 3 questions applying diagnostic stewardship: (1) Does the patient have signs or symptoms of an infectious process? (2) What is the optimal diagnostic test available to evaluate for this infection? (3) How should the diagnostic specimen be collected to optimize results?

Impact and quality of antimicrobial use in a referral pediatric intensive care unit

INTRODUCTION

We aimed to describe antimicrobial use (AU) and quality of prescriptions (QP) in a 28-bed medical-surgical PICU of a European referral children's hospital during 2019.

METHODS

AU data were expressed as days-of-therapy (DOT) over 100 days-present (DP) and as length-of-treatment (LOT). QP was based on monthly cross-sectional point-prevalence surveys. Length-of-stay (LOS), readmission rates (RR), and mortality rates (MR) were also collected.

RESULTS

PICU AU accounted for 13.5% of the global hospital AU; the median PICU density of AU was 1.4 (IQR 1.3-1.5) times higher than that of the rest of the hospital areas. Antibacterials represented 88.5% of the overall AU, cefazolin and amoxicillin-clavulanate being the most used drugs. A high QP rate was observed (149/168 optimal, 88.9%), with room for improvement in prophylactic regimens and de-escalation of broad-spectrum regimens. LOT, LOS, RR, and MR remained stable.

CONCLUSIONS

PICU AU represented a major portion of the global hospital AU. Despite high QP rates, prophylactic and broad-spectrum antibiotic regimens were optimizable.

An Evaluation of Antimicrobial Prescribing and Risk-adjusted Mortality

Supplemental Digital Content is available in the text.

The Centers for Disease Control and Prevention recommends tracking risk-adjusted antimicrobial prescribing. Prior studies have used prescribing variation to drive quality improvement initiatives without adjusting for severity of illness. The present study aimed to determine the relationship between antimicrobial prescribing and risk-adjusted ICU mortality in the Pediatric Health Information Systems (PHIS) database, assessed by IBM-Watson risk of mortality. A nested analysis sought to assess an alternative risk model incorporating laboratory data from federated electronic health records.

Association of Endotracheal Aspirate Culture Variability and Antibiotic Use in Mechanically Ventilated Pediatric Patients

IMPORTANCE

Endotracheal aspirate cultures are commonly collected from patients with mechanical ventilation to evaluate for ventilator-associated pneumonia or tracheitis. However, the respiratory tract is not sterile, making differentiating between colonization from bacterial infection challenging, and results may be unreliable owing to variable specimen quality and sample processing across laboratories. Despite these limitations, clinicians routinely interpret bacterial growth in endotracheal aspirate cultures as evidence of infection, sometimes regardless of organism significance, prompting antibiotic treatment.

OBJECTIVE

To assess the variability in endotracheal aspirate culture rates and the association between culture rates and antibiotic prescribing among patients with mechanical ventilation across children's hospitals in the US.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional retrospective analysis of data obtained from the Children's Hospital Association Pediatric Health Information System database between January 1, 2016, through December 31, 2019. Participants were all patients hospitalized with mechanical ventilation aged less than 18 years.

EXPOSURES

A charge for an endotracheal aspirate culture on a ventilated day.

MAIN OUTCOMES AND MEASURES

Endotracheal aspirate culture rate and antibiotic days of therapy per ventilated days. For mechanical ventilation, clinical transaction classification codes for mechanical ventilation other unspecified ventilator assistance were used. To identify respiratory cultures, the laboratory test code for aerobic culture was used and relevant keywords (ie, respiratory tract, sputum) were used to identify sources in the hospital charge description master.

RESULTS

A total of 152 132 patients were identified among 31 hospitals. Among these patients, 79 691 endotracheal aspirate cultures were collected on a ventilator-day (patients aged less than 1 year, 44%; 1-4 years, 27%, 5-11 years. 16%, and 12-18 years, 13%; 3% were Asian; 17% Hispanic; 21% non-Hispanic Black; 45% Non-Hispanic White patients; 14% were other; 56% of patients were male, 44% were female). The overall median rate of culture use was 46 per 1000 ventilator-days (IQR, 32-73 cultures per 1000 ventilator-days). The endotracheal aspirate culture rate was positively correlated with the hospital's antibiotic days of therapy rate (R = 0.46; P = .009). In a multivariable model adjusting for patient-level and hospital-level characteristics and among patients with mechanical ventilation, each additional endotracheal aspirate culture was associated with 2.87 (95% CI, 2.74-3.01) higher odds of receiving additional days of therapy compared with patients who did not receive and endotracheal aspirate culture.

