1
|
Vazquez Deida AA, Bizune DJ, Kim C, Sahrmann JM, Sanchez GV, Hersh AL, Butler AM, Hicks LA, Kabbani S. Opportunities to Improve Antibiotic Prescribing for Adults With Acute Sinusitis, United States, 2016-2020. Open Forum Infect Dis 2024; 11:ofae420. [PMID: 39100530 PMCID: PMC11297501 DOI: 10.1093/ofid/ofae420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 07/19/2024] [Indexed: 08/06/2024] Open
Abstract
Background Better understanding differences associated with antibiotic prescribing for acute sinusitis can help inform antibiotic stewardship strategies. We characterized antibiotic prescribing patterns for acute sinusitis among commercially insured adults and explored differences by patient- and prescriber-level factors. Methods Outpatient encounters among adults aged 18 to 64 years diagnosed with sinusitis between 2016 and 2020 were identified by national administrative claims data. We classified antibiotic agents-first-line (amoxicillin-clavulanate or amoxicillin) and second-line (doxycycline, levofloxacin, or moxifloxacin)-and ≤7-day durations as guideline concordant based on clinical practice guidelines. Modified Poisson regression was used to examine the association between patient- and prescriber-level factors and guideline-concordant antibiotic prescribing. Results Among 4 689 850 sinusitis encounters, 53% resulted in a guideline-concordant agent, 30% in a guideline-discordant agent, and 17% in no antibiotic prescription. About 75% of first-line agents and 63% of second-line agents were prescribed for >7 days, exceeding the length of therapy recommended by clinical guidelines. Adults with sinusitis living in a rural area were less likely to receive a prescription with guideline-concordant antibiotic selection (adjusted risk ratio [aRR], 0.92; 95% CI, .92-.92) and duration (aRR, 0.77; 95% CI, .76-.77). When compared with encounters in an office setting, urgent care encounters were less likely to result in a prescription with a guideline-concordant duration (aRR, 0.76; 95% CI, .75-.76). Conclusions Opportunities still exist to optimize antibiotic agent selection and treatment duration for adults with acute sinusitis, especially in rural areas and urgent care settings. Recognizing specific patient- and prescriber-level factors associated with antibiotic prescribing can help inform antibiotic stewardship interventions.
Collapse
Affiliation(s)
- Axel A Vazquez Deida
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Destani J Bizune
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christine Kim
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John M Sahrmann
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Guillermo V Sanchez
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Anne M Butler
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, 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
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
2
|
Kaur R, Schulz S, Sherman A, Andrejko K, Kobayashi M, Pichichero M. Anticipated Effects of Higher-valency Pneumococcal Conjugate Vaccines on Colonization and Acute Otitis Media. Pediatr Infect Dis J 2024:00006454-990000000-00886. [PMID: 38838209 DOI: 10.1097/inf.0000000000004413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Bacterial etiologies of acute otitis media (AOM) have shifted from the introduction of pneumococcal conjugate vaccines (PCVs), antibiotic selection and competition among species. We characterized Streptococcus pneumoniae ( Spn ), Haemophilus influenzae ( Hflu ) and Moraxella catarrhalis ( Mcat ) in the nasopharynx during well-child healthy visits and at the onset of AOM, and in middle ear fluid (MEF) of children with AOM to assess anticipated effects of higher-valency PCVs (PCV15 and PCV20). METHODS From September 2021 to September 2023, we conducted a prospective longitudinal cohort study of PCV13 immunized children 6-36 months old. MEF was collected via tympanocentesis. Serotyping and antibiotic susceptibility testing were performed on Spn , Hflu and Mcat isolates. RESULTS We obtained 825 nasopharyngeal and 216 MEF samples from 301 children. The order of frequency of nasopharyngeal colonization was Mcat , Spn and Hflu ; Hflu was the predominant otopathogen in MEF. Among Spn isolates, non-PCV15, non-PCV20 serotypes predominated in the nasopharynx and in MEF; the most frequent serotype was 35B. Among MEF samples, 30% of Spn isolates were amoxicillin nonsusceptible; 23% of Hflu isolates and 100% of Mcat isolates were β-lactamase-producing. CONCLUSION The majority of Spn isolates among young children were non-PCV15, non-PCV20 serotypes, especially serotype 35B; therefore, the impact of higher-valency PCVs in reducing pneumococcal colonization or AOM is expected to be limited. Hflu continues to be the most frequent AOM pathogen. Antibiotic susceptibility data suggest a high dose of amoxicillin/clavulanate or alternative drugs that are effective against contemporary mix of otopathogens could be considered for optimal empiric selection to provide the best efficacy.
