The Open Microbiology Journal




ISSN: 1874-2858 ― Volume 13, 2019
RESEARCH ARTICLE

Antibiotic Surveillance in the Pediatric Intensive Care Unit (PICU) at Sanglah Hospital Denpasar in the Year of 2015-2017



Dyah Kanya Wati1, *, I Wayan Gustawan1, Ni Nengah Dwi Fatmawati2, I Ketut Tunas3, Putu Andrie Setiawan4
1 Department of Child Health, Udayana University Medical School, Sanglah Hospital, Denpasar, Bali 80114, Indonesia
2 Department of Clinical Microbiology, Udayana University Medical School, Sanglah Hospital, Denpasar, Bali 80114, Indonesia
3 Public Health Dhyana Pura University, Denpasar, Bali 80361, Indonesia
4 Udayana University Medical School, Denpasar, Bali 80225, Indonesia

Abstract

Background:

Antibiotic surveillance in hospital settings is mandatory for optimal antibiotic therapy for the patient. Only a small number of studies have focused on antibiotic surveillance in hospitalized newborns, infants, and children.

Objectives:

The goal was to evaluate antibiotic use in our Pediatric Intensive Care Unit (PICU) and evaluate it for a possible association with the length of PICU stay.

Methods:

A retrospective, observational, cohort study was conducted from January 2015 to April 2017, involving subjects who were hospitalized in the PICU at Sanglah Hospital. The inclusion criteria were children aged between 1-month-12-years old, who had a blood culture and antibiotic sensitivity test result in their medical record. The exclusion criteria were incomplete medical records, blood cultures showing 2 types of bacteria at the same time (gram-positive and negative), or contaminated blood results. Factors associated with mortality were analyzed using a Chi-square test, with p < 0.05 considered to be statistically significant and the Risk Ratio (RR) of the associated factors was determined by 95% CI.

Results:

Multivariate analysis showed that the significant predictors of PICU length of stay were the appropriate continuation of antibiotics (RR 1.19; 95% CI 1.043 to 1.373; P = 0.047). There were also significant results for antibiotic compatibility and length of stay (RR 3.6; 95% CI 0.869 to 15.428; P = 0.049).

Conclusion:

Appropriate continuation of antibiotics and the compatibility of continuation antibiotics were significant predictors of length of PICU stay based on multivariate analysis.

Keywords: Antibiotic, Sensitivity, Resistance, Surveillance, Children, PICU.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 146
Last Page: 153
Publisher Id: TOMICROJ-13-146
DOI: 10.2174/1874285801913010146

Article History:

Received Date: 28/11/2018
Revision Received Date: 03/03/2019
Acceptance Date: 10/03/2019
Electronic publication date: 31/05/2019
Collection year: 2019

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© 2019 Wati et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Child Health, Udayana University Medical School, Sanglah Hospital, Denpasar, Bali, Indonesia; Tel: +6281285705152; Fax: 0361244038;E-mail: dyahpediatric@yahoo.com




1. INTRODUCTION

Antibiotics are commonly used in the hospital settings, especially in the pediatric intensive care unit. Some reasons for the administration of antibiotics are the risk of infection because of critical conditions, chronic comorbid conditions, surgical procedures, and exposure to invasive procedures and tools as a port of entry for various kinds of microorganisms [1National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from january 1992 through june 2004, issued october 2004. Am J Infect Control 2004; 32(8): 470-85.[http://dx.doi.org/10.1016/j.ajic.2004.10.001] [PMID: 15573054] , 2Banerjee SN, Grohskopf LA, Sinkowitz-Cochran RL, Jarvis WR. Incidence of pediatric and neonatal intensive care unit-acquired infections. Infect Control Hosp Epidemiol 2006; 27(6): 561-70.[http://dx.doi.org/10.1086/503337] [PMID: 16755474] ]. Moreover, patients with critical conditions, especially children, may have impaired immune systems, which facilitate the occurrence and spread of infection [3Erbay A, Bodur H, Akinci E, Colpan A. Evaluation of antibiotic use in intensive care units of a tertiary care hospital in Turkey. J Hosp Infect 2005; 59(1): 53-61.[http://dx.doi.org/10.1016/j.jhin.2004.07.026] [PMID: 15571854] ]. Without the intervention of appropriate antibiotics [4Wahyudhi A dan Triratna S. Pola kuman dan uji kepekaan antibiotik pada pasien unit perawatan intensif anak RSMH Palembang. Sari Pediatri 2010; 12(1): 1-5.], the condition of the patients may worsen to the point of organ damage or even death.

