Factors influencing antibiotic use in the paediatric intensive care unit at Universitas Hospital from 1998 to 2007

Abstract

English: Many antibiotics have been developed and are available on the market. An increase in the use of antibiotics in hospitals was observed and antibiotics are among the medicines most commonly prescribed to paediatric patients. Resistance to antibiotics is increasing and is a major problem not only in the Paediatric Intensive Care Unit at Universitas Hospital in Bloemfontein, but in South Africa in general. The continued value and effectiveness of antibiotics depend on careful use to avoid bacterial resistance from developing. Thus, guidelines for rational antibiotic use and prevention of resistance should be developed and implemented. This requires an understanding of the factors influencing antibiotic use in a particular setting, in this case the Paediatric Intensive Care Unit at Universitas Hospital. Therefore, the aim of this study is to describe the factors that influence the use of antibiotics in the Paediatric Intensive Care Unit from 1998 to 2007. This research consisted of a retrospective study of the records of patients admitted to the Paediatric Intensive Care Unit from 1998 to 2007. Using a datasheet, the following information was captured and evaluated: patients’ demography, indication for admission, co-morbid conditions, antibiotic and other drug therapy, culture and sensitivity and other relevant parameters. Of the 1 221 patients admitted during the study period, information could only be retrieved for 967 patients, and of these 685 patients (385 males and 299 females) met the study criteria. The Paediatric Intensive Care Unit performance, measured as Intensive Care Unit utilisation, was optimal at 63%, implying that no patient needing intensive care was denied. The most common conditions on admission were respiratory (23.4%), gastro-intestinal (22%) and cardiovascular (19%) related problems. Pneumonia (8.9%) was the most common infective condition. The most common infective complications while in the Paediatric Intensive Care Unit were pneumonia (35.6%), septicaemia (11.1%) and urinary tract infection (8.8%). Broad-spectrum antibiotics were prescribed the most widely. The top ten antibiotics included cefotaxime (18.2%), amikacin (14.7%), vancomycin (9.8%), cefuroxime (8.1%) imipenem (7.5%), metronidazole (7.2%), penicillin G (6.5%), cloxacillin (4.1%), co-trimoxazole (2.7%) and gentamicin (2.4%). The top ten bacteria genera cultured were Staphylococcus (29.3%), Klebsiella (11.9%), Acinetobacter (11.7%), Pseudomonas (11.2%), Escherichia (8.5%), Enterococcus (5.9%), Streptococcus (4.1%), Enterobacter (4.1%), Stenotrophomonas (3.4%) and Haemophilus (2%). There was high resistance of the Staphylococcus genus to penicillins and penicillin-allergy substitutes (>80%, with methicillin-resistance of 85%), but no resistance to vancomycin was observed. The Klebsiella and Pseudomonas genera exhibited considerable resistance to most aminoglycosides (40–78%) and cephalosporins (70–100%), but Klebsiella remained sensitive to imipenem (1.9%), while Pseudomonas was moderately sensitive to amikacin (22.9%). The nosocomial bacteria genera Acinetobacter and Stenotrophomonas were resistant (>70%) to almost all antibiotics excluding tobramycin (25.8%) for Acinetobacter and co-trimoxazole (10.5%) for Stenotrophomonas. Lastly, the persistently challenging factors that influenced antibiotic use in the Paediatric Intensive Care Unit from 1998 to 2007 were common bacteria cultured from specific specimens, bacterial innate resistance, interaction of bacterial and host factors (multiple and severe infections), disease pattern, new antibiotics, overuse of antibiotics, length of stay, personal preferences and treatment guidelines. In conclusion, it was illustrated that bacterial resistance to antibiotics is increasing, and that antibiotic use in the Paediatric Intensive Care Unit at Universitas Hospital was greatly influenced by the efforts to contain antibiotic resistance.

