番茄社区

SAN DIEGO -- Across 46 hospitals, 95% of young children intubated with respiratory syncytial virus–associated lower respiratory tract infections were prescribed antibiotics, but the timing, duration, and types of prescriptions varied across centers, results from a late-breaking trial found.

In a sample of over 2,000 children (age <2 years) in the pediatric ICU, 36% to 100% received antibiotics on both of the first 2 days of mechanical ventilation, with 9 different drugs prescribed to 5% to 49% of children across the study period, according to Steven Shein, MD, of the Rainbow Babies and Children's Hospital in Cleveland, and colleagues.

However, children given antibiotics were on mechanical ventilation for 1.21 fewer days and were in the hospital 2.07 fewer days than those who were not, after adjusting for center, demographics, and vasoactive medication prescription, Stein reported at the Society for Critical Care Medicine's (SCCM) annual meeting and in .

"There's something different about those kids that require ventilation, and what our data suggest is that a large portion of those children have some form of bacterial pneumonia," Stein said in his SCCM presentation.

Bronchiolitis leads to the hospitalization of about 2% of young kids worldwide, and respiratory syncytial virus accounts for about 80% of those infections, the authors stated.

Jason Kane, MD, of the University of Chicago, said these results support many intensivists' impulse to administer antibiotics to children who appear to be sicker without a documented infection, particularly in an era of antibiotic stewardship, where prescribing habits may be more critically monitored.

"On some level, it justifies the early use of antibiotics in a cohort of children we can't prove definitely have an infection," Kane, who was not involved in the study, told 番茄社区. "This data supports the intuition of the critical care community, which is that kids who are otherwise healthy and normal that end up with respiratory syncytial virus, but are so sick to require a mechanical ventilator to breathe, likely have a secondary bacterial infection we can't always detect."

Kane said technology used to detect secondary bacterial infections, such as bacterial pneumonia, is lagging in pediatric populations. Endotracheal aspirate cultures could be used for early diagnosis of ventilator-associated pneumonia, though this can sometimes be difficult in very young children, he added.

Shein and colleagues obtained data from the Pediatric Health Information System (PHIS), which includes administrative data from pediatric hospitals in the U.S. affiliated with the Children's Hospital Association.

Children were included if they had an ICD diagnosis code for respiratory syncytial virus, pneumonia, or bronchitis; a billing charge for ICU care; or use of mechanical ventilation recorded in the database. They were excluded if they had preexisting medical conditions such as bacteremia, meningitis, or urinary tract infections; remained in the hospital ≥90 days; or had mechanical ventilation ≥1 day prior to hospital admission.

In total, 2,107 PICU patients (median age of 1 month, 60% male) were included in the study. Antibiotics were prescribed to 1,727 (82%) of children in the "early" antibiotic usage group, defined as those who were prescribed antibiotics for both of the first 2 days of mechanical ventilation, the authors reported.

For antibiotics classified based on chemical structure, late-generation cephalosporins and macrolides (8.6% vs 0.4%) were more likely to be prescribed in the early antibiotic group, and early-generation cephalosporins were more likely to be prescribed in the late antibiotic group (P<0.001 for all).

"When classified functionally, antibiotics indicated for common CA and atypical pathogens were more likely to be prescribed in the early antibiotic group, and antibiotics effective against Pseudomonas aeruginosa ... were more likely to be prescribed in the late antibiotic group," the authors reported (P<0.001 for all).

Overall, the mean length of antibiotic treatment was 10 days, although 24.6% of children used antibiotics for 2 to 3 days, 21.9% used them for 4 to 6 days, and 53.5% used them for at least 7 days. Additionally, some children initiated antibiotics further down the line after they failed to complete a 7-day course (23%), researchers reported.

Early antibiotic use trended significantly downwards over the study period, with the number of kids prescribed early antibiotics decreasing from 85.9% in 2012 to 80.4% in 2016 (P=0.004). The average initial day of antibiotic prescription was day 4, they stated, adding that children who received antibiotics early tended to be younger and were more often prescribed vasoactive medications on the first day of mechanical ventilation than the other children in the study.

Shein noted that the primary limitation of the study was the use of administrative and pharmacy data, which could give way to misclassification or inaccuracies. Additionally, they did not calculate illness severity scores or measure subsequent infections by resistant pathogens or postdischarge outcomes in this population.

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