Fontela Patricia S, Quach Caroline, Karim Mohammad E, Willson Douglas F, Gilfoyle Elaine, McNally James Dayre, Gonzales Milagros, Papenburg Jesse, Reynolds Steven, Lacroix Jacques
1Department of Pediatrics, McGill University, Montreal, QC, Canada. 2Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada. 3Department of Microbiology, Infectious Diseases, and Immunology, University of Montreal, Montreal, QC, Canada. 4Center for Health Evaluation and Outcome Sciences (CHEOS), Providence Health Care, University of British Columbia, Vancouver, BC, Canada. 5Department of Pediatrics, Virginia Commonwealth University, Richmond, VA. 6Department of Pediatrics, University of Calgary, Calgary, AB, Canada. 7Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada. 8Research Institute of McGill University Health Center, Montreal, QC, Canada. 9Department of Medicine, University of British Columbia, Vancouver, BC, Canada. 10Department of Pediatrics, Université de Montréal, Montreal, QC, Canada.
Pediatr Crit Care Med. 2017 Sep;18(9):e395-e405. doi: 10.1097/PCC.0000000000001238.
To describe the criteria that currently guide empiric antibiotic treatment in children admitted to Canadian PICUs.
Cross-sectional survey.
Canadian PICUs.
Pediatric intensivists and pediatric infectious diseases specialists.
None.
We used focus groups and literature review to design the survey questions and its four clinical scenarios (sepsis, pneumonia, meningitis, and intra-abdominal infections). We analyzed our results using descriptive statistics and multivariate linear regression. Our response rate was 60% for pediatric intensivists (62/103) and 36% for pediatric infectious diseases specialists (37/103). Variables related to patient characteristics, disease severity, pathogens, and clinical, laboratory, and radiologic infection markers were associated with longer courses of antibiotics, with median increment ranging from 1.75 to 7.75 days. The presence of positive viral polymerase chain reaction result was the only variable constantly associated with a reduction in antibiotic use (median decrease from, -3.25 to -8.25 d). Importantly, 67-92% of respondents would still use a full course of antibiotics despite positive viral polymerase chain reaction result and marked clinical improvement for patients with suspected sepsis, pneumonia, and intra-abdominal infection. Clinical experience was associated with shorter courses of antibiotics for meningitis and sepsis (-1.3 d [95% CI, -2.4 to -0.2] and -1.8 d [95% CI, -2.8 to -0.7] per 10 extra years of clinical experience, respectively). Finally, site and specialty also influenced antibiotic practices.
Decisions about antibiotic management for PICU patients are complex and involve the assessment of several different variables. With the exception of a positive viral polymerase chain reaction, our findings suggest that physicians rarely consider reducing the duration of antibiotics despite clinical improvement. In contrast, they will prolong the duration when faced with a nonreassuring characteristic. The development of objective and evidence-based criteria to guide antibiotic therapy in critically ill children is crucial to ensure the rational use of these agents in PICUs.
描述目前指导加拿大儿科重症监护病房（PICU）收治儿童经验性抗生素治疗的标准。
横断面调查。
加拿大PICU。
儿科重症监护医师和儿科传染病专家。
无。
我们采用焦点小组讨论和文献综述来设计调查问卷及其四个临床场景（脓毒症、肺炎、脑膜炎和腹腔内感染）。我们使用描述性统计和多元线性回归分析结果。儿科重症监护医师的回复率为60%（62/103），儿科传染病专家的回复率为36%（37/103）。与患者特征、疾病严重程度、病原体以及临床、实验室和放射学感染标志物相关的变量与抗生素使用疗程延长有关，中位数增加范围为1.75至7.75天。病毒聚合酶链反应结果呈阳性是唯一始终与抗生素使用减少相关的变量（中位数减少-3.25至-8.25天）。重要的是，对于疑似脓毒症、肺炎和腹腔内感染的患者，尽管病毒聚合酶链反应结果呈阳性且临床有明显改善，但67%至92%的受访者仍会使用全程抗生素。临床经验与脑膜炎和脓毒症的抗生素疗程缩短有关（每增加10年临床经验，分别缩短-1.3天[95%可信区间，-2.4至-0.2]和-1.8天[95%可信区间，-2.8至-0.7]）。最后，地点和专业也会影响抗生素使用习惯。
PICU患者抗生素管理决策复杂，涉及多个不同变量的评估。除病毒聚合酶链反应结果呈阳性外，我们的研究结果表明，尽管临床有所改善，但医生很少考虑缩短抗生素疗程。相反，当面对令人不安的特征时，他们会延长疗程。制定客观且基于证据的标准以指导危重症儿童的抗生素治疗对于确保PICU合理使用这些药物至关重要。