Grohskopf et al. [5Grohskopf LA, Huskins WC, Sinkowitz-Cochran RL, Levine GL, Goldmann DA, Jarvis WR. Use of antimicrobial agents in United States neonatal and pediatric intensive care patients. Pediatr Infect Dis J 2005; 24(9): 766-73.[http://dx.doi.org/10.1097/01.inf.0000178064.55193.1c] [PMID: 1614 8841] ] stated that as many as 71% of PICU patients received one or more types of antibiotics. Similar results were reported by Briassoulis et al. [6Briassoulis G, Natsi L, Tsorva A, Hatzis T. Prior antimicrobial therapy in the hospital and other predisposing factors influencing the usage of antibiotics in a pediatric critical care unit. Ann Clin Microbiol Antimicrob 2004; 3(4): 4.[http://dx.doi.org/10.1186/1476-0711-3-4] [PMID: 15090066] ] who did a cohort study on the use of antibiotics. They found that as many as 67.2% of PICU patients received antibiotics on the first day of treatment and 80.5% received at least one antibiotic during PICU treatment. In addition, Ding et al. [7Ding H, Yang Y, Chen Y, Wang Y, Fan S, Shen X. Antimicrobial usage in paediatric intensive care units in China. Acta Paediatr 2008; 97(1): 100-4.[http://dx.doi.org/10.1111/j.1651-2227.2007.00580.x] [PMID: 1807 6718] ] reported that in three PICUs in China, the use of antibiotics reached 95%, with 30% of them using a combination of more than one antibiotic.

The use of antibiotics in PICU patients is often empirically based upon vital signs and laboratory results. Toltizs et al. [8Toltzis P, Rosolowski B, Salvator A. Etiology of fever and opportunities for reduction of antibiotic use in a pediatric intensive care unit. Infect Control Hosp Epidemiol 2001; 22(8): 499-504.[http://dx.doi.org/10.1086/501940] [PMID: 11700877] ] evaluated the use of antibiotics in children admitted to the PICU with fever (axillary temperature > 38.3°C). They found that only 3.3% did not receive parenteral antibiotics. Broad-spectrum antibiotics are often used as empirical therapy, with third-generation cephalosporins, vancomycin, and second generation cephalosporins most often used, according to Grohskopf et al. [5Grohskopf LA, Huskins WC, Sinkowitz-Cochran RL, Levine GL, Goldmann DA, Jarvis WR. Use of antimicrobial agents in United States neonatal and pediatric intensive care patients. Pediatr Infect Dis J 2005; 24(9): 766-73.[http://dx.doi.org/10.1097/01.inf.0000178064.55193.1c] [PMID: 1614 8841] ]. Ding et al. [7Ding H, Yang Y, Chen Y, Wang Y, Fan S, Shen X. Antimicrobial usage in paediatric intensive care units in China. Acta Paediatr 2008; 97(1): 100-4.[http://dx.doi.org/10.1111/j.1651-2227.2007.00580.x] [PMID: 1807 6718] ] found that they often used the second and third generation cephalosporins as empirical therapy. However, Tjekyan [9Tjekyan RMS. Pola Kuman dan Resistensi Antibiotik di Pediatric Intensive Care Unit (PICU) RS. Dr. Mohammad Hoesin Palembang Tahun 2013. Jurnal Kedokteran dan Kesehatan 2015; 2: 91-7.] reported that the three broad-spectrum antibiotics most often used were ampicillin (53.4%), ceftriaxone (31.1%), and meropenem (7.3%). Additionally, in Indonesia, the most commonly used antibiotics in the Cipto Mangunkusumo Hospital (RSCM) PICU were cefotaxime (30.1%), amikacin (14.46%), and piperacillin-tazobactam (12.10%) [10Yuniar I, Karyanti MR, Tambunan T, Rizkyani NA. Evaluasi penggunaan antibiotik dengan kartu monitoring antibiotik gyssens. Sari Pediatri 2013; 14(6): 384-90.[http://dx.doi.org/10.14238/sp14.6.2013.384-90] ]. Unfortunately, the use of antibiotics is still largely inappropriate. Hadi et al. [11Hadi U, Duerink DO, Lestari ES, et al. Audit of antibiotic prescribing in two governmental teaching hospitals in Indonesia. Clin Microbiol Infect 2008; 14(7): 698-707.[http://dx.doi.org/10.1111/j.1469-0691.2008.02014.x] [PMID: 1855 8943] ] conducted a study in two teaching hospitals and reported that 84% of patients received antibiotic therapy, of whom 60% received treatment that was unsuitable or without indication.