CONCLUSIONS AND RELEVANCE

In this study, notable variability was found in endotracheal aspirate culture rates across US pediatric hospitals and pediatric intensive care units, and endotracheal aspirate culture use was associated with increased antibiotic use. These findings suggest an opportunity for diagnostic and antibiotic stewardship to standardize testing and treatment of suspected ventilator-associated infections in pediatric patients with mechanical ventilation pediatric patients.

Physical and information workflow mapping of vancomycin therapeutic drug management: A single site case study revealing potential gaps in the process

Vancomycin is one of the most prescribed antibiotics in pediatric intensive care units (PICU) in US hospitals. However, a detailed understanding of workflow and information flow among various stakeholders regarding vancomycin treatment processes in clinical settings is lacking. We conducted direct observations and informant interviews to develop the mapping of key processes and information flow for vancomycin treatment, with an emphasis on therapeutic drug monitoring (TDM) dose adjustment decision-making. A health information technology (HIT) sociotechnical framework was used to identify EHR related safety concerns. A total of 27 vancomycin treatment activities were observed over a 60-h duration including infusion administration, infusion completion, trough concentration blood draw and therapeutic decision making processes. Workflow and information flow mappings revealed (1) deviations between the documented timestamp used for TDM decision making and the actual time the tasks executed and (2) the lack of information flow regarding infusion completion and interruption. Missing features, insufficient usability and lack of integration with workflow and communication in the EHR were deemed safety gaps that may affect the accuracy of therapeutic decisions. Our case study identified gaps in information flow among clinical team members via EHR in TDM processes to provide insights for the improvement of the EHR system for antibiotic treatment purposes. In particular, the potential harm of the missing, uncertain, and inaccurate documented TDM task times warrant further investigations.

Pharmacokinetics of Antibiotics in Pediatric Intensive Care: Fostering Variability to Attain Precision Medicine

Children show important developmental and maturational changes, which may contribute greatly to pharmacokinetic (PK) variability observed in pediatric patients. These PK alterations are further enhanced by disease-related, non-maturational factors. Specific to the intensive care setting, such factors include critical illness, inflammatory status, augmented renal clearance (ARC), as well as therapeutic interventions (e.g., extracorporeal organ support systems or whole-body hypothermia [WBH]). This narrative review illustrates the relevance of both maturational and non-maturational changes in absorption, distribution, metabolism, and excretion (ADME) applied to antibiotics. It hereby provides a focused assessment of the available literature on the impact of critical illness—in general, and in specific subpopulations (ARC, extracorporeal organ support systems, WBH)—on PK and potential underexposure in children and neonates. Overall, literature discussing antibiotic PK alterations in pediatric intensive care is scarce. Most studies describe antibiotics commonly monitored in clinical practice such as vancomycin and aminoglycosides. Because of the large PK variability, therapeutic drug monitoring, further extended to other antibiotics, and integration of model-informed precision dosing in clinical practice are suggested to optimise antibiotic dose and exposure in each newborn, infant, or child during intensive care.

Indirect Standardization as a Case Mix Adjustment Method to Improve Comparison of Children's Hospitals' Antimicrobial Use

Antimicrobial use (AU) in days of therapy per 1000 patient-days (DOT/1000 pd) varies widely among children's hospitals. We evaluated indirect standardization to adjust AU for case mix, a source of variation inadequately addressed by current measurements. Hospitalizations from the Pediatric Health Information System were grouped into 85 clinical strata. Observed to expected (O:E) ratios were calculated by indirect standardization and compared with DOT/1000 pd. Outliers were defined by O:E z-scores. Antibacterial DOT/1000 pd ranged from 345 to 776 (2.2-fold variation; interquartile range [IQR] 552-679), whereas O:E ratios ranged from 0.8 to 1.14 (1.4-fold variation; IQR 0.93-1.05). O:E ratios were moderately correlated with DOT/1000 pd (correlation estimate 0.44; 95% confidence interval, 0.19-0.64; P = .0009). Using indirect standardization to adjust for case mix reduces apparent AU variation and may enhance stewardship efforts by providing adjusted comparisons to inform interventions.

