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Daley MF, Reifler LM, Sterrett AT, Poole NM, Winn DB, Steiner JF, Arnold Rehring SM. Improving Antibiotic Prescribing for Children with Community-acquired Pneumonia in Outpatient Settings. J Pediatr 2024; 274:114155. [PMID: 38897380 DOI: 10.1016/j.jpeds.2024.114155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/24/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE To assess whether a two-phase intervention was associated with improvements in antibiotic prescribing among nonhospitalized children with community-acquired pneumonia. STUDY DESIGN In a large health care organization, a first intervention phase was implemented in September 2020 directed at antibiotic choice and duration for children 2 months through 17 years of age with pneumonia. Activities included clinician education and implementation of a pneumonia-specific order set in the electronic health record. In October 2021, a second phase comprised additional education and order set revisions. A narrow spectrum antibiotic (eg, amoxicillin) was recommended in most circumstances. Electronic health record data were used to identify pneumonia cases and antibiotics ordered. Using interrupted time series analyses, antibiotic choice and duration after phase one (September 2020-September 2021) and after phase two (October 2021-October 2022) were compared with a preintervention prepandemic period (January 2016-early March 2020). RESULTS Overall, 3570 cases of community-acquired pneumonia were identified: 3246 cases preintervention, 98 post-phase one, and 226 post-phase two. The proportion receiving narrow spectrum monotherapy increased from 40.6% preintervention to 68.4% post-phase one to 69.0% post-phase two (P < .001). For children with an initial narrow spectrum antibiotic, duration decreased from preintervention (mean duration 9.9 days, SD 0.5 days) to post-phase one (mean 8.2, SD 1.9) to post-phase two (mean 6.8, SD 2.3) periods (P < .001). CONCLUSIONS A two-phase intervention with educational sessions combined with clinical decision support was associated with sustained improvements in antibiotic choice and duration among children with community-acquired pneumonia.
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Affiliation(s)
- Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Andrew T Sterrett
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Nicole M Poole
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Epidemiology, University of Colorado School of Medicine, Aurora, CO
| | - D Brian Winn
- Department of Medicine, Colorado Permanente Medical Group, Denver, CO; Department of Medical Informatics, Colorado Permanente Medical Group, Denver, CO
| | - John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Department of Medical Education, Colorado Permanente Medical Group, Denver, CO; Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Sharisse M Arnold Rehring
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Department of Medical Education, Colorado Permanente Medical Group, Denver, CO
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Szymczak JE, Hayes AA, Labellarte P, Zighelboim J, Toor A, Becker AB, Gerber JS, Kuppermann N, Florin TA. Parent and Clinician Views on Not Using Antibiotics for Mild Community-Acquired Pneumonia. Pediatrics 2024; 153:e2023063782. [PMID: 38234215 DOI: 10.1542/peds.2023-063782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES Preschool-aged children with mild community-acquired pneumonia (CAP) routinely receive antibiotics even though most infections are viral. We sought to identify barriers to the implementation of a "no antibiotic" strategy for mild CAP in young children. METHODS Qualitative study using semistructured interviews conducted in a large pediatric hospital in the United States from January 2021 to July 2021. Parents of young children diagnosed with mild CAP in the previous 3 years and clinicians practicing in outpatient settings (pediatric emergency department, community emergency department, general pediatrics offices) were included. RESULTS Interviews were conducted with 38 respondents (18 parents, 20 clinicians). No parent heard of the no antibiotic strategy, and parents varied in their support for the approach. Degree of support related to their desire to avoid unnecessary medications, trust in clinicians, the emotional difficulty of caring for a sick child, desire for relief of suffering, willingness to accept the risk of unnecessary antibiotics, and judgment about the child's illness severity. Eleven (55%) clinicians were familiar with guidelines specifying a no antibiotic strategy. They identified challenges in not using antibiotics, including diagnostic uncertainty, consequences of undertreatment, parental expectations, follow-up concerns, and acceptance of the risks of unnecessary antibiotic treatment of many children if it means avoiding adverse outcomes for some children. CONCLUSIONS Although both parents and clinicians expressed broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges. Interventions will need to consider the emotional, social, and logistical aspects of managing pneumonia, in addition to developing techniques to improve diagnosis.