In addition, studies have mentioned the negative effects of antibiotic resistance on patient clinical outcomes. Hence, we conducted a retrospective study in one center to determine the appropriateness of antibiotic use, microbe patterning, and possible associations with patient clinical outcomes. The suitability of antibiotic use was based on the 12-step prevention of antimicrobial resistance by the Centers for Disease Control (CDC) [12Centers for Disease Control and Prevention. 12-step program to prevent antimicrobial resistance in health care settings 2002. Available at http://www.cdc.gov/drugresistance/healthcare/default.html]. The primary objective of this study was to determine the relationship between appropriate antibiotic use and the mortality rate of children treated in the PICU. The secondary objective of this study was to identify the degree of appropriate antibiotic use in the PICU, microbe patterns, and antibiotic resistance. We also aimed to assess the relationships between microbe pattern and patient mortality, inadequate empirical antibiotic administration and patient mortality, and antibiotic use patterns and microbe patterns. A deeper understanding of antibiotic resistance data will contribute to rational selection of antibiotics for PICU patients.

2. MATERIALS AND METHODS

This retrospective cohort was done in the PICU, Sanglah General Hospital, Denpasar from 2015 to 2017, using patients’ medical records. Informed consent was obtained from subjects’ parents or guardians.

All children admitted to the PICU of Sanglah Hospital during the study period were screened for study inclusion. Inclusion criteria were children aged 28 days-12 years when treated at the PICU, Sanglah Hospital, who had undergone blood culture examination (growth of bacteria and antibiotic sensitivity test). Patients with congenital abnormalities, incomplete medical record data (missing blood culture or sensitivity test results), or those who underwent non-standard blood culture screening procedures were excluded from the study.

Age was defined as the chronological age at the time of treatment in the PICU, expressed in months. The subjects were aged 28 days to 12 years. The 12-year age limit was used because Sanglah Hospital policy stipulates that patients’ ≤12 years of age are to be treated in the PICU (except for neonates, who should be treated in the neonatal intensive care unit).

Antibiotic sensitivity tests were determined using the Kirby-Bauer disc diffusion technique, with interpretation by the National Committee for Clinical Laboratory Standards (NCCLS) is called as the Clinical and Laboratory Standards Institute (CLSI) [4Wahyudhi A dan Triratna S. Pola kuman dan uji kepekaan antibiotik pada pasien unit perawatan intensif anak RSMH Palembang. Sari Pediatri 2010; 12(1): 1-5.]. The results of the bacterial sensitivity tests were based on the germicidal value of various types of antibiotics, and the assessment was performed by a competent expert [4Wahyudhi A dan Triratna S. Pola kuman dan uji kepekaan antibiotik pada pasien unit perawatan intensif anak RSMH Palembang. Sari Pediatri 2010; 12(1): 1-5., 13Sritippayawan S, Sri-Singh K, Prapphal N, Samransamruajkit R, Deerojanawong J. Multidrug-resistant hospital-associated infections in a pediatric intensive care unit: a cross-sectional survey in a Thai university hospital. Int J Infect Dis 2009; 13(4): 506-12.[http://dx.doi.org/10.1016/j.ijid.2008.08.022] [PMID: 19081281] ].

Use of antibiotics was defined as the administration of one or more types of antibiotics during PICU treatment. The use of antibiotics was classified as 1) empirical (antibiotic therapy for signs of infection, but no microbe-sensitivity test results yet), 2) definitive (antibiotic therapy for pathogenic pathogens), or 3) prophylactic (antibiotic therapy for patients without signs of infection, but have immune-compromised conditions, anatomical defects, indwelling device, or planned surgery [14Alamu JO. Evaluation of antimicrobial use in a pediatric intensive care unit. [PhD (Doctor of Philosophy) thesis]. 2009., 15Stocker M, Ferrao E, Banya W, Cheong J, Macrae D, Furck A. Antibiotic surveillance on a paediatric intensive care unit: easy attainable strategy at low costs and resources. BMC Pediatr 2012; 12(1): 196.[http://dx.doi.org/10.1186/1471-2431-12-196] [PMID: 23259701] ].

The appropriateness of antibiotic use was an assessment of the precision of antibiotics based on a 12-step recommendation by the CDC [12Centers for Disease Control and Prevention. 12-step program to prevent antimicrobial resistance in health care settings 2002. Available at http://www.cdc.gov/drugresistance/healthcare/default.html]. The assessment focused on two points, that were the diagnosis and efficient handling of infection and the wise use of an antibiotic. Use of antibiotic therapy was considered appropriate if it did not deviate from institutional therapy guidelines and the CDC step assessments. The antibiotic conformity was evaluated twice, i.e., at initiation and 2 days after initiation. Incompatibilities in antibiotic therapy were expressed when one of the following criteria was met: 1) there was no strong justification for initiation of antibiotics; 2) empirical therapy was continued for more than 3 days, unless there was a documented, strong reason for continuing empirical antibiotic therapy; 3) Empirical therapy was continued or antibiotics were not replaced, despite conflicting microbe-sensitivity test results; 4) the choice of definitive therapy was inconsistent with the sensitivity test, or 5) prophylactic therapy was resumed 24 hours after surgery [16Cosgrove SE, Patel A, Song X, et al. Impact of different methods of feedback to clinicians after postprescription antimicrobial review based on the Centers For Disease Control and Prevention’s 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults. Infect Control Hosp Epidemiol 2007; 28(6): 641-6.[http://dx.doi.org/10.1086/518345] [PMID: 17520534] ].