Associations of Antimicrobial-Resistant Gram-Negative Bloodstream Infections with Outcomes among Hospitalized Pediatric Patients in the United States

Objective The aim of this study was to assess the impact of pediatric antimicrobial-resistant gram-negative bloodstream infections (GNBSIs).

Methods A retrospective cohort study (2009–2016) was conducted using the Premier Healthcare Database among pediatric admissions with GNBSIs at hospitals reporting microbiology data. Infections for neonates and nonneonates were classified as multidrug resistance (MDR), resistant to one or two antibiotic drug classes (1–2DR), or susceptible.

Results Among 1,276 GNBSIs, 266 (20.8%) infections were 1–2DR and 23 (1.8%) MDR. Compared with susceptible GNBSIs, MDR nonneonates had higher mortality and higher costs, whereas 1–2DR neonates had longer stays and higher costs.

Conclusions Antimicrobial-resistant GNBSIs were associated with worse outcomes among pediatric hospitalized patients.

Impact and quality of antimicrobial use in a referral pediatric intensive care unit

INTRODUCTION

We aimed to describe antimicrobial use (AU) and quality of prescriptions (QP) in a 28-bed medical-surgical PICU of a European referral children's hospital during 2019.

METHODS

AU data were expressed as days-of-therapy (DOT) over 100 days-present (DP) and as length-of-treatment (LOT). QP was based on monthly cross-sectional point-prevalence surveys. Length-of-stay (LOS), readmission rates (RR), and mortality rates (MR) were also collected.

RESULTS

PICU AU accounted for 13.5% of the global hospital AU; the median PICU density of AU was 1.4 (IQR 1.3-1.5) times higher than that of the rest of the hospital areas. Antibacterials represented 88.5% of the overall AU, cefazolin and amoxicillin-clavulanate being the most used drugs. A high QP rate was observed (149/168 optimal, 88.9%), with room for improvement in prophylactic regimens and de-escalation of broad-spectrum regimens. LOT, LOS, RR, and MR remained stable.

CONCLUSIONS

PICU AU represented a major portion of the global hospital AU. Despite high QP rates, prophylactic and broad-spectrum antibiotic regimens were optimizable.

Importance of Reviewing Antibiotic Courses by 48 Hours: Risk Factors for Third-Generation Cephalosporin Resistance Among AmpC Harboring Organisms in Urine and Respiratory Cultures

BACKGROUND

Citrobacter, Enterobacter, Morganella, and Serratia (AmpC organisms) species can exhibit third-generation cephalosporin (TGC) resistance after TGC exposure. We aimed to assess if institutional TGC utilization correlated with institutional AmpC organism susceptibility and if prior TGC exposure ≤48 hours were associated with TGC resistance in the first culture of a future infection episode caused by an AmpC organism.

METHODS

A 5-year retrospective cohort study was performed, including AmpC organisms isolated from pediatric urinary and respiratory tract cultures at an institution with TGC courses reviewed by the antimicrobial stewardship program at 48 hours. Correlations were assessed by Pearson's correlation. Multivariable logistic regression identified factors independently associated with TGC resistance in a subcohort of infection episodes.

RESULTS

Among 654 cultures, AmpC organism TGC susceptibility increased from 74% in 2013 to 89.3% in 2017, and this correlated with a 26.1% decrease in TGC utilization (R = -0.906; P = 0.034). Among 275 AmpC organism infections, 21.1% were resistant. Resistance occurred in 13.6%, 17.4%, and 56.5% of infections with no exposure, ≤48 hours, and >48 hours of TGC exposure in the past 30 days, respectively. TGC exposure ≤48 hours was not associated with resistance (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.32-4.94; P = 0.74), whereas, TGC exposure >48 hours was (OR, 8.7; 95% CI, 3.67-20.6; P  < 0.001). Infections in 2017 were less likely to be resistant (OR, 0.25; 95% CI, 0.08-0.8; P = 0.019).

CONCLUSIONS

Decreased TGC utilization, likely related to antimicrobial stewardship, correlated with increased AmpC organism susceptibility. Limiting TGC exposure to ≤48 hours when possible may reduce AmpC organism resistance in future infections.

