301
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Giannattasio A, Lo Vecchio A, Napolitano C, Di Florio L, Guarino A. A prospective study on ambulatory care provided by primary care pediatricians during influenza season. Ital J Pediatr 2014; 40:38. [PMID: 24755009 PMCID: PMC4012523 DOI: 10.1186/1824-7288-40-38] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 04/11/2014] [Indexed: 11/22/2022] Open
Abstract
Aim of this study was to obtain a picture of the nature of the primary care pediatricians' visits during a winter season. We investigated reasons for visits, diagnosis, and pattern of prescription in 284 children. The reason for visit was a planned visit in 54% of cases, a well-being examination in 26%, and an urgent visit for an acute problem in 20% of cases. Cough was the most common symptom reported (61%). The most common pediatricians' diagnosis was flu-like syndrome (47%). No disease was found by pediatrician in 27% of children with a symptom reported by caregivers. Antibiotics were prescribed in 25% of children, the vast majority of which affected by viral respiratory infections. The unjustified access to physician's visit may lead to a inappropriate prescription of drugs.
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Affiliation(s)
- Antonietta Giannattasio
- Medicine and Health Sciences Department, University of Molise, c/da Tappino 86100, Campobasso, Italy
| | - Andrea Lo Vecchio
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Carmen Napolitano
- Medicine and Health Sciences Department, University of Molise, c/da Tappino 86100, Campobasso, Italy
| | - Laura Di Florio
- Medicine and Health Sciences Department, University of Molise, c/da Tappino 86100, Campobasso, Italy
| | - Alfredo Guarino
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
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302
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Gahbauer AM, Gonzales ML, Guglielmo BJ. Patterns of antibacterial use and impact of age, race/ethnicity, and geographic region on antibacterial use in an outpatient medicaid cohort. Pharmacotherapy 2014; 34:677-85. [PMID: 24753176 DOI: 10.1002/phar.1425] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVES To describe patterns of outpatient antibacterial use among California Medicaid (Medi-Cal) fee-for-service system beneficiaries, and to investigate the influence of demographic factors-age, race/ethnicity, state county, and population density-on those patterns. DESIGN Retrospective analysis of administrative claims data. DATA SOURCE Medi-Cal fee-for-service system claims database. PATIENTS All outpatient Medi-Cal fee-for-service system beneficiaries enrolled between 2006 and 2011 who had at least one systemic antibacterial claim. MEASUREMENTS AND MAIN RESULTS Rates of antibacterial prescribing and the proportion of broad-spectrum antibacterial use were measured over the study period and among age, racial/ethnic, and geographic (county) groups. Of the 10,018,066 systemic antibacterial claims selected for analysis, antibacterial prescribing rates decreased from 542 claims/1000 beneficiaries in 2006 to 461 claims/1000 beneficiaries in 2011 (r = -0.971, p=0.0012; τ-b = -1.00, p=0.009). Among age groups, children had the highest rate of use (605 claims/1000 beneficiaries, χ(2) (2) = 320,000, p<0.001); among racial/ethnic groups, Alaskan Natives and Native Americans had the highest rate of use (1086/1000 beneficiaries, χ(2) (5) = 197,000, p<0.001). Broad-spectrum antibacterial prescribing increased from 28.1% (95% confidence interval [CI] 28.1-28.2%) to 32.7% (95% CI 32.6-32.8%) over the study period. Senior age groups and whites received the highest proportions of broad-spectrum agents (53.4% [95% CI 52.5-54.3%] and 36.6% [95% CI 36.6-36.7%], respectively). Population density was inversely related to both overall antibacterial use (ρ = -0.432, p=0.0018) and broad-spectrum antibacterial prescribing (ρ = -0.359, p<0.001). The rate of prescribing decreased over the study period for all antibacterial classes with the exception of macrolides and sulfonamides. Amoxicillin was the most frequently prescribed agent. CONCLUSION Overall and broad-spectrum antibacterial use in the Medi-Cal fee-for-service program are less than that observed nationally. Significant variations in prescribing exist between age and racial/ethnic groups, and heavily populated areas are associated with both less antibacterial use and less broad-spectrum antibacterial prescribing. Studies are needed to determine the reasons for the observed differences in antibacterial use among demographic groups.
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Affiliation(s)
- Alice M Gahbauer
- School of Pharmacy, University of California, San Francisco, California
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303
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Michaelidis CI, Zimmerman RK, Nowalk MP, Fine MJ, Smith KJ. Cost-effectiveness of procalcitonin-guided antibiotic therapy for outpatient management of acute respiratory tract infections in adults. J Gen Intern Med 2014; 29:579-86. [PMID: 24234394 PMCID: PMC3965735 DOI: 10.1007/s11606-013-2679-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 09/20/2013] [Accepted: 10/09/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Two clinical trials suggest that procalcitonin-guided antibiotic therapy can safely reduce antibiotic prescribing in outpatient management of acute respiratory tract infections (ARTIs) in adults. Yet, it remains unclear whether procalcitonin testing is cost-effective in this setting. OBJECTIVE To evaluate the cost-effectiveness of procalcitonin-guided antibiotic therapy in outpatient management of ARTIs in adults. DESIGN Cost-effectiveness model based on results from two published European clinical trials, with all parameters varied widely in sensitivity analyses. PATIENTS Two hypothetical cohorts were modeled in separate trial-based analyses: adults with ARTIs judged by their physicians to require antibiotics and all adults with ARTIs. INTERVENTIONS Procalcitonin-guided antibiotic therapy protocols versus usual care. MAIN MEASURES Costs and cost per antibiotic prescription safely avoided. KEY RESULTS We estimated the health care system willingness-to-pay threshold as $43 (range $0–$333) per antibiotic safely avoided, reflecting the estimated cost of antibiotic resistance per outpatient antibiotic prescribed. In the cohort including all adult ARTIs judged to require antibiotics by their physicians, procalcitonin cost $31 per antibiotic prescription safely avoided and the likelihood of procalcitonin use being favored compared to usual care was 58.4 % in a probabilistic sensitivity analysis. In the analysis that included all adult ARTIs, procalcitonin cost $149 per antibiotic prescription safely avoided and the likelihood of procalcitonin use being favored was 2.8 %. CONCLUSIONS Procalcitonin-guided antibiotic therapy for outpatient management of ARTIs in adults would be cost-effective when the costs of antibiotic resistance are considered and procalcitonin testing is limited to adults with ARTIs judged by their physicians to require antibiotics.
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Affiliation(s)
- Constantinos I. Michaelidis
- />University of Pittsburgh School of Medicine, M240 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261 USA
| | - Richard K. Zimmerman
- />Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Mary Patricia Nowalk
- />Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Michael J. Fine
- />Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
- />Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA USA
| | - Kenneth J. Smith
- />Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
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304
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Leyenaar JK, Shieh MS, Lagu T, Pekow PS, Lindenauer PK. Comparative effectiveness of ceftriaxone in combination with a macrolide compared with ceftriaxone alone for pediatric patients hospitalized with community-acquired pneumonia. Pediatr Infect Dis J 2014; 33:387-92. [PMID: 24168982 PMCID: PMC4158440 DOI: 10.1097/inf.0000000000000119] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Guidelines for management of community-acquired pneumonia recommend empiric therapy with a macrolide and beta-lactam when infection with Mycoplasma pneumoniae is a significant consideration. Evidence to support this recommendation is limited. We sought to determine the effectiveness of ceftriaxone alone compared with ceftriaxone combined with a macrolide with respect to length of stay and total hospital costs. METHODS We conducted a retrospective cohort study of children 1-17 years with pneumonia, using Poisson regression and propensity score analyses to assess associations between antibiotic and length of stay. Multivariable linear regression and propensity score analyses were used to assess log-treatment costs, adjusting for patient and hospital characteristics and initial tests and therapies. RESULTS A total of 4701 children received combination therapy and 8892 received ceftriaxone alone. Among children 1-4 years of age, adjusted models revealed no significant difference in length of stay, with significantly higher costs in the combination therapy group [cost ratio: 1.08 (95% confidence interval: 1.05-1.11)]. Among children 5-17 years of age, children receiving combination therapy had a shorter length of stay [relative risk: 0.95 (95% confidence interval: 0.92-0.98)], with no significant difference in costs [cost ratio: 1.01 (95% confidence interval: 0.98-1.04)]. CONCLUSIONS Combination therapy did not appear to benefit preschool children but was associated with higher costs. Among school-aged children, combination therapy was associated with a shorter length of stay without a significant impact on cost. Development of sensitive point-of-care diagnostic tests to identify children with M. pneumoniae infection may allow for more focused prescription of macrolides and enable comparative effectiveness studies of targeted provision of combination therapy.