Specifically, empirical antibiotics were adequate if the antibiotics in isolated cultures were sensitive in vitro, and empirically administered within 24 hours after the culture was taken. The microbe pattern was the proportion and number of microbes found based on the blood culture results for each patient. We recorded microbial type (gram-negative or positive) and sensitivity to the antibiotic.

Patients treated during a predetermined time range were included in the study. All patients’ medical records were screened. The research sample data included general characteristics: name, address, age, biological sex, nutritional status, duration of PICU hospitalization, a primary underlying disease in the PICU, infection marker, comorbidity (malignancy/HIV), and patient outcome. In addition, blood culture results in the antibiotic susceptibility test results were also obtained from the medical records.

From patients’ medical record, antibiotic usage and antibiotic appropriateness were evaluated and recorded, in accordance with the above-described criteria. The determination of the suitability of antibiotics was evaluated progressively from the development sheets from the day the patient was first admitted to the PICU. As a guide to determine the appropriate use of antibiotics, we used a checklist adapted from Stocker et al. [15Stocker M, Ferrao E, Banya W, Cheong J, Macrae D, Furck A. Antibiotic surveillance on a paediatric intensive care unit: easy attainable strategy at low costs and resources. BMC Pediatr 2012; 12(1): 196.[http://dx.doi.org/10.1186/1471-2431-12-196] [PMID: 23259701] ] with necessary modifications. The checklist asks for clinical indications and possible infection at the start of antibiotic therapy. Then, this checklist was used to evaluate therapy at 48 hours and 5 days after antibiotic discontinuation, when the blood culture results were available.

The minimum required sample size was calculated by the large sample formula to test the difference of two proportions [17Sastroasmoro S, Ismael S. Pemilihan Subyek penelitian.Dasar-Dasar Metedologi Penelitian Klinis 2ed. 2008.2ed.]. By setting the rate of type I error at 5%, a type II error at 20%, and the proportion of appropriate antibiotic therapy (not considered a risk factor) according to the literature to 18%, 24 and relative risks considered significant at 2, the required sample size was estimated to be 95 patients.

Za = error rate of type I, set at 5%, equal to 1.64

Zb = value of type II error is set at 20%, equal to 0.84

P2 = proportion of patients receiving appropriate antibiotic therapy, set at 0.18 [15Stocker M, Ferrao E, Banya W, Cheong J, Macrae D, Furck A. Antibiotic surveillance on a paediatric intensive care unit: easy attainable strategy at low costs and resources. BMC Pediatr 2012; 12(1): 196.[http://dx.doi.org/10.1186/1471-2431-12-196] [PMID: 23259701] ].

RR = relative risk considered significant, set at 2.

p1 = p2 x RR [17Sastroasmoro S, Ismael S. Pemilihan Subyek penelitian.Dasar-Dasar Metedologi Penelitian Klinis 2ed. 2008.2ed.], is set at 0:36

Subjects’ data were collected and processed by 2007 Microsoft Excel software, then analyzed with SPSS 16.0 software. Results are presented as the mean and Standard Deviation (SD) for continuous and median (continuous interquartile) for continuous non-distributed continuous data. Absolute numbers (percentages) indicated categorical or nominal data.

A Chi-square test was used for bivariate analysis to assess for associations between the suitability of the antibiotics and patient mortality, microbial patterns and mortality, as well as the use of antibiotics and microbial patterns. The two-tailed Fisher Exact test was used when the expected frequency was less than 5. A p value of < 0.05 was considered to be statistically significant. The study was approved by the Ethics Committee of Udayana University Medical School, Sanglah Hospital, Denpasar.

3. RESULTS

From the 692 subjects included in the PICU register at Sanglah Hospital Denpasar, 95 (13.7%) patients had complete medical records and were included in the study. We separated the subjects’ based on the mean length of stay by local insurance in the PICU. As shown in Table 1 with the 95 subjects, 14 had less than 4 days treatment in the PICU and male subjects were dominant and represented 11 of the 14 (78.6%). It was similar for the subjects whose treatment was for more than 4 days, and the males were also dominant with 49 (60.5%). The largest categories of subjects were in the normal body weight category (35.7% and 48.1%). Bacterial growth was seen in a total of 60 patients and were separated into 9 patients with a length of stay less than 4 days and 51 patients with more than 4 days (Table 1).