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Affiliation(s)
- Julia E Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ashley A Hayes
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patricia Labellarte
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julian Zighelboim
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amandeep Toor
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam B Becker
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, California
| | - Todd A Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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3
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Wetzke M, Schütz K, Kopp MV, Seidenberg J, Vogelberg C, Ankermann T, Happle C, Voigt G, Köster H, Illig T, Lex C, Schuster A, Maier R, Panning M, Barten G, Rohde G, Welte T, Hansen G. Pathogen spectra in hospitalised and nonhospitalised children with community-acquired pneumonia. ERJ Open Res 2023; 9:00286-2022. [PMID: 36923566 PMCID: PMC10009707 DOI: 10.1183/23120541.00286-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/23/2022] [Indexed: 11/18/2022] Open
Abstract
Background Paediatric community-acquired pneumonia (CAP) is a leading cause of paediatric morbidity. However, particularly for outpatients with paediatric CAP, data on aetiology and management are scarce. Methods The prospective pedCAPNETZ study multicentrically enrols children and adolescents with outpatient-treated or hospitalised paediatric CAP in Germany. Blood and respiratory specimens were collected systematically, and comprehensive analyses of pathogen spectra were conducted. Follow-up evaluations were performed until day 90 after enrolment. Results Between December 2014 and August 2020, we enrolled 486 children with paediatric CAP at eight study sites, 437 (89.9%) of whom had radiographic evidence of paediatric CAP. Median (interquartile range) age was 4.5 (1.6-6.6) years, and 345 (78.9%) children were hospitalised. The most prevalent symptoms at enrolment were cough (91.8%), fever (89.2%) and tachypnoea (62.0%). Outpatients were significantly older, displayed significantly lower C-reactive protein levels and were significantly more likely to be symptom-free at follow-up days 14 and 90. Pathogens were detected in 90.3% of all patients (one or more viral pathogens in 68.1%; one or more bacterial strains in 18.7%; combined bacterial/viral pathogens in 4.1%). Parainfluenza virus and Mycoplasma pneumoniae were significantly more frequent in outpatients. The proportion of patients with antibiotic therapy was comparably high in both groups (92.4% of outpatients versus 86.2% of hospitalised patients). Conclusion We present first data on paediatric CAP with comprehensive analyses in outpatients and hospitalised cases and demonstrate high detection rates of viral pathogens in both groups. Particularly in young paediatric CAP patients with outpatient care, antibiotic therapy needs to be critically debated.
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Affiliation(s)
- Martin Wetzke
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in End stage and Obstructive Lung Disease (BREATH) Hannover and Airway Research Center North (ARCN) Lübeck, Member of the German Center for Lung Research (DZL), Lübeck, Germany.,These authors contributed equally
| | - Katharina Schütz
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,Excellence Cluster RESIST (EXC 2155), Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) Hannover, Hannover, Germany.,These authors contributed equally
| | - Matthias Volkmar Kopp
- Biomedical Research in End stage and Obstructive Lung Disease (BREATH) Hannover and Airway Research Center North (ARCN) Lübeck, Member of the German Center for Lung Research (DZL), Lübeck, Germany.,Department of Paediatric Allergy and Pulmonology, Clinic of Pediatrics UKSH, University of Luebeck, Lübeck, Germany.,Department of Paediatrics, Inselspital, University of Bern, Bern, Switzerland
| | - Jürgen Seidenberg
- Department of Paediatric Pneumology and Allergology, Universitätsklinik für Kinder- und Jugendmedizin Oldenburg, Oldenburg, Germany
| | - Christian Vogelberg
- University Children's Hospital, Technical University Dresden, Dresden, Germany
| | - Tobias Ankermann
- Department of Paediatric Pulmonology, Clinic of Pediatrics UKSH, University of Kiel, Kiel, Germany
| | - Christine Happle
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in End stage and Obstructive Lung Disease (BREATH) Hannover and Airway Research Center North (ARCN) Lübeck, Member of the German Center for Lung Research (DZL), Lübeck, Germany.,Excellence Cluster RESIST (EXC 2155), Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) Hannover, Hannover, Germany
| | - Gesche Voigt
- Department of Paediatric Allergy and Pulmonology, Clinic of Pediatrics UKSH, University of Luebeck, Lübeck, Germany
| | - Holger Köster
- Department of Paediatric Pneumology and Allergology, Universitätsklinik für Kinder- und Jugendmedizin Oldenburg, Oldenburg, Germany
| | - Thomas Illig
- Biomedical Research in End stage and Obstructive Lung Disease (BREATH) Hannover and Airway Research Center North (ARCN) Lübeck, Member of the German Center for Lung Research (DZL), Lübeck, Germany.,Hannover Unified Biobank, Hannover Medical School, Hannover, Germany
| | - Christiane Lex
- Department of Paediatric Pulmonology, University of Göttingen, Göttingen, Germany
| | - Antje Schuster
- Department of Paediatrics, University of Düsseldorf, Düsseldorf, Germany
| | - Ralph Maier
- Private Practice for Children, Tuttlingen, Germany
| | - Marcus Panning
- Institute of Virology, University of Freiburg, Freiburg, Germany
| | - Grit Barten
- Biomedical Research in End stage and Obstructive Lung Disease (BREATH) Hannover and Airway Research Center North (ARCN) Lübeck, Member of the German Center for Lung Research (DZL), Lübeck, Germany.,CAPNETZ STIFTUNG, Hannover, Germany
| | - Gernot Rohde
- CAPNETZ STIFTUNG, Hannover, Germany.,Department of Respiratory Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Tobias Welte
- Biomedical Research in End stage and Obstructive Lung Disease (BREATH) Hannover and Airway Research Center North (ARCN) Lübeck, Member of the German Center for Lung Research (DZL), Lübeck, Germany.,Department of Pulmonary Medicine, German Centre for Lung Research, Hannover Medical School, Hannover, Germany
| | - Gesine Hansen
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in End stage and Obstructive Lung Disease (BREATH) Hannover and Airway Research Center North (ARCN) Lübeck, Member of the German Center for Lung Research (DZL), Lübeck, Germany.,Excellence Cluster RESIST (EXC 2155), Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) Hannover, Hannover, Germany
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Joerger T, Taylor MG, Li Y, Palazzi DL, Gerber JS. Impact of Penicillin Allergy Labels on Children Treated for Outpatient Respiratory Infections. J Pediatric Infect Dis Soc 2023; 12:92-98. [PMID: 36461664 PMCID: PMC9969332 DOI: 10.1093/jpids/piac125] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Penicillin allergy is the most common antibiotic allergy, yet most children labeled as allergic tolerate penicillin. The impact of inaccurate penicillin allergy labels (PALs) on pediatric outpatients is unknown. The objective of this study was to compare outcomes between children with and without a PAL after treatment for outpatient respiratory tract infections (RTI). METHODS A retrospective, longitudinal birth cohort study was performed in children who received care in 90 pediatric primary care practices in Philadelphia and Houston metropolitan areas. Prescribing and clinical outcomes of children with a PAL at the time of an RTI were compared to non-allergic children, adjusting for potential confounders. RESULTS Antibiotics were prescribed for 663,473 non-recurrent RTIs among 200,977 children. Children with a PAL (5% of cohort) were more likely than non-allergic children to receive broad-spectrum antibiotics (adjusted relative risk (aRR) 3.24, 95% CI 3.22-3.26) and second-line antibiotics (aRR 4.87, 95% CI 4.83, 4.89). Compared to non-allergic children receiving first-line antibiotics, children with a PAL were more likely to return with adverse drug events (aRR 1.28, 95% CI 1.18-1.39). There was no difference in treatment failure between groups (aRR 0.95, 95% CI 0.90-1.00). CONCLUSIONS PALs lead to higher rates of broad-spectrum and second-line antibiotic prescribing in children treated for RTIs in primary care and contribute to unnecessary healthcare utilization through increased adverse events. Given the frequency of PALs, efforts to prevent inappropriate penicillin allergy labeling and promote de-labeling of existing inaccurate allergy labels may improve care of children treated for common bacterial infections.
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Affiliation(s)
- Torsten Joerger
- Department of Pediatrics, Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Margaret G Taylor
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, USA
| | - Debra L Palazzi
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Jeffrey S Gerber
- Department of Pediatrics, Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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5
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Chiotos K, Gerber JS. Does procalcitonin have clinical utility in the management of paediatric community-acquired pneumonia? A PRO/CON debate. JAC Antimicrob Resist 2021; 3:dlab153. [PMID: 34704033 PMCID: PMC8531865 DOI: 10.1093/jacamr/dlab153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Although the overwhelming majority of community-acquired pneumonia (CAP) in children is caused by viral infections, treatment of CAP is among the most common indications for antibiotic use in children. This is largely driven by the imprecision of clinical diagnostic tools to differentiate viral from bacterial pneumonia and highlights the need for improved approaches to optimizing management of CAP in children. In this issue of JAC-Antimicrobial Resistance, we present a PRO/CON debate that discusses the clinical utility of procalcitonin in children with CAP.
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Affiliation(s)
- Kathleen Chiotos
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey S Gerber
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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6
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Warris A. Macrolides (alone or in combination) should be used as first-line empirical therapy of community-acquired pneumonia in children: myth or maxim? Breathe (Sheff) 2021; 17:210056. [PMID: 35035545 PMCID: PMC8753631 DOI: 10.1183/20734735.0056-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/09/2021] [Indexed: 11/10/2022] Open
Abstract
Macrolides should not be used as first-line therapy for community-acquired pneumonia in children as no clinical benefit is shown and widespread use is associated with an emerging increase in macrolide resistance amongst S. pneumoniae and M. pneumoniae https://bit.ly/3yQuedF.
