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Schober T, Morris SK, Bettinger JA, Burton C, Halperin SA, Jadavji T, Kazmi K, Modler J, Sadarangani M, Papenburg J. Antibiotic use in children hospitalised for influenza, 2010-2021: the Canadian Immunization Monitoring Program Active (IMPACT). Infection 2024; 52:865-875. [PMID: 37930625 DOI: 10.1007/s15010-023-02124-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/22/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE To determine characteristics associated with inappropriate antibiotic use amongst children hospitalised for influenza. METHODS We performed active surveillance for laboratory-confirmed influenza hospitalizations amongst children ≤ 16 years old at the 12 Canadian Immunization Monitoring Program Active hospitals, from September 2010 to August 2021. Antibiotic use was presumed appropriate if any of the following indications were met: age < 1 month, immunocompromised, hemoglobinopathy, laboratory-confirmed bacterial infection, radiographically confirmed pneumonia, admission to an intensive care unit and mechanical ventilation. Regression analyses were used to identify baseline and clinical characteristics associated with antibiotic use amongst patients without an appropriate indication. RESULTS Amongst 8971 children, 6424 (71.6%) received any antibiotics during their hospitalisation. Amongst the 4429 children without an appropriate indication, 2366 (53.2%) received antibiotics. Antibiotic use amongst children without appropriate indication differed between study centres, ranging from 33.2% to 66.1% (interquartile range [IQR] 50.6-56.3%); it did not change significantly over time (p-value for trend = 0.28). In multivariable analyses, older age (adjusted odds ratio [aOR] 0.97, 95% confidence interval [CI] 0.96-0.99), presence of any high-risk condition (aOR 0.80, 95% CI 0.70-0.92), influenza virus type B (aOR 0.8, 95% CI 0.70-0.91) and croup (aOR 0.64, 95% CI 0.49-0.83) were associated with less, whilst fever ≥ 38.5 °C (aOR 1.82, 95% CI 1.42-2.35) and hospitalisation duration (aOR 1.12, 95% CI 1.09-1.15) were associated with more inappropriate antibiotic use. CONCLUSIONS Over two-third of children hospitalised for influenza received antibiotics, including over half of those without an appropriate indication for antibiotic treatment. Differences amongst study centres suggest the importance of contextual determinants of antibiotic use.
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Affiliation(s)
- Tilmann Schober
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, E05.1905, 1001 Décarie Blvd, Montreal, QC, H4A 3J1, Canada
- Division of Pediatric Infectious Diseases, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Shaun K Morris
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Julie A Bettinger
- Vaccine Evaluation Center, BC Children's Hospital Research Institute,, University of British Columbia, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Catherine Burton
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Scott A Halperin
- Canadian Center for Vaccinology, IWK Health Center, Dalhousie University, Halifax, NS, Canada
| | - Taj Jadavji
- Section of Infectious Diseases, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Kescha Kazmi
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jacqueline Modler
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montreal, QC, Canada
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute,, University of British Columbia, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Jesse Papenburg
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, E05.1905, 1001 Décarie Blvd, Montreal, QC, H4A 3J1, Canada.
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montreal, QC, Canada.
- Division of Microbiology, Department of Clinical Laboratory Medicine, McGill University Health Centre, Montreal, QC, Canada.
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2
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Moore DP, Chetty T, Pillay A, Karsas M, Cloete J, Balakrishna Y, Reddy T, Archary M, van Kwawegen A, Thomas R, Nakwa FL, Waggie Z, Magrath S, Goga A, Jeena P. Antibiotic and antifungal use in paediatric departments at three academic hospitals in South Africa. IJID REGIONS 2024; 10:151-158. [PMID: 38314394 PMCID: PMC10835277 DOI: 10.1016/j.ijregi.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 02/06/2024]
Abstract
Objectives South Africa implemented a National Strategic Framework to optimise antimicrobial stewardship in 2014; however, there is limited data on how this has affected prescribing, especially to children treated in academic centres. Methods We conducted a point prevalence survey using the World Health Organization (WHO) methodology to evaluate antibiotic and antifungal prescribing practices in paediatric departments at three academic hospitals in South Africa. Results We recorded 1946 antimicrobial prescriptions in 1191 children, with 55.2% and 39.2% of the antibiotics classified as WHO AWaRe Access and Watch drugs, respectively. There were significant differences in prescription of Reserve antibiotics and antifungals between institutions. Receipt of WHO Watch and Reserve antibiotics was independently associated with infancy (<12 months) and adolescents (13-17 years) (adjusted relative risk [aRR]: 2.09-9.95); prolonged hospitalisation (aRR: 3.29-30.08); rapidly or ultimately fatal illness (aRR: 1.94 to 5.52); and blood transfusion (aRR: 3.28-5.70). Antifungal prescribing was associated with treatment of hospital-associated infection (aRR: 2.90), medical prophylaxis (aRR: 3.30), and treatment in intensive care units (aRR: 2.15-2.27). Conclusions Guidance on optimisation of infection prevention and control practice and strengthening of antimicrobial stewardship would impact positively on the care of sick children in our setting.
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Affiliation(s)
- David P. Moore
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Terusha Chetty
- HIV And Other Infectious Diseases Unit, South African Medical Research Council & Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ashendri Pillay
- Department of Paediatrics and Child Health, Inkosi Alert Luthuli Central Hospital and University of KwaZulu-Natal, Durban, South Africa
| | - Maria Karsas
- Department of Paediatrics and Child Health, Steve Biko Academic Hospital and University of Pretoria, Pretoria, South Africa
| | - Jeané Cloete
- Department of Paediatrics and Child Health, Steve Biko Academic Hospital and University of Pretoria, Pretoria, South Africa
| | - Yusentha Balakrishna
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Tarylee Reddy
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Moherndran Archary
- Department of Paediatrics and Child Health, Inkosi Alert Luthuli Central Hospital and University of KwaZulu-Natal, Durban, South Africa
| | - Alison van Kwawegen
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - Reenu Thomas
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - Firdose L. Nakwa
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - Zainab Waggie
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - Stephanie Magrath
- Faculty of Health Sciences, University of the Witwatersrand, York Road, Parktown, Johannesburg, South Africa
| | - Ameena Goga
- Department of Paediatrics and Child Health, Steve Biko Academic Hospital and University of Pretoria, Pretoria, South Africa
- South African Medical Research Council, Pretoria, South Africa
| | - Prakash Jeena
- Department of Paediatrics and Child Health, Inkosi Alert Luthuli Central Hospital and University of KwaZulu-Natal, Durban, South Africa
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3
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Alfraij A, Abdelmoniem A, Elseadawy M, Surour M, Basuni M, Papenburg J, Alghounaim M. The effect of Telehealth Antimicrobial Stewardship Program (Tele-ASP) on antimicrobial use in a pediatric intensive care unit: Pre- and post-implementation single center study. J Infect Public Health 2023; 16:1361-1367. [PMID: 37437429 DOI: 10.1016/j.jiph.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/24/2023] [Accepted: 06/11/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Overuse or misuse of antimicrobials is common in pediatric intensive care units (PICU) and may be associated with poor clinical outcomes. Although an antimicrobial stewardship program (ASP) has been found to improve this practice, the required expertise in infectious diseases may be limited in some centers. We aimed to evaluate the effect of telehealth ASP on the rate of PICU antimicrobial use in a center without a local Infectious Diseases consultation service. METHODS A retrospective cohort study was performed between October 1st, 2018, and October 31st, 2020, in Farwaniya Hospital PICU, a 20-bed unit. All pediatric patients who were admitted to PICU and received systemic antimicrobials during the study period were included and followed until hospital discharge. The ASP team provided weekly prospective audit and feedback on antimicrobial use starting October 8th, 2019. A pediatric infectious diseases specialist joined the ASP rounds remotely. Descriptive analyses and a pre-post intervention comparison of days of therapy (DOT) were used to assess the effectiveness of the ASP intervention. RESULTS There were 272 and 156 PICU admissions received systemic antimicrobial before and after the initiation of ASP, respectively. Bronchiolitis and pneumonia were the most common admission diagnoses, together compromising 60.7% and 61.2% of cases pre- and post-ASP. The requirement for respiratory support was higher post-ASP (76.5% vs. 91.5%, p < 0.001). Average monthly antimicrobial use decreased from 922 (95%CI 745-1000) to 485 DOT/1000 patient-days (95%CI 246-722, P < 0.05). A decline in DOT was observed across most antibiotic classes, except for ceftriaxone. No effect on the length of PICU stay, length of hospitalization, or mortality was observed. Most (89.7%) ASP recommendations were followed either fully or partially. CONCLUSION In settings where Infectious Diseases consultation services are unavailable, PICU telehealth ASP can be effectively implemented and associated with significantly reducing antimicrobial use.
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Affiliation(s)
- Abdulla Alfraij
- Pediatric Intensive Care Unit, Department of Pediatrics, Farwaniya Hospital, Sabah Al-Nasser, Al Farwaniya, Kuwait; Pediatric Intensive Care Unit, Department of Pediatrics, General Ahmadi Hospital, Kuwait Oil Company (KOC), Al-Ahmadi, Kuwait
| | - Ahmed Abdelmoniem
- Pediatric Intensive Care Unit, Department of Pediatrics, Farwaniya Hospital, Sabah Al-Nasser, Al Farwaniya, Kuwait
| | - Mohamed Elseadawy
- Pediatric Intensive Care Unit, Department of Pediatrics, Farwaniya Hospital, Sabah Al-Nasser, Al Farwaniya, Kuwait
| | - Mohammad Surour
- Pediatric Intensive Care Unit, Department of Pediatrics, Farwaniya Hospital, Sabah Al-Nasser, Al Farwaniya, Kuwait
| | - Mohamed Basuni
- Pediatric Intensive Care Unit, Department of Pediatrics, Farwaniya Hospital, Sabah Al-Nasser, Al Farwaniya, Kuwait
| | - Jesse Papenburg
- Departments of Pediatrics and Medical Microbiology, McGill University Health Centre, Montreal, Quebec, Canada
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A European International Multicentre Survey on the Current Practice of Perioperative Antibiotic Prophylaxis for Paediatric Liver Transplantations. Antibiotics (Basel) 2023; 12:antibiotics12020292. [PMID: 36830202 PMCID: PMC9952614 DOI: 10.3390/antibiotics12020292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
(1) Background: Postoperative infections are major contributors of morbidity and mortality after paediatric liver transplantation (pLTX). Evidence and recommendations regarding the most effective antimicrobial strategy are lacking. (2) Results: Of 39 pLTX centres, 20 responded. Aminopenicillins plus ß-lactamase inhibitors were used by six (30%) and third generation cephalosporins by three (15%), with the remaining centres reporting heterogenous regimens. Broad-spectrum regimens were the standard in 10 (50%) of centres and less frequent in the 16 (80%) centres with an infectious disease specialist. The duration ranged mainly between 24-48 h and 3-5 days in the absence and 3-5 days or 6-10 days in the presence of risk factors. Strategies regarding antifungal, antiviral, adjunctive antimicrobial, and surveillance strategies varied widely. (3) Methods: This international multicentre survey endorsed by the European Liver Transplant Registry queried all European pLTX centres from the registry on their current practice of perioperative antibiotic prophylaxis and antimicrobial strategies via an online questionnaire. (4) Conclusions: This survey found great heterogeneity regarding all aspects of postoperative antimicrobial treatment, surveillance, and prevention of infections in European pLTX centres. Evidence-based recommendations are urgently needed to optimise antimicrobial strategies and reduce the spectrum and duration of antimicrobial exposure.
