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Klein E, Saheed M, Irvin N, Balhara KS, Badaki-Makun O, Poleon S, Kelen G, Cosgrove SE, Hinson J. Racial and Socioeconomic Disparities Evident in Inappropriate Antibiotic Prescribing in the Emergency Department. Ann Emerg Med 2024; 84:101-110. [PMID: 38260931 DOI: 10.1016/j.annemergmed.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/21/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024]
Abstract
STUDY OBJECTIVE Inappropriate antibiotic prescribing for acute respiratory tract infections is a common source of low-value care in the emergency department (ED). Racial and socioeconomic disparities have been noted in episodes of low-value care, particularly in children. We evaluated whether prescribing rates for acute respiratory tract infections when antibiotics would be inappropriate by guidelines differed by race and socioeconomics. METHODS A retrospective cross-sectional analysis of adult and pediatric patient encounters in the emergency department (ED) between 2015 and 2023 at 5 hospitals for acute respiratory tract infections that did not require antibiotics by guidelines. Multivariable regression was used to calculate the risk ratio between race, ethnicity, and area deprivation index and inappropriate antibiotic prescribing, controlling for patient age, sex, and relevant comorbidities. RESULTS A total of 147,401 ED encounters (55% pediatric, 45% adult) were included. At arrival, 4% patients identified as Asian, 50% as Black, 5% as Hispanic, and 23% as White. Inappropriate prescribing was noted in 7.6% of overall encounters, 8% for Asian patients, 6% for Black patients, 5% for Hispanic patients, and 12% for White patients. After adjusting for age, sex, comorbidities, and area deprivation index, White patients had a 1.32 (95% confidence interval, 1.26 to 1.38) higher likelihood of receiving a prescription compared with Black patients. Patients residing in areas of greater socioeconomic deprivation, regardless of race and ethnicity, had a 0.74 (95% confidence interval, 0.70 to 0.78) lower likelihood of receiving a prescription. CONCLUSION Our results suggest that although overall inappropriate prescribing was relatively low, White patients and patients from wealthier areas were more likely to receive an inappropriate antibiotic prescription.
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Affiliation(s)
- Eili Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; OneHealthTrust, Washington, DC.
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nathan Irvin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kamna S Balhara
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Oluwakemi Badaki-Makun
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeremiah Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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2
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Bohn MK, Havelka A, Eriksson M, Adeli K. Validation of Serum Calprotectin Relative to Other Biomarkers of Infection in Febrile Infants Presenting to the Emergency Department. Antibiotics (Basel) 2024; 13:425. [PMID: 38786153 PMCID: PMC11117379 DOI: 10.3390/antibiotics13050425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/29/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024] Open
Abstract
Antimicrobial stewardship involves a delicate balance between the risk of undertreating individuals and the potential societal burden of overprescribing antimicrobials. This balance is especially crucial in neonatal care. In this observational study, the usefulness of biomarkers of infectious diseases (calprotectin, procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBCs) were evaluated in 141 febrile infants aged 28-90 days presenting to an emergency department. Since our focus was on the usefulness of serum calprotectin, this biomarker was not part of clinical decision-making. A significant difference was observed in the levels of all biomarkers, related to final discharge diagnosis and disposition status. The difference in levels related to antibiotic prescription was significant for all biomarkers but WBCs. The performance of calprotectin in the detection of bacterial infections (AUC (95% CI): 0.804 (0.691, 0.916)) was comparable to the performance of both PCT (0.901 (0.823, 0.980)) and CRP (0.859 (0.764, 0.953)) and superior to the WBC count (0.684 (0.544, 0.823)). Procalcitonin and CRP demonstrated a statistically significantly higher specificity relative to calprotectin. In this cohort, antibiotic use did not always correlate to a definite diagnosis of confirmed bacterial infection. The sample size was limited due to associated challenges with recruiting febrile infants. Hence, there is a need for adequate diagnostic tools to help discriminate between various kinds of infections. This study suggests serum calprotectin, procalcitonin, and CRP may serve as valuable biomarkers to differentiate between types of infection, in addition to clinical input and decision-making.
