title: Prior antimicrobial therapy in the hospital and other predisposing factors influencing the usage of antibiotics in a pediatric critical care unit.
abstract: BACKGROUND
  The aim of this study was to determine whether prior antimicrobial therapy is an important risk factor for extended antimicrobial therapy among critically ill children. To evaluate other predisposing factors influencing the usage of antibiotics in a pediatric intensive care unit (PICU) setting. To examine the relationship between the extent of antimicrobial treatment and the incidence of nosocomial infections and outcome.
  
  
  METHODS
  This prospective observational cohort study was conducted at a university-affiliated teaching hospital (760 beds) in Athens. Clinical data were collected upon admission and on each consecutive PICU day. The primary reason for PICU admission was recorded using a modified classification for mutually exclusive disease categories. All administered antibiotics to the PICU patients were recorded during a six-month period. Microbiological and pharmacological data were also collected over this period. The cumulative per patient and the maximum per day numbers of administered antibiotics, as well as the duration of administration were related to the following factors: Number of antibiotics which the patients were already receiving the day before admission, age groups, place of origin, the severity of illness, the primary disease and its complications during the course of hospitalization, the development of nosocomial infections with positive cultures, the presence of chronic disease or immunodeficiency, various interventional techniques (mechanical ventilation, central catheters), and PICU outcome.
  
  
  RESULTS
  During a six-month period 174 patients were admitted to the PICU and received antibiotics for a total of 950 days (62.3% of the length of stay days). While in PICU, 34 patients did not receive antimicrobial treatment (19.5%), 69 received one antibiotic (39.7%), 42 two (24.1%), 17 three (9.8%), and 12 more than three (6.9%). The number of antibiotics prescribed in PICU or at discharge did not differ from that at admission. Indications for receiving antibiotics the day before admission and throughout during hospitalization into PICU were significantly correlated. Although the cumulative number of administered antibiotics did not correlate with mortality (9.8%), it was significantly related to the severity scoring systems PRISM (p <.001), TISS (p <.002) and was significantly related to the number of isolated microorganisms (p <.0001). Multiple regression analysis demonstrated that independent determinants of the cumulative number of antibiotics were: prior administration of antibiotics, presence of a bloodstream infection, positive bronchial cultures, immunodeficiency, and severity of illness.
  
  
  CONCLUSIONS
  Prior antimicrobial therapy should be recognized as an important risk factor for extended antimicrobial therapy among critically ill children. Severity of illness, immunodeficiency, and prolonged length of stay are additional risk factors.
authors.affiliation: Pediatric Intensive Care Unit, Aghia Sophia Children's Hospital, Athens, Greece. briassg@otenet.gr
authors.forename: George
authors.initials: G
authors.lastname: Briassoulis
authors.forename: Labrini
authors.initials: L
authors.lastname: Natsi
authors.forename: Athina
authors.initials: A
authors.lastname: Tsorva
authors.forename: Tassos
authors.initials: T
authors.lastname: Hatzis