The use of recruitment maneuvers (RMs) is suggested to improve severe oxygenation failure in patients with acute respiratory distress syndrome (ARDS). Lung ultrasound (LUS) is a non-invasive, safe, and easily repeatable tool. It could be used to monitor the lung recruitment process in real-time. This paper aims to evaluate bedside LUS for assessing PEEP-induced pulmonary reaeration during RMs in pediatric patients. A case of a child with severe ARDS due to Haemophilus influenzae infection is presented. Due to his poor clinical, laboratory, and radiological evolution, he was placed on venovenous extracorporeal membrane oxygenation (ECMO). Despite all measures, severe pulmonary collapse prevented proper improvement. Thus, RMs were indicated, and bedside LUS was successfully used for monitoring and assessing lung recruitment. The initial lung evaluation before the maneuver showed a tissue pattern characterized by a severe loss of lung aeration with dynamic air bronchograms and multiple coalescent B-lines. While raising a PEEP of 30 mmH₂O, LUS showed the presence of A-lines, which was considered a predictor of reaeration in response to the recruitment maneuver. The LUS pattern could be used to assess modifications in the lung aeration, evaluate the effectiveness of RMs, and prevent lung overdistension.

The emergence of multidrug-resistant (MDR) bacteria in children is a growing concern, particularly among septic patients, given the need for first-right dosing. Our aim was to determine the incidence rates and factors associated with MDR-sepsis in the pediatric intensive care unit (PICU), using data from the Spanish ENVIN-HELICS PICU registry between 2013 and 2019. The rate of MDR bacteria among septic children ranged between 5.8 and 16.2% throughout this study period, with a significant increase since 2015 (p = 0.013). MDR-gram-negative bacteria (92%), particularly EBL-Enterobacterales (63.7%), were the most frequent causative microorganisms of MDR-sepsis. During this study period, sixteen MDR-sepsis (32.6%) corresponded to intrahospital infections, and 33 (67.4%) had community-onset sepsis, accounting for 10.5% of the overall community-onset sepsis. Independent risk factors associated with MDR-sepsis were antibiotics 48 h prior to PICU admission (OR 2.38) and PICU onset of sepsis (OR 2.58) in >1 year-old children, and previous malnourishment (OR 4.99) in <1 year-old children. Conclusions: There was an alarming increase in MDR among septic children in Spain, mainly by gram-negative (ESBL-Enterobacterales), mostly coming from the community setting. Malnourished infants and children on antibiotics 48 h prior to PICU are at increased risk and therefore require closer surveillance.

Background/objectives: Infections caused by carbapenem-resistant Enterobacterales (CRE) are progressively increasing in Pediatric Intensive Care Units (PICUs). Its treatment is challenging due to the lack of pediatric trials. CRE infections are associated with significantly poor outcomes, but ceftazidime–avibactam (CAZ-AVI) has been reported to be successful in their treatment. This study aimed to describe the use and outcome of CAZ-AVI in a PICU. Results: Ten patients were included, with 12 episodes of clinical suspicion or confirmed multidrug-resistant (MDR) bacterial infections treated with CAZ-AVI for surgical prophylaxis, suspicion of sepsis, pneumonia, and surgical wound infection. Of these patients, 80% received empirical treatment because of previous MDR bacterial colonization, and 60% were administrated combination therapy with aztreonam for Metallo-β-Lactamases (MBL)strains. No bacteria were resistant to CAZ-AVI. The average duration of the treatment was 3 days when cultures turned negative and 7 days when MDR bacteria were isolated. Methods: This was an observational prospective study of children treated with CAZ-AVI in the PICU of a tertiary hospital in 2022. Epidemiological, clinical, microbiological, and outcome data were collected. Conclusions: The most frequent use of CAZ-AVI in our PICU was the short-term empirical treatment for patients with previous MDR bacterial colonization and clinical suspicion of bacteremia or sepsis. Furthermore, the combination of CAZ-AVI plus aztreonam could be more effective for CRE infections, especially type Ambler class B as MBL strains.

Background: Inappropriate antibiotic use contributes to antimicrobial resistance. Evidence regarding the impact of antimicrobial stewardship programs (ASPs) in pediatric intensive care units (PICUs) remains limited. The study aims to evaluate the impact of a multidisciplinary prospective post-prescription review and feedback (PPRF) ASP in a European PICU on antimicrobial use and prescription quality (PQ). Methods: A prospective quasi-experimental study was conducted using interrupted time-series analysis to evaluate antimicrobial use trends before (July 2018–December 2020) and after (January 2021–March 2025) the implementation of a multifaceted ASP, integrated within a hospital-wide ASP, in a tertiary 24-bed medical–surgical PICU in Barcelona, Spain. Antimicrobial use was measured as days of therapy per 100 patient-days (DOT/100 PD) and per 100 discharges (DOT/100 D) and was analyzed by WHO AWaRe group and by individual drug. PQ was evaluated by means of cross-sectional point-prevalence surveys (PPSs). Results: During the study-period, median monthly activity in the PICU remained stable: 475 patient-days (IQR: 396–534) and 113 patients discharged (IQR: 102–124). Following ASP implementation, total antibiotic consumption significantly decreased, with an immediate reduction of 18.2 DOT/100 patient-days (p = 0.006) and a sustained monthly decline of 0.73 DOT/100 patient-days (p = 0.028). The COVID-19 pandemic did not significantly affect overall antibiotic consumption. Access and Reserve antibiotic use decreased significantly after ASP implementation, whereas Watch antibiotic use remained unchanged. Overall antifungal consumption was not significantly modified, although a transient increase was observed during the pandemic. At the individual drug level, several antibiotics demonstrated significant immediate decreases after ASP implementation. Prescription quality remained high (>88% optimal prescriptions), and PICU length of stay and mortality were unchanged. Conclusions: Implementation of a multidisciplinary PPRF-based ASP in a tertiary PICU was associated with a sustained reduction in antibiotic exposure without compromising prescription quality or clinical safety. These data support the effectiveness of collaborative stewardship in one of the most complex pediatric healthcare settings.