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Affiliation(s)
- Mary Kathryn Bohn
- Department of Pathology and Laboratory Medicine, University of Toronto, Toronto, ON M5G 1X8, Canada;
- Molecular Medicine, SickKids Research Institute, Toronto, ON M5G 0A4, Canada
| | - Aleksandra Havelka
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76 Stockholm, Sweden;
- Gentian AS, 1596 Moss, Norway
| | - Mats Eriksson
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, 751 85 Uppsala, Sweden;
- NOVA Medical School, New University of Lisbon, 1099-085 Lisbon, Portugal
| | - Khosrow Adeli
- Department of Pathology and Laboratory Medicine, University of Toronto, Toronto, ON M5G 1X8, Canada;
- Molecular Medicine, SickKids Research Institute, Toronto, ON M5G 0A4, Canada
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3
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Slopen N, Chang AR, Johnson TJ, Anderson AT, Bate AM, Clark S, Cohen A, Jindal M, Karbeah J, Pachter LM, Priest N, Suglia SF, Bryce N, Fawcett A, Heard-Garris N. Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:147-158. [PMID: 38242597 DOI: 10.1016/s2352-4642(23)00251-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 08/02/2023] [Accepted: 09/08/2023] [Indexed: 01/21/2024]
Abstract
Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.
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Affiliation(s)
- Natalie Slopen
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Center on the Developing Child, Harvard University, Boston, MA, USA.
| | - Andrew R Chang
- Harvard Medical School, Harvard University, Boston, MA, USA
| | | | - Ashaunta T Anderson
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Aleha M Bate
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Stanely Manne Children's Research Institute, Chicago, IL, USA
| | - Shawnese Clark
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Stanely Manne Children's Research Institute, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alyssa Cohen
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Monique Jindal
- Department of Clinical Medicine, University of Illinois, Chicago, IL, USA
| | - J'Mag Karbeah
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Lee M Pachter
- Institute for Research on Equity and Community Health, ChristianaCare, Wilmington, DE, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA; School of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | - Naomi Priest
- Centre for Social Research and Methods, Australian National University, Canberra, ACT, Australia; Population Health, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Shakira F Suglia
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Nessa Bryce
- Department of Psychology, Harvard University, Boston, MA, USA
| | - Andrea Fawcett
- Department of Clinical and Organizational Development, Chicago, IL, USA
| | - Nia Heard-Garris
- Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Chicago, IL, USA; Department of Pediatrics, Chicago, IL, USA; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Kim C, Kabbani S, Dube WC, Neuhauser M, Tsay S, Hersh A, Marcelin JR, Hicks LA. Health Equity and Antibiotic Prescribing in the United States: A Systematic Scoping Review. Open Forum Infect Dis 2023; 10:ofad440. [PMID: 37671088 PMCID: PMC10475752 DOI: 10.1093/ofid/ofad440] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/17/2023] [Indexed: 09/07/2023] Open
Abstract
We performed a scoping review of articles published from 1 January 2000 to 4 January 2022 to characterize inequities in antibiotic prescribing and use across healthcare settings in the United States to inform antibiotic stewardship interventions and research. We included 34 observational studies, 21 cross-sectional survey studies, 4 intervention studies, and 2 systematic reviews. Most studies (55 of 61 [90%]) described the outpatient setting, 3 articles were from dentistry, 2 were from long-term care, and 1 was from acute care. Differences in antibiotic prescribing were found by patient's race and ethnicity, sex, age, socioeconomic factors, geography, clinician's age and specialty, and healthcare setting, with an emphasis on outpatient settings. Few studies assessed stewardship interventions. Clinicians, antibiotic stewardship experts, and health systems should be aware that prescribing behavior varies according to both clinician- and patient-level markers. Prescribing differences likely represent structural inequities; however, no studies reported underlying drivers of inequities in antibiotic prescribing.
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Affiliation(s)
- Christine Kim
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - William C Dube
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melinda Neuhauser
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon Tsay
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adam Hersh
- University of Utah, Salt Lake City, Utah, USA
| | | | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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5
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Goodman KE, Baghdadi JD, Magder LS, Heil EL, Sutherland M, Dillon R, Puzniak L, Tamma PD, Harris AD. Patterns, Predictors, and Intercenter Variability in Empiric Gram-Negative Antibiotic Use Across 928 United States Hospitals. Clin Infect Dis 2023; 76:e1224-e1235. [PMID: 35737945 PMCID: PMC9907550 DOI: 10.1093/cid/ciac504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Empiric antibiotic use among hospitalized adults in the United States (US) is largely undescribed. Identifying factors associated with broad-spectrum empiric therapy may inform antibiotic stewardship interventions and facilitate benchmarking. METHODS We performed a retrospective cohort study of adults discharged in 2019 from 928 hospitals in the Premier Healthcare Database. "Empiric" gram-negative antibiotics were defined by administration before day 3 of hospitalization. Multivariable logistic regression models with random effects by hospital were used to evaluate associations between patient and hospital characteristics and empiric receipt of broad-spectrum, compared to narrow-spectrum, gram-negative antibiotics. RESULTS Of 8 017 740 hospitalized adults, 2 928 657 (37%) received empiric gram-negative antibiotics. Among 1 781 306 who received broad-spectrum therapy, 30% did not have a common infectious syndrome present on admission (pneumonia, urinary tract infection, sepsis, or bacteremia), surgery, or an intensive care unit stay in the empiric window. Holding other factors constant, males were 22% more likely (adjusted odds ratio [aOR], 1.22 [95% confidence interval, 1.22-1.23]), and all non-White racial groups 6%-13% less likely (aOR range, 0.87-0.94), to receive broad-spectrum therapy. There were significant prescribing differences by region, with the highest adjusted odds of broad-spectrum therapy in the US West South Central division. Even after model adjustment, there remained substantial interhospital variability: Among patients receiving empiric therapy, the probability of receiving broad-spectrum antibiotics varied as much as 34+ percentage points due solely to the admitting hospital (95% interval of probabilities: 43%-77%). CONCLUSIONS Empiric gram-negative antibiotic use is highly variable across US regions, and there is high, unexplained interhospital variability. Sex and racial disparities in the receipt of broad-spectrum therapy warrant further investigation.
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Affiliation(s)
- Katherine E Goodman
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Mark Sutherland
- Division of Critical Care, Departments of Emergency Medicine and Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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6
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Cohen HA, Gerstein M, Loewenberg Weisband Y, Richenberg Y, Jacobson E, Cohen M, Shkalim Zemer V, Machnes MD. Pediatric Antibiotic Stewardship for Community-Acquired Pneumonia: A Pre-Post Intervention Study. Clin Pediatr (Phila) 2022; 61:795-801. [PMID: 35673872 DOI: 10.1177/00099228221102827] [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] [Indexed: 11/16/2022]
Abstract
We aimed to investigate the effectiveness of an antibiotic stewardship program (ASP) on antibiotic prescription in children with community-acquired pneumonia (CAP). Antibiotic purchasing data were collected for children aged 3 months to 18 years diagnosed with CAP from November 2016 to April 2017 (pre-intervention period) and from November 2017 to April 2018 (post-intervention period). The intervention was a 1-day seminar for primary care pediatricians on the diagnosis and treatment of CAP in children according to national guidelines. There was a substantial decrease in the use of azithromycin after the intervention. In younger children, there was a 42% decrease, alongside an increased use of amoxicillin (P < .001). In older children, there was a smaller, non-statistically significant decrease in the use of azithromycin (P = .45). Our data demonstrate that the implementation of an ASP was associated with a reduction in the use of broad-spectrum antibiotics and macrolides and increased guideline adherence for the safe treatment of CAP.
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Affiliation(s)
- Herman Avner Cohen
- Pediatric Ambulatory Community Clinic, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya Gerstein
- Pediatric Ambulatory Community Clinic, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Eyal Jacobson
- Clalit Health Services, Dan-Petach Tikva District, Israel
| | | | - Vered Shkalim Zemer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Clalit Health Services, Petach Tikva, Israel
| | - Maayan Diti Machnes
- Pediatric Ambulatory Community Clinic, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Schroeder AM, Lewis SS, Sahmoun AE, Beal JR. Antibiotic utilization for adult acute respiratory tract infections in United States Emergency Departments. Am J Emerg Med 2021; 47:66-69. [PMID: 33774452 DOI: 10.1016/j.ajem.2021.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/23/2021] [Accepted: 03/05/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Antibiotic stewardship programs have been a major focus in recent years to curtail antibiotic resistance. The purpose of this study was to evaluate antibiotic utilization for acute respiratory tract infections (ARTI) in the Emergency Department (ED) setting. MATERIAL AND METHODS A retrospective analysis of adult ARTI visits to EDs utilizing 2011-2017 National Hospital Ambulatory Medical Care Survey- Emergency Department (NHAMCS-ED) datasets was conducted. Included were all visits of adults (≥18 years) diagnosed with ARTI. Antibiotics were determined based upon NHAMCS-ED use of the Multum Lexicon Drug Database coding system. All significance tests were two-sided, P-value <0.05 for significance. RESULTS A total of 4632 unweighted ED visits, which represented more than 28 million US ED visits from 2011 to 2017, with 57.2% receiving a prescription for antibiotics. Antibiotic prescriptions for ARTI significantly declined from 65.8% in 2011 to 54.3% in 2017 (P = 0.046). Among all visits, patients were more likely to receive an antibiotic if they were over age 45 (33.0% vs 27.6%, P = 0.005), male (36.7% vs. 32.3%, P = 0.039), and presenting in a non-MSA ED (21.4% vs. 14.5%, P = 0.002). No association was found between antibiotic prescription and race (P = 0.076) insurance (P = 0.488), CBC (P = 0.148), x-ray (P = 0.278), and blood cultures (P = 0.182). CONCLUSION We found a significant reduction in the utilization of antibiotics among adult ARTI visits to U.S. EDs from 2011 to 2017. This is an improvement from previous studies which showed no change, suggesting that antimicrobial stewardship efforts may be impacting overall antibiotic use and should continue to be practiced.
