Antibiotic Indications and Appropriateness in the Pediatric Intensive Care Unit: A 10-Center Point Prevalence Study

Abstract

Background: Antibiotics are prescribed to most pediatric intensive care unit (PICU) patients, but data describing indications and appropriateness of antibiotic orders in this population are lacking.

Methods: We performed a multicenter point prevalence study that included children admitted to 10 geographically diverse PICUs over 4 study days in 2019. Antibiotic orders were reviewed for indication, and appropriateness was assessed using a standardized rubric.

Results: Of 1462 patients admitted to participating PICUs, 843 (58%) had at least 1 antibiotic order. A total of 1277 antibiotic orders were reviewed. Common indications were empiric therapy for suspected bacterial infections without sepsis or septic shock (260 orders, 21%), nonoperative prophylaxis (164 orders, 13%), empiric therapy for sepsis or septic shock (155 orders, 12%), community-acquired pneumonia (CAP; 118 orders, 9%), and post-operative prophylaxis (94 orders, 8%). Appropriateness was assessed for 985 orders for which an evidence-based rubric for appropriateness could be created. Of these, 331 (34%) were classified as inappropriate. Indications with the most orders classified as inappropriate were empiric therapy for suspected bacterial infection without sepsis or septic shock (78 orders, 24%), sepsis or septic shock (55 orders, 17%), CAP (51 orders, 15%), ventilator-associated infections (47 orders, 14%), and post-operative prophylaxis (44 orders, 14%). The proportion of antibiotics classified as inappropriate varied across institutions (range, 19%-43%).

Conclusions: Most PICU patients receive antibiotics. Based on our study, we estimate that one-third of antibiotic orders are inappropriate. Improved antibiotic stewardship and research focused on strategies to optimize antibiotic use in critically ill children are needed.

Keywords: antibiotic; antimicrobial stewardship; pediatric intensive care unit; sepsis.

Figure 1.

A, Top inappropriate antibiotic orders by drug. The total bar is the number of antibiotic orders that were reviewed for appropriateness, sorted by antibiotic. The black stacked bar indicates antibiotic orders classified as inappropriate. The gray portion of the stacked bar indicates the antibiotic orders classified as appropriate. The numbers on each bar indicate the total number of antibiotic orders. B, Top inappropriate antibiotic order indications. The total bar is the number of antibiotics that were reviewed for appropriateness, sorted by indication. The black stacked bar indicates antibiotic orders classified as inappropriate. The gray portion of the stacked bar indicates the antibiotic orders classified as appropriate. The numbers on each bar indicate the total number of antibiotic orders. Abbreviations: CAP, community-acquired pneumonia; HAP, hospital-acquired pneumonia; IAI, intraabdominal infection; SBI, suspected bacterial infection; UTI, urinary tract infection; VAI, ventilator-associated infection.

Figure 2.

Variation in inappropriate antibiotic orders by institution. The black portion of the stacked bar indicates the proportion of antibiotic orders classified as inappropriate. The gray portion of the stacked bar indicates the proportion of antibiotic orders classified as appropriate. The numbers on each bar indicate the total number of antibiotic orders.