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Affiliation(s)
- Joanna K Leyenaar
- From the *Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston; †Center for Quality of Care Research, Baystate Medical Center, Springfield; ‡Tufts University School of Medicine, Department of Medicine, Boston; §Division of General Medicine, Baystate Medical Center, Springfield; and ¶School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA
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305
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Campfield B, Chen K, Kolls JK. Vaccine approaches for multidrug resistant Gram negative infections. Curr Opin Immunol 2014; 28:84-9. [PMID: 24637162 DOI: 10.1016/j.coi.2014.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 02/04/2014] [Indexed: 01/24/2023]
Abstract
Multidrug resistant (MDR) Gram negative bacterial infections are increasing in frequency and are associated with significant financial costs, morbidity and mortality. Current antibiotic therapies are associated with unacceptably poor clinical outcomes and toxicity. Unfortunately, the development of novel antimicrobials is stagnant leaving a significant clinical need for alternative treatments of MDR Gram negative rod infections. Recent preclinical studies have identified Th17 cells as critical mediators of broadly protective adaptive immunity, including protection against MDR infections. Studies of Th17 eliciting antigens, adjuvants and routes of immunization have identified potential vaccine strategies that may confer long-lived adaptive immunity against MDR Gram negative bacterial infections.
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Affiliation(s)
- Brian Campfield
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Kong Chen
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Jay K Kolls
- Richard King Mellon Foundation Institute for Pediatric Research, Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.
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306
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Zhou Z, Ma D. Anaesthetics-induced neurotoxicity in developing brain: an update on preclinical evidence. Brain Sci 2014; 4:136-49. [PMID: 24961704 PMCID: PMC4066242 DOI: 10.3390/brainsci4010136] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 02/06/2014] [Accepted: 03/04/2014] [Indexed: 01/13/2023] Open
Abstract
Every year millions of young people are treated with anaesthetic agents for surgery and sedation in a seemingly safe manner. However, growing and convincing preclinical evidence in rodents and nonhuman primates, together with recent epidemiological observations, suggest that exposure to anaesthetics in common clinical use can be neurotoxic to the developing brain and lead to long-term neurological sequelae. These findings have seriously questioned the safe use of general anaesthetics in obstetric and paediatric patients. The mechanisms and human applicability of anaesthetic neurotoxicity and neuroprotection have remained under intense investigation over the past decade. Ongoing pre-clinical investigation may have significant impact on clinical practice in the near future. This review represents recent developments in this rapidly emerging field. The aim is to summarise recently available laboratory data, especially those being published after 2010, in the field of anaesthetics-induced neurotoxicity and its impact on cognitive function. In addition, we will discuss recent findings in mechanisms of early-life anaesthetics-induced neurotoxicity, the role of human stem cell-derived models in detecting such toxicity, and new potential alleviating strategies.
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Affiliation(s)
- Zhaowei Zhou
- Section of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK.
| | - Daqing Ma
- Section of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK.
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307
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Trends and seasonal variation in outpatient antibiotic prescription rates in the United States, 2006 to 2010. Antimicrob Agents Chemother 2014; 58:2763-6. [PMID: 24590486 DOI: 10.1128/aac.02239-13] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Antibiotic-resistant bacteria are an increasing threat to the effectiveness of antibiotics. The majority of antibiotics are prescribed in primary care settings for upper respiratory tract infections. The purpose of this study was to describe seasonal trends in outpatient antibiotic prescriptions (Rx) in the United States over a 5-year period. This study was a retrospective, cross-sectional observation of systemic antibiotic prescriptions in the outpatient setting from 2006 to 2010. Winter months were defined as the first and fourth quarters of the calendar year. Antibiotic prescribing rates were calculated (prescriptions/1,000 population) using annual U.S. Census Bureau population data. Over 1.34 billion antibiotic prescriptions were dispensed over the 5-year period. The antibiotic prescription (Rx) rate decreased from 892 Rx/1,000 population in 2006 to 867 Rx/1,000 population in 2010. Penicillins and macrolides were the primary antibiotic classes prescribed, but penicillin prescribing decreased while macrolide prescribing increased over the study period. Overall, antibiotic prescriptions were 24.5% higher in winter months than in the summer, with the largest difference (28.8%) in 2008 and the smallest (20.4%) in 2010. This seasonality was consistently drug class dependent, driven by 75% and 100% increases in penicillin and macrolide prescriptions, respectively, in the winter months. The mean outpatient antibiotic prescription rate decreased in the United States from 2006 to 2010. More antibiotic prescribing, predominately driven by the macrolide and penicillin classes, in the outpatient setting was observed in the winter months. Understanding annual variability in antibiotic use can assist with designing interventions to improve the judicious use of antibiotics.
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308
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Affiliation(s)
- Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts; RAND Health, Boston, Massachusetts, and Santa Monica, California; and Beth Israel Deaconess Hospital, Boston, Massachusetts
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309
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Variation in antibiotic susceptibility of uropathogens by age among ambulatory pediatric patients. J Pediatr Nurs 2014; 29:152-7. [PMID: 24091131 PMCID: PMC3943820 DOI: 10.1016/j.pedn.2013.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 07/30/2013] [Accepted: 09/05/2013] [Indexed: 11/20/2022]
Abstract
We compared uropathogen antibiotic susceptibility across age groups of ambulatory pediatric patients. For Escherichia coli (n=5,099) and other Gram-negative rods (n=626), significant differences (p<0.05) existed across age groups for ampicillin, cefazolin, and trimethoprim/sulfamethoxazole susceptibility. In E. coli, differences in trimethoprim/sulfamethoxazole susceptibility varied from 79% in children under 2 to 88% in ages 16-18 (p<0.001), while ampicillin susceptibility varied from 30% in children under 2 to 53% in ages 2-5 (p=0.015). Uropathogen susceptibility to common urinary anti-infectives may be lower in the youngest children. Further investigation into these differences is needed to facilitate appropriate and prudent treatment of urinary tract infections.
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310
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Vaz LE, Kleinman KP, Raebel MA, Nordin JD, Lakoma MD, Dutta-Linn MM, Finkelstein JA. Recent trends in outpatient antibiotic use in children. Pediatrics 2014; 133:375-85. [PMID: 24488744 PMCID: PMC3934343 DOI: 10.1542/peds.2013-2903] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal of this study was to determine changes in antibiotic-dispensing rates among children in 3 health plans located in New England [A], the Mountain West [B], and the Midwest [C] regions of the United States. METHODS Pharmacy and outpatient claims from September 2000 to August 2010 were used to calculate rates of antibiotic dispensing per person-year for children aged 3 months to 18 years. Differences in rates by year, diagnosis, and health plan were tested by using Poisson regression. The data were analyzed to determine whether there was a change in the rate of decline over time. RESULTS Antibiotic use in the 3- to <24-month age group varied at baseline according to health plan (A: 2.27, B: 1.40, C: 2.23 antibiotics per person-year; P < .001). The downward trend in antibiotic dispensing slowed, stabilized, or reversed during this 10-year period. In the 3- to <24-month age group, we observed 5.0%, 9.3%, and 7.2% annual declines early in the decade in the 3 plans, respectively. These dropped to 2.4%, 2.1%, and 0.5% annual declines by the end of the decade. Third-generation cephalosporin use for otitis media increased 1.6-, 15-, and 5.5-fold in plans A, B, and C in young children. Similar attenuation of decline in antibiotic use and increases in use of broad-spectrum agents were seen in other age groups. CONCLUSIONS Antibiotic dispensing for children may have reached a new plateau. Along with identifying best practices in low-prescribing areas, decreasing broad-spectrum use for particular conditions should be a continuing focus of intervention efforts.
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Affiliation(s)
- Louise Elaine Vaz
- Division of Infectious Diseases and Department of Laboratory Medicine and,Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Kenneth P. Kleinman
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Marsha A. Raebel
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado;,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado; and
| | - James D. Nordin
- Health Partners Institute for Education and Research, Minneapolis, Minnesota
| | - Matthew D. Lakoma
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - M. Maya Dutta-Linn
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jonathan A. Finkelstein
- Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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311
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Reducing antibiotic prescribing for children with respiratory tract infections in primary care: a systematic review. Br J Gen Pract 2014; 63:e445-54. [PMID: 23834881 DOI: 10.3399/bjgp13x669167] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Respiratory tract infections (RTIs) in children are common and often result in antibiotic prescription despite their typically self-limiting course. AIM To assess the effectiveness of primary care based interventions to reduce antibiotic prescribing for children with RTIs. DESIGN AND SETTING Systematic review. METHOD MEDLINE(®), Embase, CINAHL(®), PsycINFO, and the Cochrane library were searched for randomised, cluster randomised, and non-randomised studies testing educational and/or behavioural interventions to change antibiotic prescribing for children (<18 years) with RTIs. Main outcomes included change in proportion of total antibiotic prescribing or change in 'appropriate' prescribing for RTIs. Narrative analysis of included studies was used to identify components of effective interventions. RESULTS Of 6301 references identified through database searching, 17 studies were included. Interventions that combined parent education with clinician behaviour change decreased antibiotic prescribing rates by between 6-21%; structuring the parent-clinician interaction during the consultation may further increase the effectiveness of these interventions. Automatic computerised prescribing prompts increased prescribing appropriateness, while passive information, in the form of waiting room educational materials, yielded no benefit. CONCLUSION Conflicting evidence from the included studies found that interventions directed towards parents and/or clinicians can reduce rates of antibiotic prescribing. The most effective interventions target both parents and clinicians during consultations, provide automatic prescribing prompts, and promote clinician leadership in the intervention design.
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312
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Hudson LL, Woods CW, Ginsburg GS. A novel diagnostic approach may reduce inappropriate antibiotic use for acute respiratory infections. Expert Rev Anti Infect Ther 2014; 12:279-82. [PMID: 24502765 DOI: 10.1586/14787210.2014.881717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Respiratory infections can be due to a multitude of etiologies and are common throughout the world. Most are viral and self-limited, yet these infections are commonly treated with antibiotics thus contributing to the increase in resistance. Historically, infectious disease diagnostics have focused on identification of the microbial culprit at the site of infection but the specificity of host response as measured by the host transcriptome, now enables us to classify the etiology of infection agnostic to pathogen class. The ability to rapidly determine whether a similar set of symptoms is due to a virus, bacteria, or other agent from a common specimen (blood) will have far-reaching public health benefits, and further research is warranted to transfer this technology into the clinical setting.
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Affiliation(s)
- Lori L Hudson
- Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC 27710, USA
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313
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Bell IR, Boyer NN. Homeopathic medications as clinical alternatives for symptomatic care of acute otitis media and upper respiratory infections in children. Glob Adv Health Med 2014; 2:32-43. [PMID: 24381823 PMCID: PMC3833578 DOI: 10.7453/gahmj.2013.2.1.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The public health and individual risks of inappropriate antibiotic prescribing and conventional over-the-counter symptomatic drugs in pediatric treatment of acute otitis media (AOM) and upper respiratory infections (URIs) are significant. Clinical research suggests that over-the-counter homeopathic medicines offer pragmatic treatment alternatives to conventional drugs for symptom relief in children with uncomplicated AOM or URIs. Homeopathy is a controversial but demonstrably safe and effective 200-year-old whole system of complementary and alternative medicine used worldwide. Numerous clinical studies demonstrate that homeopathy accelerates early symptom relief in acute illnesses at much lower risk than conventional drug approaches. Evidence-based advantages for homeopathy include lower antibiotic fill rates during watchful waiting in otitis media, fewer and less serious side effects, absence of drug-drug interactions, and reduced parental sick leave from work. Emerging evidence from basic and preclinical science research counter the skeptics' claims that homeopathic remedies are biologically inert placebos. Consumers already accept and use homeopathic medicines for self care, as evidenced by annual US consumer expenditures of $2.9 billion on homeopathic remedies. Homeopathy appears equivalent to and safer than conventional standard care in comparative effectiveness trials, but additional well-designed efficacy trials are indicated. Nonetheless, the existing research evidence on safety supports pragmatic use of homeopathy in order to “first do no harm” in the early symptom management of otherwise uncomplicated AOM and URIs in children.
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Affiliation(s)
- Iris R Bell
- Department of Family and Community Medicine, The University of Arizona College of Medicine and College of Nursing, The University of Arizona, Tucson, United States
| | - Nancy N Boyer
- Private Practice, Rochester, New York, United States
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314
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Dose optimisation of antibiotics in children: application of pharmacokinetics/pharmacodynamics in paediatrics. Int J Antimicrob Agents 2013; 43:223-30. [PMID: 24389079 DOI: 10.1016/j.ijantimicag.2013.11.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 11/11/2013] [Indexed: 11/24/2022]
Abstract
The judicious use of antibiotics to combat infections in children relies upon appropriate selection of an agent, dose and duration to maximise efficacy and to minimise toxicity. Critical to dose optimisation is an understanding of the pharmacokinetics and pharmacodynamics of available drugs. Optimal dosing strategies may take advantage of pharmacokinetic/pharmacodynamic (PK/PD) principles so that antibiotic dosing can be individualised to assure effective bacterial killing in patients who have altered pharmacokinetics or who have infections with less susceptible or resistant organisms. This review will outline the fundamentals of antimicrobial pharmacokinetics/pharmacodynamics through discussion of antibacterial agents most often used in children. We aim to highlight the importance of dose optimisation in paediatrics and describe non-conventional dosing strategies that can take advantage of PK/PD principles at the bedside.
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315
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Brett A, Bielicki J, Newland JG, Rodrigues F, Schaad UB, Sharland M. Neonatal and pediatric antimicrobial stewardship programs in Europe-defining the research agenda. Pediatr Infect Dis J 2013; 32:e456-65. [PMID: 23958812 DOI: 10.1097/inf.0b013e31829f0460] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The relationship between suboptimal use of antimicrobials and antimicrobial resistance has become increasingly clear. Despite significant international effort aimed at reducing inappropriate antimicrobial prescribing in hospitals, antimicrobial resistance remains a major public health threat. Antimicrobial Stewardship Programs (ASPs) comprise a series of measures aimed at optimizing the use of antimicrobials, while improving the quality of patient care and promoting cost-effectiveness. This discussion article aims to summarize some of the approaches that have been used in neonatal and pediatric ASPs, with a particular focus on the European healthcare setting. Current evidence demonstrates neonatal and pediatric ASPs to be safe, practical to implement, generally cost-effective and possibly associated with a reduction in antimicrobial resistance rates. This review identified that, despite the recognized need for additional evidence and information on implementation, published data on pediatric ASPs derives mainly from the United States, with very few published reports on formal ASPs in European children's hospitals. Consequently, the optimal method of implementation remains unknown within a European setting. Future research needs to include novel study designs on how best to introduce ASPs, monitoring of clinically relevant outcomes and cost-effectiveness with improved measurement of the impact on antimicrobial resistance.
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Affiliation(s)
- Ana Brett
- From the *Infectious Diseases Unit and Emergency Service, Hospital Pediátrico, Centro, Hospitalar e Universitário de Coimbra, Coimbra, Portugal; †Paediatric Infectious Diseases Research Group, St George's University London, London, United Kingdom; ‡Division of Pediatric Infectious Diseases, Children's Mercy Hospital and Clinics, University of Missouri-Kansas City, MO; and §Paediatric Infectious Diseases Division, University Children's Hospital, Basel, Switzerland
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316
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Hersh AL, Jackson MA, Hicks LA. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics 2013; 132:1146-54. [PMID: 24249823 DOI: 10.1542/peds.2013-3260] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Most upper respiratory tract infections are caused by viruses and require no antibiotics. This clinical report focuses on antibiotic prescribing strategies for bacterial upper respiratory tract infections, including acute otitis media, acute bacterial sinusitis, and streptococcal pharyngitis. The principles for judicious antibiotic prescribing that are outlined focus on applying stringent diagnostic criteria, weighing the benefits and harms of antibiotic therapy, and understanding situations when antibiotics may not be indicated. The principles can be used to amplify messages from recent clinical guidelines for local guideline development and for patient communication; they are broadly applicable to antibiotic prescribing in general.
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317
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Moore AM, Patel S, Forsberg KJ, Wang B, Bentley G, Razia Y, Qin X, Tarr PI, Dantas G. Pediatric fecal microbiota harbor diverse and novel antibiotic resistance genes. PLoS One 2013; 8:e78822. [PMID: 24236055 PMCID: PMC3827270 DOI: 10.1371/journal.pone.0078822] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 09/10/2013] [Indexed: 12/13/2022] Open
Abstract
Emerging antibiotic resistance threatens human health. Gut microbes are an epidemiologically important reservoir of resistance genes (resistome), yet prior studies indicate that the true diversity of gut-associated resistomes has been underestimated. To deeply characterize the pediatric gut-associated resistome, we created metagenomic recombinant libraries in an Escherichia coli host using fecal DNA from 22 healthy infants and children (most without recent antibiotic exposure), and performed functional selections for resistance to 18 antibiotics from eight drug classes. Resistance-conferring DNA fragments were sequenced (Illumina HiSeq 2000), and reads assembled and annotated with the PARFuMS computational pipeline. Resistance to 14 of the 18 antibiotics was found in stools of infants and children. Recovered genes included chloramphenicol acetyltransferases, drug-resistant dihydrofolate reductases, rRNA methyltransferases, transcriptional regulators, multidrug efflux pumps, and every major class of beta-lactamase, aminoglycoside-modifying enzyme, and tetracycline resistance protein. Many resistance-conferring sequences were mobilizable; some had low identity to any known organism, emphasizing cryptic organisms as potentially important resistance reservoirs. We functionally confirmed three novel resistance genes, including a 16S rRNA methylase conferring aminoglycoside resistance, and two tetracycline-resistance proteins nearly identical to a bifidobacterial MFS transporter (B. longum s. longum JDM301). We provide the first report to our knowledge of resistance to folate-synthesis inhibitors conferred by a predicted Nudix hydrolase (part of the folate synthesis pathway). This functional metagenomic survey of gut-associated resistomes, the largest of its kind to date, demonstrates that fecal resistomes of healthy children are far more diverse than previously suspected, that clinically relevant resistance genes are present even without recent selective antibiotic pressure in the human host, and that cryptic gut microbes are an important resistance reservoir. The observed transferability of gut-associated resistance genes to a gram-negative (E. coli) host also suggests that the potential for gut-associated resistomes to threaten human health by mediating antibiotic resistance in pathogens warrants further investigation.
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Affiliation(s)
- Aimée M. Moore
- Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Sanket Patel
- Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Kevin J. Forsberg
- Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Bin Wang
- Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Gayle Bentley
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Yasmin Razia
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Division of Gastroenterology, Department of Pediatrics, Children’s Hospital and Regional Medical Center, Seattle, Washington, United States of America
| | - Xuan Qin
- Department of Microbiology, Seattle Children’s Hospital, Seattle, Washington, United States of America
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, United States of America
| | - Phillip I. Tarr
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Gautam Dantas
- Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, United States of America
- * E-mail:
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318
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Obasi CN, Barrett B, Brown R, Vrtis R, Barlow S, Muller D, Gern J. Detection of viral and bacterial pathogens in acute respiratory infections. J Infect 2013; 68:125-30. [PMID: 24211414 PMCID: PMC3947238 DOI: 10.1016/j.jinf.2013.10.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 10/28/2013] [Accepted: 10/31/2013] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The role of bacteria in acute respiratory illnesses (ARI) of adults and interactions with viral infections is incompletely understood. This study tested the hypothesis that bacterial co-infection during ARI adds to airway inflammation and illness severity. METHODS Two groups of 97 specimens each were randomly selected from multiplex-PCR identified virus-positive and virus-negative nasal specimens obtained from adults with new onset ARI, and 40 control specimens were collected from healthy adults. All specimens were analyzed for Haemophilus influenzae(HI), Moraxella catarrhalis(MC) and Streptococcus pneumoniae(SP) by quantitative-PCR. General linear models tested for relationships between respiratory pathogens, biomarkers (nasal wash neutrophils and CXCL8), and ARI-severity. RESULTS Nasal specimens from adults with ARIs were more likely to contain bacteria (37% overall; HI = 28%, MC = 14%, SP = 7%) compared to specimens from healthy adults (5% overall; HI = 0%, MC = 2.5%, SP = 2.5%; p < 0.001). Among ARI specimens, bacteria were more likely to be detected among virus-negative specimens compared to virus-positive specimens (46% vs. 27%; p = 0.0046). The presence of bacteria was significantly associated with increased CXCL8 and neutrophils, but not increased symptoms. CONCLUSION Pathogenic bacteria were more often detected in virus-negative ARI, and also associated with increased inflammatory biomarkers. These findings suggest the possibility that bacteria may augment virus-induced ARI and contribute to airway inflammation.
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Affiliation(s)
- Chidi N Obasi
- Department of Family Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1100 Delaplaine Ct., Madison, WI 53715, USA.
| | - Bruce Barrett
- Department of Family Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1100 Delaplaine Ct., Madison, WI 53715, USA
| | - Roger Brown
- Schools of Nursing, Medicine and Public Health, Research Design & Statistics Unit, University of Wisconsin-Madison, USA
| | - Rose Vrtis
- School of Medicine, Departments of Pediatrics and Medicine, University of Wisconsin-Madison, USA
| | - Shari Barlow
- Department of Family Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1100 Delaplaine Ct., Madison, WI 53715, USA
| | - Daniel Muller
- Department of Medicine - Rheumatology, University of Wisconsin-Madison, School of Medicine and Public Health, USA
| | - James Gern
- School of Medicine, Departments of Pediatrics and Medicine, University of Wisconsin-Madison, USA
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319
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320
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Williams DJ, Hall M, Shah SS, Parikh K, Tyler A, Neuman MI, Hersh AL, Brogan TV, Blaschke AJ, Grijalva CG. Narrow vs broad-spectrum antimicrobial therapy for children hospitalized with pneumonia. Pediatrics 2013; 132:e1141-8. [PMID: 24167170 PMCID: PMC4530302 DOI: 10.1542/peds.2013-1614] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America community-acquired pneumonia (CAP) guideline recommends narrow-spectrum antimicrobial therapy for most children hospitalized with CAP. However, few studies have assessed the effectiveness of this strategy. METHODS Using data from 43 children's hospitals, we conducted a retrospective cohort study to compare outcomes and resource utilization among children hospitalized with CAP between 2005 and 2011 receiving either parenteral ampicillin/penicillin (narrow spectrum) or ceftriaxone/cefotaxime (broad spectrum). Children with complex chronic conditions, interhospital transfers, recent hospitalization, or the occurrence of any of the following during the first 2 calendar days of hospitalization were excluded: pleural drainage procedure, admission to intensive care, mechanical ventilation, death, or hospital discharge. RESULTS Overall, 13,954 children received broad-spectrum therapy (89.7%) and 1610 received narrow-spectrum therapy (10.3%). The median length of stay was 3 days (interquartile range 3-4) in the broad- and narrow-spectrum therapy groups (adjusted difference 0.12 days, 95% confidence interval [CI]: -0.02 to 0.26). One hundred fifty-six children (1.1%) receiving broad-spectrum therapy and 13 children (0.8%) receiving narrow-spectrum therapy were admitted to intensive care (adjusted odds ratio 0.85, 95% CI: 0.27 to 2.73). Readmission occurred for 321 children (2.3%) receiving broad-spectrum therapy and 39 children (2.4%) receiving narrow-spectrum therapy (adjusted odds ratio 0.85, 95% CI: 0.45 to 1.63). Median costs for the hospitalization were $3992 and $4375 (adjusted difference -$14.4, 95% CI: -177.1 to 148.3). CONCLUSIONS Clinical outcomes and costs for children hospitalized with CAP are not different when treatment is with narrow- compared with broad-spectrum therapy.
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Affiliation(s)
- Derek J Williams
- 1161 21st Ave South, CCC 5311 Medical Center North, Nashville, TN 37232.
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321
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Tschudin-Sutter S, Tamma PD, Naegeli AN, Speck KA, Milstone AM, Perl TM. Distinguishing community-associated from hospital-associated Clostridium difficile infections in children: implications for public health surveillance. Clin Infect Dis 2013; 57:1665-72. [PMID: 24046303 DOI: 10.1093/cid/cit581] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Children are increasingly recognized as being at risk for C. difficile infection (CDI), even without prior exposure to antibiotics or the healthcare environment. We aimed to distinguish risk factors, clinical course, and outcomes between healthcare facility-associated (HA) and community-associated (CA) CDI. METHODS This was a retrospective, observational cohort study conducted at the Johns Hopkins Children's Center, Baltimore, Maryland. All inpatients, aged ≥1 year, hospitalized from July 2003 to July 2012 and diagnosed with CDI based on clinical characteristics and confirmatory laboratory testing were included. The main outcome was CDI, categorized as HA-CDI, CA-CDI, and "indeterminate" (classified as disease onset in the community, 4-12 weeks from hospital discharge). RESULTS Two hundred two pediatric inpatients were diagnosed with CDI, of whom 38 had CA-CDI, 144 had HA-CDI, and 20 had indeterminate CDI. Children with indeterminate CDI had baseline characteristics similar to those identified for HA-CDI. Children hospitalized with CA-CDI were less likely to have comorbidities (odds ratio [OR], 0.14; 95% confidence interval [CI], .03-.65; P = .013), to have been exposed to antibiotics (OR, 0.17; 95% CI, .07-.44; P < .001), or prior surgeries (OR, 0.03; 95% CI, .00-.24; P = .001), compared to children with HA-CDI. Compared with HA-CDI, children with CA-CDI had a trend toward more episodes of septic shock (P = .07), toxic megacolon (P = .04), and recurrences (P = .04). CONCLUSIONS In a hospitalized cohort, CA-CDI is more often seen in previously healthy children without antibiotic exposure or comorbid conditions and has more frequent complications and recurrences compared to HA-CDI. For surveillance purposes, "indeterminate" CDI should be allocated to HA-CDI rather than CA-CDI.
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322
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Maltezou HC, Fotiou A, Antonakopoulos N, Kallogriopoulou C, Katerelos P, Dimopoulou A, Tsoutsa V, Siahanidou T, Papagaroufalis C, Kostis E, Papantoniou N, Antsaklis A, Theodoridou M. Impact of Postpartum Influenza Vaccination of Mothers and Household Contacts in Preventing Febrile Episodes, Influenza-like Illness, Healthcare Seeking, and Administration of Antibiotics in Young Infants During the 2012-2013 Influenza Season. Clin Infect Dis 2013; 57:1520-6. [DOI: 10.1093/cid/cit599] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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323
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Creeley CE, Olney JW. Drug-Induced Apoptosis: Mechanism by which Alcohol and Many Other Drugs Can Disrupt Brain Development. Brain Sci 2013; 3:1153-81. [PMID: 24587895 PMCID: PMC3938204 DOI: 10.3390/brainsci3031153] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 07/08/2013] [Accepted: 07/11/2013] [Indexed: 01/18/2023] Open
Abstract
Maternal ingestion of alcohol during pregnancy can cause a disability syndrome termed Fetal Alcohol Spectrum Disorder (FASD), which may include craniofacial malformations, structural pathology in the brain, and a variety of long-term neuropsychiatric disturbances. There is compelling evidence that exposure to alcohol during early embryogenesis (4th week of gestation) can cause excessive death of cell populations that are essential for normal development of the face and brain. While this can explain craniofacial malformations and certain structural brain anomalies that sometimes accompany FASD, in many cases these features are absent, and the FASD syndrome manifests primarily as neurobehavioral disorders. It is not clear from the literature how alcohol causes these latter manifestations. In this review we will describe a growing body of evidence documenting that alcohol triggers widespread apoptotic death of neurons and oligodendroglia (OLs) in the developing brain when administered to animals, including non-human primates, during a period equivalent to the human third trimester of gestation. This cell death reaction is associated with brain changes, including overall or regional reductions in brain mass, and long-term neurobehavioral disturbances. We will also review evidence that many drugs used in pediatric and obstetric medicine, including general anesthetics (GAs) and anti-epileptics (AEDs), mimic alcohol in triggering widespread apoptotic death of neurons and OLs in the third trimester-equivalent animal brain, and that human children exposed to GAs during early infancy, or to AEDs during the third trimester of gestation, have a significantly increased incidence of FASD-like neurobehavioral disturbances. These findings provide evidence that exposure of the developing human brain to GAs in early infancy, or to alcohol or AEDs in late gestation, can cause FASD-like neurodevelopmental disability syndromes. We propose that the mechanism by which alcohol, GAs and AEDs produce neurobehavioral deficit syndromes is by triggering apoptotic death and deletion of neurons and OLs (or their precursors) from the developing brain. Therefore, there is a need for research aimed at deciphering mechanisms by which these agents trip the apoptosis trigger, the ultimate goal being to learn how to prevent these agents from causing neurodevelopmental disabilities.
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Affiliation(s)
| | - John W. Olney
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA; E-Mail:
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324
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Redmond NM, Davies R, Christensen H, Blair PS, Lovering AM, Leeming JP, Muir P, Vipond B, Thornton H, Fletcher M, Delaney B, Little P, Thompson M, Peters TJ, Hay AD. The TARGET cohort study protocol: a prospective primary care cohort study to derive and validate a clinical prediction rule to improve the targeting of antibiotics in children with respiratory tract illnesses. BMC Health Serv Res 2013; 13:322. [PMID: 23958109 PMCID: PMC3765099 DOI: 10.1186/1472-6963-13-322] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 08/14/2013] [Indexed: 11/10/2022] Open
Abstract
Background Children with respiratory tract infections are the single most frequent patient group to make use of primary care health care resources. The use of antibiotics remains highly prevalent in young children, but can lead to antimicrobial resistance as well as reinforcing the idea that parents should re-consult for similar symptoms. One of the main drivers of indiscriminate antimicrobial use is the lack of evidence for, and therefore uncertainty regarding, which children are at risk of poor outcome. This paper describes the protocol for the TARGET cohort study, which aims to derive and validate a clinical prediction rule to identify children presenting to primary care with respiratory tract infections who are at risk of hospitalisation. Methods/design The TARGET cohort study is a large, multicentre prospective observational study aiming to recruit 8,300 children aged ≥3 months and <16 years presenting to primary care with a cough and respiratory tract infection symptoms from 4 study centres (Bristol, London, Oxford and Southampton). Following informed consent, symptoms, signs and demographics will be measured. In around a quarter of children from the Bristol centre, a single sweep, dual bacterial-viral throat swab will be taken and parents asked to complete a symptom diary until the child is completely well or for 28 days, whichever is sooner. A review of medical notes including clinical history, re-consultation and hospitalisations will be undertaken. Multivariable logistic regression will be used to identify the independent clinical predictors of hospitalisation as well as the prognostic significance of upper respiratory tract microbes. The clinical prediction rule will be internally validated using various methods including bootstrapping. Discussion The clinical prediction rule for hospitalisation has the potential to help identify a small group of children for hospitalisation and a much larger group where hospitalisation is very unlikely and antibiotic prescribing would be less warranted. This study will also be the largest natural history study to date of children presenting to primary care with acute cough and respiratory tract infections, and will provide important information on symptom duration, re-consultations and the microbiology of the upper respiratory tract.
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Affiliation(s)
- Niamh M Redmond
- Centre for Academic Primary Care, School of Social and Community Based Medicine, NIHR School of Primary Care Research, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, UK.
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325
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Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09. J Antimicrob Chemother 2013; 69:234-40. [PMID: 23887867 DOI: 10.1093/jac/dkt301] [Citation(s) in RCA: 320] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine patterns of ambulatory antibiotic prescribing in US adults, including the use of broad-spectrum versus narrow-spectrum agents, to provide a description of the diagnoses for which antibiotics are prescribed and to identify patient and physician factors associated with broad-spectrum antibiotic prescribing. METHODS We used data for patients aged ≥ 18 years from the National Ambulatory and National Hospital Ambulatory Medical Care Surveys (2007-09). These are nationally representative surveys of patient visits to offices, hospital outpatient departments and emergency departments (EDs) in the USA, collectively referred to as ambulatory visits. We determined the types of antibiotics prescribed, including the use of broad-spectrum versus narrow-spectrum antibiotics, and examined prescribing patterns by diagnoses. We used multivariable logistic regression to identify factors associated with broad-spectrum antibiotic prescribing. RESULTS Antibiotics were prescribed during 101 million (95% CI: 91-111 million) ambulatory visits annually, representing 10% of all visits. Broad-spectrum agents were prescribed during 61% of visits in which antibiotics were prescribed. The most commonly prescribed antibiotics were quinolones (25% of antibiotics), macrolides (20%) and aminopenicillins (12%). Antibiotics were most commonly prescribed for respiratory conditions (41% of antibiotics), skin/mucosal conditions (18%) and urinary tract infections (9%). In multivariable analysis, among patients prescribed antibiotics, broad-spectrum agents were more likely to be prescribed than narrow-spectrum antibiotics for respiratory infections for which antibiotics are rarely indicated (e.g. bronchitis), during visits to EDs and for patients ≥ 60 years. CONCLUSIONS Broad-spectrum agents constitute the majority of antibiotics in ambulatory care. More than 25% of prescriptions are for conditions for which antibiotics are rarely indicated. Antibiotic stewardship interventions targeting respiratory and non-respiratory conditions are needed in ambulatory care.
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Affiliation(s)
- Daniel J Shapiro
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
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327
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Ovetchkine P, Rieder MJ. Azithromycin use in paediatrics: A practical overview. Paediatr Child Health 2013. [DOI: 10.1093/pch/18.6.311] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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328
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Nett RJ, Campana D, Custis CL, Helgerson SD. Office-related antibiotic prescribing for Medicaid-enrolled children. Clin Pediatr (Phila) 2013; 52:403-10. [PMID: 23460649 DOI: 10.1177/0009922813479158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prudent antibiotic prescribing practices are essential to limiting antibiotic resistance. OBJECTIVE To assess the trend in percentage of office visits for acute respiratory infections (ARIs) linked with an antibiotic prescription. METHODS Retrospective analysis of Montana Medicaid billing claims data for each year, 1999 to 2010, was done. Participants included continuously enrolled children aged ≤14 years. Primary outcomes were ARI-related office visits and filled antibiotic prescriptions within 10 days of the office visit. RESULTS Of the 873 244 office visits identified, 116 962 (13%) had an ARI as the primary diagnosis. Among ARI-related office visits, 64 250 (55%) were linked with an antibiotic prescription. From 1999 to 2010, the odds of ARI-related visits being linked with an antibiotic prescription did not change (odds ratio = 1.00; 95% confidence interval = 0.995-1.002). CONCLUSIONS The percentage of ARI-related visits linked with an antibiotic prescription did not decrease from 1999 to 2010. Further efforts are needed to reduce antibiotic treatment for ARIs.
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Affiliation(s)
- Randall J Nett
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
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329
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Stockmann C, Ampofo K, Hersh AL, Carleton ST, Korgenski K, Sheng X, Pavia AT, Byington CL. Seasonality of acute otitis media and the role of respiratory viral activity in children. Pediatr Infect Dis J 2013; 32:314-9. [PMID: 23249910 PMCID: PMC3618601 DOI: 10.1097/inf.0b013e31827d104e] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute otitis media (AOM) occurs as a complication of viral upper respiratory tract infections in young children. AOM and respiratory viruses both display seasonal variation. Our objective was to examine the temporal association between circulating respiratory viruses and the occurrence of pediatric ambulatory care visits for AOM. METHODS This retrospective study included 9 seasons of respiratory viral activity (2002 to 2010) in Utah. We used Intermountain Healthcare electronic medical records to assess community respiratory viral activity via laboratory-based active surveillance and to identify children <18 years with outpatient visits and International Classification of Diseases, Ninth Revision codes for AOM. We assessed the strength of the association between AOM and individual respiratory viruses using interrupted time series analyses. RESULTS During the study period, 96,418 respiratory viral tests were performed; 46,460 (48%) were positive. The most commonly identified viruses were respiratory syncytial virus (22%), rhinovirus (8%), influenza (8%), parainfluenza (4%), human metapneumovirus (3%) and adenovirus (3%). AOM was diagnosed during 271,268 ambulatory visits. There were significant associations between peak activity of respiratory syncytial virus, human metapneumovirus, influenza A and office visits for AOM. Adenovirus, parainfluenza and rhinovirus were not associated with visits for AOM. CONCLUSIONS Seasonal respiratory syncytial virus, human metapneumovirus and influenza activity were temporally associated with increased diagnoses of AOM among children. These findings support the role of individual respiratory viruses in the development AOM. These data also underscore the potential for respiratory viral vaccines to reduce the burden of AOM.
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Affiliation(s)
- Chris Stockmann
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah Health Sciences Center
| | - Krow Ampofo
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah Health Sciences Center
| | - Adam L. Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah Health Sciences Center
| | - Scott T. Carleton
- Division of Hospitalist Medicine, Department of Pediatrics, University of Utah Health Sciences Center
| | - Kent Korgenski
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah Health Sciences Center
- Primary Children's Medical Center, Intermountain Healthcare, Salt Lake City, UT
| | - Xiaoming Sheng
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah Health Sciences Center
| | - Andrew T. Pavia
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah Health Sciences Center
| | - Carrie L. Byington
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah Health Sciences Center
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330
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Gerber JS, Prasad PA, Localio AR, Fiks AG, Grundmeier RW, Bell LM, Wasserman RC, Rubin DM, Keren R, Zaoutis TE. Racial differences in antibiotic prescribing by primary care pediatricians. Pediatrics 2013; 131:677-84. [PMID: 23509168 PMCID: PMC9923585 DOI: 10.1542/peds.2012-2500] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine whether racial differences exist in antibiotic prescribing among children treated by the same clinician. METHODS Retrospective cohort study of 1,296,517 encounters by 208,015 children to 222 clinicians in 25 practices in 2009. Clinical, antibiotic prescribing, and demographic data were obtained from a shared electronic health record. We estimated within-clinician associations between patient race (black versus nonblack) and (1) antibiotic prescribing or (2) acute respiratory tract infection diagnosis after adjusting for potential patient-level confounders. RESULTS Black children were less likely to receive an antibiotic prescription from the same clinician per acute visit (23.5% vs 29.0%, odds ratio [OR] 0.75; 95% confidence interval [CI]: 0.72-0.77) or per population (0.43 vs 0.67 prescriptions/child/year, incidence rate ratio 0.64; 95% CI 0.63-0.66), despite adjustment for age, gender, comorbid conditions, insurance, and stratification by practice. Black children were also less likely to receive diagnoses that justified antibiotic treatment, including acute otitis media (8.7% vs 10.7%, OR 0.79; 95% CI 0.75-0.82), acute sinusitis (3.6% vs 4.4%, OR 0.79; 95% CI 0.73-0.86), and group A streptococcal pharyngitis (2.3% vs 3.7%, OR 0.60; 95% CI 0.55-0.66). When an antibiotic was prescribed, black children were less likely to receive broad-spectrum antibiotics at any visit (34.0% vs 36.9%, OR 0.88; 95% CI 0.82-0.93) and for acute otitis media (31.7% vs 37.8%, OR 0.75; 95% CI 0.68-0.83). CONCLUSIONS When treated by the same clinician, black children received fewer antibiotic prescriptions, fewer acute respiratory tract infection diagnoses, and a lower proportion of broad-spectrum antibiotic prescriptions than nonblack children. Reasons for these differences warrant further study.
