Effect of an antimicrobial stewardship program on antibiotic use in critically ill infants with bronchiolitis
CCCF ePoster library. Noel K. 11/12/19; 283418; EP73
Kim Noel
Kim Noel
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Topic: Retrospective or Prospective Cohort Study or Case Series

Noël, Kim C.1; Aljassim, Nada2; Maratta, Christina3; Tam, Ingrid4; Papenburg, Jesse1,5; Quach, Caroline6; Thampi, Nisha7; Dendukuri, Nandini1; O'Donnell, Shauna8; Fontela, Patricia S.1,9
1Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada; 2King Fahad Medical City, Riyadh, Saudi Arabia; 3Pediatric Critical Care, Hospital for Sick Children, Toronto, Canada; 4Faculty of Medicine, University of Limerick, Limerick, Ireland; 5Division of Pediatric Infectious Diseases, Department of Pediatrics, McGill University, Montreal, Canada; 6Department of Microbiology, Infectious Diseases and Immunology, Université de Montréal, Montreal, Canada; 7Department of Pediatrics, University of Ottawa, Ottawa, Canada; 8Research Institute of the McGill University Health Centre, Montreal, Canada; 9Department of Pediatrics, McGill University, Montreal, Canada

INTRODUCTION: Bronchiolitis is the most common lower respiratory tract infection in children <2 years old.1 Despite the fact that most cases are caused by viruses and incidence rates of concomitant bacterial infection are low, antibiotics are frequently used in the management of bronchiolitis.2 As such, inappropriate antibiotic use in this patient population is widespread.3,4 We currently do not know the impact of antimicrobial stewardship programs (ASPs) for reducing unnecessary antibiotic use in infants with bronchiolitis.
OBJECTIVES: To determine the effect of an ASP in critically ill children with bronchiolitis on 1) the proportion of patients prescribed antibiotics, 2) the duration of antibiotic treatment in days, and 3) the proportion of patients in whom antibiotics were stopped within 72 hours of hospital admission.
METHODS: A retrospective cohort study of infants <2 years old admitted to pediatric intensive care units (PICUs) at the Montreal Children's Hospital (MCH), the Centre Hospitalier Universitaire de Sainte Justine (CHUSJ), or the Children's Hospital of Eastern Ontario (CHEO) between November 2016 and April 2017 (season one), and November 2017 and April 2018 (season two). We assessed the impact of an ASP (intervention) introduced at the MCH in May 2018, by comparing antibiotic use before (first season) and after (second season) its implementation. The ASP included weekly meetings between the PICU, infection control, and pharmacy teams to discuss appropriateness of antimicrobial treatments in PICU patients. The other hospital sites served as controls, as CHUSJ (temporal control) had no ASP and CHEO (positive control) had a well-established ASP over the study period. We analyzed data using descriptive statistics and linear and logistic multivariable regression models.
RESULTS: 372 patients were included in the study. Mean age was 4.8±5.3 months. Overall, 46 (27%, season 1) and 41 (22%, season 2) patients had a clinical diagnosis for a bacterial infection. Among patients at the MCH with a viral infection only, the proportion of antibiotics prescribed on admission day was 19 (40%, season 1) and 10 (23%, season 2). The average duration of antibiotic treatment was 4.0±2.9 days (season 1) and 3.2±2.6 days (season 2). The proportion of patients in whom antibiotics were stopped within 72 hours of admission was 12 (55%, season 1) and 14 (82%, season 2). Regression models including patients with viral infection only showed that the ASP was associated with fewer prescriptions on admission day (OR 0.3, 95%CI 0.1, 0.8) and increased odds of stopping antibiotics within 72 hours of admission (OR 17.4 95%CI 2.2, 198.6). There was no significant impact on antibiotic duration, but a trend towards reduced duration was observed (-3.2, 95%CI -6.7, 0.2). In addition, pediatric risk of mortality (PRISM) scores were associated with prolonged antibiotic duration (0.2, 95%CI 0.1, 0.5) and decreased odds of stopping antibiotics within 72 hours of admission (OR 0.8, 95%CI 0.7, 0.99).
CONCLUSION: Our study showed that the presence of an ASP reduced unnecessary antibiotic prescriptions and increased the proportion of antibiotics stopped within 72 hours of admission among bronchiolitis patients with a viral infection only. Furthermore, more severe disease was associated with an increase in antibiotic use. Future studies are needed to evaluate whether ASPs can improve the rational use of antibiotics in other patient populations.

1. Bont L, Checchia PA, Fauroux B, et al. Defining the Epidemiology and Burden of Severe Respiratory Syncytial Virus Infection Among Infants and Children in Western Countries. 2016;5:271-98.
2. Nair H, Nokes DJ, Gessner BD, et al. Global burden of acute lower respiratory infections due to respiratory syncytial virus in young children: a systematic review and meta-analysis. Lancet 2010;375:1545-55.
3. Farley R, Spurling GKP, Eriksson L, Del Mar CB. Antibiotics for bronchiolitis in children under two years of age. Cochrane Database of Systematic Reviews 2014.
4. Papenburg J, Fontela PS, Freitas RR, Burstein B. Inappropriate Antibiotic Prescribing for Acute Bronchiolitis in US Emergency Departments, 2007–2015. Journal of the Pediatric Infectious Diseases Society 2019.
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