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Background: Bacterial infections (BIs) are widespread in ICU. The aims of this study were to assess the compliance with antibiotic recommendations, and factors associated with non-compliance. Methods: We conducted an observational study in eight French Pediatric and Neonatal ICUs with an antimicrobial stewardship program mostly once a week. All children receiving antibiotics for a suspected or proven BI were evaluated. Newborns <72 hours old, neonates <37 weeks, age ≥18 years, and antibiotic for prophylaxis were excluded. Results: 139 suspected (or proven) BI episodes in 134 children were prospectively included during six separate time-periods over one year. The final diagnosis was 26.6% no bacterial infection, 40.3% presumed bacterial infection, and 35.3% documented bacterial infection. Non-compliance for all parameters occurred in 51.1%, with errors mainly concerning the antimicrobials’ choice (27.3%), duration of each antimicrobial (26.3%), and duration of antibiotic therapy (18.0%). In multivariate analysis, main independent risk factors of non-compliance were prescribing ≥2 antibiotics (OR 4.06, 95% CI 1.69-9.74, p=0.0017), a duration of broad-spectrum antibiotic therapy ≥4 days (OR 2.59, 95% CI 1.16-5.78, p=0.0199), suspecting catheter-related bacteremia (ORs 3.70 and 5.42, 95% CIs 1.32 to 15.07, p<0.02), a BI site with no clear treatment guidelines (ORs 3.29 and 15.88, 95% CIs 1.16 to 104.76, p<0.03), and ≥1 risk factor for ESBL Enterobacteriaceae (OR 2.56, 95% CI 1.07-6.14, p=0.0353). Main independent factors of compliance were having antibiotic therapy protocols (OR 0.42, 95% CI 0.19-0.92, p=0.0313), respiratory failure (OR 0.36, 95% CI 0.14-0.90, p=0.0281), and aspiration pneumonia (OR 0.37, 95% CI 0.14-0.99, p=0.0486). Conclusions: Half of antibiotic prescriptions remain non-compliant with guidelines. Intensivists should daily reassess the benefit of using several or broad-spectrum antimicrobials and stop antibiotics that are no longer indicated. Developing consensus about treating specific illnesses and using service protocols seem necessary to reduce errors. A daily ASP could also improve compliance in these error-prone situations. Trial registration: This trial was approved by Toulouse University Hospital, and is registered in its register of data study, number RnIPH2019-79, and with ClinicalTrials.gov, number NCT04642560. The date of first trial registration in ClinicalTrials.gov was 24/11/2020.

Background Bacterial infections (BIs) are widespread in ICUs. The aims of this study were to assess the compliance with antibiotic recommendations, and factors associated with non-compliance. Methods We conducted an observational study in eight French Paediatric and Neonatal ICUs with an antimicrobial stewardship programme, mostly once a week. All children receiving antibiotics for a suspected or proven BI were evaluated. Newborns < 72 hours old, neonates < 37 weeks, age ≥ 18 years, and children under antimicrobial prophylaxis were excluded. Results 139 suspected (or proven) BI episodes in 134 children were prospectively included during six separate time-periods over one year. The final diagnosis was 26.6% no BI, 40.3% presumed (i.e., not documented) BI, and 35.3% documented BI. Non-compliance for all parameters combined occurred in 51.1%. The main reasons for non-compliance were inappropriate choice of antimicrobials (27.3%), duration of one or more antimicrobials (26.3%), and duration of antibiotic therapy (18.0%). In multivariate analyses, main independent risk factors for non-compliance were prescribing ≥ 2 antibiotics (OR 4.06, 95%CI 1.69–9.74, p = 0.0017), a duration of broad-spectrum antibiotic therapy ≥ 4 days (OR 2.59, 95%CI 1.16–5.78, p = 0.0199), neurologic compromise at ICU admission (OR 3.41, 95%CI 1.04–11.20, p = 0.0431), suspected catheter-related bacteraemia (ORs 3.70 and 5.42, 95%CIs 1.32 to 15.07, p < 0.02), a BI site classified as “other” (ORs 3.29 and 15.88, 95%CIs 1.16 to 104.76, p < 0.03), sepsis with ≥ 2 organ dysfunctions (OR 4.21, 95%CI 1.42–12.55, p = 0.0098), late-onset ventilator-associated pneumonia (OR 6.30, 95%CI 1.15–34.44, p = 0.0338), and ≥ 1 risk factor for ESBL Enterobacteriaceae (OR 2.56, 95%CI 1.07–6.14, p = 0.0353). Main independent factors for compliance were having antibiotic therapy protocols (OR 0.42, 95%CI 0.19–0.92, p = 0.0313), respiratory failure at ICU admission (OR 0.36, 95%CI 0.14–0.90, p = 0.0281), and aspiration pneumonia (OR 0.37, 95%CI 0.14–0.99, p = 0.0486). Conclusions Half of antibiotic prescriptions remain non-compliant with guidelines. Intensivists should reassess on a daily basis the benefit of using several antimicrobials or any broad-spectrum antimicrobials and stop antibiotics that are no longer indicated. Developing consensus about treating specific illnesses and using department protocols seem necessary to reduce non-compliance. A daily ASP could also improve compliance in these situations. Trial registration : ClinicalTrials.gov: number NCT04642560. The date of first trial registration was 24/11/2020.

La procalcitonine (PCT) est un biomarqueur d’infection bactérienne de plus en plus utilisé en pratique clinique. Dans un service de réanimation, l’interprétation des dosages sanguins de PCT peut être affectée par de nombreuses situations inflammatoires (brûlure, traumatisme, chirurgies extensives dont cardiaque, transfusion massive, insuffisance rénale…). Une revue de la littérature pédiatrique est réalisée et axée sur l’utilisation de la PCT dans trois domaines : marqueur diagnostique d’infection bactérienne ; marqueur d’exclusion d’infection bactérienne ; guide de la durée d’antibiothérapie. En réanimation pédiatrique, la PCT a une précision modérée pour le diagnostic d’infection bactérienne. La suspicion d’infection bactérienne doit rester clinique et conduire, quelle que soit la valeur de la PCT, à l’administration précoce d’une antibiothérapie probabiliste large spectre, secondairement adaptée à l’agent pathogène identifié et à son profil de sensibilité. De par sa valeur prédictive négative élevée, l’utilisation d’un algorithme guidé par la PCT semble intéressante en réanimation pédiatrique pour raccourcir la durée d’antibiothérapie totale et large spectre sans augmentation de réinfection, en utilisant des critères tels que PCT <0.5 ng/mL ou diminuant ≥50-80% par rapport à la valeur maximale. L'algorithme a démontré son efficacité et sa sécurité avec un haut niveau de preuve en réanimation adulte. Cependant, toutes les études pédiatriques publiées précédemment n’étaient pas randomisées. Deux essais contrôlés randomisés pédiatriques sont actuellement en cours : une large étude multicentrique française en réanimation néonatale et une étude monocentrique américaine en réanimation pédiatrique. Le nombre de sujet à inclure doit être suffisamment important pour valider l’objectif de sécurité (non infériorité en termes de mortalité). Enfin, le respect des recommandations pourrait à lui seul diminuer la durée d’antibiothérapie actuelle.