Collapse
Affiliation(s)
- Ravinder Kaur
- From the Center for Infectious Diseases and Immunology, Rochester General Hospital Research Institute, Rochester, New York
| | - Steven Schulz
- From the Center for Infectious Diseases and Immunology, Rochester General Hospital Research Institute, Rochester, New York
| | - Andrew Sherman
- From the Center for Infectious Diseases and Immunology, Rochester General Hospital Research Institute, Rochester, New York
| | - Kristin Andrejko
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Miwako Kobayashi
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael Pichichero
- From the Center for Infectious Diseases and Immunology, Rochester General Hospital Research Institute, Rochester, New York
| |
Collapse
|
3
|
Nawrin SS, Inada H, Momma H, Nagatomi R. Twenty-four-hour physical activity patterns associated with depressive symptoms: a cross-sectional study using big data-machine learning approach. BMC Public Health 2024; 24:1254. [PMID: 38714982 PMCID: PMC11075341 DOI: 10.1186/s12889-024-18759-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Depression is a global burden with profound personal and economic consequences. Previous studies have reported that the amount of physical activity is associated with depression. However, the relationship between the temporal patterns of physical activity and depressive symptoms is poorly understood. In this exploratory study, we hypothesize that a particular temporal pattern of daily physical activity could be associated with depressive symptoms and might be a better marker than the total amount of physical activity. METHODS To address the hypothesis, we investigated the association between depressive symptoms and daily dominant activity behaviors based on 24-h temporal patterns of physical activity. We conducted a cross-sectional study on NHANES 2011-2012 data collected from the noninstitutionalized civilian resident population of the United States. The number of participants that had the whole set of physical activity data collected by the accelerometer is 6613. Among 6613 participants, 4242 participants had complete demography and Patient Health Questionnaire-9 (PHQ-9) questionnaire, a tool to quantify depressive symptoms. The association between activity-count behaviors and depressive symptoms was analyzed using multivariable logistic regression to adjust for confounding factors in sequential models. RESULTS We identified four physical activity-count behaviors based on five physical activity-counting patterns classified by unsupervised machine learning. Regarding PHQ-9 scores, we found that evening dominant behavior was positively associated with depressive symptoms compared to morning dominant behavior as the control group. CONCLUSIONS Our results might contribute to monitoring and identifying individuals with latent depressive symptoms, emphasizing the importance of nuanced activity patterns and their probability of assessing depressive symptoms effectively.
Collapse
Affiliation(s)
- Saida Salima Nawrin
- Laboratory of Health and Sports Sciences, Tohoku University Graduate School of Biomedical Engineering, Sendai, Miyagi, Japan
| | - Hitoshi Inada
- Laboratory of Health and Sports Sciences, Tohoku University Graduate School of Biomedical Engineering, Sendai, Miyagi, Japan.
- Present Address: Department of Biochemistry & Cellular Biology, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan.
| | - Haruki Momma
- Department of Medicine and Science in Sports and Exercise, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Ryoichi Nagatomi
- Laboratory of Health and Sports Sciences, Tohoku University Graduate School of Biomedical Engineering, Sendai, Miyagi, Japan.
- Department of Medicine and Science in Sports and Exercise, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
| |
Collapse
|
4
|
Nedved A, Bizune D, Fung M, Liu CM, Tsay S, Hamdy RF, Montalbano A. Communication Strategies to Improve Antibiotic Prescribing in Pediatric Urgent Care Centers. Pediatr Emerg Care 2024; 40:265-269. [PMID: 37195689 PMCID: PMC10906363 DOI: 10.1097/pec.0000000000002977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Urgent care (UC) clinicians frequently prescribe inappropriate antibiotics for upper respiratory illnesses. In a national survey, pediatric UC clinicians reported family expectations as a primary driver for prescribing inappropriate antibiotics. Communication strategies effectively reduce unnecessary antibiotics while increasing family satisfaction. We aimed to reduce inappropriate prescribing practices in otitis media with effusion (OME), acute otitis media (AOM), and pharyngitis in pediatric UC clinics by a relative 20% within 6 months using evidence-based communication strategies. METHODS We recruited participants via e-mails, newsletters, and Webinars from pediatric and UC national societies. We defined antibiotic-prescribing appropriateness based on consensus guidelines. Family advisors and UC pediatricians developed script templates based on an evidence-based strategy. Participants submitted data electronically. We reported data using line graphs and shared deidentified data during monthly Webinars. We used χ 2 tests to evaluate change in appropriateness at the beginning and end of the study period. RESULTS The 104 participants from 14 institutions submitted 1183 encounters for analysis in the intervention cycles. Using a strict definition of inappropriateness, overall inappropriate antibiotic prescriptions for all diagnoses trended downward from 26.4% to 16.6% ( P = 0.13). Inappropriate prescriptions trended upward in OME from 30.8% to 46.7% ( P = 0.34) with clinicians' increased use of "watch and wait" for this diagnosis. Inappropriate prescribing for AOM and pharyngitis improved from 38.6% to 26.5% ( P = 0.03) and 14.5% to 8.8% ( P = 0.44), respectively. CONCLUSIONS Using templates to standardize communication with caregivers, a national collaborative decreased inappropriate antibiotic prescriptions for AOM and had downward trend in inappropriate antibiotic prescriptions for pharyngitis. Clinicians increased the inappropriate use of "watch and wait" antibiotics for OME. Future studies should evaluate barriers to the appropriate use of delayed antibiotic prescriptions.
Collapse
Affiliation(s)
- Amanda Nedved
- Division of Urgent Care, Children’s Mercy Kansas City; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Destani Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Melody Fung
- Antibiotic Resistance Action Center, Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Cindy M. Liu
- Antibiotic Resistance Action Center, Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Sharon Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Rana F. Hamdy
- Division of Infectious Diseases, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Amanda Montalbano
- Division of Urgent Care, Children’s Mercy Kansas City; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| |
Collapse
|
5
|
Stevens RW, Manz J, Mathre M, Bell N, Virk A, Vergidis P, Jensen K. Cracking the code(s): Optimization of encounter-level diagnosis coding to inform outpatient antimicrobial stewardship data modeling. Infect Control Hosp Epidemiol 2024; 45:550-552. [PMID: 38234184 DOI: 10.1017/ice.2023.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Affiliation(s)
- Ryan W Stevens
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - James Manz
- Division of Spine and Neurosurgery, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - Margo Mathre
- Center for Digital Health, Data and Analytics, Healthcare Terminology, Mayo Clinic, Phoenix, Arizona
| | - Natalie Bell
- Center for Digital Health, Data and Analytics, Healthcare Terminology, Mayo Clinic, Rochester, Minnesota
| | - Abinash Virk
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota
| | - Paschalis Vergidis
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kelsey Jensen
- Department of Pharmacy, Mayo Clinic Health System, Austin, Minnesota
| |
Collapse
|
6
|
Hersh AL, Shapiro DJ, Sanchez GV, Hicks LA. Comparison of antibiotic prescribing between physicians and advanced practice clinicians. Infect Control Hosp Epidemiol 2024; 45:117-119. [PMID: 37553696 PMCID: PMC10782197 DOI: 10.1017/ice.2023.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/12/2023] [Accepted: 06/22/2023] [Indexed: 08/10/2023]
Abstract
We compared antibiotic prescribing rates for respiratory conditions in a national sample of outpatient visits from 2010 to 2018 between physicians and advanced practice clinicians (APCs). APCs prescribed antibiotics more frequently than physicians (58% vs 52%), but there were no differences in selection of guideline recommended first-line agents between specialties.
Collapse
Affiliation(s)
- Adam L. Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Daniel J. Shapiro
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Guillermo V. Sanchez
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauri A. Hicks
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
7
|
Fu M, Gong Z, Li C, Ling K, Zhu Y, Li H, Shi L, Guan X. Appropriate use of antibiotics for acute respiratory infections at primary healthcare facilities in China: a nationwide cross-sectional study from 2017 to 2019. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 40:100880. [PMID: 37636127 PMCID: PMC10458636 DOI: 10.1016/j.lanwpc.2023.100880] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/25/2023] [Accepted: 08/06/2023] [Indexed: 08/29/2023]
Abstract
Background The appropriateness of antibiotic use for acute respiratory infections (ARIs) in Chinese primary healthcare facilities (PHFs) remained uncertain. We aimed to evaluate to what degree antibiotic prescribing for ARIs were aligned with guideline recommendations in primary settings across China. Methods We collected outpatient prescriptions from 262 Chinese PHFs in 27 cities of six provinces between 2017 and 2019. The appropriate antibiotic prescribing was defined as prescribing antibiotic classes that were recommended by Chinese clinical guidelines, if patients were prescribed antibiotics. We evaluated the magnitude of antibiotics prescribed for acute upper respiratory infections (AURIs), acute bronchitis, and community-acquired pneumonia (CAP) and their appropriateness. Findings Overall, 55.1% (87,684/159,150), 66.8% (30,836/46,153), and 68.5% (4615/6733) of outpatients with AURIs, acute bronchitis, and CAP treated at PHFs in China were prescribed with antibiotics. Of all antibiotic prescriptions, only 20.0% (17,542/87,684), 18.6% (5724/30,836) and 69.6% (3211/4615) used antibiotic classes that were recommended by the guidelines for AURIs, acute bronchitis, and CAP, respectively. Patients residing in the Chinese central region (17.0%, 15.4%, 69.3% for AURIs, acute bronchitis, and CAP, respectively) were less likely to be prescribed with antibiotics that were appropriately selected. Interpretation Unnecessary antibiotics were widely prescribed for patients with AURIs or acute bronchitis and most patients with ARIs did not receive guideline-recommended antibiotic classes in Chinese PHFs. Interventions to promote evidence-based treatment and the appropriate use of antibiotics are urgently needed at the primary level across China. Funding This work was supported by the National Natural Science Foundation of China [grant number 72074007, 81973294].
Collapse
Affiliation(s)
- Mengyuan Fu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Zhiwen Gong
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Can Li
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Kexin Ling
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Yuezhen Zhu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Huangqianyu Li
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| |
Collapse
|
8
|
Heren JE, Lund BC, Alexander B, Livorsi DJ. Procalcitonin Monitoring and Antibiotic Duration in Presumed Lower Respiratory Tract Infections: A Propensity Score-Matched Cohort Across the Veterans Health Administration. Open Forum Infect Dis 2023; 10:ofad520. [PMID: 37942465 PMCID: PMC10629903 DOI: 10.1093/ofid/ofad520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
Background Randomized controlled trials have shown that procalcitonin-guided algorithms can reduce antibiotic duration for lower respiratory tract infections (LRTIs). The goal of this study was to compare antibiotic duration for LRTIs with and without procalcitonin testing in real-life practice. Methods This retrospective cohort study included all acute care hospital admissions for presumed LRTIs between 1/2018 and 12/2021 at 81 Veterans Affairs facilities with on-site procalcitonin testing. The exposure was procalcitonin testing; the primary outcome was antibiotic duration. We used 1:1 nearest-neighbor propensity score matching to estimate the difference in outcome between procalcitonin-tested and nontested patients. Results A total of 35 610 patients with LRTIs were included (6015 [16.9%] with procalcitonin testing; 29 595 [83.1%] without testing). In tested patients, the median number of procalcitonin levels checked (interquartile range) was 2 (1-3). The mean antibiotic duration was 10.0 days in the procalcitonin group compared with 8.3 days in nontested patients (unadjusted difference, 1.7 days; P < .0001). After propensity score matching with 3903 pairs, antibiotic duration remained greater in the procalcitonin group (9.6 days vs 9.2 days; P < .0001). In a subgroup analysis of 2241 tested patients with a procalcitonin value at the standard threshold for antibiotic discontinuation, antibiotic duration was shorter in tested vs nontested patients, with a mean difference of 0.1 days (P < .01). Conclusions In this retrospective propensity-matched cohort of patients with presumed LRTIs across a geographically diverse group of hospitals, patients who underwent procalcitonin testing did not have a meaningful reduction in antibiotic duration compared with those who were not tested. Poor implementation of procalcitonin testing may have undermined its effectiveness.
Collapse
Affiliation(s)
- Jamie E Heren
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Brian C Lund
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Bruce Alexander
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Daniel J Livorsi
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| |
Collapse
|
9
|
King LM, Andrejko KL, Kabbani S, Tartof SY, Hicks LA, Cohen AL, Kobayashi M, Lewnard JA. Pediatric outpatient visits and antibiotic use attributable to higher valency pneumococcal conjugate vaccine serotypes. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.24.23294570. [PMID: 37662372 PMCID: PMC10473805 DOI: 10.1101/2023.08.24.23294570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Importance Streptococcus pneumoniae is a known etiology of acute respiratory infections (ARIs), which account for large proportions of outpatient visits and antibiotic use in children. In 2023, 15- and 20-valent pneumococcal conjugate vaccines (PCV15, PCV20) were recommended for routine use in infants. However, the burden of outpatient healthcare utilization among U.S. children attributable to the additional, non-PCV13 serotypes in PCV15/20 is unknown. Objective To estimate the incidence of outpatient visits and antibiotic prescriptions in U.S. children for acute otitis media, pneumonia, and sinusitis associated with PCV15- and PCV20-additional serotypes (non-PCV13 serotypes) to quantify potential impacts of PCV15/20 on outpatient visits and antibiotic prescriptions for these conditions. Design Multi-component study including descriptive analyses of cross-sectional and cohort data on outpatient visits and antibiotic prescriptions from 2016-2019 and meta-analyses of pneumococcal serotype distribution in non-invasive respiratory infections. Setting Outpatient visits and antibiotic prescriptions among U.S. children. Participants Pediatric visits and antibiotic prescriptions among children captured in the National Ambulatory Medical Care Survey (NAMCS), the National Hospital Ambulatory Medicare Care Survey (NHAMCS), and Merative MarketScan, collectively representing healthcare delivery across all outpatient settings. Incidence denominators estimated using census (NAMCS/NHAMCS) and enrollment (MarketScan) data. Main outcomes and measures Pediatric outpatient visit and antibiotic prescription incidence for acute otitis media, pneumonia, and sinusitis associated with PCV15/20-additional serotypes. Results We estimated that per 1000 children annually, PCV15-additional serotypes accounted for 2.7 (95% confidence interval 1.8-3.9) visits and 2.4 (1.6-3.4) antibiotic prescriptions. PCV20-additional serotypes resulted in 15.0 (11.2-20.4) visits and 13.2 (9.9-18.0) antibiotic prescriptions annually per 1,000 children. Projected to national counts, PCV15/20-additional serotypes account for 173,000 (118,000-252,000) and 968,000 (722,000-1,318,000) antibiotic prescriptions among U.S. children each year, translating to 0.4% (0.2-0.6%) and 2.1% (1.5-3.0%) of all outpatient antibiotic use among children. Conclusions and relevance PCV15/20-additional serotypes account for a large burden of pediatric outpatient healthcare utilization. Compared with PCV15-additional serotypes, PCV20-additional serotypes account for >5 times the burden of visits and antibiotic prescriptions. These higher-valency PCVs, especially PCV20, may contribute to preventing ARIs and antibiotic use in children.
Collapse
Affiliation(s)
- Laura M King
- School of Public Health, University of California, Berkeley, Berkeley, CA
| | - Kristin L Andrejko
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sara Y Tartof
- Kaiser Permanente Department of Research & Evaluation Southern California, Pasadena, CA
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Adam L Cohen
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Miwako Kobayashi
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Joseph A Lewnard
- School of Public Health, University of California, Berkeley, Berkeley, CA
| |
Collapse
|
10
|
Bizune D, Tsay S, Palms D, King L, Bartoces M, Link-Gelles R, Fleming-Dutra K, Hicks LA. Regional Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Tract Infections in a Commercially Insured Population, United States, 2017. Open Forum Infect Dis 2023; 10:ofac584. [PMID: 36776774 PMCID: PMC9905267 DOI: 10.1093/ofid/ofac584] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/10/2022] [Indexed: 02/10/2023] Open
Abstract
Background Studies have shown that the Southern United States has higher rates of outpatient antibiotic prescribing rates compared with other regions in the country, but the reasons for this variation are unclear. We aimed to determine whether the regional variability in outpatient antibiotic prescribing for respiratory diagnoses can be explained by differences in prescriber clinical factors found in a commercially insured population. Methods We analyzed the 2017 IBM MarketScan Commercial Database of commercially insured individuals aged <65 years. We included visits with acute respiratory tract infection (ARTI) diagnoses from retail clinics, urgent care centers, emergency departments, and physician offices. ARTI diagnoses were categorized based on antibiotic indication. We calculated risk ratios and 95% CIs stratified by ARTI tier and region using log-binomial models controlling for patient age, comorbidities, care setting, prescriber type, and diagnosis. Results Of the 14.9 million ARTI visits, 40% received an antibiotic. The South had the highest proportion of visits with an antibiotic prescription (43%), and the West the lowest (34%). ARTI visits in the South are 34% more likely receive an antibiotic for rarely antibiotic-appropriate ARTI visits when compared with the West in multivariable modeling (relative risk, 1.34; 95% CI, 1.33-1.34). Conclusions It is likely that higher antibiotic prescribing in the South is in part due to nonclinical factors such as regional differences in clinicians' prescribing habits and patient expectations. There is a need for future studies to define and characterize these factors to better inform regional and local stewardship interventions and achieve greater health equity in antibiotic prescribing.
Collapse
Affiliation(s)
- Destani Bizune
- Correspondence: Destani Bizume, MPH, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd, Mailstop H16-2, Atlanta, GA 30329 ()
| | - Sharon Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Danielle Palms
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Laura King
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Monina Bartoces
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ruth Link-Gelles
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine Fleming-Dutra
- National Center for Immunization and Emerging Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | |
Collapse
|
11
|
Nasopharyngeal rapid diagnostic testing to reduce unnecessary antibiotic use and individualize management of acute otitis media. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2023; 3:e49. [PMID: 36970427 PMCID: PMC10031585 DOI: 10.1017/ash.2023.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 03/17/2023]
Abstract
Abstract
Background:
Acute otitis media (AOM) is the most common indication for antibiotics in children. The associated organism can influence the likelihood of antibiotic benefit and optimal treatment. Nasopharyngeal polymerase chain reaction can effectively exclude the presence of organisms in middle-ear fluid. We explored the potential cost-effectiveness and reduction in antibiotics with nasopharyngeal rapid diagnostic testing (RDT) to direct AOM management.
Methods:
We developed 2 algorithms for AOM management based on nasopharyngeal bacterial otopathogens. The algorithms provide recommendations on prescribing strategy (ie, immediate, delayed, or observation) and antimicrobial agent. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed as cost per quality-adjusted life day (QALD) gained. We used a decision-analytic model to evaluate the cost-effectiveness of the RDT algorithms compared to usual care from a societal perspective and the potential reduction in annual antibiotics used.
Results:
An RDT algorithm that used immediate prescribing, delayed prescribing, and observation based on pathogen (RDT-DP) had an ICER of $1,336.15 per QALD compared with usual care. At an RDT cost of $278.56, the ICER for RDT-DP exceeded the willingness to pay threshold; however, if the RDT cost was <$212.10, the ICER was below the threshold. The use of RDT was estimated to reduced annual antibiotic use, including broad-spectrum antimicrobial use, by 55.7% ($4.7 million for RDT vs $10.5 million for usual care).