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Affiliation(s)
- Jeffrey S. Gerber
- Division of Infectious Diseases,,The Center for Pediatric Clinical Effectiveness,,Department of Pediatrics, and,Address correspondence to Jeffrey S. Gerber, MD, PhD, Division of Infectious Diseases, The Children’s Hospital of Philadelphia, 3535 Market St, Ste 1518, Philadelphia, PA 19104. E-mail:
| | - Priya A. Prasad
- Division of Infectious Diseases,,The Center for Pediatric Clinical Effectiveness
| | - A. Russell Localio
- The Center for Pediatric Clinical Effectiveness,,PolicyLab,,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Alexander G. Fiks
- The Center for Pediatric Clinical Effectiveness,,PolicyLab,,Division of General Pediatrics, and,Department of Pediatrics, and
| | - Robert W. Grundmeier
- Division of General Pediatrics, and,The Center for Biomedical Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;,Department of Pediatrics, and
| | - Louis M. Bell
- Division of Infectious Diseases,,The Center for Pediatric Clinical Effectiveness,,Division of General Pediatrics, and,Department of Pediatrics, and
| | - Richard C. Wasserman
- Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont
| | - David M. Rubin
- PolicyLab,,Division of General Pediatrics, and,Department of Pediatrics, and,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Ron Keren
- The Center for Pediatric Clinical Effectiveness,,Division of General Pediatrics, and,Department of Pediatrics, and,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Theoklis E. Zaoutis
- Division of Infectious Diseases,,The Center for Pediatric Clinical Effectiveness,,Department of Pediatrics, and,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and
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331
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Jenkins TC, Irwin A, Coombs L, Dealleaume L, Ross SE, Rozwadowski J, Webster B, Dickinson LM, Sabel AL, Mackenzie TD, West DR, Price CS. Effects of clinical pathways for common outpatient infections on antibiotic prescribing. Am J Med 2013; 126:327-335.e12. [PMID: 23507206 PMCID: PMC3666348 DOI: 10.1016/j.amjmed.2012.10.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 10/05/2012] [Accepted: 10/05/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use. METHODS Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all 8 conditions during a 2-year baseline and 1-year intervention period. RESULTS In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (P<.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (P=.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively (14.4% relative reduction) (P<.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (P=.35). There were significant differences in the trends of prescriptions for acute respiratory infections (P<.0001) and broad-spectrum antibiotic use (P=.001) between the study and control groups during the intervention period, with greater declines in the study group. CONCLUSIONS This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted.
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Affiliation(s)
- Timothy C Jenkins
- Department of Medicine, Denver Health Medical Center, Denver, CO 80204, USA.
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332
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Goldman JL, Jackson MA, Herigon JC, Hersh AL, Shapiro DJ, Leeder JS. Trends in adverse reactions to trimethoprim-sulfamethoxazole. Pediatrics 2013; 131:e103-8. [PMID: 23209098 PMCID: PMC3529952 DOI: 10.1542/peds.2012-1619] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To examine temporal trends of adverse drug reactions (ADRs) associated with trimethoprim-sulfamethoxazole (TMP-SMX) use in children. METHODS We performed a retrospective observational study to characterize TMP-SMX ADRs in children between 2000 and 2009. We completed a chart review at our institution by identifying children diagnosed with TMP-SMX ADRs. To compare local trends to comparable institutions, we estimated the frequency of hospitalizations for TMP-SMX ADRs at 25 tertiary pediatric hospitals utilizing the Pediatric Health Information System database. To determine whether changes in outpatient prescribing rates occurred, we used the National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey. RESULTS At our institution, 109 children were diagnosed with a TMP-SMX ADR (5 cases from 2000 to 2004 as compared with 104 cases from 2005 to 2009). Fifty-eight percent had been treated for a skin and soft tissue infection (SSTI). A similar trend was observed nationally, where the incidence of TMP-SMX ADRs more than doubled from 2004 to 2009 at comparable pediatric hospitals (P < .001). Although national outpatient data revealed no change in overall TMP-SMX prescribing, the percentage of children prescribed TMP-SMX for SSTI sharply increased during the study period (0%-2% [2000-2004]; 9%-17% [2005-2009]). CONCLUSIONS The majority of TMP-SMX ADRs at our institution occurred in conjunction with SSTI treatment. TMP-SMX ADRs have occurred more frequently coincident with increased prescribing for SSTI. Increased usage alone may explain the increasing trend of TMP-SMX ADRs in children; however drug-disease interaction may play a role and requires further investigation.
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Affiliation(s)
- Jennifer L. Goldman
- Section of Pediatric Infectious Diseases and,Division of Clinical Pharmacology and Medical Toxicology
| | | | - Joshua C. Herigon
- Office of Evidence Based Medicine, Children’s Mercy Hospitals & Clinics, University of Missouri, Kansas City, Missouri
| | - Adam L. Hersh
- Division of Pediatric Infectious Disease, University of Utah, Salt Lake City, Utah; and
| | - Daniel J. Shapiro
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California
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333
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Dinur-Schejter Y, Cohen-Cymberknoh M, Tenenbaum A, Brooks R, Averbuch D, Kharasch S, Kerem E. Antibiotic treatment of children with community-acquired pneumonia: comparison of penicillin or ampicillin versus cefuroxime. Pediatr Pulmonol 2013; 48:52-8. [PMID: 22431471 DOI: 10.1002/ppul.22534] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 01/24/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Adherence to current guidelines for treatment of non-complicated community-acquired pneumonia (CAP) in children, recommending penicillin or ampicillin as first-line treatment, has been poor. Our objective was to examine whether cefuroxime confers an advantage over penicillin or ampicillin for the treatment of children hospitalized with non-complicated CAP. PATIENTS AND METHODS All children aged 3 months to 2 years with non-complicated CAP treated with penicillin or ampicillin or cefuroxime, admitted during 2003-2008, in the Departments of Pediatrics, Hadassah University Medical Center were included. Presenting signs, symptoms, laboratory findings at presentation, clinical parameters including number of days with IV antibiotics, oxygen treatment, length of hospital stay, change of antibiotics, and clinical course 72 hr and 1 week after admission, were compared. RESULTS Of the 319 children admitted for non-complicated CAP, 66 were treated with IV penicillin or ampicillin, 253 with IV cefuroxime. Number of days of IV treatment, days of oxygen requirement, and days of hospitalization were similar (2.36 ± 1.6 days vs. 2.59 ± 1.6 days, 0.31 ± 1.2 days vs. 0.64 ± 1.3 days, and 2.67 ± 1.4 days vs. 2.96 ± 1.7 days, respectively). Treatment failure was not significantly different (7.6% vs. 4.7%). The number of patients who were febrile or required oxygen 72 hr after admission was similar (13.0% vs. 16.5% and 8.7% vs. 20.9%, respectively). One week after admission no difference between the two groups was seen. CONCLUSIONS In previously healthy children, parenteral penicillin or ampicillin for treatment of non-complicated CAP in-hospital is as effective as cefuroxime, and should remain the recommended first-line therapy.
