Antibiotic Use Varies 40-Fold at California NICUs

Diedtra Henderson

April 20, 2015

Neonatal intensive care units (NICUs) in California registered a 40-fold variation in antibiotics prescribing practices, with half of intermediate-level NICUs reporting infection rates of zero while also reporting the highest use of antibiotics, according to a retrospective cohort study.

Joseph Schulman, MD, from the California Department of Health Care Services, California Children's Services, Sacramento, and colleagues report their findings in an article published online April 20 and in the May issue of Pediatrics.

NICUs traditionally have considered treatment of infection "a mainstay," and recent quality improvement efforts have targeted such hospital-acquired infections as central line–associated bloodstream infections, Dr Schulman and colleagues write. Antibiotics in this setting, however, are associated with increased risk for necrotizing enterocolitis, as well as mortality.

The research team studied 127 California NICUs that admitted 52,061 infants during 2013 and analyzed their annual antibiotic use rate (AUR), the number of patient-days infants were given at least one antibacterial or antifungal agent per 100 patient-days. Overall, they found a 40-fold variation in AUR, ranging from 2.4% of patient-days to 97.1% of patient-days, with intermediate NICUs that treat less sick infants notching the highest, an almost 31-fold variation. The authors found no linkage between antibiotic use and proven infection, necrotizing enterocolitis, volume of surgeries, or mortality rate.

"Variation in antibiotic prescribing practice appears to hinge on variation in how practitioners frame, interpret, and respond to clinical situations ultimately considered unproven infection. Thus, a considerable portion of the observed variation in antibiotic use appears unwarranted; in some NICUs, antibiotics are overused," Dr Schulman and coauthors write.

In a companion editorial, Roger F. Soll, MD, from the University of Vermont College of Medicine, Burlington, and William H. Edwards, MD, from the Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, write that most antibiotic use in the NICU is "empirical, initiated for suspected infection rather than proven infection."

Improved diagnostic and clinical approaches and additional research can lead to more judicious antibiotics use, according to Dr Soll and Dr Edwards. "Sources of variation in the use of antibiotics need to be identified and understood, including unit culture and beliefs about infection, variation in thresholds for starting and stopping therapy and emphasizing the importance of using potentially harmful therapies only when there is clear benefit."

The study authors also suggest that select clinical thresholds for beginning or continuing antibiotic use "can be raised without harm" and that metrics used to evaluate NICU performance should include AUR.

"The 40-fold variation in antibiotic use across California NICUs is unsupported by the burden of proven infection, other factors unambiguously warranting antibiotic exposure, or the peer-reviewed literature," Dr Schulman and colleagues conclude.

Financial support for the study was provided by the California Department of Health Care Services and the California Perinatal Quality Care Collaborative. The study authors and the commentators have disclosed no relevant financial relationships.

Pediatrics. 2015;135:826-833, 928-929. Article abstract

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