Use of Prospective Audit and Feedback to Reduce Antibiotic Exposure in a Pediatric Cardiac ICU

OBJECTIVES

We sought to determine whether a prospective audit and feedback intervention decreased antibiotic utilization in a pediatric cardiac ICU and to describe the characteristics of prospective audit and feedback audits and recommendations.

DESIGN

Before-after study.

SETTING

Pediatric cardiac ICU of a freestanding children's hospital.

PATIENTS

All patients admitted to the cardiac ICU.

INTERVENTIONS

A prospective audit and feedback program was established in our hospital's pediatric cardiac ICU on December 7, 2015. The antimicrobial stewardship program audited IV antibiotics, communicated prospective audit and feedback recommendations to the cardiac ICU, and regularly reviewed recommendation adherence. Mean monthly antibiotic utilization 18 months before ("preprospective audit and feedback"; from June 1, 2014 to November 30, 2015) and 24 months after ("prospective audit and feedback"; from January 1, 2016 to December 31, 2017) prospective audit and feedback implementation was compared. Antibiotic audit data during the prospective audit and feedback period were reviewed to capture the characteristics of prospective audit and feedback audits, recommendations, and adherence.

MEASUREMENTS AND MAIN RESULTS

Mean cardiac ICU IV antibiotic use decreased 20% (701 vs 880 days of therapy per 1,000 patient days, p = 0.001) during the prospective audit and feedback period compared with the preprospective audit and feedback period. There was no difference in mean cardiac ICU length of stay (p = 0.573), mean hospital length of stay (p = 0.722), or the rate of discharge due to death (p = 0.541). There were 988 antibiotic audits and 370 prospective audit and feedback recommendations (37% recommendation rate) during the study period. The most commonly audited antibiotic category was broad-spectrum gram-negative agents and the most common indication for use was sepsis. Broad-spectrum gram-positive agents were more likely to be associated with a recommendation.

CONCLUSIONS

There was a significant reduction in antibiotic use following implementation of a prospective audit and feedback program in our pediatric cardiac ICU. Over one-third of antibiotics audited in our cardiac ICU were associated with a prospective audit and feedback recommendation, revealing important targets for future antimicrobial stewardship efforts in this population.

Variability in Ceftriaxone Dosing Across 32 US Acute Care Children's Hospitals

Ceftriaxone is one of the most common antibiotics prescribed for hospitalized children in the United States. However, ceftriaxone is not dosed consistently. Sepsis/serious bacterial infection had high dosing variability. Dosing for central nervous system infection was frequently suboptimal. Future efforts should focus on optimizing and standardizing ceftriaxone dosing.

Evaluating antimicrobial appropriateness in a tertiary care pediatric ICU in Saudi Arabia: a retrospective cohort study

Background

Inappropriate antibiotic utilization is associated with the emergence of antimicrobial resistance (AMR) and a decline in antibiotic susceptibility in many pathogenic organisms isolated in intensive care units. Antibiotic stewardship programs (ASPs) have been recommended as a strategy to reduce and delay the impact of AMR. A crucial step in ASPs is understanding antibiotic utilization practices and quantifying the problem of inappropriate antibiotic use to support a targeted solution. We aim to characterize antibiotic utilization and determine the appropriateness of antibiotic prescription in a tertiary care pediatric intensive care unit.

Methods

A retrospective cohort study was conducted at King Abdullah Specialized Children’s Hospital, Riyadh, Saudi Arabia, over a 6-month period. Days of therapy (DOT) and DOT per 1000 patient-days were used as measures of antibiotic consumption. The appropriateness of antibiotic use was assessed by two independent pediatric infectious disease physicians based on the Centers for Disease Control and Prevention 12-step Campaign to prevent antimicrobial resistance among hospitalized children.

Results

During the study period, 497 patients were admitted to the PICU, accounting for 3009 patient-days. A total of 274 antibiotic courses were administered over 2553 antibiotic days. Forty-eight percent of antibiotic courses were found to be nonadherent to at least 1 CDC step. The top reasons were inappropriate antibiotic choice (empirical or definitive) and inappropriate prophylaxis durations. Cefazolin and vancomycin contributed to the highest percentage of inappropriate DOTs.

Conclusions

Antibiotic consumption was high with significant inappropriate utilization. These data could inform decision-making in antimicrobial stewardship programs and strategies. The CDC steps provide a more objective tool and limit biases when assessing antibiotic appropriateness

International Survey on Determinants of Antibiotic Duration and Discontinuation in Pediatric Critically Ill Patients

OBJECTIVES

We hypothesized that antibiotic use in PICUs is based on criteria not always supported by evidence. We aimed to describe determinants of empiric antibiotic use in PICUs in eight different countries.

DESIGN

Cross-sectional survey.

SETTING

PICUs in Canada, the United States, France, Italy, Saudi Arabia, Japan, Thailand, and Brazil.

SUBJECTS

Pediatric intensivists.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We used literature review and focus groups to develop the survey and its clinical scenarios (pneumonia, septic shock, meningitis, and intra-abdominal infections) in which cultures were unreliable due to antibiotic pretreatment. Data analyses included descriptive statistics and linear regression with bootstrapped SEs. Overall response rate was 39% (482/1,251), with individual country response rates ranging from 25% to 76%. Respondents in all countries prolonged antibiotic duration based on patient characteristics, disease severity, pathogens, and radiologic findings (from a median increase of 1.8 d [95% CI, 0.5-4.0 d] to 9.5 d [95% CI, 8.5-10.5 d]). Younger age, severe disease, and ventilator-associated pneumonia prolonged antibiotic treatment duration despite a lack of evidence for such practices. No variables were reported to shorten treatment duration for all countries. Importantly, more than 39% of respondents would use greater than or equal to 7 days of antibiotics for patients with a positive viral polymerase chain reaction test in all scenarios, except in France for pneumonia (29%), septic shock (13%), and meningitis (6%). The use of elevated levels of inflammatory markers to prolong antibiotic treatment duration varied among different countries.

CONCLUSIONS

Antibiotic-related decisions are complex and may be influenced by cultural and contextual factors. Evidence-based criteria are necessary to guide antibiotic duration and ensure the rational use of antibiotics in PICUs.

Medications for Children Receiving Intensive Care: A National Sample

OBJECTIVE

To examine medication administration records through electronic health record data to provide a broad description of the pharmaceutical exposure of critically ill children.

DESIGN

Retrospective cohort study using the Cerner Health Facts database.

SETTING

United States.

PATIENTS

A total of 43,374 children 7 days old to less than 22 years old receiving intensive care with available pharmacy data.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 907,440 courses of 1,080 unique medications were prescribed with a median of nine medications (range, 1-99; 25-75th percentile, 5-16) per patient. The most common medications were acetaminophen, ondansetron, and morphine. Only 45 medications (4.2%) were prescribed to more than 5% of patients, and these accounted for 442,067 (48.7%) of the total courses of medications. Each additional medication was associated with increased univariate risk of mortality (odds ratio, 1.05; 95% CI, 1.05-1.06; p < 0.001).

CONCLUSIONS

Children receiving intensive care receive a median of nine medications per patient and one quarter are prescribed at least than 16 medications. Only 45 medications were prescribed to more than 5% of patients, but these accounted for almost half of all medication courses.

Pediatric Antimicrobial Stewardship Programs: Current Perspectives

With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.

Model-Informed Precision Dosing of Vancomycin in Hospitalized Children: Implementation and Adoption at an Academic Children's Hospital

Background

Model-informed precision dosing (MIPD) can serve as a powerful tool during therapeutic drug monitoring (TDM) to help individualize dosing in populations with large pharmacokinetic variation. Yet, adoption of MIPD in the clinical setting has been limited. Overcoming technologic hurdles that allow access to MIPD at the point-of-care and placing it in the hands of clinical specialists focused on medication dosing may encourage adoption.

Objective

To describe the hospital implementation and usage of a MIPD clinical decision support (CDS) tool for vancomycin in a pediatric population.

Methods

Within an academic children’s hospital, MIPD for vancomycin was implemented via a commercial cloud-based CDS tool that utilized Bayesian forecasting. Clinical pharmacists were recognized as local champions to facilitate adoption of the tool and operated as end-users. Integration within the electronic health record (EHR) and automatic transmission of patient data to the tool were identified as important requirements. A web-link icon was developed within the EHR which when clicked sends users and needed patient-level clinical data to the CDS platform. Individualized pharmacokinetic predictions and exposure metrics for vancomycin are then presented in the form of a web-based dashboard. Use of the CDS tool as part of TDM was tracked and users were surveyed on their experience.

