Calidad de la prescripción antibiótica en un servicio de urgencias pediátrico hospitalario

[Adecuacy of pediatric antimicrobial prescribing in the Emergency Department at discharge]

INTRODUCTION

In January 2019, Community of Madrid's Health Department published a guide about the use of antimicrobials in outpatient children. Taking this regional Guide as reference, this study was aimed at estimating the adequacy of the antimicrobial stewardship at discharge from a pediatric Emergency Department (ED). Secondarily, the differences in adequacy according to the diagnosis and the prescriber were studied, and the agreement between this Guide and the protocols of the ED was assessed.

MATERIAL AND METHODS

An observational, descriptive, retrospective study was conducted on patients under 16 years old, with a diagnosis included in the regional Guide who were discharged from a pediatric ED between March of 2018 and February of 2019. Prescription was considered adequate when the indication, the antibiotic and the posology (dosage, dosing interval, length of treatment and route of administration) were correct.

RESULTS

165 out of 648 (25,5%) infectious diseases processes analyzed received antimicrobial treatment. In 23 processes treated with antimicrobial, the adequacy could not be evaluated due to the absence of data necessary to assess any aspect of posology. Therapy was considered appropriate in 550/625 processes (88.0%). When antimicrobial treatment was prescribed, 70/142 (49.3%) were appropriate and no statistically significant differences in adequacy were found between prescribers. Posology was the worst handled point of the prescription (26.3%). Tract urinary infection, conjunctivitis and otitis media were the pathologies with the lowest adecuacy (44.4%; 50.0% and 52.2%) and presented the highest discrepancy between the Guide and the center protocols (k=0.308; k=0.000; k=0.586).

CONCLUSIONS

The adequacy of the management of infectious processes to the reference Guide in our pediatric ED was high, but it was below 50% when antimicrobial treatment was required. The degree of adequacy to the local protocols of the center was greater than to the regional Guide. This reveals a discrepancy between the 2documents that should be analyzed and corrected according to the available scientific evidence.

[Appropriateness of antimicrobial prescriptions in the emergency department of a tertiary hospital]

OBJECTIVE

Antibiotics are widely prescribed in the Emergency Department (ED), representing 26-62% of outpatient antibiotic prescriptions. Around 40% of antibiotic prescriptions in hospitalized patients are inappropriate or unnecessary. The aim of the study was to assess the appropriateness of antibiotic prescriptions according to local empirical antibiotic treatment guidelines, in the ED of a tertiary hospital.

METHODS

Observational, retrospective study including patients attending the ED in November 2016, with an antibiotic prescription, excluding those from residents.

RESULTS

A total of 676 patients were included, 57.1% women, mean age 47.4 ± 21.2 years. Patient's diagnoses were 27.2% urinary tract infections (UTI), 24.1% lower respiratory tract infections, 15.4% skin and soft tissue infections (SSTI), 13.8% upper respiratory tract infections, 11.8% oral infections, 2.7% genital/sexually transmitted infections, 1.6% gastrointestinal infections, 0.3% ocular infections and 3.1% other. The most prescribed antibiotic families were: 44.1% penicillins, 21.3% fluoroquinolones. The most prescribed antibiotics were: fosfomycin trometamol in UTI (32.1%), levofloxacin in lower respiratory tract (46.2%) and amoxicillin/clavulanate in oral infections (71.6%), SSTI (62.5%) and upper respiratory tract (46.6%). In 56.8% (384) of the prescriptions antibiotics were indicated. An appropriated antibiotic was selected in 62% (238) of the prescriptions. Appropriated dosage and duration were selected in 82.8% (197) and 45.4% (108) of the prescriptions, respectively.

CONCLUSIONS

Appropriateness of antibiotic prescriptions was low, mainly due to an overuse of antibiotics when not indicated, broad spectrum and incorrect treatment duration. These data reinforce the need to enhance adherence to local empirical antibiotic treatment guidelines by developing an antimicrobial stewardship program in the ED.

Antibiotics in respiratory tract infections in hospital pediatric emergency departments

BACKGROUND

Respiratory tract infections are one of the most frequent problems in pediatric clinics and generate an elevated prescription of antibiotics. The aim of this study was to find out the standard of care practice about antibiotic use in these infections in a pediatric emergency department and to evaluate compliance with clinical guidelines.

METHODS

A pediatric emergency department database was reviewed from July 2005 to October 2007 under the category "respiratory infection", including variables such as age, antibiotic prescription and compliance with current clinical recommendations.

RESULTS

Out of the 23,114 reviewed reports, 32.7% (7,567) were upper respiratory tract infections (URTI) (cold, acute otitis media [AOM], sinusitis and tonsillopharyngitis) or lower respiratory tract infections (LRTI) (laryngitis, bronchitis, bronchiolitis and pneumonia). Children under the age of 2 were the most represented age group. Amongst URTI, rhinopharyngitis was the most frequent infection, while bronchitis was the most frequent among LRTI. Antibiotic therapy (mainly amoxicillin) was prescribed in 30.8% of URTI (5.7% rhinopharyngitis, 96.5% AOM, and 36.7% tonsillopharyngitis) and in 12.4% of LRTI.