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5
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Dos Santos Alves DF, Moraes ÉS, Conti PBM, Bueno GCV, de Souza TH, Pereira EOP, Brandão MB, Peterlini MAS, Pedreira MLG. A Pediatric Intensive Care Checklist for Interprofessional Rounds: The R-PICniC Study. Am J Crit Care 2022; 31:383-389. [PMID: 36045045 DOI: 10.4037/ajcc2022533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Daniela Fernanda Dos Santos Alves
- Daniela Fernanda dos Santos Alves is a professor of pediatric nursing, School of Nursing, State University of Campinas, Brazil, and a postdoctorate fellow, São Paulo School of Nursing, Federal University of São Paulo, São Paulo, Brazil
| | - Érika Sana Moraes
- Érika Sana Moraes is a PhD student, Clinical Hospital, State University of Campinas
| | | | | | | | | | | | - Maria Angélica Sorgini Peterlini
- Maria Angélica Sorgini Peterlini is a professor of pediatric nursing, São Paulo School of Nursing, Federal University of São Paulo
| | - Mavilde Luz Gonçalves Pedreira
- Mavilde Luz Gonçalves Pedreira is a professor of pediatric nursing, São Paulo School of Nursing, Federal University of São Paulo
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6
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Antibiotic treatment duration for bloodstream infections in critically ill children—A survey of pediatric infectious diseases and critical care clinicians for clinical equipoise. PLoS One 2022; 17:e0272021. [PMID: 35881618 PMCID: PMC9321425 DOI: 10.1371/journal.pone.0272021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/11/2022] [Indexed: 11/28/2022] Open
Abstract
Objective To describe antibiotic treatment durations that pediatric infectious diseases (ID) and critical care clinicians usually recommend for bloodstream infections in critically ill children. Design Anonymous, online practice survey using five common pediatric-based case scenarios of bloodstream infections. Setting Pediatric intensive care units in Canada, Australia and New Zealand. Participants Pediatric intensivists, nurse practitioners, ID physicians and pharmacists. Main outcome measures Recommended treatment durations for common infectious syndromes associated with bloodstream infections and willingness to enrol patients into a trial to study treatment duration. Results Among 136 survey respondents, most recommended at least 10 days antibiotics for bloodstream infections associated with: pneumonia (65%), skin/soft tissue (74%), urinary tract (64%) and intra-abdominal infections (drained: 90%; undrained: 99%). For central vascular catheter-associated infections without catheter removal, over 90% clinicians recommended at least 10 days antibiotics, except for infections caused by coagulase negative staphylococci (79%). Recommendations for at least 10 days antibiotics were less common with catheter removal. In multivariable linear regression analyses, lack of source control was significantly associated with longer treatment durations (+5.2 days [95% CI: 4.4–6.1 days] for intra-abdominal infections and +4.1 days [95% CI: 3.8–4.4 days] for central vascular catheter-associated infections). Most clinicians (73–95%, depending on the source of bloodstream infection) would be willing to enrol patients into a trial of shorter versus longer antibiotic treatment duration. Conclusions The majority of clinicians currently recommend at least 10 days of antibiotics for most scenarios of bloodstream infections in critically ill children. There is practice heterogeneity in self-reported treatment duration recommendations among clinicians. Treatment durations were similar across different infectious syndromes. Under appropriate clinical conditions, most clinicians would be willing to enrol patients into a trial of shorter versus longer treatment for common syndromes associated with bloodstream infections.
