(307) High-Volume Pediatric Transplant Center Antibiotic Use Is Not Associated With Risk-Adjusted Survival

Introduction: There is broad variability in antibiotic (ABX) use across pediatric intensive care units (PICUs), though less is known about ABX use among children with solid or liquid-organ transplants (SLT) in the PICU. This study aims to characterize parenteral ABX use among patients with history of SLT at high volume, pediatric transplant centers relative to non-SLT PICU patients.

Methods: This is a retrospective cohort study using the Pediatric Health Information Systems database. Centers with >500 admissions for children with SLT, both initial and subsequent encounters, from 1/1/15-12/31/22 were included. Patient demographics, ABX days, survival, and predicted mortality were queried. Non-parametric continuous data were compared with the Wilcoxon rank sum test, categorical data with the Chi-squared test, and correlation was assessed with linear regression. All statistical analyses were performed with R.

Results: There were 222,193 PICU encounters across 9 hospitals, of which 6,032/222,193 (2.7%) had prior SLT. Most patients with SLT were male (3,295 [54.6%]), significantly older (10 [3, 6] vs 4 [1, 12] years), and more likely to have cardiovascular, gastrointestinal, oncologic, metabolic, or urologic comorbidities compared to children without SLT (all P< 0.001). SLT recipients had significantly longer hospital length of stay (LOS) (21 [11, 52] vs 5 [3, 11]), PICU LOS (6 [2, 16] vs 2 [1, 5] days), received more PICU ABX (5 [2, 16] vs 2 [0, 4] days), and lower survival (5,596/6,032 [92.8%] vs 210,685/216,161 [97.5%]) (all P< 0.001). Mean ABX/1000 PICU days ranged widely across centers (612-1,072 among all patients vs 673-1,421 among SLT recipients), decreased slightly over time among all patients (833 in 2015 vs 808 in 2022) but remained stable among SLT recipients (1,085 in 2015 vs 1,100 in 2022). There were no associations between center ABX use and either unadjusted or adjusted mortality among all patients. ABX use was directly associated with unadjusted mortality among SLT recipients (p=0.008, β-coefficient = 0.006) but not with adjusted mortality.

Conclusions: Among high-volume, pediatric transplant centers, ABX use is variable and not associated with risk-adjusted survival. These findings suggest opportunities exist for improved ABX stewardship among children with history of SLT admitted to the PICU.