Compliance with antibiotic therapy guidelines in french paediatric intensive care units: a multicentre observational study.

BACKGROUND: Bacterial infections (BIs) are widespread in ICUs. The aims of this study were to assess compliance with antibiotic recommendations and factors associated with non-compliance. METHODS: We conducted an observational study in eight French Paediatric and Neonatal ICUs with an antimicrobial stewardship programme (ASP) organised once a week for the most part. All children receiving antibiotics for a suspected or proven BI were evaluated. Newborns < 72 h old, neonates < 37 weeks, age ≥ 18 years and children under surgical antimicrobial prophylaxis were excluded. RESULTS: 139 suspected (or proven) BI episodes in 134 children were prospectively included during six separate time-periods over one year. The final diagnosis was 26.6% with no BI, 40.3% presumed (i.e., not documented) BI and 35.3% documented BI. Non-compliance with antibiotic recommendations occurred in 51.1%. The main reasons for non-compliance were inappropriate choice of antimicrobials (27.3%), duration of one or more antimicrobials (26.3%) and length of antibiotic therapy (18.0%). In multivariate analyses, the main independent risk factors for non-compliance were prescribing ≥ 2 antibiotics (OR 4.06, 95%CI 1.69-9.74, p = 0.0017), duration of broad-spectrum antibiotic therapy ≥ 4 days (OR 2.59, 95%CI 1.16-5.78, p = 0.0199), neurologic compromise at ICU admission (OR 3.41, 95%CI 1.04-11.20, p = 0.0431), suspected catheter-related bacteraemia (ORs 3.70 and 5.42, 95%CIs 1.32 to 15.07, p < 0.02), a BI site classified as "other" (ORs 3.29 and 15.88, 95%CIs 1.16 to 104.76, p < 0.03), sepsis with ≥ 2 organ dysfunctions (OR 4.21, 95%CI 1.42-12.55, p = 0.0098), late-onset ventilator-associated pneumonia (OR 6.30, 95%CI 1.15-34.44, p = 0.0338) and ≥ 1 risk factor for extended-spectrum ß-lactamase-producing Enterobacteriaceae (OR 2.56, 95%CI 1.07-6.14, p = 0.0353). Main independent factors for compliance were using antibiotic therapy protocols (OR 0.42, 95%CI 0.19-0.92, p = 0.0313), respiratory failure at ICU admission (OR 0.36, 95%CI 0.14-0.90, p = 0.0281) and aspiration pneumonia (OR 0.37, 95%CI 0.14-0.99, p = 0.0486). CONCLUSIONS: Half of antibiotic prescriptions remain non-compliant with guidelines. Intensivists should reassess on a day-to-day basis the benefit of using several antimicrobials or any broad-spectrum antibiotics and stop antibiotics that are no longer indicated. Developing consensus about treating specific illnesses and using department protocols seem necessary to reduce non-compliance. A daily ASP could also improve compliance in these situations. TRIAL REGISTRATION: ClinicalTrials.gov: number NCT04642560. The date of first trial registration was 24/11/2020.

Impact of the French National Lockdown on Admissions to 14 Pediatric Intensive Care Units During the 2020 COVID-19 Pandemic-A Retrospective Multicenter Study.

Background: After the COVID-19 pandemic reached France in January 2020, a national lockdown including school closures was officially imposed from March 17, 2020, to May 10, 2020. Pediatric intensive care units (PICUs) admit critically ill infants, children and teenagers with severe acute conditions, in particular infectious and traumatic diseases. We hypothesized that PICU admissions would be considerably modified by the lockdown. Aims: The objectives of the study were to describe the type of admissions to French PICUs and to compare the occupation of PICU beds according to local epidemic conditions during the French national lockdown period, compared with the same period the previous year. Methods: We conducted a retrospective multicenter study in 14 French PICUs. All children aged from 7 days to 18 years admitted to one of the 14 participating PICUs over two 3-month period (March 1, 2020, to May 31, 2020 and March 1, 2019, to May 31, 2019) were included. Analysis was based on data extracted from the medicalized information systems program (a national database used in all French hospitals, into which all admissions and their diagnoses are coded for the purpose of calculating hospital funding). Each main diagnosis was reclassified in 13 categories, corresponding to normal PICU admissions. Results: We analyzed a total of 3,040 admissions, 1,323 during the 2020 study period and 1,717 during the same period in 2019. Total admissions decreased by 23% [incidence rate ratio (IRR) 0.77, 95% CI 0.71-0.83, p < 0.001], in particular for viral respiratory infections (-36%, IRR 0.64, 95% CI 0.44-0.94, p = 0.001). Admissions for almost all other diagnostic categories decreased, except intoxications and diabetes which increased, while admissions for cardiac and hemodynamic disorders were stable. Patient age and the sex ratio did not differ between the two periods. Median length of stay in the PICU was longer in 2020 [4 (IQR 2-9) vs. 3 (IQR 1-8) days, p = 0.002] in 2019. Mortality remained stable. Conclusions: In this large national study, we showed a decrease in the number of PICU admissions. The most severe patients were still admitted to intensive care and overall mortality remained stable.

