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

Published online by Cambridge University Press:  08 May 2018

Caitlin W. Elgarten*
Affiliation:
Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
Staci D. Arnold
Affiliation:
Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
Yimei Li
Affiliation:
Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
Yuan-Shung V. Huang
Affiliation:
Center of Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Marcie L. Riches
Affiliation:
Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Jeffrey S. Gerber
Affiliation:
Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Center of Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Richard Aplenc
Affiliation:
Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Center of Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Wael Saber
Affiliation:
Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin
Brian T. Fisher
Affiliation:
Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Center of Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
*
Address correspondence to Caitlin W. Elgarten, MD, 3501 Civic Center Blvd, Clinical and Translational Research Building, 10th floor, Philadelphia, PA 19104 (elgartenc@email.chop.edu).

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.

Infect Control Hosp Epidemiol 2018;797–805

Type
Original Article
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 

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