The appropriate use of antibiotics during initiation and continuation is displayed in Table 2. We found that 80% of subjects used appropriate antibiotic during initiation and 70.5% of subjects used antibiotics appropriately during continuation (Table 2). In this study, we also found that 40% of subjects died and we found an association between mortality and the appropriate use of antibiotic during initiation (p = 0.021; RR = 0.542; CI = 0.341-0.9861) (Table 3). Meanwhile, we did not find an association between mortality and the appropriate use of antibiotic during the continuation (p = 0.408; RR = 0.855; CI = 0.578-1.264) (Table 4).

In this study, we also looked for an association between mortality and the microbial gram status (Table 5) and there was no significant association (p = 0.090; RR = 0.584; CI = 0.311-1.110). The length of stay variable was found to be associated with the compatibility of antibiotic use, although the association was not very strong in the population (p = 0.049; RR = 3.661; CI = 0.869-15.428). Not only was compatibility associated with length of stay, but also the appropriate continuation variable (p = 0.047; RR = 1.196; CI = 1.043-1.373). However, no other variable was associated with the length of stay, including mortality (p = 0.813; RR = 1.125; CI = 0.424-2.985), appropriate use of antibiotic during initiation (p = 0.563; RR = 1.500; CI = 0.366-6.144), and microbial gram status (p = 0.971; RR = 1.023; CI = 0.304-3.438) (Table 6).

Table 1
Characteristic of subjects.


Table 2
Analysis of the level of appropriate of antibiotic usage.


Table 3
Association between appropriate use of antibiotic during initiation and mortality.


Table 4
Association between appropriate use of antibiotic during continuation and mortality.


Table 5
Analysis of microbial pattern and mortality.


Table 6
Association between the length of stay and mortality, appropriate use during initiation, appropriate use during continuation, the pattern of bacteria, and compatibility of continuation antibiotics.


Table 7
Percentage of gram sensitivity to several antibiotics (%).


4. DISCUSSION

The extensive use of antibiotics has been closely linked to the subsequent problem of antibiotic resistance [18WHO. Containing antimicrobial resistance, WHO policy perspectives of medicine. 2005.]. Antibiotic resistance occurs as a result of continuous use of antibiotics over a longer time period. In addition, the empirical use of antibiotics, not based on bacterial sensitivity results, also contributes to antibiotic resistance [7Ding H, Yang Y, Chen Y, Wang Y, Fan S, Shen X. Antimicrobial usage in paediatric intensive care units in China. Acta Paediatr 2008; 97(1): 100-4.[http://dx.doi.org/10.1111/j.1651-2227.2007.00580.x] [PMID: 1807 6718] ]. To date, antibiotic resistance remains a threat, particularly in PICU patients [14Alamu JO. Evaluation of antimicrobial use in a pediatric intensive care unit. [PhD (Doctor of Philosophy) thesis]. 2009.]. Erbay et al. [3Erbay A, Bodur H, Akinci E, Colpan A. Evaluation of antibiotic use in intensive care units of a tertiary care hospital in Turkey. J Hosp Infect 2005; 59(1): 53-61.[http://dx.doi.org/10.1016/j.jhin.2004.07.026] [PMID: 15571854] ] found that antibiotic use was not appropriate in 47.3% of the cases (OR = 3.8; 95% CI: 1.1-13.1), as the empirical use of antibiotics often does not conform to definitive antibiotic therapy (corresponding to culture and sensitivity test results). Isolation of antibiotic-resistant bacteria is more often found in patients who received prior antibiotic therapy, with the highest prevalence of antibiotic-resistant bacteria in hospitals with the highest antibiotic use [14Alamu JO. Evaluation of antimicrobial use in a pediatric intensive care unit. [PhD (Doctor of Philosophy) thesis]. 2009.]. In addition, Sritippayawan et al. [13Sritippayawan S, Sri-Singh K, Prapphal N, Samransamruajkit R, Deerojanawong J. Multidrug-resistant hospital-associated infections in a pediatric intensive care unit: a cross-sectional survey in a Thai university hospital. Int J Infect Dis 2009; 13(4): 506-12.[http://dx.doi.org/10.1016/j.ijid.2008.08.022] [PMID: 19081281] ] reported that two weeks of broad-spectrum antibiotic therapy increased the risk of bacterial infection by Multidrug-Resistant (MDR) bacteria by 9.7 times (95% CI: 1.8 to 53.4). Additionally, Soroush et al. [20Soroush S, Haghi-Ashtiani MT, Taheri-Kalani M, et al. Antimicrobial resistance of nosocomial strain of Acinetobacter baumannii in Children’s Medical Center of Tehran: a 6-year prospective study. Acta Med Iran 2010; 48(3): 178-84.[PMID: 21137655] ] reported resistant Acinetobacter baumannii in patients previously given broad-spectrum antibiotics.

