title: Neonatal intensive care unit antibiotic use.
abstract: OBJECTIVE
  Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay.
  
  
  METHODS
  In a retrospective cohort study of 52,061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles.
  
  
  RESULTS
  Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile.
  
  
  CONCLUSIONS
  Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.
authors.affiliation: California Department of Health Care Services, California Children's Services, Sacramento, California; joseph.schulman@dhcs.ca.gov.
authors.forename: Joseph
authors.initials: J
authors.lastname: Schulman
authors.affiliation: California Department of Health Care Services, California Children's Services, Sacramento, California;
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Dimand
authors.affiliation: Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and California Perinatal Quality Care Collaborative, Stanford, California.
authors.forename: Henry C
authors.initials: HC
authors.lastname: Lee
authors.affiliation: Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and California Perinatal Quality Care Collaborative, Stanford, California.
authors.forename: Grace V
authors.initials: GV
authors.lastname: Duenas
authors.affiliation: Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and California Perinatal Quality Care Collaborative, Stanford, California.
authors.forename: Mihoko V
authors.initials: MV
authors.lastname: Bennett
authors.affiliation: Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and California Perinatal Quality Care Collaborative, Stanford, California.
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Gould
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001424:Bacterial Infections / Q000453:epidemiology* / Q000517:prevention & control*; D015331:Cohort Studies; D004363:Drug Utilization / Q000706:statistics & numerical data*; D020345:Enterocolitis, Necrotizing / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control*; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D012189:Retrospective Studies
chemical_list: D000900:Anti-Bacterial Agents
keywords: antibiotic stewardship; bacterial infections and mycoses; benchmarking; health services research; neonatal intensive care