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Affiliation(s)
- Yael Dinur-Schejter
- Departments of Pediatrics, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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334
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Hashikawa AN, Stevens MW, Juhn YJ, Nimmer M, Copeland K, Simpson P, Brousseau DC. Self-Report of Child Care Directors Regarding Return-to-Care. Pediatrics 2012; 130:1046-52. [PMID: 23147967 DOI: 10.1542/peds.2012-1184] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The American Academy of Pediatrics (AAP) introduced revised return-to-care recommendations for mildly ill children in 2009 that were added to national standards in 2011. Child care directors' practices in a state without clear emphasis on return-to-care guidelines are unknown. We investigated director return-to-care practices just before the release of recently revised AAP guidelines. METHODS A telephone survey with 5 vignettes of mild illness (cold symptoms, conjunctivitis, vomiting/diarrhea, fever, and ringworm) was administered to randomly sampled directors in metropolitan Milwaukee, Wisconsin. Directors were asked about return-to-care criteria for each illness. Questions for return-to-care criteria were open-ended; multiple responses were allowed. Answers were compared with AAP return-to-care recommendations. RESULTS A total of 305 directors participated. Based on director responses to vignettes, the percentage of correct responses regarding return-to-child care management compared with AAP return-to-care recommendations was low: fever (0%); conjunctivitis (0%); diarrhea (1.6%); cold symptoms (12%); ringworm (21%); and vomiting (80%). Two illnesses (conjunctivitis and cold symptoms) would require the child to have an urgent medical evaluation or treatment not recommended by the AAP, as follows: Conjunctivitis-antibiotics for 24 hours (62%), physician visit (49%), any antibiotic treatment (6%), and symptom resolution (4%); and Cold Symptoms-physician visit (45.6%), antibiotics (10%), and symptom resolution (25%). CONCLUSIONS Directors' self-reported return-to-child care practices differed substantially before the release of revised AAP return-to-care recommendations. Active adoption of AAP return-to-child care guidelines would decrease the need for unnecessary urgent medical evaluation and treatment as well as unnecessary exclusion of a child from child care.
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Affiliation(s)
- Andrew N Hashikawa
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI 48105, USA.
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335
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Kronman MP, Zaoutis TE, Haynes K, Feng R, Coffin SE. Antibiotic exposure and IBD development among children: a population-based cohort study. Pediatrics 2012; 130:e794-803. [PMID: 23008454 PMCID: PMC4074626 DOI: 10.1542/peds.2011-3886] [Citation(s) in RCA: 275] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To determine whether childhood antianaerobic antibiotic exposure is associated with the development of inflammatory bowel disease (IBD). METHODS This retrospective cohort study employed data from 464 UK ambulatory practices participating in The Health Improvement Network. All children with ≥ 2 years of follow-up from 1994 to 2009 were followed between practice enrollment and IBD development, practice deregistration, 19 years of age, or death; those with previous IBD were excluded. All antibiotic prescriptions were captured. Antianaerobic antibiotic agents were defined as penicillin, amoxicillin, ampicillin, penicillin/β-lactamase inhibitor combinations, tetracyclines, clindamycin, metronidazole, cefoxitin, carbapenems, and oral vancomycin. RESULTS A total of 1072426 subjects contributed 6.6 million person-years of follow-up; 748 developed IBD. IBD incidence rates among antianaerobic antibiotic unexposed and exposed subjects were 0.83 and 1.52/10000 person-years, respectively, for an 84% relative risk increase. Exposure throughout childhood was associated with developing IBD, but this relationship decreased with increasing age at exposure. Exposure before 1 year of age had an adjusted hazard ratio of 5.51 (95% confidence interval [CI]: 1.66-18.28) but decreased to 2.62 (95% CI: 1.61-4.25) and 1.57 (95% CI: 1.35-1.84) by 5 and 15 years, respectively. Each antibiotic course increased the IBD hazard by 6% (4%-8%). A dose-response effect existed, with receipt of >2 antibiotic courses more highly associated with IBD development than receipt of 1 to 2 courses, with adjusted hazard ratios of 4.77 (95% CI: 2.13-10.68) versus 3.33 (95% CI: 1.69-6.58). CONCLUSIONS Childhood antianaerobic antibiotic exposure is associated with IBD development.
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Affiliation(s)
- Matthew P. Kronman
- Division of Infectious Diseases, Seattle Children’s Hospital, University of Washington, Seattle, Washington
| | - Theoklis E. Zaoutis
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Department of Biostatistics and Epidemiology, the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Haynes
- Department of Biostatistics and Epidemiology, the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rui Feng
- Department of Biostatistics and Epidemiology, the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan E. Coffin
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Department of Biostatistics and Epidemiology, the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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336
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Campos J. [Antibiotic use in the community--the prevalence as a starting point]. Enferm Infecc Microbiol Clin 2012; 30:589-90. [PMID: 22955003 DOI: 10.1016/j.eimc.2012.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/09/2012] [Indexed: 10/27/2022]
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337
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Newland JG, Banerjee R, Gerber JS, Hersh AL, Steinke L, Weissman SJ. Antimicrobial Stewardship in Pediatric Care: Strategies and Future Directions. Pharmacotherapy 2012; 32:735-43. [DOI: 10.1002/j.1875-9114.2012.01155.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jason G. Newland
- Section of Infectious Diseases; Department of Pediatrics; University of Missouri-Kansas City; Children's Mercy Hospitals & Clinics; Kansas City; Missouri
| | - Ritu Banerjee
- Division of Pediatric Infectious Diseases; Department of Pediatrics and Adolescent Medicine; Mayo Clinic College of Medicine; Mayo Children's Hospital; Rochester; Minnesota
| | - Jeffrey S. Gerber
- Division of Infectious Diseases; Department of Pediatrics; University of Pennsylvania School of Medicine; Children's Hospital of Philadelphia; Philadelphia; Pennsylvania
| | - Adam L. Hersh
- Division of Infectious Diseases; Department of Pediatrics; University of Utah; Primary Children's Medical Center; Salt Lake City; Utah
| | - Leah Steinke
- Department of Pharmacy; Children's Hospital of Michigan; Detroit Medical Center; Detroit; Michigan
| | - Scott J. Weissman
- Division of Infectious Diseases; Department of Pediatrics; University of Washington Medical Center; Seattle Children's Hospital; Seattle; Washington
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338
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The evolution of eProtocols that enable reproducible clinical research and care methods. J Clin Monit Comput 2012; 26:305-17. [PMID: 22491960 DOI: 10.1007/s10877-012-9356-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 03/15/2012] [Indexed: 02/05/2023]
Abstract
Unnecessary variation in clinical care and clinical research reduces our ability to determine what healthcare interventions are effective. Reducing this unnecessary variation could lead to further healthcare quality improvement and more effective clinical research. We have developed and used electronic decision support tools (eProtocols) to reduce unnecessary variation. Our eProtocols have progressed from a locally developed mainframe computer application in one clinical site (LDS Hospital) to web-based applications available in multiple languages and used internationally. We use eProtocol-insulin as an example to illustrate this evolution. We initially developed eProtocol-insulin as a local quality improvement effort to manage stress hyperglycemia in the adult intensive care unit (ICU). We extended eProtocol-insulin use to translate our quality improvement results into usual clinical care at Intermountain Healthcare ICUs. We exported eProtocol-insulin to support research in other US and international institutions, and extended our work to the pediatric ICU. We iteratively refined eProtocol-insulin throughout these transitions, and incorporated new knowledge about managing stress hyperglycemia in the ICU. Based on our experience in the development and clinical use of eProtocols, we outline remaining challenges to eProtocol development, widespread distribution and use, and suggest a process for eProtocol development. Technical and regulatory issues, as well as standardization of protocol development, validation and maintenance, need to be addressed. Resolution of these issues should facilitate general use of eProtocols to improve patient care.
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