For years, studies have shown increased infection rates by antibiotic-resistant microbes and their corresponding negative effects. Kapoor et al. [21Kapoor K, Jain S, Jajoo M, Dublish S, Dabas V, Manchanda V. Risk factors and predictor of mortality in critically ill children with extensively drug resistant Acinetobacter baumanii infection in a pediatric intensive care unit. Iran J Pediatr 2014; 24(5): 569-74.[PMID: 25793063] ] showed that 100% of Acinetobacter baumannii cases were resistant to ampicillin-sulbactam, ceftriaxone, cefotaxime, cefipime, ceftazidime, and levofloxacin. Soroush et al. [20Soroush S, Haghi-Ashtiani MT, Taheri-Kalani M, et al. Antimicrobial resistance of nosocomial strain of Acinetobacter baumannii in Children’s Medical Center of Tehran: a 6-year prospective study. Acta Med Iran 2010; 48(3): 178-84.[PMID: 21137655] ] reported a decrease from 2001 to 2007 in the sensitivity of Acinetobacter baumannii to ceftriaxone (43.7% vs. 16.2%, respectively), ceftazidime (50% vs. 14.7%, respectively), ampicillin (18.7% vs. 10.4%, respectively), gentamicin (50% vs. 34.3%, respectively), and amikacin (81.2% vs. 41.5%, respectively). In addition, Johnson [22Johnson AP. Surveillance of antibiotic resistance. Phil Trans R Soc 2015; B370[http://dx.doi.org/10.1098/rstb.2014.0080] ] noted an increase in the proportion of isolates of Methicillin-resistant Staphylococcus Aureus from blood samples in Wales and the UK, where the proportion of methicillin-resistant Staphylococcus aureus (MRSA) in 1992 was <5%, which significantly increased in 2001 to more than 40%. Similarly, gram-negative bacteria, which are confirmed carbapenemase producers, increased dramatically from 2005 to 2013 (Table 7).

Cosgrove [23Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin Infect Dis 2006; 42(Suppl. 2): S82-9.[http://dx.doi.org/10.1086/499406] [PMID: 16355321] ] reported the negative effects of antibiotic-resistant bacterial infection to-include an increase in the mortality of patients infected with MRSA compared to those infected with methicillin-susceptible Staphylococcus aureus (MSSA) (OR = 3.4; P = 0.003). The duration of hospitalization was also elevated in MRSA-infected patients (mean 29.1 days) and compared with MSSA-infected patients (mean 13.2 days). In addition, patients with MRSA required higher treatment costs (US $118,414) than those with MSSA (US $73,165). Similarly, infection with Enterobacter resistant to third-generation cephalosporins increased the risk of death by 5.09 times (P = 0.01), increased the duration of hospitalization by 1.47 times (P < 0.001), and increased treatment costs up to 1.5-fold (P < 0.001). In addition, Roberts et al. [24Roberts RR, Hota B, Ahmad I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis 2009; 49(8): 1175-84.[http://dx.doi.org/10.1086/605630] [PMID: 19739972] ] reported that in 2009, the maintenance costs because of antibiotic-resistant infections ranged from US $18,588 to $29,069 in a teaching hospital in Chicago. The duration of hospitalization for these patients was also longer, ranging from 6.4-12.7 days. The mortality from this study caused by gram positive 41.6%, gram negative 58.3% and 3 from gram positive was from MRSI category.