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7
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Pong S, Fowler RA, Murthy S, Pernica JM, Gilfoyle E, Fontela P, Rishu AH, Mitsakakis N, Hutchison JS, Science M, Seto W, Jouvet P, Daneman N. Antimicrobial treatment duration for uncomplicated bloodstream infections in critically ill children: a multicentre observational study. BMC Pediatr 2022; 22:179. [PMID: 35382774 PMCID: PMC8981828 DOI: 10.1186/s12887-022-03219-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/14/2022] [Indexed: 11/22/2022] Open
Abstract
Background Bloodstream infections (BSIs) cause significant morbidity and mortality in critically ill children but treatment duration is understudied. We describe the durations of antimicrobial treatment that critically ill children receive and explore factors associated with treatment duration. Methods We conducted a retrospective observational cohort study in six pediatric intensive care units (PICUs) across Canada. Associations between treatment duration and patient-, infection- and pathogen-related characteristics were explored using multivariable regression analyses. Results Among 187 critically ill children with BSIs, the median duration of antimicrobial treatment was 15 (IQR 11–25) days. Median treatment durations were longer than two weeks for all subjects with known sources of infection: catheter-related 16 (IQR 11–24), respiratory 15 (IQR 11–26), intra-abdominal 20 (IQR 14–26), skin/soft tissue 17 (IQR 15–33), urinary 17 (IQR 15–35), central nervous system 33 (IQR 15–46) and other sources 29.5 (IQR 15–55) days. When sources of infection were unclear, the median duration was 13 (IQR 10–16) days. Treatment durations varied widely within and across PICUs. In multivariable linear regression, longer treatment durations were associated with severity of illness (+ 0.4 days longer [95% confidence interval (CI), 0.1 to 0.7, p = 0.007] per unit increase in PRISM-IV) and central nervous system infection (+ 17 days [95% CI, 6.7 to 27.4], p = 0.001). Age and pathogen type were not associated with treatment duration. Conclusions Most critically ill children with BSIs received at least two weeks of antimicrobial treatment. Further study is needed to determine whether shorter duration therapy would be effective for selected critically ill children. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03219-z.
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Affiliation(s)
- Sandra Pong
- Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Srinivas Murthy
- Department of Pediatrics, Division of Critical Care, University of British Columbia, Vancouver, BC, Canada.,Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Jeffrey M Pernica
- Division of Infectious Diseases, McMaster University, Hamilton, ON, Canada
| | - Elaine Gilfoyle
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Patricia Fontela
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Asgar H Rishu
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nicholas Mitsakakis
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - James S Hutchison
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michelle Science
- Division of Infectious Diseases, Department of Paediatric Medicine, The Hospital for Children, Toronto, ON, Canada
| | - Winnie Seto
- Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, Sainte-Justine Hospital University Center, Montreal, QC, Canada.,Department of Pediatrics, Université de Montréal, Montreal, QC, Canada
| | - Nick Daneman
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Bruns N, Dohna-Schwake C. Antibiotics in critically ill children-a narrative review on different aspects of a rational approach. Pediatr Res 2022; 91:440-446. [PMID: 34873285 PMCID: PMC8816725 DOI: 10.1038/s41390-021-01878-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 12/19/2022]
Abstract
Especially critically ill children are exposed to antibiotic overtreatment, mainly caused by the fear of missing out a severe bacterial infection. Potential adverse effects and selection of multi-drug resistant bacteria play minor roles in decision making. This narrative review first describes harm from antibiotics and second focuses on different aspects that could help to reduce antibiotic overtreatment without harming the patient: harm from antibiotic treatment, diagnostic approaches, role of biomarkers, timing of antibiotic therapy, empiric therapy, targeted therapy, and therapeutic drug monitoring. Wherever possible, we linked the described evidence to the current Surviving Sepsis Campaign guidelines. Antibiotic stewardship programs should help guiding antibiotic therapy for critically ill children. IMPACT: Critically ill children can be harmed by inadequate or overuse of antibiotics. Hemodynamically unstable children with a suspicion of infection should be immediately treated with broad-spectrum antibiotics. In contrast, in hemodynamically stable children with sepsis and organ dysfunction, a time frame of 3 h for proper diagnostics may be adequate before starting antibiotics if necessary. Less and more targeted antibiotic treatment can be achieved via antibiotic stewardship programs.
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Affiliation(s)
- Nora Bruns
- grid.5718.b0000 0001 2187 5445Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany. .,Westdeutsches Zentrum für Infektiologie, University of Duisburg-Essen, Essen, Germany.