Results

After a successful pilot phase in the neonatal intensive care unit, implementation of MIPD was expanded to the pediatric intensive care unit, followed by availability to the entire hospital. During the first 2+ years since implementation, a total of 853 patient-courses (n = 96 neonates, n = 757 children) and 2,148 TDM levels were evaluated using the CDS tool. For the most recent 6 months, the CDS tool was utilized to support 79% (181/230) of patient-courses in which TDM was performed. Of 26 users surveyed, > 96% agreed or strongly agreed that automatic transmission of patient data to the tool was a feature that helped them complete tasks more efficiently; 81% agreed or strongly agreed that they were satisfied with the CDS tool.

Conclusions

Integration of a vancomycin CDS tool within the EHR, along with leveraging the expertise of clinical pharmacists, allowed for successful adoption of MIPD in clinical care.

Considerable variability in antibiotic use among US children's hospitals in 2017-2018

OBJECTIVE

To characterize the prevalence of and seasonal and regional variation in inpatient antibiotic use among hospitalized US children in 2017-2018.

DESIGN

We conducted a cross-sectional examination of hospitalized children. The assessments were conducted on a single day in spring (May 3, 2017), summer (August 2, 2017), fall (October 25, 2017), and winter (January 31, 2018). The main outcome of interest was receipt of an antibiotic on the study day.

SETTING

The study included 51 freestanding US children's hospitals that participate in the Pediatric Health Information System (PHIS).

PATIENTS

This study included all patients <18 years old who were admitted to a participating PHIS hospital, excluding patients who were admitted solely for research purposes.

RESULTS

Of 52,769 total hospitalized children, 19,174 (36.3%) received antibiotics on the study day and 6,575 of these (12.5%) received broad-spectrum antibiotics. The overall prevalence of antibiotic use varied across hospitals from 22.3% to 51.9%. Antibiotic use prevalence was 29.2% among medical patients and 47.7% among surgical patients. Although there was no significant seasonal variation in antibiotic use prevalence, regional prevalence varied, ranging from 32.7% in the Midwest to 40.2% in the West (P < .001). Among units, pediatric intensive care unit patients had the highest prevalence of both overall and broad-spectrum antibiotic use at 58.3% and 26.6%, respectively (P < .001).

CONCLUSIONS

On any given day in a national network of children's hospitals, more than one-third of hospitalized children received an antibiotic, and 1 in 8 received a broad-spectrum antibiotic. Variation across hospitals, setting and regions identifies potential opportunities for enhanced antibiotic stewardship activities.

Decision-Making Around Positive Tracheal Aspirate Cultures: The Role of Neutrophil Semiquantification in Antibiotic Prescribing

OBJECTIVES

Ventilator-associated infections are a major contributor to antibiotic use in the PICU. Quantitative or semiquantitative assessment of neutrophils (microscopic purulence) is routinely reported in positive cultures from tracheal aspirates. The role of microscopic purulence in guiding antibiotic therapy or its association with symptoms of ventilator-associated infections is less described in children. We examine microscopic purulence as an independent predictor of antibiotic use for positive tracheal aspirate cultures in the PICU.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care pediatric hospital.

PATIENTS

Children admitted to the PICU, neuro-PICU, or cardiac PICU with a positive tracheal aspirate culture from January 1, 2016, to December 31, 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Positive tracheal aspirate cultures were reviewed. The outcome variable was antibiotic treatment that targeted the positive tracheal aspirate culture. The predictor variable was microscopic purulence, defined as moderate or many neutrophils on Gram stain report. Competing predictors included demographics, comorbidities, vital signs changes, respiratory support, and laboratory values. Of 361 positive cultures in the cohort, 81 (22%) were treated with antibiotics. Positive cultures with microscopic purulence were targeted for therapy more frequently (30% vs 11%). Microscopic purulence was the strongest predictor for antibiotic therapy (odds ratio, 3.3; 95% CI, 1.6-6.8) compared with fever (odds ratio, 2.0; 95% CI, 1.0-4.1) or increased respiratory support (odds ratio, 2.3; 95% CI, 1.2-4.3). There was no significant variation in symptomatology between microscopic purulence reported as moderate or many versus other (e.g., fever -24% vs 22%, increased respiratory support -36% vs 28%). Microscopic purulence was less prevalent with longer ventilator durations at the time of sampling.