Therefore, to decrease the high rate of antibiotic resistance, which in recent years has gained worldwide attention, antibiotic use should be justifiable, based on microbe-sensitivity data available in the treatment room, especially in the PICU [10Yuniar I, Karyanti MR, Tambunan T, Rizkyani NA. Evaluasi penggunaan antibiotik dengan kartu monitoring antibiotik gyssens. Sari Pediatri 2013; 14(6): 384-90.[http://dx.doi.org/10.14238/sp14.6.2013.384-90] ]. To reduce inappropriate antibiotic use, the CDC issued a 12-step recommendation to limit resistance to antimicrobials, educate clinicians about antibiotic resistance, and provide a variety of strategies to change clinical practice, including the prescription of antibiotics [12Centers for Disease Control and Prevention. 12-step program to prevent antimicrobial resistance in health care settings 2002. Available at http://www.cdc.gov/drugresistance/healthcare/default.html]. This recommendation has been widely adopted, according to the previous studies [15Stocker M, Ferrao E, Banya W, Cheong J, Macrae D, Furck A. Antibiotic surveillance on a paediatric intensive care unit: easy attainable strategy at low costs and resources. BMC Pediatr 2012; 12(1): 196.[http://dx.doi.org/10.1186/1471-2431-12-196] [PMID: 23259701] , 16Cosgrove SE, Patel A, Song X, et al. Impact of different methods of feedback to clinicians after postprescription antimicrobial review based on the Centers For Disease Control and Prevention’s 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults. Infect Control Hosp Epidemiol 2007; 28(6): 641-6.[http://dx.doi.org/10.1086/518345] [PMID: 17520534] , 25Patel SJ, Oshodi A, Prasad P, et al. Antibiotics use in neonatal intensive care units and adherence with Centers for Disease Control and Prevention 12 step campaign to prevent antimicrobial resistance. Pediatr Infect Dis J 2009; 28(12): 1047-51.[http://dx.doi.org/10.1097/INF.0b013e3181b12484] [PMID: 1985 8773] ]. Stocker et al. [15Stocker M, Ferrao E, Banya W, Cheong J, Macrae D, Furck A. Antibiotic surveillance on a paediatric intensive care unit: easy attainable strategy at low costs and resources. BMC Pediatr 2012; 12(1): 196.[http://dx.doi.org/10.1186/1471-2431-12-196] [PMID: 23259701] ] mentioned that the 12-step CDC Guideline is useful for evaluating the therapeutic use of antibiotics in PICU patients, even in settings with limited funding and resources. The study also suggested that the proportion of conformity of antibiotic therapy in patients with negative culture results increased, ranging from only 18% before implementation to 74% after implementation. Similarly, the proportion of empirical antibiotic use for <3 days increased from 18% to 35%, and the precision of definitive therapy increased from 58% to 83%.

CONCLUSION

In conclusion, an appropriate continuation of antibiotic therapy is a significant predictor of length of PICU patient stay, based on the bivariate analysis. However, multivariate analysis revealed that appropriate continuation of antibiotics was not a significant predictor.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Ethical clearance of this study was approved by the Ethical Committee with the reference number 1774/UN.14.2/KEP/2007.

HUMAN AND ANIMAL RIGHTS

No Animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

Informed consent was obtained from subjects’parents or guardians.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from january 1992 through june 2004, issued october 2004. Am J Infect Control 2004; 32(8): 470-85.[http://dx.doi.org/10.1016/j.ajic.2004.10.001] [PMID: 15573054]
[2] Banerjee SN, Grohskopf LA, Sinkowitz-Cochran RL, Jarvis WR. Incidence of pediatric and neonatal intensive care unit-acquired infections. Infect Control Hosp Epidemiol 2006; 27(6): 561-70.[http://dx.doi.org/10.1086/503337] [PMID: 16755474]
[3] Erbay A, Bodur H, Akinci E, Colpan A. Evaluation of antibiotic use in intensive care units of a tertiary care hospital in Turkey. J Hosp Infect 2005; 59(1): 53-61.[http://dx.doi.org/10.1016/j.jhin.2004.07.026] [PMID: 15571854]
[4] Wahyudhi A dan Triratna S. Pola kuman dan uji kepekaan antibiotik pada pasien unit perawatan intensif anak RSMH Palembang. Sari Pediatri 2010; 12(1): 1-5.
[5] Grohskopf LA, Huskins WC, Sinkowitz-Cochran RL, Levine GL, Goldmann DA, Jarvis WR. Use of antimicrobial agents in United States neonatal and pediatric intensive care patients. Pediatr Infect Dis J 2005; 24(9): 766-73.[http://dx.doi.org/10.1097/01.inf.0000178064.55193.1c] [PMID: 1614 8841]
[6] Briassoulis G, Natsi L, Tsorva A, Hatzis T. Prior antimicrobial therapy in the hospital and other predisposing factors influencing the usage of antibiotics in a pediatric critical care unit. Ann Clin Microbiol Antimicrob 2004; 3(4): 4.[http://dx.doi.org/10.1186/1476-0711-3-4] [PMID: 15090066]
[7] Ding H, Yang Y, Chen Y, Wang Y, Fan S, Shen X. Antimicrobial usage in paediatric intensive care units in China. Acta Paediatr 2008; 97(1): 100-4.[http://dx.doi.org/10.1111/j.1651-2227.2007.00580.x] [PMID: 1807 6718]
[8] Toltzis P, Rosolowski B, Salvator A. Etiology of fever and opportunities for reduction of antibiotic use in a pediatric intensive care unit. Infect Control Hosp Epidemiol 2001; 22(8): 499-504.[http://dx.doi.org/10.1086/501940] [PMID: 11700877]
[9] Tjekyan RMS. Pola Kuman dan Resistensi Antibiotik di Pediatric Intensive Care Unit (PICU) RS. Dr. Mohammad Hoesin Palembang Tahun 2013. Jurnal Kedokteran dan Kesehatan 2015; 2: 91-7.
[10] Yuniar I, Karyanti MR, Tambunan T, Rizkyani NA. Evaluasi penggunaan antibiotik dengan kartu monitoring antibiotik gyssens. Sari Pediatri 2013; 14(6): 384-90.[http://dx.doi.org/10.14238/sp14.6.2013.384-90]
[11] Hadi U, Duerink DO, Lestari ES, et al. Audit of antibiotic prescribing in two governmental teaching hospitals in Indonesia. Clin Microbiol Infect 2008; 14(7): 698-707.[http://dx.doi.org/10.1111/j.1469-0691.2008.02014.x] [PMID: 1855 8943]
[12] Centers for Disease Control and Prevention. 12-step program to prevent antimicrobial resistance in health care settings 2002. Available at http://www.cdc.gov/drugresistance/healthcare/default.html
[13] Sritippayawan S, Sri-Singh K, Prapphal N, Samransamruajkit R, Deerojanawong J. Multidrug-resistant hospital-associated infections in a pediatric intensive care unit: a cross-sectional survey in a Thai university hospital. Int J Infect Dis 2009; 13(4): 506-12.[http://dx.doi.org/10.1016/j.ijid.2008.08.022] [PMID: 19081281]
[14] Alamu JO. Evaluation of antimicrobial use in a pediatric intensive care unit. [PhD (Doctor of Philosophy) thesis]. 2009.
[15] Stocker M, Ferrao E, Banya W, Cheong J, Macrae D, Furck A. Antibiotic surveillance on a paediatric intensive care unit: easy attainable strategy at low costs and resources. BMC Pediatr 2012; 12(1): 196.[http://dx.doi.org/10.1186/1471-2431-12-196] [PMID: 23259701]
[16] Cosgrove SE, Patel A, Song X, et al. Impact of different methods of feedback to clinicians after postprescription antimicrobial review based on the Centers For Disease Control and Prevention’s 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults. Infect Control Hosp Epidemiol 2007; 28(6): 641-6.[http://dx.doi.org/10.1086/518345] [PMID: 17520534]
[17] Sastroasmoro S, Ismael S. Pemilihan Subyek penelitian.Dasar-Dasar Metedologi Penelitian Klinis 2ed. 2008.2ed.
[18] WHO. Containing antimicrobial resistance, WHO policy perspectives of medicine. 2005.
[19] Katragkou A, Kotsiou M, Antachopoulos C, et al. Acquisition of imipenem-resistant Acinetobacter baumannii in a pediatric intensive care unit: A case-control study. Intensive Care Med 2006; 32(9): 1384-91.[http://dx.doi.org/10.1007/s00134-006-0239-x] [PMID: 16788807]
[20] Soroush S, Haghi-Ashtiani MT, Taheri-Kalani M, et al. Antimicrobial resistance of nosocomial strain of Acinetobacter baumannii in Children’s Medical Center of Tehran: a 6-year prospective study. Acta Med Iran 2010; 48(3): 178-84.[PMID: 21137655]
[21] Kapoor K, Jain S, Jajoo M, Dublish S, Dabas V, Manchanda V. Risk factors and predictor of mortality in critically ill children with extensively drug resistant Acinetobacter baumanii infection in a pediatric intensive care unit. Iran J Pediatr 2014; 24(5): 569-74.[PMID: 25793063]
[22] Johnson AP. Surveillance of antibiotic resistance. Phil Trans R Soc 2015; B370[http://dx.doi.org/10.1098/rstb.2014.0080]
[23] Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin Infect Dis 2006; 42(Suppl. 2): S82-9.[http://dx.doi.org/10.1086/499406] [PMID: 16355321]
[24] Roberts RR, Hota B, Ahmad I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis 2009; 49(8): 1175-84.[http://dx.doi.org/10.1086/605630] [PMID: 19739972]
[25] Patel SJ, Oshodi A, Prasad P, et al. Antibiotics use in neonatal intensive care units and adherence with Centers for Disease Control and Prevention 12 step campaign to prevent antimicrobial resistance. Pediatr Infect Dis J 2009; 28(12): 1047-51.[http://dx.doi.org/10.1097/INF.0b013e3181b12484] [PMID: 1985 8773]

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