Afrikaans: Baie antibiotika is al ontwikkel en is in die handel beskikbaar. ’n Toename in die gebruik van antibiotika in hospitale is waargeneem en antibiotika is van die algemeenste medisyne wat aan pediatriese pasiënte voorgeskryf word. Antibiotikaweerstandigheid is aan die toeneem en is ’n groot probleem in die Pediatriese Intensiewe Sorgeenheid van Universitas Hospitaal in Bloemfontein, sowel as in Suid- Afrika in die algemeen. Die volgehoue waarde en effektiwiteit van antibiotika is onderworpe aan die sorgvuldige gebruik daarvan ten einde te voorkom dat bakteriële weerstandigheid ontwikkel. Riglyne vir die rasionele gebruik van antibiotika moet dus ontwikkel en geïmplementeer word om weerstandigheid te verhoed. Dit vereis begrip van die faktore wat die gebruik van antibiotika in ’n spesifieke omgewing beïnvloed, in hierdie geval die Pediatriese Intensiewe Sorgeenheid van Universitas Hospitaal. Gevolglik is die doel van hierdie studie om die faktore te beskryf wat die gebruik van antibiotika in die Pediatriese Intensiewe Sorgeenheid vanaf 1998 tot 2007 beïnvloed het. Hierdie navorsing behels ’n retrospektiewe studie van pasiëntrekords wat vanaf 1998 tot 2007 in die Pediatriese Intensiewe Sorgeenheid opgeneem is. Die volgende inligting is deur middel van ’n datavel versamel en geëvalueer: demografie van die pasiënt, aanduiding vir opname, ko-morbiede toestande, antibiotika en ander geneesmiddel terapie, kultuur en sensitiwiteit en ander toepaslike parameters. Van die 1 221 pasiënte wat tydens die studieperiode opgeneem is, kon inligting vir slegs 967 van die pasiënte verkry word, waarvan 685 pasiënte (385 manlike- en 299 vroulike pasiënte) aan die studie-kriteria voldoen het. Die Pediatriese Intensiewe Sorgeenheid-prestasie, gemeet as Intensiewe Sorgeenheidbenutting, was optimaal teen 63%, wat daarop dui dat geen pasiënt wat intensiewe sorg benodig het, weggewys is nie. Die algemeenste siektetoestande tydens opname was respiratoriese (23.4%), gastrointestinale (22%) en kardiovaskulêre (19%) verwante probleme. Pneumonie (8.9%) was die algemeenste infektiewe toestand. Die algemeenste infektiewe komplikasies gedurende verblyf in die Pediatriese Intensiewe Sorgeenheid was pneumonie (35.6%), septisemie (11.1%) en urienweginfeksie (8.8%). Breë-spektrum antibiotika is die meeste voorgeskryf. Die toptien antibiotika was kefotaksiem (18.2%), amikasien (14.7%), vankomisien (9.8%), kefuroksiem (8.1%), imipenem (7.5%), metronidasool (7.2%), penisillien G (6.5%), kloksasillien (4.1%), ko-trimoksasool (2.7%) en gentamisien (2.4%). Die toptien gekweekte bakterie genera was Staphylococcus (29.3%), Klebsiella (11.9%), Acinetobacter (11.7%), Pseudomonas (11.2%), Escherichia (8.5%), Enterococcus (5.9%), Streptococcus (4.1%), Enterobacter (4.1%), Stenotrophomonas (3.4%) en Haemophilus (2%). Daar was hoë weerstandigheid van die Staphylococcusgenus teen penisilliene en penisillien-allergieplaasvervangers (>80%, met metisillienweerstandigheid van 85%), maar vankomisien-weerstandigheid is nie waargeneem nie. Klebsiella- en Pseudomonas-genera het aansienlike weerstand teen die meeste van die aminoglikosiede (40–78%) en kefalosporiene (70–100%) getoon, maar Klebsiella het sensitief vir imipenem (1.9%) gebly, terwyl Pseudomonas matig sensitief vir amikasien (22.9%) was. Die hospitaalverworwe bakterie genera Acinetobacter en Stenotrophomonas was weerstandig (>70%) teen amper alle antibiotika behalwe tobramisien (25.8%) vir Acinetobacter en ko-trimoksasool (10.5%) vir Stenotrophomonas. Laastens, die steeds uitdagende faktore wat die gebruik van antibiotika in die Pediatriese Intensiewe Sorgeenheid beïnvloed het, was algemene bakterieë wat van spesifieke monsters gekweek is, ingebore bakteriële weerstandigheid, interaksie van bakteriële faktore met gasheerfaktore (veelvoudige en erge infeksies), siektepatroon, nuwe antibiotika, oorgebruik van antibiotika, duur van opname, persoonlike voorkeure en behandelingsriglyne. Ten slotte is geïllustreer dat bakteriële weerstandigheid teen antibiotika toeneem, en dat die gebruik van antibiotika in die Pediatriese Intensiewe Sorgeenheid in Universitas Hospitaal grootliks beïnvloed is deur die pogings om antibiotika-weerstandigheid in bedwang te hou.