CONCLUSIONS

Microscopic purulence was an independent predictor of antibiotic therapy for positive tracheal aspirate cultures in our PICUs. However, microscopic purulence was not associated with clinical symptomatology.

Hospital-wide Description of Clinical Indications for Pediatric Anti-infective Use

PURPOSE

This study is the first description of hospital-wide anti-infective use according to clinical indication for a pediatric hospital. Children's Hospital Colorado (CHCO) is uniquely poised to examine its anti-infective use after the implementation of provider-selected order indications (PSOIs), which are distinct from Diagnosis Related Group classifications in that they are used for clinical treatment as opposed to final diagnosis codes for billing and thus are more granular.

METHODS

This study used our institution's mandatory PSOIs to describe overall clinical indications for anti-infective use. For 2016, all anti-infective orders were extracted from the electronic medical record (Epic), including drug name, route, prescribing unit, and PSOI. We calculated the number of times each drug was associated with each indication and the number of times an indication was attributed to each drug, and then analyzed these data in Excel.

FINDINGS

There were 29,258 orders at CHCO in 2016 with at least 1 indication. The most common clinical indication was "prophylaxis-medical/surgical," accounting for 23% of all orders and commonly associated with cefazolin (42% of prophylaxis-medical/surgical orders). This was followed by the indications of "sepsis/bacteremia" and "pneumonia/sinusitis." The most commonly prescribed anti-infectives for nonprophylactic clinical indications were IV vancomycin (14%), ceftriaxone (11%), and ampicillin (6%).

IMPLICATIONS

Knowledge of the clinical reasons for hospital-wide anti-infective use enables hospitals to identify targets for improved use through education and guideline and policy development. This description provides better details than billing codes about the clinical reasons anti-infectives are used and offers a useful template for implementation at other hospitals.

Antibiotic Prescription in Young Children With Respiratory Syncytial Virus-Associated Respiratory Failure and Associated Outcomes

OBJECTIVES

To describe antibiotic prescribing practices during the first 2 days of mechanical ventilation among previously healthy young children with respiratory syncytial virus-associated lower respiratory tract infection and evaluate associations between the prescription of antibiotics at onset of mechanical ventilation with clinical outcomes.

DESIGN

Retrospective cohort study.

SETTING

Forty-six children's hospitals in the United States.

PATIENTS

Children less than 2 years old discharged between 2012 and 2016 with an International Classification of Diseases diagnosis of respiratory syncytial virus-associated lower respiratory tract infection, no identified comorbid conditions, and receipt of mechanical ventilation.

INTERVENTIONS

Antibiotic prescription during the first 2 days of mechanical ventilation.

MEASUREMENTS AND MAIN RESULTS

We compared duration of mechanical ventilation and hospital length of stay between children prescribed antibiotics on both of the first 2 days of mechanical ventilation and children not prescribed antibiotics during the first 2 days of mechanical ventilation. We included 2,107 PICU children with respiratory syncytial virus-associated lower respiratory tract infection (60% male, median age of 1 mo [interquartile range, 1-4 mo]). The overall proportion of antibiotic prescription on both of the first 2 days of mechanical ventilation was 82%, decreasing over the study period (p = 0.004) and varying from 36% to 100% across centers. In the bivariate analysis, antibiotic prescription was associated with a shorter duration of mechanical ventilation (6 d [4-9 d] vs 8 d [6-11 d]; p < 0.001) and a shorter hospital length of stay (11 d [8-16 d] vs 13 d [10-18 d]; p < 0.001). After adjustment for center, demographics, and vasoactive medication prescription, antibiotic prescription was associated with a 1.21-day shorter duration of mechanical ventilation and a 2.07-day shorter length of stay. Ultimately, 95% of children were prescribed antibiotics sometime during hospitalization, but timing, duration, and antibiotic choice varied markedly.

CONCLUSIONS

Although highly variable across centers and decreasing over time, the practice of instituting antibiotics after intubation in young children with respiratory syncytial virus-associated lower respiratory tract infection was associated with a shortened clinical course after adjustment for the limited available covariates. A prudent approach to identify and optimally treat bacterial coinfection is needed.

Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes

Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.