CONCLUSIONS

The percentage of respiratory tract infections was similar to previous studies and the antibiotic prescriptions followed current guidelines, except for cases diagnosed with AOM. Prescription compliance and clinical course of the cases should be monitored.

[Appropriateness of antibiotic prescribing in a primary care area: a cross-sectional study]

OBJECTIVE

To assess the profile of patients receiving antibiotics and the appropriateness of these prescriptions for the clinical conditions.

METHODS

DESIGN

Cross-sectional study of prescription-indication.

SETTING

A primary health care area in Andalusia.

SUBJECTS

Patients assigned to primary care centres. Patients with antibiotic prescriptions during 2009 were selected by simple random sampling (confidence level: 95%, accuracy: 5%). Primary endpoint: appropriateness of antibiotics prescribing to recommendations included in local guidelines. Data were obtained through the billing computerised prescriptions system and medical histories.

RESULTS

Twenty-five per cent of the population area received antibiotics during 2009. The 1,266 patient samples showed the following characteristics: 57.9% were women, with a mean age of 41 (±1) years. There were 39.3% pensioners. The percentage of appropriate antibiotic prescriptions was 19.9%, with no difference due to gender. Statistically significant differences were related to age, being those over 65 years the group of patients with the highest percentage of inappropriateness. The main reasons for inappropriateness were: no recording of the infectious process (44.5%), a wrong treatment duration (15.5%), and the use of an inadequate antibiotic (11.5%).

CONCLUSION

There is a high level of inappropriateness in antibiotic prescribing in primary care. The high level of under-recording of diagnoses, mainly in elderly patients, followed by the use of wrong schedules, and the wrong type of antibiotics were the main reasons of inappropriateness.

[Prescribing of antibiotics in patients admitted from Emergency Departments: a multicenter study]

INTRODUCTION

The infectious disease is the main source of care demand in Pediatric Emergency Departments (PED) and is a frequent cause of hospital admission with antibiotics. Our objectives are: 1) to determine the diseases that are seen in PED that required admission with antibiotics; 2) to determine the microbiological methods used and, 3) to analyze the characteristics of the indicated treatment.

MATERIAL AND METHODS

A prospective multicenter study was conducted in 22 Spanish hospitals. We included patients younger than 18 years seen in PED on day 14 of each month between June 2009 and May 2010 who required hospitalization with systemic antibiotics. Patients admitted to Intensive Care Unit were excluded.

RESULTS

There were 30,632 consultations in the PED during the study period. A total of 1,446 (4.7%) patients were hospitalized, 395 (27.3%) of them with antibiotics. Ninety-five patients (24.1%) had received antibiotics before admission. Three hundred twenty (81%) children underwent at least one microbiological test, with blood culture (69.9%) and urine culture (30.9%) being the most requested ones. The main diagnoses at admission were pneumonia (29.4%), urinary tract infection (15.4%), and fever without source (12.1%). Twenty five different antibiotics were prescribed, with cefotaxime (27.8%) and amoxicillin-clavulanate (23.4%) being the most prescribed ones. A single antibiotic was prescribed to 80.8% of patients, and parenteral administration was the most indicated (93.7%).

CONCLUSIONS

Antibiotic therapy was prescribed in one in every 4 patients who required admission to hospital. Pneumonia was the most common source. Blood culture was the most frequent microbiological test requested in the PED. A limited number of beta-lactam antibiotics represented the majority of antibiotic prescriptions.

[Consensus document on the diagnosis and treatment of acute tonsillopharyngitis]

Acute tonsillopharyngitis is one of the most common childhood diseases. Viruses are the most frequent origin. Group A Streptococcus (Streptococcus pyogenes) is the main bacterial cause. A culture or a rapid antigen-detection test of a throat-swab specimen should only be done on the basis of clinical scores, in order to avoid over-diagnosis of bacterial origin and unnecessary antibiotic prescription. The objectives of treatment are: the reduction of symptoms, reduce the contagious period, and prevent local suppurative and systemic complications. Ideally, only confirmed cases should receive antibiotics. If there is no possibility to perform a rapid antigen-detection test, or in some cases if the result is negative, it is recommended to perform a culture and, if there is high suspicious index, to prescribe antibiotics. Penicillin is the treatment of choice, although amoxicillin is also accepted as the first option. Amoxicillin/clavulanate is not indicated in any case as empirical treatment. Macrolides are not a first choice antibiotic, and should be reserved for those patients with immediate penicillin allergy reaction or for the treatment of streptococcal carriers. It is of primordial importance to adapt the prescribing of antibiotics to the scientific evidence.