Dhungana, Prabij

Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. There are currently no guidelines for antimicrobial prophylaxis. We analyzed 7 years of prophylactic antimicrobial use across 3 time series for patients on ECMO at our institution in the development, improvement, and streamlining of our ECMO antimicrobial prophylaxis protocol. Methods In this quasi-experimental interrupted time series analysis, we evaluated the impact of an initial ECMO antimicrobial prophylaxis protocol, implemented in 2014, on antimicrobial use and National Healthcare Safety Network–reportable infection rates. Then, following a revision and streamlining of the protocol in November 2018, we reevaluated the same metrics. Results Our study population included 338 intensive care unit patients who received ECMO between July 2011 and November 2019. After implementation of the first version of the protocol, we did not observe significant changes in antimicrobial use or infection rates in these patients; however, following revision and streamlining of the protocol, we demonstrated a significant reduction in broad-spectrum antimicrobial use for prophylaxis in patients on ECMO without any evidence of a compensatory increase in infection rates. Conclusions Our final protocol significantly reduces broad-spectrum antimicrobial use for prophylaxis in patients on ECMO. We propose a standard antimicrobial prophylaxis regimen for patients on ECMO based on current evidence and our experience. Summary: There are no guidelines for antimicrobial prophylaxis in patients on extracorporeal membrane oxygenation (ECMO). A rational approach employing concepts of antimicrobial stewardship can drive logical antimicrobial selection for prophylaxis in patients on ECMO without adversely impacting outcomes.

Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. Patients on ECMO are at high risk for infections, with 20.5% of adults acquiring infections while on ECMO. An Extracorporeal Life Support Organization (ELSO) Infectious Disease Task Force statement concluded that no antibiotic prophylaxis is needed for patients on ECMO though it also noted that this was based on limited data. We implemented an antimicrobial prophylaxis protocol for patients on ECMO at our institution and analyzed antimicrobial use and outcomes in these patients with a pre- and post-analysis. Methods We conducted a retrospective review of 294 patients on ECMO between July 1, 2011 and July 1, 2017. An ECMO antimicrobial prophylaxis guideline was initially implemented on July 1, 2014; there was poor adherence to the guideline and antimicrobial use actually increased. A more restrictive protocol was implemented in November 2018 with input from stakeholders including cardiac surgeons, critical care and infectious disease (ID) providers. We had a cohort of 161 patients before (July 2014–November 2018) and 37 patients after (November 2018–April 2018) the implementation of the updated protocol. We evaluated primary outcomes of gross days of antimicrobial use, percent of antibiotic-free days and days of individual antimicrobial use, adjusted for APACHE scores and ECMO duration. Results When adjusted for days on ECMO, mean antibiotic days decreased after implementation of the protocol; for vancomycin (0.27 vs. 0.02, P < 0.0003), cefepime (0.15 vs. 0.02, P < 0.02), meropenem (0.09 vs. 0, P < 0.02), zosyn (0.16 vs. 0, P < 0.002), caspofungin (0.346, 0.138 P < 0.003). This was accompanied by a nonsignificant increase in mean fluconazole use (0.29 vs. 0.37, P < 0.3). There was no impact on patient mortality or nosocomial infection rate. Additional results can be found in table. Conclusion The use of an antimicrobial prophylaxis protocol in ECMO patients led to improvement in antimicrobial usage without increasing nosocomial infections in a population at a high risk of infection. Disclosures All authors: No reported disclosures.