Neonatal Intensive Care Unit Antibiotic Use

Abstract

BACKGROUND AND OBJECTIVES: Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay. METHODS:In a retrospective cohort study of 52 061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles.RESULTS: Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile.CONCLUSIONS: Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.

Variations in Neonatal Antibiotic Use

“…The 2016 AUR correlated neither with proven infection nor NEC, echoing our 2013 findings 1 (Table 2). Only among regional NICUs did the 2016 AUR correlate with surgical case volume (ρ = 0.53; P = .01), NICU mortality rate (ρ = 0.57; P = .004), and average length of stay (ρ = 0.62; P = .002).…”

“…Recent work reveals that a considerable portion of NICU antibiotic use is unwarranted 1 , 2 . In a 2013 sample of 52061 infants receiving 746051 patient-days of care, antibiotic use rates (AURs) varied widely across NICUs and were unexplained by the corresponding burden of proven infection or other clearly warranted indications for treatment 1 .…”

“…In a 2013 sample of 52061 infants receiving 746051 patient-days of care, antibiotic use rates (AURs) varied widely across NICUs and were unexplained by the corresponding burden of proven infection or other clearly warranted indications for treatment 1 . Antibiotic prescribing practice variation apparently hinges on variation in how practitioners frame, interpret, and respond to clinical situations that are ultimately considered unproven infection.…”

Adverse consequences of neonatal antibiotic exposure

“…[37*] A forty-fold variation in NICU antibiotic prescribing practice was observed in a review of over 50,000 NICU patients in 127 California NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality. [38**] A review of antibiotic use in 89 NICUs participating in the European Study of Neonatal Exposure to Excipients identified variation in antibiotic dosing among the most commonly used antibiotics, with significant under- and over-dosing of antibiotics (based on dosing guidelines produced by the British National Formulary for Children). [39*] Under-dosing of antibiotics leads to low concentrations of antibiotics, particularly at sites of heavy microbial concentrations such as mucosal surfaces and biofilms surrounding central lines, and increases the likelihood of developing resistant microbes.…”

Antibiotic Use in Neonatal Intensive Care

“…Schulman et al 3 have demonstrated that not only is variation present, but, in NICUs in California, there is a remarkable 40-fold variation in antibiotic use. This study represents the largest and most diverse examination of antibiotic use in neonatal intensive care, involving 127 NICUs, 52 601 infants, and almost three-quarters of a million patientdays.…”