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Affiliation(s)
| | - Sarah S Lewis
- University of North Dakota School of Medicine, Grand Forks, ND, USA
| | - Abe E Sahmoun
- University of North Dakota School of Medicine, Department of Internal Medicine, Grand Forks, ND, USA
| | - James R Beal
- University of North Dakota School of Medicine, Department of Family and Community Medicine, Grand Forks, ND, USA.
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8
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van de Maat JS, Garcia Perez D, Driessen GJA, van Wermeskerken AM, Smit FJ, Noordzij JG, Tramper-Stranders G, Obihara CC, Punt J, Moll HA, Oostenbrink R. The influence of chest X-ray results on antibiotic prescription for childhood pneumonia in the emergency department. Eur J Pediatr 2021; 180:2765-2772. [PMID: 33754207 PMCID: PMC8346381 DOI: 10.1007/s00431-021-03996-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 02/02/2021] [Accepted: 02/10/2021] [Indexed: 12/02/2022]
Abstract
The aim of this study is to evaluate the influence of chest X-ray (CXR) results on antibiotic prescription in children suspected of lower respiratory tract infections (RTI) in the emergency department (ED). We performed a secondary analysis of a stepped-wedge, cluster randomized trial of children aged 1 month to 5 years with fever and cough/dyspnoea in 8 EDs in the Netherlands (2016-2018), including a 1-week follow-up. We analysed the observational data of the pre-intervention period, using multivariable logistic regression to evaluate the influence of CXR result on antibiotic prescription. We included 597 children (median age 17 months [IQR 9-30, 61% male). CXR was performed in 109/597 (18%) of children (range across hospitals 9 to 50%); 52/109 (48%) showed focal infiltrates. Children who underwent CXR were more likely to receive antibiotics, also when adjusted for clinical signs and symptoms, hospital and CXR result (OR 7.25 [95% CI 2.48-21.2]). Abnormalities on CXR were not significantly associated with antibiotic prescription.Conclusion: Performance of CXR was independently associated with more antibiotic prescription, regardless of its results. The limited influence of CXR results on antibiotic prescription highlights the inferior role of CXR on treatment decisions for suspected lower RTI in the ED. What is Known: • Chest X-ray (CXR) has a high inter-observer variability and cannot distinguish between bacterial or viral pneumonia. • Current guidelines recommend against routine use of CXR in children with uncomplicated respiratory tract infections (RTIs) in the outpatient setting. What is New: • CXR is still frequently performed in non-complex children suspected of lower RTIs in the emergency department • CXR performance was independently associated with more antibiotic prescriptions, regardless of its results, highlighting the inferior role of chest X-rays in treatment decisions.
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Affiliation(s)
- Josephine S. van de Maat
- grid.416135.4Department of General Paediatrics, Erasmus MC – Sophia Children’s Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Daniella Garcia Perez
- grid.416135.4Department of General Paediatrics, Erasmus MC – Sophia Children’s Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Gertjan J. A. Driessen
- grid.414786.8Department of Paediatrics, HAGA-Juliana Children’s Hospital, Den Haag, The Netherlands
| | | | - Frank J. Smit
- grid.416213.30000 0004 0460 0556Department of Paediatrics, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - Jeroen G. Noordzij
- grid.415868.60000 0004 0624 5690Department of Paediatrics, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Gerdien Tramper-Stranders
- grid.461048.f0000 0004 0459 9858Department of Paediatrics, Franciscus Gasthuis &Vlietland, locatie Gasthuis, Rotterdam, The Netherlands
| | - Charlie C. Obihara
- Department of Paediatrics, Elisabeth Tweestedenziekenhuis, Tilburg, The Netherlands
| | - Jeanine Punt
- Department of Paediatrics, Langeland Ziekenhuis, Zoetermeer, The Netherlands
| | - Henriette A. Moll
- grid.416135.4Department of General Paediatrics, Erasmus MC – Sophia Children’s Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC - Sophia Children's Hospital, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands.
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9
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Lipshaw MJ, Eckerle M, Florin TA, Crotty EJ, Lipscomb J, Jacobs J, Rattan MS, Ruddy RM, Shah SS, Ambroggio L. Antibiotic Use and Outcomes in Children in the Emergency Department With Suspected Pneumonia. Pediatrics 2020; 145:peds.2019-3138. [PMID: 32179662 PMCID: PMC7111492 DOI: 10.1542/peds.2019-3138] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Antibiotic therapy is often prescribed for suspected community-acquired pneumonia (CAP) in children despite a lack of knowledge of causative pathogen. Our objective in this study was to investigate the association between antibiotic prescription and treatment failure in children with suspected CAP who are discharged from the hospital emergency department (ED). METHODS We performed a prospective cohort study of children (ages 3 months-18 years) who were discharged from the ED with suspected CAP. The primary exposure was antibiotic receipt or prescription. The primary outcome was treatment failure (ie, hospitalization after being discharged from the ED, return visit with antibiotic initiation or change, or antibiotic change within 7-15 days from the ED visit). The secondary outcomes included parent-reported quality-of-life measures. Propensity score matching was used to limit potential bias attributable to treatment selection between children who did and did not receive an antibiotic prescription. RESULTS Of 337 eligible children, 294 were matched on the basis of propensity score. There was no statistical difference in treatment failure between children who received antibiotics and those who did not (odds ratio 1.0; 95% confidence interval 0.45-2.2). There was no difference in the proportion of children with return visits with hospitalization (3.4% with antibiotics versus 3.4% without), initiation and/or change of antibiotics (4.8% vs 6.1%), or parent-reported quality-of-life measures. CONCLUSIONS Among children with suspected CAP, the outcomes were not statistically different between those who did and did not receive an antibiotic prescription.
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Affiliation(s)
| | - Michelle Eckerle
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Todd A. Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois; and
| | - Eric J. Crotty
- Radiology,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Mantosh S. Rattan
- Radiology,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Richard M. Ruddy
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Samir S. Shah
- Hospital Medicine, and,Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado Denver and Sections of Emergency Medicine and Hospital Medicine, Children’s Hospital Colorado, Denver, Colorado
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van Houten CB, Cohen A, Engelhard D, Hays JP, Karlsson R, Moore E, Fernández D, Kreisberg R, Collins LV, de Waal W, de Winter-de Groot KM, Wolfs TFW, Meijers P, Luijk B, Oosterheert JJ, Heijligenberg R, Sankatsing SUC, Bossink AWJ, Stubbs A, Stein M, Reisfeld S, Klein A, Rachmilevitch R, Ashkar J, Braverman I, Kartun V, Chistyakov I, Bamberger E, Srugo I, Odeh M, Schiff E, Dotan Y, Boico O, Navon R, Friedman T, Etshtein L, Paz M, Gottlieb TM, Pri-Or E, Kronenfeld G, Simon E, Oved K, Eden E, Bont LJ. Antibiotic misuse in respiratory tract infections in children and adults-a prospective, multicentre study (TAILORED Treatment). Eur J Clin Microbiol Infect Dis 2019; 38:505-514. [PMID: 30707378 PMCID: PMC6394715 DOI: 10.1007/s10096-018-03454-2] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/05/2018] [Indexed: 12/20/2022]
Abstract
Respiratory tract infections (RTI) are more commonly caused by viral pathogens in children than in adults. Surprisingly, little is known about antibiotic use in children as compared to adults with RTI. This prospective study aimed to determine antibiotic misuse in children and adults with RTI, using an expert panel reference standard, in order to prioritise the target age population for antibiotic stewardship interventions. We recruited children and adults who presented at the emergency department or were hospitalised with clinical presentation of RTI in The Netherlands and Israel. A panel of three experienced physicians adjudicated a reference standard diagnosis (i.e. bacterial or viral infection) for all the patients using all available clinical and laboratory information, including a 28-day follow-up assessment. The cohort included 284 children and 232 adults with RTI (median age, 1.3 years and 64.5 years, respectively). The proportion of viral infections was larger in children than in adults (209(74%) versus 89(38%), p < 0.001). In case of viral RTI, antibiotics were prescribed (i.e. overuse) less frequently in children than in adults (77/209 (37%) versus 74/89 (83%), p < 0.001). One (1%) child and three (2%) adults with bacterial infection were not treated with antibiotics (i.e. underuse); all were mild cases. This international, prospective study confirms major antibiotic overuse in patients with RTI. Viral infection is more common in children, but antibiotic overuse is more frequent in adults with viral RTI. Together, these findings support the need for effective interventions to decrease antibiotic overuse in RTI patients of all ages.
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Affiliation(s)
- Chantal B van Houten
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, P.O. Box 85090, Office KC.03.063.0, 3508 AB, Utrecht, The Netherlands
| | | | - Dan Engelhard
- Division of Paediatric Infectious Disease Unit, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - John P Hays
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Roger Karlsson
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Edward Moore
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | - Wouter de Waal
- Department of Paediatrics, Diakonessenhuis, Utrecht, The Netherlands
| | - Karin M de Winter-de Groot
- Department of Paediatric Respiratory Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tom F W Wolfs
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, P.O. Box 85090, Office KC.03.063.0, 3508 AB, Utrecht, The Netherlands
| | - Pieter Meijers
- Department of Paediatrics, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Bart Luijk
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rik Heijligenberg
- Department of Internal Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | | | - Aik W J Bossink
- Department of Respiratory Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Andrew Stubbs
- Department of Bioinformatics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Michal Stein
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Sharon Reisfeld
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Adi Klein
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | | | - Jalal Ashkar
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Itzhak Braverman
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Valery Kartun
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Irena Chistyakov
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Ellen Bamberger
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Isaac Srugo
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Majed Odeh
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Elad Schiff
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Yaniv Dotan
- Department of Internal Medicine, Bnai Zion Medical Centre, Haifa, Israel
| | | | | | | | | | | | | | | | | | | | | | | | - Louis J Bont
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, P.O. Box 85090, Office KC.03.063.0, 3508 AB, Utrecht, The Netherlands.
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van de Voort EMF, Mintegi S, Gervaix A, Moll HA, Oostenbrink R. Antibiotic Use in Febrile Children Presenting to the Emergency Department: A Systematic Review. Front Pediatr 2018; 6:260. [PMID: 30349814 PMCID: PMC6186802 DOI: 10.3389/fped.2018.00260] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 08/31/2018] [Indexed: 01/30/2023] Open
Abstract
Introduction: While fever is the main complaint among pediatric emergency services and high antibiotic prescription are observed, only a few studies have been published addressing this subject. Therefore this systematic review aims to summarize antibiotic prescriptions in febrile children at the ED and assess its determinants. Methods: We extracted studies published from 2000 to 2017 on antibiotic use in febrile children at the ED from different databases. Author, year, and country of publishing, study design, inclusion criteria, primary outcome, age, and number of children included in the study was extracted. To compare the risk-of-bias all articles were assessed using the MINORS criteria. For the final quality assessment we additionally used the sample size and the primary outcome. Results: We included 26 studies reporting on antibiotic prescription and 28 intervention studies on the effect on antibiotic prescription. In all 54 studies antibiotic prescriptions in the ED varied from 15 to 90.5%, pending on study populations and diagnosis. Respiratory tract infections were mostly studied. Pediatric emergency physicians prescribed significantly less antibiotics then general emergency physicians. Most frequent reported interventions to reduce antibiotics are delayed antibiotic prescription in acute otitis media, viral testing and guidelines. Conclusion: Evidence on antibiotic prescriptions in children with fever presenting to the ED remains inconclusive. Delayed antibiotic prescription in acute otitis media and guidelines for fever and respiratory infections can effectively reduce antibiotic prescription in the ED. The large heterogeneity of type of studies and included populations limits strict conclusions, such a gap in knowledge on the determining factors that influence antibiotic prescription in febrile children presenting to the ED remains.
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Affiliation(s)
| | - Santiago Mintegi
- Pediatric Emergency Department, Cruces University Hospital, University of the Basque Country, Bilbao, Spain
| | - Alain Gervaix
- Division of Pediatric Emergency Medicine, Department of Child and Adolescent, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Henriette A. Moll
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Rianne Oostenbrink
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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