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Affiliation(s)
- Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, UK; Great Ormond Street Hospital, London, UK
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7
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Shapiro DJ, Hall M, Lipsett SC, Hersh AL, Ambroggio L, Shah SS, Brogan TV, Gerber JS, Williams DJ, Grijalva CG, Blaschke AJ, Neuman MI. Short- Versus Prolonged-Duration Antibiotics for Outpatient Pneumonia in Children. J Pediatr 2021; 234:205-211.e1. [PMID: 33745996 DOI: 10.1016/j.jpeds.2021.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/15/2021] [Accepted: 03/11/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify practice patterns in the duration of prescribed antibiotics for the treatment of ambulatory children with community-acquired pneumonia (CAP) and to compare the frequency of adverse clinical outcomes between children prescribed short-vs prolonged-duration antibiotics. STUDY DESIGN We performed a retrospective cohort study from 2010-2016 using the IBM Watson MarketScan Medicaid Database, a claims database of publicly insured patients from 11 states. We included children 1-18 years old with outpatient CAP who filled a prescription for oral antibiotics (n = 121 846 encounters). We used multivariable logistic regression to determine associations between the duration of prescribed antibiotics (5-9 days vs 10-14 days) and subsequent hospitalizations, new antibiotic prescriptions, and acute care visits. Outcomes were measured during the 14 days following the end of the dispensed antibiotic course. RESULTS The most commonly prescribed duration of antibiotics was 10 days (82.8% of prescriptions), and 10.5% of patients received short-duration therapy. During the follow-up period, 0.2% of patients were hospitalized, 6.2% filled a new antibiotic prescription, and 5.1% had an acute care visit. Compared with the prolonged-duration group, the aORs for hospitalization, new antibiotic prescriptions, and acute care visits in the short-duration group were 1.16 (95% CI 0.80-1.66), 0.93 (95% CI 0.85-1.01), and 1.06 (95% CI 0.98-1.15), respectively. CONCLUSIONS Most children treated for CAP as outpatients are prescribed at least 10 days of antibiotic therapy. Among pediatric outpatients with CAP, no significant differences were found in rates of adverse clinical outcomes between patients prescribed short-vs prolonged-duration antibiotics.
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Affiliation(s)
- Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | | | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, CO
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medicine Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Anne J Blaschke
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, CO
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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8
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Lipsett SC, Hall M, Ambroggio L, Hersh AL, Shah SS, Brogan TV, Gerber JS, Williams DJ, Grijalva CG, Blaschke AJ, Neuman MI. Antibiotic Choice and Clinical Outcomes in Ambulatory Children with Community-Acquired Pneumonia. J Pediatr 2021; 229:207-215.e1. [PMID: 33045236 PMCID: PMC7856045 DOI: 10.1016/j.jpeds.2020.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/09/2020] [Accepted: 10/05/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To describe antibiotic prescribing patterns in ambulatory children with community-acquired pneumonia and to assess the relationship between antibiotic selection and clinical outcomes. STUDY DESIGN This was a retrospective cohort study of ambulatory Medicaid-enrolled children 0-18 years of age diagnosed with community-acquired pneumonia from 2010 to 2016. The exposure was antibiotic class: narrow-spectrum (aminopenicillins), broad-spectrum (amoxicillin/clavulanate and cephalosporins), macrolide monotherapy, macrolides with narrow-spectrum antibiotics, or macrolides with broad-spectrum antibiotics. The associations between antibiotic selection and the outcomes of subsequent hospitalization and development of severe pneumonia (chest drainage procedure, intensive care admission, mechanical ventilation) were assessed, controlling for measures of illness severity. RESULTS Among 252 177 outpatient pneumonia visits, macrolide monotherapy was used in 43.2%, narrow-spectrum antibiotics in 26.1%, and broad-spectrum antibiotics in 24.7%. A total of 1488 children (0.59%) were subsequently hospitalized and 117 (0.05%) developed severe pneumonia. Compared with children receiving narrow-spectrum antibiotics, the odds of subsequent hospitalization were higher in children receiving broad-spectrum antibiotics (aOR, 1.34; 95% CI, 1.17-1.52) and lower in children receiving macrolide monotherapy (aOR, 0.64; 95% CI, 0.55-0.73) and macrolides with narrow-spectrum antibiotics (aOR, 0.62; 95% CI, 0.39-0.97). Children receiving macrolide monotherapy had lower odds of developing severe pneumonia than children receiving narrow-spectrum antibiotics (aOR, 0.56; 95% CI, 0.33-0.93). However, the absolute risk difference was <0.5% for all analyses. CONCLUSIONS Macrolides are the most commonly prescribed antibiotic for ambulatory children with community-acquired pneumonia. Subsequent hospitalization and severe pneumonia are rare. Future efforts should focus on reducing broad-spectrum and macrolide antibiotic prescribing.
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Affiliation(s)
- Susan C Lipsett
- Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | | | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Denver, CO
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medicine Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Anne J Blaschke
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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