Feasibility of New Transthoracic Three-Dimensional Echocardiographic Automated Software for Left Heart Chamber Quantification in Children.

BACKGROUND: New three-dimensional echocardiographic automated software (HeartModel) is now available to quantify the left heart chambers. The aims of this study were to assess the feasibility, reproducibility, and analysis time of this technique and its correlation with manual three-dimensional echocardiography (3DE) and cardiac magnetic resonance (CMR) in children. METHODS: Ninety-two children (5-17 years of age) were prospectively included in two separate protocols. In protocol 1, 73 healthy children underwent two-dimensional and three-dimensional transthoracic echocardiography. Left ventricular (LV) end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV ejection fraction (LVEF), and left atrial volume at ventricular end-systole (LAV) by automated 3DE were compared with the same measurements obtained using manual 3DE. In protocol 2, automated three-dimensional echocardiographic measurements from 19 children with cardiomyopathy were compared with CMR values. RESULTS: Automated 3DE was feasible in 77% of data sets and significantly reduced the analysis time compared with manual 3DE. In protocol 1, there were excellent correlations for LVEDV, LVESV, and LAV between automated 3DE and manual 3DE (r = 0.89 to 0.99, P < .0001 for all) and a weak correlation for LVEF, despite contour adjustment (r = 0.57, P < .0001). Automated 3DE overestimated LVEDV, LVEF, and LAV with small biases and underestimated LVESV with wider bias. With contour adjustment, the biases and limits of agreement were reduced (bias: LVEDV, 0.9 mL; LVESV, -1.2 mL; LVEF, 2.2%). In protocol 2, correlations between automated 3DE with contour edit and CMR were good for LV volumes and LAV (r = 0.76 to 0.94, P < .0003 for all) but remained weak for LVEF (r = 0.46, P = .05). Automated 3DE slightly underestimated LV volumes (relative bias, -7.2% to -7.8%) and significantly underestimated LAV (relative bias, -31.6%). The limits of agreement were clinically acceptable only for LVEDV. Finally, test-retest, intraobserver, and interobserver variability values were low (<12%). CONCLUSIONS: HeartModel is feasible, reproducible, faster than manual 3DE, and comparable with manual 3DE for measurements of LV and left atrial volumes in children >5 years of age. However, compared with CMR, only LVEDV measured by automated 3DE with contour edit seems applicable for clinical practice.

Assessment of Ventricular Septal Defect Size and Morphology by Three-Dimensional Transthoracic Echocardiography.

BACKGROUND: Morphologic description of ventricular septal defect (VSD) is mandatory before performing the newly developed transcatheter closure procedure. Inaccurate estimation of defect size has been reported using conventional two-dimensional (2D) transthoracic echocardiography (TTE). The aim of this study was to assess VSD morphology and size using three-dimensional (3D) TTE compared with 2D TTE and surgery. METHODS: Forty-eight children aged 21.4 ± 29.3 months with isolated muscular (n = 11 [22.9%]) and membranous (n = 37 [77.1%]) VSDs were prospectively included. Three-dimensional images were acquired using full-volume single-beat mode. Minimal diameter, maximal diameter, and systolic and diastolic VSD areas were measured from 3D data sets using multiplanar reconstruction mode (QLAB 9). Maximal-to-minimal VSD diameter ratio was used to assess VSD geometry. Linear regression analysis and the Bland-Altman method were used to compare 3D measurements with 2D and surgical measurements in a subgroup of 15 patients who underwent surgical VSD closure. RESULTS: VSD 3D diameters and areas were measured in all patients (100%; 95% CI, 92.6%-100%). Maximal diameter was lower on 2D TTE compared with 3D TTE (7.3 vs 11.3 mm, P < .0001). Mean bias was 4 mm, with 95% of values ranging from -1.76 to 9.75 mm. Correlation between 3D maximal diameter and surgical diameter was strong (r(2) = 0.97, P < .0001), while correlation between maximal 2D diameter and surgical diameter was moderate (r(2) = 0.63, P < .0001). VSDs had an oval shape when assessed by 3D TTE. Maximal-to-minimal diameter ratio assessed by 3D TTE was significantly higher in muscular VSDs compared with membranous VSDs (3.20 ± 1.51 vs 2.13 ± 1.28, respectively, P = .01). VSD area variation throughout the cardiac cycle was 32% and was higher in muscular compared with membranous VSDs (49% vs 26%, P = .0001). CONCLUSIONS: Three-dimensional TTE allows better VSD morphologic and maximal diameter assessment compared with 2D TTE. VSD shape and its changes during the cardiac cycle can be visually and quantitatively displayed. Three-dimensional echocardiography may thus be particularly useful before and during percutaneous VSD closure.

3D transthoracic echocardiography to assess pulmonary valve morphology and annulus size in patients with Tetralogy of Fallot.

BACKGROUND: Accurate evaluation of the pulmonary valve (PV) is crucial before surgical repair of Tetralogy of Fallot (TOF). AIMS: To assess PV and pulmonary annulus (PA) morphology using three-dimensional (3D) transthoracic echocardiography (TTE) in infants referred for surgical repair of TOF. Also, to compare PA measurements obtained by 3D TTE with those from other imaging modalities, including two-dimensional (2D) TTE and computed tomography (CT), with reference to surgical measurements. METHODS: 3D zoom mode was used to assess PV morphology. 2D TTE and CT PA diameters were compared to both vertical and horizontal diameters obtained from 3D datasets. Surgical PA diameters were measured using Hegar's dilators. RESULTS: A total of 29 patients with TOF (median [range] age 6 [3-24] months) were included and all successfully underwent 2D and 3D TTE; 22 also underwent CT. The number of pulmonary leaflets could be visualized in 24 patients (82.8%), with complete concordance with surgical findings. Vertical diameter was significantly longer than horizontal diameter (P<0.001)-underlying PA eccentricity-and was more important in bicuspid than tricuspid valves. Correlations between 2D and 3D TTE diameters were good. Surgical diameter was better correlated with 2D and 3D diameters than with CT diameter. 3D minimum, 2D and CT diameters were significantly lower than surgical diameters, but 3D mean and maximum diameters were not. CONCLUSION: 3D TTE is accurate to assess PV morphology and PA size in patients with TOF. 2D TTE and CT underestimate PA diameter with reference to surgical diameter, however 3D mean and maximum diameters did not differ significantly.

Safety and efficiency of the new micro-multiplane transoesophageal probe in paediatric cardiology.

BACKGROUND: Transoesophageal echocardiography (TOE) is feasible in neonates using a miniaturized probe, but is not widely used because of low imaging quality. AIMS: To assess handling and imaging quality of a new release of a micro-TOE probe in children. METHODS: Thirty-eight consecutive children, enrolled during February and May 2013, underwent TOE with the Philips S8-3t probe. Insertion, handling and image quality were assessed. RESULTS: The 38 children (aged 7days to 12years; weight 3.1-27kg) underwent 75 TOE (30 [40.0%] before cardiac surgery, 31 [41.3%] after cardiac surgery, 4 [5.3%] during a percutaneous procedure, 10 [13.3%] in the intensive care unit). Insertion of the micro-TOE probe was 'very easy' in 37/38 patients (97.4%). Handling was better in the lightest children (P=0.001). Image quality was mainly 'good' or 'very good', with no significant changes between preoperative and postoperative examinations or over time. Total scores (insertion, handling, image quality) were significantly better in the lightest children (P=0.02). Preoperative TOE did not provide additional information over transthoracic echocardiography. Postoperative TOE was useful to assess surgical results, but no residual lesions required extracorporeal circulation return. Micro-TOE was useful during the postoperative care of neonatal surgery with open breastbone to assess the surgical result and ventricular function. It was also useful to guide extracorporeal membrane oxygenation (ECMO) indication and withdrawal; and was a useful guide for percutaneous procedures. CONCLUSION: Micro-multiplane TOE is safe and efficient for use in neonates and children. This minimally invasive tool increases the impact of TOE in paediatric cardiology.