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Determinants of Antibiotic Tailoring in Pediatric Intensive Care: A National Survey*

Fontela, Patricia S. MD, PhD1,2; Quach, Caroline MD, MSc1,2,3; Karim, Mohammad E. PhD4; Willson, Douglas F. MD5; Gilfoyle, Elaine MD, MMEd6; McNally, James Dayre MD, PhD7; Gonzales, Milagros MSc8; Papenburg, Jesse MD, MSc1,2; Reynolds, Steven MD9; Lacroix, Jacques MD10Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Networkon behalf of the Canadian Critical Care Trials Group

doi: 10.1097/PCC.0000000000001238
Online Clinical Investigations

Objectives: To describe the criteria that currently guide empiric antibiotic treatment in children admitted to Canadian PICUs.

Design: Cross-sectional survey.

Setting: Canadian PICUs.

Subjects: Pediatric intensivists and pediatric infectious diseases specialists.

Interventions: None.

Measurements and Main Results: We used focus groups and literature review to design the survey questions and its four clinical scenarios (sepsis, pneumonia, meningitis, and intra-abdominal infections). We analyzed our results using descriptive statistics and multivariate linear regression. Our response rate was 60% for pediatric intensivists (62/103) and 36% for pediatric infectious diseases specialists (37/103). Variables related to patient characteristics, disease severity, pathogens, and clinical, laboratory, and radiologic infection markers were associated with longer courses of antibiotics, with median increment ranging from 1.75 to 7.75 days. The presence of positive viral polymerase chain reaction result was the only variable constantly associated with a reduction in antibiotic use (median decrease from, –3.25 to –8.25 d). Importantly, 67–92% of respondents would still use a full course of antibiotics despite positive viral polymerase chain reaction result and marked clinical improvement for patients with suspected sepsis, pneumonia, and intra-abdominal infection. Clinical experience was associated with shorter courses of antibiotics for meningitis and sepsis (–1.3 d [95% CI, –2.4 to –0.2] and –1.8 d [95% CI, –2.8 to –0.7] per 10 extra years of clinical experience, respectively). Finally, site and specialty also influenced antibiotic practices.

Conclusions: Decisions about antibiotic management for PICU patients are complex and involve the assessment of several different variables. With the exception of a positive viral polymerase chain reaction, our findings suggest that physicians rarely consider reducing the duration of antibiotics despite clinical improvement. In contrast, they will prolong the duration when faced with a nonreassuring characteristic. The development of objective and evidence-based criteria to guide antibiotic therapy in critically ill children is crucial to ensure the rational use of these agents in PICUs.

Supplemental Digital Content is available in the text.

1Department of Pediatrics, McGill University, Montreal, QC, Canada.

2Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.

3Department of Microbiology, Infectious Diseases, and Immunology, University of Montreal, Montreal, QC, Canada.

4Center for Health Evaluation and Outcome Sciences (CHEOS), Providence Health Care, University of British Columbia, Vancouver, BC, Canada.

5Department of Pediatrics, Virginia Commonwealth University, Richmond, VA.

6Department of Pediatrics, University of Calgary, Calgary, AB, Canada.

7Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.

8Research Institute of McGill University Health Center, Montreal, QC, Canada.

9Department of Medicine, University of British Columbia, Vancouver, BC, Canada.

10Department of Pediatrics, Université de Montréal, Montreal, QC, Canada.

*See also p. 903.

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 (http://journals.lww.com/pccmjournal).

All authors have made significant contributions to the study conception and design, article revision, and have given final approval for the submitted version. The specific contributions of each author are the following: Dr. Fontela: study design and conduction, survey development, data analysis, manuscript writing; Dr. Quach: study design, survey development, manuscript review; Dr. Karim: data analysis and manuscript review; Dr. Willson: study design, survey development, manuscript review; Dr. Gilfoyle: study design, survey testing, manuscript review; Dr. McNally: study design, survey testing, manuscript review; Ms. Gonzales: survey development and distribution, manuscript review; Dr. Papenburg: study design, survey testing, manuscript writing; Dr. Reynolds: study design, survey development; Dr. Lacroix: study design, survey development, manuscript review. Supported by the Research Institute of the McGill University Health Center, Montreal, QC, Canada. Dr. Quach’s institution received funding from GlaxoSmithKline (principal investigator–initiated research grant on rotavirus surveillance [2012–2014]), AbbVie (principal investigator–initiated research grant on surveillance of respiratory syncytial virus in transplant patients [2013–2015]), and Sage (principal investigator–initiated research grant on risk factors for central line-associated bloodstream infection in the neonatal ICU [2013–2015]). Dr. Gilfoyle institution received funding from Alberta Children’s Hospital Research Institute, Department of Pediatrics, University of Calgary, Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada and disclosed other support from Alberta Innovates Health Solutions. Dr. Papenburg received funding from Cepheid, AbbVie, and RPS Diagnostics, Inc., and his institution received funding from AbbVie. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: patricia.fontela@mcgill.ca

©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies