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A3691 - Emergency Department Antibiotic Protocol Improves Empiric Antibiotic Appropriateness in Critically Ill Children with Severe Bacterial Pneumonia
Author Block: M. Akande1, N. Jamieson2, S. P. Spencer2, T. J. Karsies1; 1Critical Care, Nationwide Childrens Hospital, Columbus, OH, United States, 2Emergency Department, Nationwide Childrens Hospital, Columbus, OH, United States.
Rationale Bacterial pneumonia frequently causes pediatric acute respiratory failure. Delayed administration of appropriate empiric antibiotics has been associated with adverse outcomes in these patients. Locally, we identified delays in appropriate antibiotic administration with a minority of these patients receiving appropriate antibiotics pre-ICU. We hypothesized that application of our PICU risk-stratified empiric antibiotic protocol in the emergency department (ED) would result in appropriate empiric antibiotic for at least 95% of critically ill children with severe bacterial pneumonia and at least 85% would receive at least 1 appropriate antibiotic prior to PICU admission.
Methods We retrospectively reviewed all patients with suspected lower respiratory tract infection admitted to the PICU after ED intubation over 5 years (July 2012 to July 2017). Lower respiratory cultures were obtained within 1 hour of intubation per ED protocol. ED physicians prescribed antibiotics using a protocol stratified by risk factors for healthcare-associated pneumonia. Bacterial pneumonia was defined by clinical and microbiological criteria. Antibiotic susceptibility testing results determined initial empiric antibiotic appropriateness (those prescribed within the 1st 24 hours of hospital admission).
Results Of the 399 patients, 135 (34%) patients had confirmed bacterial pneumonia. 54 (40%) patients had polybacterial infection. The most common pathogens were Moraxella catarrhalis (36%), Haemophilus influenzae (35%), Staphylococcus aureus (25%) and Streptococcus pneumoniae (14%). 98% of these patients received appropriate empiric antibiotics. Median time to administration of at least 1 appropriate antibiotic was 1.3 hours (IQR: 0.7-2.3 hours). 125 (93%) patients received the first appropriate antibiotic prior to ICU admission. MRSA was identified in 9% and was always appropriately covered with initial antibiotics. Based on our local risk factors, 48 (36%) patients were considered high risk for healthcare-associated pneumonia. Nearly all these patients (98%) were started on appropriate empiric antibiotics in the ED. In this subgroup, Haemophilus influenzae (33%), Moraxella catarrhalis (25%), and Staphylococcus aureus (23%) remained most common, with Pseudomonas aeruginosa identified in 17%. Stenotrophomonas maltophilia was identified in only 3 patients and was only appropriately covered in the 1st 24 hours in 1 patient. A median of 2 (IQR: 2-3) antibiotics per patient were administered in the 1st 24 hours of hospitalization.
Conclusions In this PICU cohort with severe bacterial pneumonia, ED implementation of a risk-stratified empiric antibiotic protocol resulted in timely administration of appropriate empiric antibiotics with at least 1 appropriate antibiotic administered prior to ICU admission for nearly all patients.