Evaluating antimicrobial appropriateness in a tertiary care pediatric ICU in Saudi Arabia: a retrospective cohort study

Abstract

Background Inappropriate antibiotic utilization is associated with the emergence of antimicrobial resistance (AMR) and a decline in antibiotic susceptibility in many pathogenic organisms isolated in intensive care units. Antibiotic stewardship programs (ASPs) have been recommended as a strategy to reduce and delay the impact of AMR. A crucial step in ASPs is understanding antibiotic utilization practices and quantifying the problem of inappropriate antibiotic use to support a targeted solution. We aim to characterize antibiotic utilization and determine the appropriateness of antibiotic prescription in a tertiary care pediatric intensive care unit. Methods A retrospective cohort study was conducted at King Abdullah Specialized Children’s Hospital, Riyadh, Saudi Arabia, over a 6-month period. Days of therapy (DOT) and DOT per 1000 patient-days were used as measures of antibiotic consumption. The appropriateness of antibiotic use was assessed by two independent pediatric infectious disease physicians based on the Centers for Disease Control and Prevention 12-step Campaign to prevent antimicrobial resistance among hospitalized children. Results During the study period, 497 patients were admitted to the PICU, accounting for 3009 patient-days. A total of 274 antibiotic courses were administered over 2553 antibiotic days. Forty-eight percent of antibiotic courses were found to be nonadherent to at least 1 CDC step. The top reasons were inappropriate antibiotic choice (empirical or definitive) and inappropriate prophylaxis durations. Cefazolin and vancomycin contributed to the highest percentage of inappropriate DOTs. Conclusions Antibiotic consumption was high with significant inappropriate utilization. These data could inform decision-making in antimicrobial stewardship programs and strategies. The CDC steps provide a more objective tool and limit biases when assessing antibiotic appropriateness

Antimicrobial use among paediatric inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program, 2017/2018

“…Glycopeptide use among PICUs (98 DOT/1000pd) was more than three-times higher than glycopeptide use among non-ICU wards (30 DOT/1000pd); this is likely due in part to more frequent use of central lines and coverage for coagulase negative staphylococci on PICUs. Glycopeptide use among PICUs in this study was similar to use on a German PICU (90 DOT/1000pd) [56], but lower than Brazilian, Saudi Arabian and South African PICUs (151 to 263 DOT/1000pd) [52,[54][55][56]. Differences in glycopeptide use may be partially due to differences in rates of methicillin-resistant Staphylococcus aureus across jurisdictions [56].…”

“…A large study of billing data from 41 PICUs in the United States reported a median-adjusted rate of 1043/1000pd in 2010–2014 [ 45 ]. Studies from Saudi Arabia in the mid-2010s found AMU rates among PICUs between 697 and 849 DOT/1000pd [ 54 , 55 ]. A German intervention study found an AMU rate of 1226 DOT/1000pd [ 49 ].…”

“…Differences in glycopeptide use may be partially due to differences in rates of methicillin-resistant Staphylococcus aureus across jurisdictions [56]. Vancomycin has also been found to represent a high percentage of inappropriate use in some jurisdictions [55,[57][58][59].…”

Antibiotic Exposure of Critically Ill Children at a Tertiary Care Paediatric Intensive Care Unit in Switzerland

“…However, a larger study conducted in the USA included 41 PICUs and reported a median antibiotic exposure of 104.3 DOT/100pd in 2010–2014 [ 22 ]. In a single-centre study conducted in Saudi Arabia in 2017, antibiotic consumption in PICU patients was found to be 84.9 DOT/100pd [ 33 ], while a similar study conducted in South Africa in 2015 revealed a rate of 113.7 DOT/100pd [ 8 ]. The mentioned studies showed large-scale differences in prescribing patterns that might arise from differing demographic characteristics, from variations in infectious diseases and resistance patterns, and from the availability of AMS programs: some institutions might have well-developed programs while others seem to lack effective ones [ 32 ].…”

Determinants of Inadequate Empiric Antimicrobial Therapy in ICU Sepsis Patients in Al-Madinah Al-Munawwarah, Saudi Arabia: A Comparison of Artificial Neural Network and Regression Analysis

“…There have been several studies conducted among ICU sepsis patients in Saudi Arabia. However, most of these studies focused on the spectrum and antimicrobial sensitivity of the bacteria pathogens in neonatal sepsis [ 19 ], the impact of empiric antimicrobial therapy on the mortality of septic shock patients with liver cirrhosis [ 20 ], and pediatric ICU patients [ 21 ]. In addition, there is a lack of evidence on the adequacy of empiric antimicrobials provided to ICU sepsis patients and their determinants in Middle Eastern countries [ 22 ].…”