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Development of an Antibiotic Guideline for Children With Suspected Ventilator-Associated Infections*

Shein, Steven L. MD1; Karam, Oliver MD, PhD2; Beardsley, Andrew MD, MSCR3; Karsies, Todd MD, MPH4; Prentice, Elizabeth DO5; Tarquinio, Keiko M. MD6; Willson, Douglas F. MD2; in collaboration with the Pediatric Acute Lung Injury and Sepsis Investigator (PALISI) Network

Pediatric Critical Care Medicine: August 2019 - Volume 20 - Issue 8 - p 697-706
doi: 10.1097/PCC.0000000000001942
Feature Articles

Objectives: To develop a guideline for the decision to continue or stop antibiotics at 48–72 hours after their initiation in children with suspected ventilator-associated infection.

Design: Prospective, multicenter observational data collection and subsequent development of an antibiotic guideline.

Setting: Twenty-two PICUs.

Patients: Children less than 3 years old receiving mechanical ventilation who underwent clinical testing and initiation of antibiotics for suspected ventilator-associated infection.

Interventions: None.

Measurements and Main Results: Phase 1 was a prospective data collection in 281 invasively ventilated children with suspected ventilator-associated infection. The median age was 8 months (interquartile range, 4–16 mo) and 75% had at least one comorbidity. Phase 2 was development of the guideline scoring system by an expert panel employing consensus conferences, literature search, discussions with institutional colleagues, and refinement using phase 1 data. Guideline scores were then applied retrospectively to the phase 1 data. Higher scores correlated with duration of antibiotics (p < 0.001) and higher PEdiatric Logistic Organ Dysfunction 2 scores (p < 0.001) but not mortality, PICU-free days or ventilator-free days. Considering safety and outcomes based on the phase 1 data and aiming for a 25% reduction in antibiotic use, the panel recommended stopping antibiotics at 48–72 hours for guideline scores less than or equal to 2, continuing antibiotics for scores greater than or equal to 6, and offered no recommendation for scores 3, 4, and 5. The acceptability and effect of these recommendations on antibiotic use and outcomes will be prospectively tested in phase 3 of the study.

Conclusions: We developed a scoring system with recommendations to guide the decision to stop or continue antibiotics at 48–72 hours in children with suspected ventilator-associated infection. The safety and efficacy of the recommendations will be prospectively tested in the planned phase 3 of the study.

1Division of Pediatric Critical Care, Rainbow Babies and Children’s Hospital, Cleveland, OH.

2Division of Pediatric Critical Care, Children’s Hospital of Richmond at VCU, Richmond, VA.

3Division of Pediatric Critical Care, Riley Hospital for Children, Indianapolis, IN.

4Division of Pediatric Critical Care, Nationwide Children’s Hospital, Columbus, OH.

5Division of Pediatric Critical Care, Helen DeVos Children’s Hospital, Grand Rapids, MI.

6Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA.

*See also p. 773.

Members of the Pediatric Acute Lung Injury and Sepsis Investigator (PALISI) Network are listed in Appendix 1.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

This study was supported, in part, by the Gerber Grant (number 4156) as well as the Clinical and Translational Science Awards number UL1TR000058 from the National Center for Advancing Translational Sciences (for access to Research Electronic Data Capture).

Dr. Shein received funding from Accelerate Diagnostics. Drs. Karam’s, Beardsley’s, Karsies’s, Prentice’s, and Willson’s institutions received funding from Gerber Foundation. Drs. Prentice and Willson received support for article research from Gerber Foundation. Dr. Tarquinio disclosed that she does not have any potential conflicts of interest.

Address requests for reprints to: Steven L. Shein, MD, Division of Pediatric Critical Care, Rainbow Babies and Children’s Hospital, 11100 Euclid Avenue, Cleveland OH, 44106. E-mail:

Copyright © 2019 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies