Antibiotic Choice and Clinical Outcomes in Ambulatory Children with Community-Acquired Pneumonia

Improving Antibiotic Prescribing for Children with Community-acquired Pneumonia in Outpatient Settings

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.

Cost of Pediatric Pneumonia Episodes With or Without Chest Radiography

BACKGROUND AND OBJECTIVES

Despite its routine use, it is unclear whether chest radiograph (CXR) is a cost-effective strategy in the workup of community-acquired pneumonia (CAP) in the pediatric emergency department (ED). We sought to assess the costs of CAP episodes with and without CXR among children discharged from the ED.

METHODS

This was a retrospective cohort study within the Healthcare Cost and Utilization Project State ED and Inpatient Databases of children aged 3 months to 18 years with CAP discharged from any EDs in 8 states from 2014 to 2019. We evaluated total 28-day costs after ED discharge, including the index visit and subsequent care. Mixed-effects linear regression models adjusted for patient-level variables and illness severity were performed to evaluate the association between CXR and costs.

RESULTS

We evaluated 225c781 children with CAP, and 86.2% had CXR at the index ED visit. Median costs of the 28-day episodes, index ED visits, and subsequent visits were $314 (interquartile range [IQR] 208-497), $288 (IQR 195-433), and $255 (IQR 133-637), respectively. There was a $33 (95% confidence interval [CI] 22-44) savings over 28-days per patient for those who received a CXR compared with no CXR after adjusting for patient-level variables and illness severity. Costs during subsequent visits ($26 savings, 95% CI 16-36) accounted for the majority of the savings as compared with the index ED visit ($6, 95% CI 3-10).

CONCLUSIONS

Performance of CXR for CAP diagnosis is associated with lower costs when considering the downstream provision of care among patients who require subsequent health care after initial ED discharge.

Assessing the utilization of antimicrobial agents in pediatric pneumonia during the era of the 13-valent pneumococcal conjugate vaccine: A retrospective, single-center study

BACKGROUND AND PURPOSE

Pneumonia and bronchopneumonia are the most common infectious diseases in children. This study aimed to analyze changes in causative pathogens and antibiotic use for bronchopneumonia or pneumonia after the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in children.

METHODS

This retrospective study was conducted from 2009 to 2019. Hospitalized children aged 6 months-3 years with a discharge diagnosis of bronchopneumonia or pneumonia were included to analyze changes in the potential mismatch between the diagnosed pathogen and antibiotic use.

RESULTS

The cohort comprised 1100 patients, including 648 (59%) and 452 (41%) with a discharge diagnosis of bronchopneumonia and pneumonia, respectively. The trend of viral pneumonia increased every year (rs = 0.101, p < 0.05) Antibiotics were administered in 97% patients, with an increasing annual trend in macrolide use (rs = 0.031, p = 0.009). Regarding antibiotic utilization, no significant variations were observed in the days of therapy (DOT) (rs = 0.076, p = 0.208) or length of therapy (LOT) (rs = -0.027, p = 0.534) per patient-year throughout the study duration. Interestingly, the LOT for combined therapy with macrolides and first-line beta-lactams was high (rs = 0.333, p = 0.028). In viral pneumonia treatment, neither the DOT nor LOT exhibited significant variations (rs = -0.006, p = 0.787 and rs = -0.156, p = 0.398).

CONCLUSION

After the introduction of PCV13 in Taiwan, no decrease in antibiotic use has been observed among children aged 6 months-3 years with a discharge diagnosis of bronchopneumonia and pneumonia.

Quality of antibiotic prescribing for pediatric community-acquired Pneumonia in outpatient care

BACKGROUND

Antibiotics remain the primary treatment for community acquired pneumonia (CAP), however rising rates of antimicrobial resistance may jeopardize their future efficacy. With higher rates of disease reported in the youngest populations, effective treatment courses for pediatric pneumonia are of paramount importance. This study is the first to examine the quality of pediatric antibiotic use by agent, dose and duration.

METHODS

A retrospective cohort study included all outpatient/primary care physician visits for pediatric CAP (aged < 19 years) between January 1 2014 to December 31 2018. Relevant practice guidelines were identified, and treatment recommendations extracted. Amoxicillin was the primary first-line agent for pediatric CAP. Categories of prescribing included: guideline adherent, effective but unnecessary (excess dose and/or duration), under treatment (insufficient dose and/or duration), and not recommended. Proportions of attributable-antibiotic use were examined by prescribing category, and then stratified by age and sex.

RESULT(S)

A total of 42,452 episodes of pediatric CAP were identified. Of those, 31,347 (76%) resulted in an antibiotic prescription. Amoxicillin accounted for 51% of all prescriptions. Overall, 27% of prescribing was fully guideline adherent, 19% effective but unnecessary, 10% under treatment, and 44% not recommended by agent. Excessive duration was the hallmark of effective but unnecessary prescribing (97%) Macrolides accounted for the majority on non-first line agent use, with only 32% of not recommended prescribing preceded by a previous course of antibiotics.

CONCLUSION(S)

This study is the first in Canada to examine prescribing quality for pediatric CAP by agent, dose and duration. Utilizing first-line agents, and shorter-course treatments are targets for stewardship.

Use of antibiotics contrary to guidelines for children's lower respiratory tract infections in different health care settings

This study aimed to evaluate antibiotic prescriptions for children with lower respiratory tract infection (LRTI) in public and private primary care clinics and in a hospital's pediatric emergency department (PED) in 2012-2013 (pre-guideline) and in 2014-2015 (post-guideline). Special attention was paid to guideline compliance, especially regarding macrolide prescriptions, which the guidelines discourage. Retrospective data of 1431 children with LRTI in November-December 2012-2015 were collected from electronic registers and checked manually. Three diagnostic groups were analyzed: community-acquired pneumonia (CAP), wheezing bronchitis, and non-wheezing bronchitis. A comparison of the pre- and post-guideline periods revealed antibiotic prescription rates of 48.7% and 48.9% (p = 0.955) for all LRTIs, respectively, and 77.6% and 71.0% (p = 0.053) for non-wheezing bronchitis. The prescription rates for all LRTIs were 24.9% in PED and 45.9% in public (p < 0.001 vs. PED) and 75.4% in private clinics (p < 0.001 vs. PED and p < 0.001 vs. public clinics). During post-guideline periods, antibiotics were prescribed for CAP less often in private (56.3%) than in public clinics (84.6%; p = 0.037) or in PED (94.3%; p < 0.001 vs. private and p = 0.091 vs. public primary clinics). Macrolide prescriptions were highest in private clinics (42.8%), followed by public primary care clinics (28.5%; p < 0.05) and PED (0.8%; p < 0.05 vs. both public and private primary care). Amoxicillin was the predominant antibiotic in public primary care and PED and macrolides in private primary care.

CONCLUSION

 Antibiotic prescribing for children with LRTI differed significantly between healthcare providers. CAP was undertreated and bronchitis overtreated with antibiotics in primary care, especially in the private clinics.

WHAT IS KNOWN

• Clinical Treatment Guidelines tend to have modest effect on physicians' antibiotic prescribing habits. • Pediatric viral LRTIs are widely treated with unnecessary antibiotics.

WHAT IS NEW

• Remarkable differences in antibiotic prescriptions in pediatric LRTIs between Finnish private and public providers were observed. • Overuse of macrolides was common especially in private clinics.

Regional Perspective of Antimicrobial Stewardship Programs in Latin American Pediatric Emergency Departments

Antibiotic stewardship (AS) programs have become a priority for health authorities to reduce the number of infections by super-resistant microorganisms. The need for these initiatives to minimize the inadequate use of antimicrobials is essential, and the election of the antibiotic in the emergency department usually impacts the choice of treatment if the patients need hospital admission, becoming an opportunity for antibiotic stewardship. In the pediatric population, broad-spectrum antibiotics are more likely to be overprescribed without any evidence-based management, and most of the publications have focused on the prescription of antibiotics in ambulatory settings. Antibiotic stewardship efforts in pediatric emergency departments in Latin American settings are limited. The lack of literature on AS programs in the pediatric emergency departments in Latin America (LA) limits the information available. The aim of this review was to give a regional perspective on how pediatric emergency departments in LA are working towards antimicrobial stewardship.

Antibiotic use and outcomes among children hospitalized with suspected pneumonia

BACKGROUND

Although viral etiologies predominate, antibiotics are frequently prescribed for community-acquired pneumonia (CAP).

OBJECTIVE

We evaluated the association between antibiotic use and outcomes among children hospitalized with suspected CAP.

DESIGNS, SETTINGS AND PARTICIPANTS

We performed a secondary analysis of a prospective cohort of children hospitalized with suspected CAP.

INTERVENTION

The exposure was the receipt of antibiotics in the emergency department (ED).

MAIN OUTCOME AND MEASURES

Clinical outcomes included length of stay (LOS), care escalation, postdischarge treatment failure, 30-day ED revisit, and quality-of-life (QoL) measures from a follow-up survey 7-15 days post discharge. To minimize confounding by indication (e.g., radiographic CAP), we performed inverse probability treatment weighting with propensity analyses.

RESULTS

Among 523 children, 66% were <5 years, 88% were febrile, 55% had radiographic CAP, and 55% received ED antibiotics. The median LOS was 41 h (IQR: 25, 54). After propensity analyses, there were no differences in LOS, escalated care, treatment failure, or revisits between children who received antibiotics and those who did not. Seventy-one percent of patients completed follow-up surveys after discharge. Among 16% of patients with fevers after discharge, the median fever duration was 2 days, and those who received antibiotics had a 37% decrease in the mean number of days with fever (95% confidence interval: 20% and 51%). We found no statistical differences in other QoL measures.

Variation in bacterial pneumonia diagnoses and outcomes among children hospitalized with lower respiratory tract infections

BACKGROUND

Current diagnostics do not permit reliable differentiation of bacterial from viral causes of lower respiratory tract infection (LRTI), which may lead to over-treatment with antibiotics for possible bacterial community-acquired pneumonia (CAP).

OBJECTIVES

We sought to describe variation in the diagnosis and treatment of bacterial CAP among children hospitalized with LRTIs and determine the association between CAP diagnosis and outcomes.

DESIGN, SETTING AND PARTICIPANTS

This multicenter cross-sectional study included children hospitalized between 2017 and 2019 with LRTIs at 42 children's hospitals.

MAIN OUTCOME AND METHODS

We calculated the proportion of children with LRTIs who were diagnosed with and treated for bacterial CAP. After adjusting for confounders, hospitals were grouped into high, moderate, and low CAP diagnosis groups. Multivariable regression was used to examine the association between high and low CAP diagnosis groups and outcomes.

RESULTS

We identified 66,581 patients hospitalized with LRTIs and observed substantial variation across hospitals in the proportion diagnosed with and treated for bacterial CAP (median 27%, range 12%-42%). Compared with low CAP diagnosing hospitals, high diagnosing hospitals had higher rates of CAP-related revisits (0.6% [95% confidence interval: 0.5, 0.7] vs. 0.4% [0.4, 0.5], p = .04), chest radiographs (58% [53, 62] vs. 46% [41, 51], p = .02), and blood tests (43% [33, 53] vs. 26% [19, 35], p = .046). There were no significant differences in length of stay, all-cause revisits or readmissions, CAP-related readmissions, or costs.

CONCLUSION

There was wide variation across hospitals in the proportion of children with LRTIs who were treated for bacterial CAP. The lack of meaningful differences in clinical outcomes among hospitals suggests that some institutions may over-diagnose and overtreat bacterial CAP.

Antibiotic prescriptions for children with lower respiratory tract infections fell from 2014 to 2020, but misuse was still an issue

AIM

We evaluated main trends in antibiotic prescriptions for children with lower respiratory tract infection (LRTI) by Terveystalo, Finland's largest private healthcare company.

METHODS

The study comprised of 89,359 children aged 0-17 years (57.2% boys) who visited Terveystalo primary care clinics from 2014 to 2020 with LRTI. The data were assessed by age, study year, location, the doctor's speciality and whether the diagnosis was bronchitis or community-acquired pneumonia (CAP).

RESULTS

There were gradual decreases in overall antibiotic prescription rates during the study period (37.0% in 2014 vs. 20.1% in 2020) and in prescribed macrolides (16.8% vs. 7.5%). Altogether, 31.3% of 72,737 children with bronchitis and 22.5% of those 16,622 with CAP-received antibiotics. Macrolides were the most frequently prescribed antibiotics for bronchitis, at more than 40%, without any substantial relative decrease during the study. Costs of antibiotics increased from 2014 to 2016 and then decreased in line with the reduction in prescriptions. However, there was still a marked overuse of antibiotics, especially macrolides, for children with bronchitis. The relative use of amoxicillin for CAP increased from 41.4% to 65.4% between 2016 and 2020, in line with current guidelines.

CONCLUSION

Despite an overall reduction in prescribed antibiotics, some antibiotics were still overused, particularly macrolides for bronchitis.

Antibiotic Use in Children Before, During and After Hospitalization

Purpose

To investigate ambulatory antibiotic use in children during 1 year before and 1 year after in‐hospital antibiotic exposure compared to children from the general population that had not received antibiotics in‐hospital.

Methods

Explorative data‐linkage cohort study from Norway of children aged 3 months to 17 years. One group had received antibiotics in‐Hospital (H+), and one group had not received antibiotics in‐hospital (H‐). The H+ group was recruited during admission in 2017. Using the Norwegian Population Registry, 10 children from the H‐ group were matched with one child from the H+ group according to county of residence, age and sex. We used the Norwegian Prescription Database to register antibiotic use 1 year before and 1 year after the month of hospitalisation.

Results

Of 187 children in the H+ group, 83 (44%) received antibiotics before hospitalisation compared to 288/1870 (15%) in the H‐ group, relative risk (RR) 2.88 (95% confidence interval 2.38–3.49). After hospitalisation, 86 (46%) received antibiotics in the H+ group compared to 311 (17%) in the H‐ group, RR 2.77 (2.30–3.33). Comorbidity‐adjusted RR was 2.30 (1.84–2.86) before and 2.25 (1.81–2.79) after hospitalisation. RR after hospitalisation was 2.55 (1.99–3.26) in children 3 months‐2 years, 4.03 (2.84–5.71) in children 3–12 years and 2.07 (1.33–3.20) in children 13–17 years.

Conclusions

Children exposed to antibiotics in‐hospital had two to three times higher risk of receiving antibiotics in ambulatory care both before and after hospitalisation. The link between in‐hospital and ambulatory antibiotic exposure should be emphasised in future antibiotic stewardship programs.

Association Between Procalcitonin and Antibiotics in Children With Community-Acquired Pneumonia

OBJECTIVE

To determine whether empirical antibiotic initiation and selection for children with pneumonia was associated with procalcitonin (PCT) levels when results were blinded to clinicians.

METHODS

We enrolled children <18 years with radiographically confirmed pneumonia at 2 children's hospitals from 2014 to 2019. Blood for PCT was collected at enrollment (blinded to clinicians). We modeled associations between PCT and (1) antibiotic initiation and (2) antibiotic selection (narrow versus broad-spectrum) using multivariable logistic regression models. To quantify potential stewardship opportunities, we calculated proportions of noncritically ill children receiving antibiotics who also had a low likelihood of bacterial etiology (PCT <0.25 ng/mL) and those receiving broad-spectrum therapy, regardless of PCT level.

RESULTS

We enrolled 488 children (median PCT, 0.37 ng/mL; interquartile range [IQR], 0.11-2.38); 85 (17%) received no antibiotics (median PCT, 0.32; IQR, 0.09-1.33). Among the 403 children receiving antibiotics, 95 (24%) received narrow-spectrum therapy (median PCT, 0.24; IQR, 0.08-2.52) and 308 (76%) received broad-spectrum (median PCT, 0.46; IQR, 0.12-2.83). In adjusted analyses, PCT values were not associated with antibiotic initiation (odds ratio [OR], 1.02, 95% confidence interval [CI], 0.97%-1.06%) or empirical antibiotic selection (OR 1.07; 95% CI, 0.97%-1.17%). Of those with noncritical illness, 246 (69%) were identified as potential targets for antibiotic stewardship interventions.

CONCLUSION

Neither antibiotic initiation nor empirical antibiotic selection were associated with PCT values. Whereas other factors may inform antibiotic treatment decisions, the observed discordance between objective likelihood of bacterial etiology and antibiotic use suggests important opportunities for stewardship.

Antibiotic therapy in children with community-acquired pneumonia

PubMed was reviewed on antibiotic treatment of community-acquired pneumonia (CAP) in children for the years 2011-2020, and three clinical trials in high-income and eight in low-income countries were found. Prospective studies combining laboratory and clinical findings for steering of antibiotic treatment found that five-day courses were equally effective as longer courses. No new antibiotics were launched for children's CAP during the last 10 years. Five-day courses are equally effective as 7- to 10-day courses for CAP in children. Stewardship of antibiotics needs lessening of exposure to antibiotics by better targeting their use and by shortening the lengths of antibiotic courses.

Macrolides (alone or in combination) should be used as first-line empirical therapy of community-acquired pneumonia in children: myth or maxim?

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.

Short- Versus Prolonged-Duration Antibiotics for Outpatient Pneumonia in Children

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.

Assessment of nasopharyngeal Streptococcus pneumoniae colonization does not permit discrimination between Canadian children with viral and bacterial respiratory infection: a matched-cohort cross-sectional study

Background

Readily-available diagnostics do not reliably discriminate between viral and bacterial pediatric uncomplicated pneumonia, both of which are common. Some have suggested that assessment of pneumococcal carriage could be used to identify those children with bacterial pneumonia. The objective of this study was to determine if nasopharyngeal pneumococcal colonization patterns differed between children with definite viral disease, definite bacterial disease, and respiratory disease of indeterminate etiology.

Methods

Three groups of subjects were recruited: children with critical respiratory illness, previously healthy children with respiratory illness admitted to the ward, and previously healthy children diagnosed in the emergency department with non-severe pneumonia. Subjects were categorized as follows: a) viral infection syndrome (eg. bronchiolitis), b) bacterial infection syndrome (ie. pneumonia complicated by effusion/empyema), or c) ‘indeterminate’ pneumonia. Subjects’ nasopharyngeal swabs underwent quantitative PCR testing for S. pneumoniae. Associations between categorical variables were determined with Fisher’s exact, chi-square, or logistic regression, as appropriate. Associations between quantitative genomic load and categorical variables was determined by linear regression.

Results

There were 206 children in Group 1, 122 children in Group 2, and 179 children in Group 3. Only a minority (227/507, 45%) had detectable pneumococcal carriage; in those subjects, there was no association of quantitative genomic load with age, recruitment group, or disease category. In multivariate logistic regression, pneumococcal colonization > 3 log copies/mL was associated with younger age and recruitment group, but not with disease category.

Conclusions

The nasopharyngeal S. pneumoniae colonization patterns of subjects with definite viral infection were very similar to colonization patterns of those with definite bacterial infection or indeterminate pneumonia. Assessment and quantification of nasopharyngeal pneumococcal colonization does not therefore appear useful to discriminate between acute viral and bacterial respiratory disease; consequently, this diagnostic testing is unlikely to reliably determine which children with indeterminate pneumonia have a bacterial etiology and/or require antibiotic treatment.