Hospital-Level Variability in Broad-Spectrum Antibiotic Use for Children With Acute Leukemia Undergoing Hematopoietic Cell Transplantation

• Type of Material: Article
• Authors: Caitlin W. Elgarten, University of Pennsylvania; Staci Arnold, Emory University; Yimei Li, University of Pennsylvania; Yuan-Shung V. Huang, The Children's Hospital of Philadelphia; Marcie L. Riches, University of North Carolina; Jeffrey S. Gerber, University of Pennsylvania; Richard Aplenc, University of Pennsylvania; Wael Saber, Center for International Blood and Marrow Transplant Research; Brian T. Fisher, University of Pennsylvania
• Language: English
• Date: 2018-07-01
• Publisher: Cambridge University Press (CUP): STM Journals
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
• Final Published Version (URL): http://dx.doi.org/10.1017/ice.2018.96
• Title of Journal or Parent Work: Infection Control and Hospital Epidemiology
• ISSN: 0899-823X
• Volume: 39
• Issue: 7
• Start Page: 797
• End Page: 805
• Grant/Funding Information: This study was supported by a training grant from the National Institutes of Health, Clinical Pharmacoepidemiology training grant (grant no. T32-GM075766 to C.W.E.).
• Keywords: GUIDELINES; Life Sciences & Biomedicine; INTENSIVE-CARE; INTESTINAL MICROBIOTA; NEUTROPENIC PATIENTS; PEDIATRIC ONCOLOGY; Infectious Diseases; ANTIMICROBIAL AGENTS; Public, Environmental & Occupational Health; MORTALITY; INFECTIOUS-DISEASES SOCIETY; RISK; Science & Technology; HEALTH-CARE EPIDEMIOLOGY
• Research Categories: Health Sciences, Medicine and Surgery; Health Sciences, General; Health Sciences, Oncology

Abstract

OBJECTIVE To explore the prevalence and drivers of hospital-level variability in antibiotic utilization among hematopoietic cell transplant (HCT) recipients to inform antimicrobial stewardship initiatives.DESIGN Retrospective cohort study using data merged from the Pediatric Health Information System and the Center for International Blood and Marrow Transplant Research.SETTING The study included 27 transplant centers in freestanding children's hospitals.METHODS The primary outcome was days of broad-spectrum antibiotic use in the interval from day of HCT through neutrophil engraftment. Hospital antibiotic utilization rates were reported as days of therapy (DOTs) per 1,000 neutropenic days. Negative binomial regression was used to estimate hospital utilization rates, adjusting for patient covariates including demographics, transplant characteristics, and severity of illness. To better quantify the magnitude of hospital variation and to explore hospital-level drivers in addition to patient-level drivers of variation, mixed-effects negative binomial models were also constructed.RESULTS Adjusted hospital rates of antipseudomonal antibiotic use varied from 436 to 1121 DOTs per 1,000 neutropenic days, and rates of broad-spectrum, gram-positive antibiotic use varied from 153 to 728 DOTs per 1,000 neutropenic days. We detected variability by hospital in choice of antipseudomonal agent (ie, cephalosporins, penicillins, and carbapenems), but gram-positive coverage was primarily driven by vancomycin use. Considerable center-level variability remained even after controlling for additional hospital-level factors. Antibiotic use was not strongly associated with days of significant illness or mortality.CONCLUSION Among a homogenous population of children undergoing HCT for acute leukemia, both the quantity and spectrum of antibiotic exposure in the immediate posttransplant period varied widely. Antimicrobial stewardship initiatives can apply these data to optimize the use of antibiotics in transplant patients.