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. 2018 May 18;1(1):e180164.
doi: 10.1001/jamanetworkopen.2018.0164.

Temporal Trends and Center Variation in Early Antibiotic Use Among Premature Infants

Dustin D Flannery  1   2 , Rachael K Ross  1   3 , Sagori Mukhopadhyay  1   2 , Alison C Tribble  4 , Karen M Puopolo  1   2 , Jeffrey S Gerber  1   3
Affiliations

Temporal Trends and Center Variation in Early Antibiotic Use Among Premature Infants

Dustin D Flannery et al. JAMA Netw Open. .

Abstract

Importance: Premature infants are frequently administered empirical antibiotic therapy at birth. Early and prolonged antibiotic exposures among infants without culture-confirmed infection have been associated with increased risk of adverse outcomes.

Objective: To examine early antibiotic use among premature infants over time and across hospitals in the United States.

Design, setting, and participants: This retrospective cohort study used a comprehensive administrative database of inpatient encounters from 297 academic and community hospitals across the United States to examine data concerning very low-birth-weight (VLBW) infants (<1500 g), including extremely low-birth-weight (ELBW) infants (<1000 g), who were admitted to the neonatal intensive care unit and survived for at least 1 day. Data collection took place in November 2015 and analysis took place from February 2016 to November 2016.

Exposures: Antibiotic initiation within the first 3 days of age and subsequent antibiotic administration for more than 5 days.

Main outcomes and measures: Temporal trends in early antibiotic initiation and duration from 2009 to 2015, and center variation in early antibiotic use from 2014 to 2015.

Results: We identified 40 364 VLBW infants (20 447 female [50.7%]) who survived for at least 1 day, including 12 947 ELBW infants, from 297 centers. The majority of premature infants had early antibiotic initiation (31 715 VLBW infants [78.6%] and 11 264 ELBW infants [87.0%]), and no differences were observed over time in temporal trend analyses (P = .12 for VLBW and P = .52 for ELBW). The annual risk difference in the proportion of VLBW infants administered early antibiotic therapy ranged from -0.75% (95% CI, -1.61% to 0.11%) to -0.87% (95% CI, -2.04% to 0.30%); in ELBW infants the annual risk difference ranged from -0.34% (95% CI, -1.28% to 0.61%) to -0.38% (95% CI, -1.61% to 0.85%). There was a small but significant decrease over time in the rate of prolonged antibiotic duration for VLBW infants (P = .02), but not for ELBW infants (P = .22). The annual risk difference in the proportion of VLBW infants with prolonged antibiotic duration ranged from -0.94% (95% CI, -1.65% to -0.23%) to -1.08% (95% CI, -2.00% to -0.16%); in ELBW infants the annual risk difference ranged from -0.72% (95% CI, -1.83% to 0.39%) to -0.75% (95% CI, -1.96% to 0.46%). We also observed variation in early antibiotic exposures across centers. Sixty-nine of 113 centers (61.1%) started antibiotic therapy for more than 75% of VLBW infants, and 56 of 66 centers (84.8%) started antibiotic therapy for more than 75% of ELBW infants. The proportion of VLBW and ELBW infants administered prolonged antibiotics ranged from 0% to 80.4% and 0% to 92.0% across centers, respectively.

Conclusions and relevance: Most premature infants in this study received empirical early antibiotic therapy with little change over a recent 7-year period. The variability in exposure rates across centers, however, suggests that neonatal antimicrobial stewardship efforts are warranted to optimize antibiotic use for VLBW and ELBW infants.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Tribble reports grants from the National Institutes of Health and from the Pediatric Infectious Diseases Society during the conduct of the study. Dr Puopolo reports grants from the National Institutes of Health both during the conduct of the study and outside the submitted work, as well as personal fees from Vermont-Oxford Network outside the submitted work. She also serves on the American Academy of Pediatrics Committee on the Fetus and Newborn.

Figures

Figure 1.
Figure 1.. Patient Flow Diagram
APR-DRG indicates All Patient Refined Diagnosis Related Group; NICU, neonatal intensive care unit; VLBW, very low-birth-weight. aPatient did not have any services billed in the first 3 days of admission. bFor the year 2015, which only includes 3 quarters, patients at hospitals with fewer than 15 NICU patients were excluded.
Figure 2.
Figure 2.. Duration of Early Antibiotic Therapy
The graph includes very low-birth-weight infants who received antibiotic therapy starting in the first 3 days, were admitted to the hospital, and survived for at least 5 days.
Figure 3.
Figure 3.. Temporal Trend Analyses of Antibiotic Initiation and Continuation From 2009 to 2015
A, There were no significant differences in early antibiotic initiation rates over time for very low-birth-weight (VLBW) and extremely low-birth-weight (ELBW) infants. B, There was a statistically significant decrease over time in the rate of prolonged antibiotic duration for VLBW infants but not for ELBW infants. A and B, The VLBW cohort includes ELBW infants. Q indicates quarter.
Figure 4.
Figure 4.. Variation Analysis of Early Antibiotic Use Across Centers
Sixty-nine of 113 centers (61.1%) started antibiotic therapy for more than 75% of very low-birth-weight (VLBW) infants, and 56 of 66 centers (84.8%) started antibiotic therapy for more than 75% of extremely low-birth-weight (ELBW) infants. The graphs reflect data from a 12-month period comprising the fourth quarter of 2014 to the third quarter of 2015. A and B, Variation in antibiotic initiation was noted across centers for both VLBW and ELBW infants. C and D, Even greater variation was observed across centers in prolonged antibiotic administration, particularly among ELBW infants. A and C, Hospitals with fewer than 10 VLBW neonates were excluded. B and D, Hospitals with fewer than 10 ELBW neonates were excluded.
See this image and copyright information in PMC

Comment in

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