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Yoshida K, Hatachi T, Okamoto Y, Aoki Y, Kyogoku M, Moon Miyashita K, Inata Y, Shimizu Y, Fujiwara F, Takeuchi M. Application of Multiplex Polymerase Chain Reaction for Pathogen Identification and Antibiotic Use in Children With Respiratory Infections in a PICU. Pediatr Crit Care Med 2021; 22:e644-e648. [PMID: 34224509 DOI: 10.1097/pcc.0000000000002794] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To compare the pathogen identification rate and use of antibiotics before and after the implementation of multiplex polymerase chain reaction testing in children with respiratory infections in a PICU. DESIGN Single-center, pre-post study. SETTING PICU of Osaka Women's and Children's Hospital, Osaka, Japan. PATIENTS Consecutive children with respiratory infections who were admitted to the PICU between December 2017 and November 2018 (premultiplex polymerase chain reaction period) and between March 2019 and February 2020 (postmultiplex polymerase chain reaction period). INTERVENTIONS Conventional rapid antigen tests and bacterial culture tests were performed throughout the study period. Multiplex polymerase chain reaction testing using the FilmArray respiratory panel (BioFire Diagnostics, Salt Lake City, UT) was conducted to detect 17 viruses and three bacterial pathogens. During the postmultiplex polymerase chain reaction period, we did not recommend prescribing antibiotics for stable children, depending on the virus species and laboratory test results. MEASUREMENTS AND MAIN RESULTS Ninety-six and 85 children were enrolled during the pre- and postmultiplex polymerase chain reaction periods, respectively. Rapid antigen tests identified pathogens in 22% of the children (n = 21) during the premultiplex polymerase chain reaction period, whereas rapid antigen tests and/or multiplex polymerase chain reaction testing identified pathogens in 67% of the children (n = 57) during the postmultiplex polymerase chain reaction period (p < 0.001). The most commonly identified pathogen using multiplex polymerase chain reaction testing was human rhino/enterovirus. Bacterial pathogens were identified in 50% of the children (n = 48) and 60% of the children (n = 51) during the pre- and postmultiplex polymerase chain reaction periods (p = 0.18). There were no differences in antibiotic use (84% vs 75%; p = 0.14), broad-spectrum antibiotic use (33% vs 34%; p = 0.91), or the duration of antibiotic use within 14 days of admission (6.0 vs 7.0 d; p = 0.45) between the pre- and postmultiplex polymerase chain reaction periods. CONCLUSIONS Although the pathogen identification rate, especially for viral pathogens, increased using multiplex polymerase chain reaction testing, antibiotic use did not reduce in children with respiratory infections in the PICU. Definitive identification of bacterial pathogens and implementation of evidence-based antimicrobial stewardship programs employing multiplex polymerase chain reaction testing are warranted.
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Affiliation(s)
- Kota Yoshida
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Takeshi Hatachi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yuya Okamoto
- Department of Laboratory Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yoshihiro Aoki
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
- Department of Emergency and Critical Care Medicine, Aizawa Hospital, Nagano, Japan
| | - Miyako Kyogoku
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kazue Moon Miyashita
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yu Inata
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yoshiyuki Shimizu
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Futoshi Fujiwara
- Department of Laboratory Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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10
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Kazzaz YM, AlTurki H, Aleisa L, Alahmadi B, Alfattoh N, Alattas N. Evaluating antimicrobial appropriateness in a tertiary care pediatric ICU in Saudi Arabia: a retrospective cohort study. Antimicrob Resist Infect Control 2020; 9:173. [PMID: 33143749 PMCID: PMC7640689 DOI: 10.1186/s13756-020-00842-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 10/27/2020] [Indexed: 02/07/2023] Open
Abstract
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
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Affiliation(s)
- Yasser M Kazzaz
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia. .,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia. .,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Haneen AlTurki
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Lama Aleisa
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Bashaer Alahmadi
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Nora Alfattoh
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Nadia Alattas
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
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