Conclusion:
The use of a nasopharyngeal RDT for AOM could be cost-effective and substantially reduce unnecessary antibiotic use. These iterative algorithms could be modified to guide management of AOM as pathogen epidemiology and resistance evolve.
Collapse
|
12
|
Frost HM, Bizune D, Gerber JS, Hersh AL, Hicks LA, Tsay SV. Amoxicillin Versus Other Antibiotic Agents for the Treatment of Acute Otitis Media in Children. J Pediatr 2022; 251:98-104.e5. [PMID: 35944719 PMCID: PMC10122571 DOI: 10.1016/j.jpeds.2022.07.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/17/2022] [Accepted: 07/22/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The objective of the study was to compare the antibiotic treatment failure and recurrence rates between antibiotic agents (amoxicillin, amoxicillin-clavulanate, cefdinir, and azithromycin) for children with uncomplicated acute otitis media (AOM). STUDY DESIGN We completed a retrospective cohort study of children 6 months-12 years of age with uncomplicated AOM identified in a nationwide claims database. The primary exposure was the antibiotic agent, and the primary outcomes were treatment failure and recurrence. Logistic regression was used to estimate ORs, and analyses were stratified by primary exposure, patient age, and antibiotic duration. RESULTS Among the 1 051 007 children included in the analysis, 56.6% were prescribed amoxicillin, 13.5% were prescribed amoxicillin-clavulanate, 20.6% were prescribed cefdinir, and 9.3% were prescribed azithromycin. Most prescriptions (93%) were for 10 days, and 98% were filled within 1 day of the medical encounter. Treatment failure and recurrence occurred in 2.2% (95% CI: 2.1, 2.2) and 3.3% (3.2, 3.3) of children, respectively. Combined failure and recurrence rates were low for all agents including amoxicillin (1.7%; 1.7, 1.8), amoxicillin-clavulanate (11.3%; 11.1, 11.5), cefdinir (10.0%; 9.8, 10.1), and azithromycin (9.8%; 9.6, 10.0). CONCLUSIONS Despite microbiologic changes in AOM etiology, treatment failure and recurrence were uncommon for all antibiotic agents and were lower for amoxicillin than for other agents. These findings support the continued use of amoxicillin as a first-line agent for AOM when antibiotics are prescribed.
Collapse
Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO; Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Destani Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City, UT
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sharon V Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| |
Collapse
|
13
|
Seibert AM, Hersh AL, Patel PK, Matheu M, Stanfield V, Fino N, Hicks LA, Tsay SV, Kabbani S, Stenehjem E. Urgent-care antibiotic prescribing: An exploratory analysis to evaluate health inequities. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e184. [PMID: 36406162 PMCID: PMC9672912 DOI: 10.1017/ash.2022.329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 06/16/2023]
Abstract
Healthcare disparities and inequities exist in a variety of environments and manifest in diagnostic and therapeutic measures. In this commentary, we highlight our experience examining our organization's urgent care respiratory encounter antibiotic prescribing practices. We identified differences in prescribing based on several individual characteristics including patient age, race, ethnicity, preferred language, and patient and/or clinician gender. Our approach can serve as an electronic health record (EHR)-based methodology for disparity and inequity audits in other systems and for other conditions.
Collapse
Affiliation(s)
- Allan M. Seibert
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
| | - Adam L. Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Payal K. Patel
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
| | - Michelle Matheu
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
| | | | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Lauri A. Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sharon V. Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Edward Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
| |
Collapse
|
14
|
Tsay SV, Bartoces M, Gouin K, Kabbani S, Hicks LA. Antibiotic Prescriptions Associated With COVID-19 Outpatient Visits Among Medicare Beneficiaries, April 2020 to April 2021. JAMA 2022; 327:2018-2019. [PMID: 35394497 PMCID: PMC8994157 DOI: 10.1001/jama.2022.5471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This study of Medicare claims data examines the prescribing of antibiotics to older US patients who had outpatient visits for COVID-19 in an effort to address unnecessary antibiotic use for viral infections.
Collapse
Affiliation(s)
- Sharon V. Tsay
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monina Bartoces
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katryna Gouin
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah Kabbani
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauri A. Hicks
- Division of Healthcare Quality and Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|