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Opportunities for antibiotic reduction in mechanically ventilated children*

Toltzis, Philip MD; Elward, Alexis MD; Davis, Daniela MD; Helfaer, Mark MD; Smathers, Sarah MPH; Zaoutis, Theoklis MD

Pediatric Critical Care Medicine:
doi: 10.1097/PCC.0b013e3181f39f0e
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Abstract

Objective: To identify opportunities to safely reduce antibiotic use in critically ill children with moderately severe respiratory failure.

Design: Prospective observational.

Setting: Four pediatric intensive care units at three American tertiary care children's hospitals.

Patients: Children aged 2 months to 18 yrs who were mechanically ventilated, had an abnormal chest radiograph, and for whom the attending physicians had initiated antibiotics for presumed bacterial pneumonia.

Intervention: Nonbronchoscopic bronchoalveolar lavage.

Methods and Main Results: Eligible children were subjected to nonbronchoscopic bronchoalveolar lavage within 12 hrs of initiating antibiotics. The concentration of bacteria in the lavage fluid was determined by quantitative assay, and the diagnosis of pneumonia was confirmed if >104 pathogenic bacteria/mL were cultivated. Twenty-one subjects were enrolled, in whom 20 nonbronchoscopic bronchoalveolar lavage procedures were completed. Six of 20 subjects had nonbronchoscopic bronchoalveolar lavage results confirmatory of bacterial pneumonia, three additional subjects had bacteria isolated at concentrations below levels conventionally used to diagnose bacterial pneumonia, and the remaining 11 demonstrated no growth. Clinical parameters reflective of severity of disease and laboratory parameters reflective of systemic and local inflammation were tested for their association with a positive nonbronchoscopic bronchoalveolar lavage, but none was demonstrated.

Conclusions: Eleven of 20 mechanically ventilated children treated with antibiotics for presumed infectious pneumonia had undetectable concentrations of bacteria in their lower respiratory tract, and three others had organisms present at low concentrations, suggesting that opportunities exist to reduce antibiotic exposure in this population.

Author Information

From the Division of Pharmacology and Critical Care (PT), Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH; Department of Infection Control (AE), St. Louis Children's Hospital, St. Louis, MO; Department of Anesthesiology and Critical Care Medicine (DD), Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesia, Critical Care, Pediatrics, and Nursing (MH), Hospital of the University of Pennsylvania Schools of Medicine and Nursing, Philadelphia, PA; Department of Critical Care Medicine (MH), The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Infection Prevention (SS), Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics and Epidemiology (TZ), University of Pennsylvania School of Medicine, Philadelphia, PA; and Division of Infectious Diseases (TZ), Children's Hospital of Philadelphia, Philadelphia, PA.

Dr. Elward has disclosed that he is receiving grant research/funding from Sage Products, Inc. Dr. Zaoutis has disclosed that he was the recipient of grants/research funds from Astra Zeneca and Merck and that he is currently receiving research funds from and is a consultant/advisor for Merck.

Supported, in part, by Grant HHSN272200900022C from the National Institute of Allergy and Infectious Diseases, through contract CON100900 for the Bacteriology and Mycology Study Group. Dr. Elward consulted with Trinity and received a grant from Sage. Dr. Zaoutis received grants from AstraZeneca and Merck. The remaining authors have not disclosed any potential conflicts of interest.

Presented, in part, at the Canadian Critical Care Conference, Whistler, British Columbia, Canada, March 17, 2009.

For information regarding this article, E-mail: pxt2@case.edu

©2011The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies