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Wang ME, Winslow DL, Shah SS. The hospital medicine-infectious diseases career path: Opportunities and insights. J Hosp Med 2024. [PMID: 39363507 DOI: 10.1002/jhm.13513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Revised: 09/11/2024] [Accepted: 09/12/2024] [Indexed: 10/05/2024]
Affiliation(s)
- Marie E Wang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Dean L Winslow
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
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Cooper BJ, Mitchell ML, Melamed S, Liegl M, Pan AY, Burek AG. Improving Antibiotic Use in Pediatric Preseptal Cellulitis Using a Clinical Practice Guideline. Hosp Pediatr 2024; 14:791-798. [PMID: 39246158 DOI: 10.1542/hpeds.2023-007581] [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: 10/31/2023] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 09/10/2024]
Abstract
OBJECTIVES The purpose of this study was to evaluate the impact of a clinical practice guideline (CPG) on antibiotic use and resource utilization for pediatric preseptal cellulitis. METHODS This retrospective quasiexperimental study included patients between the age of 2 months and 17 years admitted for preseptal cellulitis between January 2013 and December 2023. The preseptal cellulitis CPG was implemented in December 2020 using a multifaceted strategy that included buy-in from key stakeholders, education of frontline providers, the official CPG launch, and stakeholder check-ins. The primary outcome was the use of broad-spectrum antibiotics, including dual/triple therapy and methicillin-resistant Staphylococcus aureus (MRSA) active antibiotics. The secondary outcome was resource utilization including blood testing and imaging. Outcomes were compared pre- and post-CPG implementation using the Fisher exact test and logistic regressions. RESULTS Of 236 patients meeting inclusion criteria, 175 and 61 patients composed the pre- and post-CPG cohorts, respectively. Median age (interquartile range) was 4.0 (1.8-8.3) years and 46% of the population were female. Post-CPG implementation changes in empirical antibiotic use included decreases in broad-spectrum use from 100% to 66% (P < .001), dual/triple therapy from 47% to 16% (P < .001), and MRSA active agents from 86% to 26% (P < .001). There was a decrease in complete blood count and blood culture orders from 75% to 57% (P = .014) and 32% to 18% (P = .047), respectively. CONCLUSIONS Use of broad-spectrum antibiotics, including dual/triple therapy and MRSA active antibiotics for the treatment of pediatric preseptal cellulitis, decreased after CPG implementation.
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Affiliation(s)
| | - Michelle L Mitchell
- Department of Pediatrics, Medical College of Wisconsin
- Children's Wisconsin, Milwaukee, Wisconsin
| | | | - Melodee Liegl
- Department of Pediatrics, Division of Quantitative Health Services, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Amy Y Pan
- Department of Pediatrics, Division of Quantitative Health Services, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alina G Burek
- Department of Pediatrics, Medical College of Wisconsin
- Children's Wisconsin, Milwaukee, Wisconsin
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Chiotos K, Lee G, Sydney G, Woods-Hill C, Wolfe H, Stinson HR, Piccione J, Blumenthal J, Keim G, Li Y, Traynor D, Dudhia A, Doll A, Harris R, Gerber J. Impact of a tracheal aspirate culture diagnostic test stewardship intervention in a tertiary care PICU. Infect Control Hosp Epidemiol 2024:1-9. [PMID: 39229740 DOI: 10.1017/ice.2024.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
OBJECTIVE To assess the impact of a diagnostic test stewardship intervention focused on tracheal aspirate cultures. DESIGN Quality improvement intervention. SETTING Tertiary care pediatric intensive care unit (PICU). PATIENTS Mechanically ventilated children admitted between 9/2018 and 8/2022. METHODS We developed and implemented a consensus guideline for obtaining tracheal aspirate cultures through a series of Plan-Do-Study-Act cycles. Change in culture rates and broad-spectrum antibiotic days of therapy (DOT) per 100 ventilator days were analyzed using statistical process control charts. A secondary analysis comparing the preintervention baseline (9/2018-8/2020) to the postintervention period (9/2020-8/2021) was performed using Poisson regression. RESULTS The monthly tracheal aspirate culture rate prior to the COVID-19 pandemic (9/2018-3/2020) was 4.6 per 100 ventilator days. A centerline shift to 3.1 cultures per 100 ventilator days occurred in 4/2020, followed by a second shift to 2.0 cultures per 100 ventilator days in 12/2020 after guideline implementation. In our secondary analysis, the monthly tracheal aspirate culture rate decreased from 4.3 cultures preintervention (9/2018-8/2020) to 2.3 cultures per 100 ventilator days postintervention (9/2020-8/2021) (IRR 0.52, 95% CI 0.47-0.59, P < 0.01). Decreases in tracheal aspirate culture use were driven by decreases in inappropriate cultures. Treatment of ventilator-associated infections decreased from 1.0 to 0.7 antibiotic courses per 100 ventilator days (P = 0.03). There was no increase in mortality, length of stay, readmissions, or ventilator-associated pneumonia postintervention. CONCLUSION A diagnostic test stewardship intervention was both safe and effective in reducing the rate of tracheal aspirate cultures and treatment of ventilator-associated infections in a tertiary PICU.
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Affiliation(s)
- Kathleen Chiotos
- Division of Critical Care Medicine and Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Giyoung Lee
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | - Guy Sydney
- Department of Medicine, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Charlotte Woods-Hill
- Division of Critical Care Medicine and Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wolfe
- Division of Critical Care Medicine and Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Hannah R Stinson
- Division of Critical Care Medicine and Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph Piccione
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Blumenthal
- Division of Critical Care Medicine and Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Garrett Keim
- Division of Critical Care Medicine and Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Danielle Traynor
- Department of Nursing and Clinical Care Services, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aaditya Dudhia
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ashlee Doll
- Department of Nursing and Clinical Care Services, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rebecca Harris
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
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Markham JL, Hall M, Shah SS, Burns A, Goldman JL. Antibiotic Diversity Index: A novel metric to assess antibiotic variation among hospitalized children. J Hosp Med 2024. [PMID: 39099133 DOI: 10.1002/jhm.13470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 07/11/2024] [Accepted: 07/14/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Despite nationally endorsed treatment guidelines and stewardship programs, variation and deviation from evidence-based antibiotic prescribing occur, contributing to inappropriate use and medication-related adverse events. Measures of antibiotic prescribing variability can aid in quantifying this problem but are not adequate. OBJECTIVE The objective of this study is to develop a standardized metric to quantify antibiotic prescribing variability (diversity) within and across children's hospitals, and to examine its association with outcomes. METHODS We performed a cross-sectional study of empiric antibiotic exposure among children hospitalized during 2017-2019 with one of 15 common pediatric infections using the Pediatric Health Information System database. Encounters for children with complex chronic conditions, transfers in, and birth hospitalizations were excluded. Using the Shannon-Weiner entropy index, we quantified antibiotic diversity for each infection type using the d-measure of diversity. Generalized linear mixed-effects models were used to examine the association between hospital-level antibiotic diversity and risk-adjusted length of stay and costs. RESULTS A total of 79,515 hospitalizations for common pediatric infections were included. Antibiotic diversity varied within and across hospitals. Infections with low mean antibiotic diversity included appendicitis (mean diversity [mDiv] = 4.9, SD = 2.5) and deep neck space infections (mDiv = 5.9, SD = 1.9). Infections with high mean antibiotic diversity included pneumonia (mDiv = 23.4, SD = 5.6) and septicemia/bacteremia (mDiv = 28.5, SD = 12.1). There was no statistically significant association between hospital-level antibiotic diversity and risk-adjusted LOS or costs. CONCLUSIONS We developed and applied a novel metric to quantify diversity in antibiotic prescribing that permits comparisons across hospitals and can be leveraged to identify high-priority areas for local and national stewardship interventions.
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alaina Burns
- Department of Pharmacy, Children's Mercy Kansas City, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri, USA
| | - Jennifer L Goldman
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- University of Kansas School of Medicine, Kansas City, Kansas, USA
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Akintan P, Oshun P, Osuagwu C, Ola-Bello O, Fajolu I, Roberts A, Temiye E, Oduyebo O. Point prevalence surveys of antibiotic prescribing in children at a tertiary hospital in a resource constraint, low-income sub-Saharan African country-the impact of an antimicrobial stewardship program. BMC Pediatr 2024; 24:383. [PMID: 38834956 DOI: 10.1186/s12887-024-04847-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 05/22/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Resistance to multiple antibiotics by several pathogens has been widely described in children and has become a global health emergency. This is due to increased use by parents, caregivers, and healthcare providers. This study aims to describe the prevalence rates of antibiotic prescribing, ascertain the impact of antimicrobial stewardship programs, and target improving the quality of antibiotic prescribing in the paediatric population over time in a hospital. METHOD A point prevalence survey of antibiotic use was performed yearly for 4 years to monitor trends in antibiotic prescribing. Data from all patients admitted before 8 a.m. on the day of the PPS were included. A web-based application designed by the University of Antwerp was used for data entry, validation, and analysis ( http://www.global-pps.com ). RESULTS A total of 260 children, including 90 (34.6%) neonates and 170 (65.4%) older children, were admitted during the four surveys. Overall, 179 (68.8%) patients received at least one antibiotic. In neonates, the prevalence of antibiotic use increased from 78.9 to 89.5% but decreased from 100 to 58.8% in older children. There was a reduction in the use of antibiotics for prophylaxis from 45.7 to 24.6%. The most frequently prescribed antibiotic groups were third generation cephalosporins and aminoglycosides. The most common indications for antibiotic prescription were sepsis in neonates and central nervous system infection in older children. The documentation of reason in notes increased from 33 to 100%, while the stop-review date also increased from 19.4 to 70%. CONCLUSION The indicators for appropriate antibiotic prescription improved over time with the introduction of antibiotic stewardship program in the department.
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Affiliation(s)
- Patricia Akintan
- Department of Paediatric College of Medicine, University of Lagos, Lagos, Nigeria.
- Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria.
| | - Philip Oshun
- Department of Medical Microbiology and Parasitology College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Medical Microbiology and Parasitology, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Chioma Osuagwu
- Department of Medical Microbiology and Parasitology College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Medical Microbiology and Parasitology, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Olafoyekemi Ola-Bello
- Department of Medical Microbiology and Parasitology, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Iretiola Fajolu
- Department of Paediatric College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Alero Roberts
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Community Health and Primary Care, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Edamisan Temiye
- Department of Paediatric College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Paediatrics, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Oyinlola Oduyebo
- Department of Medical Microbiology and Parasitology College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Medical Microbiology and Parasitology, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
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Sobel AL, Melamed J, Haas D, LeBlanc G, Cirone A, Constantinides MG. Antibiotic use in early life subsequently impairs MAIT cell-mediated immunity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.10.593643. [PMID: 38798453 PMCID: PMC11118404 DOI: 10.1101/2024.05.10.593643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Mucosal-associated invariant T (MAIT) cells are predominantly located in barrier tissues where they rapidly respond to pathogens and commensals by recognizing microbial derivatives of riboflavin synthesis. Early-life exposure to these metabolites imprints the abundance of MAIT cells within tissues, so we hypothesized that antibiotic use during this period may abrogate their development. We identified antibiotics that deplete riboflavin-synthesizing commensals and revealed an early period of susceptibility during which antibiotic administration impaired MAIT cell development. The reduction in MAIT cell abundance rendered mice more susceptible to pneumonia, while MAIT cell-deficient mice were unaffected by early-life antibiotics. Concomitant administration of a riboflavin-synthesizing commensal during antibiotic treatment was sufficient to restore MAIT cell development and immunity. Our work demonstrates that transient depletion of riboflavin-synthesizing commensals in early life can adversely affect responses to subsequent infections.
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McCulloh RJ, Kerns E, Flores R, Cane R, El Feghaly RE, Marin JR, Markham JL, Newland JG, Wang ME, Garber M. A National Quality Improvement Collaborative to Improve Antibiotic Use in Pediatric Infections. Pediatrics 2024; 153:e2023062246. [PMID: 38682258 DOI: 10.1542/peds.2023-062246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Nearly 25% of antibiotics prescribed to children are inappropriate or unnecessary, subjecting patients to avoidable adverse medication effects and cost. METHODS We conducted a quality improvement initiative across 118 hospitals participating in the American Academy of Pediatrics Value in Inpatient Pediatrics Network 2020 to 2022. We aimed to increase the proportion of children receiving appropriate: (1) empirical, (2) definitive, and (3) duration of antibiotic therapy for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infections to ≥85% by Jan 1, 2022. Sites reviewed encounters of children >60 days old evaluated in the emergency department or hospital. Interventions included monthly audit with feedback, educational webinars, peer coaching, order sets, and a mobile app containing site-specific, antibiogram-based treatment recommendations. Sites submitted 18 months of baseline, 2-months washout, and 10 months intervention data. We performed interrupted time series (analyses for each measure. RESULTS Sites reviewed 43 916 encounters (30 799 preintervention, 13 117 post). Overall median [interquartile range] adherence to empirical, definitive, and duration of antibiotic therapy was 67% [65% to 70%]; 74% [72% to 75%] and 61% [58% to 65%], respectively at baseline and was 72% [71% to 72%]; 79% [79% to 80%] and 71% [69% to 73%], respectively, during the intervention period. Interrupted time series revealed a 13% (95% confidence interval: 1% to 26%) intercept change at intervention for empirical therapy and a 1.1% (95% confidence interval: 0.4% to 1.9%) monthly increase in adherence per month for antibiotic duration above baseline rates. Balancing measures of care escalation and revisit or readmission did not increase. CONCLUSIONS This multisite collaborative increased appropriate antibiotic use for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infection among diverse hospitals.
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Affiliation(s)
- Russell J McCulloh
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
- Divisions of Pediatric Hospital Medicine
| | - Ellen Kerns
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
- Care Transformation, Children's Nebraska, Omaha, Nebraska
| | - Ricky Flores
- Care Transformation, Children's Nebraska, Omaha, Nebraska
| | - Rachel Cane
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rana E El Feghaly
- Divisions of Infectious Diseases
- Department of Pediatrics, University of Missouri Kansas City, Kansas City, Missouri
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jessica L Markham
- Pediatric Hospital Medicine, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
- Department of Pediatrics, University of Missouri Kansas City, Kansas City, Missouri
| | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine, Division of Pediatric Infectious Diseases, St Louis, Missouri
| | - Marie E Wang
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Matthew Garber
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
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Meesters K, Chappell F, Demirjian A. Trends in Antibiotic Use in a Large Children's Hospital in London (United Kingdom): 5 Years of Point Prevalence Surveys. Antibiotics (Basel) 2024; 13:172. [PMID: 38391558 PMCID: PMC10886203 DOI: 10.3390/antibiotics13020172] [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: 12/31/2023] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Background: Antibiotics are commonly prescribed in paediatrics. As their excessive use contributes to adverse drug events, increased healthcare costs, and antimicrobial resistance, antimicrobial stewardship initiatives are essential to optimising medical care. These single-centre point prevalence surveys aimed to provide insights into antibiotic prescribing trends and identify targets for paediatric AMS activities. Methods: 14 point prevalence surveys were conducted from March 2016-April 2021, collecting data on antibiotic prescriptions, indication, adherence to guidelines, and route of administration. The UK adapted the World Health Organisation's AWaRe classification-guided antibiotic categorization. Results: 32.5% of all inpatients were on at least one antimicrobial; this remained stable during all surveys (range: 20-44%, p = 0.448). Of all prescriptions, 67.2% had an end- or review-date, and the majority was for agents in the Watch category (46.8-70.5%). Amoxicillin and clavulanate were the most frequently prescribed antibiotics (20.8%), followed by gentamicin (15.3%). Approximately 28.8% of all prescriptions were for prophylactic indications, while 7.6% of the prescriptions were not adherent to the hospital guidelines. Conclusions: This study highlights the importance of ongoing monitoring and robust AMS initiatives to ensure prudent antibiotic prescribing in paediatric healthcare. It underscores the need for tailored guidelines, educational efforts, and targeted interventions to enhance the quality of antibiotic usage, ultimately benefiting both individual patients and public health.
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Affiliation(s)
- Kevin Meesters
- Department of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, London SE1 7EH, UK
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC V5Z 4H4, Canada
| | - Faye Chappell
- Department of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, London SE1 7EH, UK
| | - Alicia Demirjian
- Department of Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, London SE1 7EH, UK
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London NW9 5EQ, UK
- Faculty of Life Sciences & Medicine, King's College London, London WC2R 2LS, UK
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Cheng J, Liu Y, Li S, Pu K, Yang L, Tan L. Incidence of and Risk Factors for Third-Generation Cephalosporin-Resistant Escherichia coli Bloodstream Infections in Children. Infect Drug Resist 2024; 17:543-550. [PMID: 38352624 PMCID: PMC10863459 DOI: 10.2147/idr.s449731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/06/2024] [Indexed: 02/16/2024] Open
Abstract
Objective Third-generation cephalosporin-resistant (3GC-R) bloodstream infection (BSI) is associated with poor prognosis. We investigated the incidence of and risk factors for 3GC-R Escherichia coli (E. coli) BSI in children. Methods Patients with E. coli BSIs who were hospitalized at the Children's Hospital of Chongqing Medical University were retrospectively enrolled. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors for 3GC-R BSI. Results Two hundred fifty-two children with E. coli BSIs were enrolled. The mortality rate was 11.51% (29/252). The infection rate of 3GC-R E. coli was 48.81% (123/252), and the incidence of E. coli BSI during hospitalization was 18.58 per 1000 person-days. Approximately half (47.22%, 119/252) of the children were infected with extended-spectrum beta-lactamases (ESBLs) produced by E. coli. More than one-third (37.30%, 94/252) of the children were unnecessarily administrated carbapenems. According to our logistic regression analysis, a history of carbapenem administration, an elevated Pediatric Sequential Organ Failure Assessment (pSOFA) score ≥2, and antimicrobial agent administration before blood culture were independently associated with 3GC-R BSI (odds ratio [OR] 2.05, 95% confidence interval [CI] 1.08-3.94, P=0.029; OR 2.00, 95% CI 1.10-3.71, P=0.025, OR 1.86, 95% CI 1.02-3.42, P=0.044, respectively). Conclusion In this study, the incidence of 3GC-R E. coli BSI among children was retrospectively evaluated. Patients with a history of carbapenem administration, an elevated pSOFA score ≥2 and who were administrated antimicrobial agents before blood culture had an increased risk of 3GC-R E. coli BSI.
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Affiliation(s)
- Jie Cheng
- Department of Emergency, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing, 400014, People’s Republic of China
| | - Ya Liu
- Department of Pediatrics, Chongqing Youyoubaobei Women and Children’s Hospital, Chongqing, 401147, People’s Republic of China
| | - Shaojun Li
- Department of Emergency, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing, 400014, People’s Republic of China
| | - Kaibin Pu
- Department of Emergency, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing, 400014, People’s Republic of China
| | - Lin Yang
- Department of Emergency, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing, 400014, People’s Republic of China
| | - Liping Tan
- Department of Emergency, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Rare Diseases in Infection and Immunity, Children’s Hospital of Chongqing Medical University, Chongqing, 400014, People’s Republic of China
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Ayhan M, Coşkun B, Kayaaslan B, Hasanoğlu İ, Kalem AK, Eser F, Bilir YA, Ünlü S, Güner R. Point prevalence of antibiotic usage in major referral hospital in Turkey. PLoS One 2024; 19:e0296900. [PMID: 38295065 PMCID: PMC10830045 DOI: 10.1371/journal.pone.0296900] [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: 07/18/2022] [Accepted: 12/21/2023] [Indexed: 02/02/2024] Open
Abstract
INTRODUCTION The most important and undesirable consequence of inappropriate antibiotic use is the spread of antibiotic resistance, increased adverse effects, increased mortality and healthcare costs. We aimed to assess antibiotic usage characteristics in inpatient setting in our center. MATERIALS AND METHODS A one-day, single center point-prevalence study was carried out on June 9th 2021, in Ankara City Hospital in Turkey. Data of antibiotic consumption, appropriateness of usage and predictors of inappropriate use in adult patients were evaluated. RESULTS Out of 2640 adult patients, 893 (33.8%) were receiving at least one antibiotic. A total of 1212 antibiotic prescriptions with an average of 1.44±0.64 were found. Antibiotics were most commonly used for therapeutic purpose (84.7%), followed by surgical prophylaxis (11.6%). Majority of therapeutically used antibiotics were empirical (67.9%). Infectious diseases consultation was present in 68.3% with a compliance rate of 95.7%. Rate of inappropriate use was 20%. The most frequent cause of inappropriateness was unnecessary use (52.5%). Most commonly and most inappropriately used antibiotics were carbapenems (17.5%) and first generation cephalosporins (38.7%), respectively. Most of the inappropriateness observed in first-generation cephalosporins was due to inappropriate longer surgical prophylaxis. While age is an independent risk factor for inappropriate antibiotic use (p = 0.042), COVID-19 unit admission, use for therapeutic purpose and infectious diseases consultation were protective factors (p<0.001, p<0.001, p<0.001). CONCLUSION Rate of inappropriate use was low, but inappropriate surgical prophylaxis remains an important problem in surgical units. There is a considerable need to implement an antimicrobial stewardship program that focuses on surgical prophylaxis practices.
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Affiliation(s)
- Müge Ayhan
- Department of Infectious Diseases and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Belgin Coşkun
- Department of Infectious Diseases and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Bircan Kayaaslan
- Department of Infectious Diseases and Clinical Microbiology, Ankara Yıldırım Beyazıt University, Ankara City Hospital, Ankara, Turkey
| | - İmran Hasanoğlu
- Department of Infectious Diseases and Clinical Microbiology, Ankara Yıldırım Beyazıt University, Ankara City Hospital, Ankara, Turkey
| | - Ayşe Kaya Kalem
- Department of Infectious Diseases and Clinical Microbiology, Ankara Yıldırım Beyazıt University, Ankara City Hospital, Ankara, Turkey
| | - Fatma Eser
- Department of Infectious Diseases and Clinical Microbiology, Ankara Yıldırım Beyazıt University, Ankara City Hospital, Ankara, Turkey
| | - Yeşim Aybar Bilir
- Department of Infectious Diseases and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Serpil Ünlü
- Department of Infectious Diseases and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Rahmet Güner
- Department of Infectious Diseases and Clinical Microbiology, Ankara Yıldırım Beyazıt University, Ankara City Hospital, Ankara, Turkey
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11
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Crawford L, Pertsovskaya V, Shanklin A, Zhang A, Hamdy RF. Predictive Value of Methicillin-Resistant Staphylococcus aureus Nasal Swab PCR Assay for MRSA Infection in Critically Ill Pediatric Patients. J Pediatric Infect Dis Soc 2024; 13:84-90. [PMID: 38070165 DOI: 10.1093/jpids/piad111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/07/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Critically ill pediatric patients are frequently initiated methicillin-resistant Staphylococcus aureus (MRSA) active antibiotics during infection evaluation even though MRSA infections are rare in many patient populations. The MRSA nasal swab polymerase chain reaction assay (MRSA-NS-PCR) is a test that has been shown to have a high negative predictive value (NPV) for MRSA infection in adults. This study evaluated the diagnostic test characteristics of the MRSA-NS-PCR in predicting the presence of MRSA infection in critically ill pediatric patients. STUDY DESIGN A retrospective cohort study was performed in a 44-bed pediatric intensive care unit (PICU) between 2013 and 2017. 3860 pediatric patients (54% male, median age 4 years [IQR 1-11 years]) admitted to the PICU who met pediatric systemic inflammatory response syndrome (pSIRS) criteria, were screened with a MRSA-NS-PCR, and had cultures obtained within seven days of MRSA-NS-PCR collection were included. Predictive values and post-test probabilities of the MRSA-NS-PCR for MRSA infection were calculated. RESULTS MRSA-NS-PCR was positive in 8.6% of patients. MRSA infection was identified in 40 patients, equaling an incidence rate of 2 per 1000 patient days. The MRSA-NS-PCR demonstrated a positive predictive value (PPV) of 9.7%, a NPV of 99.8%, and a post-test probability for a negative test of 0.2% for MRSA infection. CONCLUSIONS The MRSA-NS-PCR has a poor PPV but a high NPV for MRSA infection in PICU patients when the incidence of MRSA infection is low. Creation of protocols to guide antimicrobial selection based on MRSA-NS-PCR results may lead to improved antimicrobial stewardship and significant risk reduction.
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Affiliation(s)
- Lexi Crawford
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Vera Pertsovskaya
- The George Washington University School of Medicine and Health Sciences, Department of Pediatrics, The George Washington University, Washington, District of Columbia, USA
| | - Alice Shanklin
- Division of Critical Care Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Anqing Zhang
- The George Washington University School of Medicine and Health Sciences, Department of Pediatrics, The George Washington University, Washington, District of Columbia, USA
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, District of Columbia, USA
| | - Rana F Hamdy
- The George Washington University School of Medicine and Health Sciences, Department of Pediatrics, The George Washington University, Washington, District of Columbia, USA
- Division of Infectious Diseases, Children's National Hospital, Washington, District of Columbia, USA
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12
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Aboza Garcia M, Goycochea-Valdivia W, Peñalva G, Falcon Neyra L, Moleón Ruiz M, Rodriguez-Villodres A, Montero Valladares C, Olbrich P, Sánchez-Valderrabanos E, Jiménez F, Molina M, Moreno Madueño G, Valencia Martin R, Gil Navarro MV, Molina J, Neth O, Cisneros JM. Long-term outcomes of an educational paediatric antimicrobial stewardship programme: a quality improvement study. Arch Dis Child 2024; 109:144-151. [PMID: 37940361 DOI: 10.1136/archdischild-2022-323802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 10/17/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Antimicrobial stewardship programmes (ASPs) have resulted in antimicrobial consumption (AMC) reduction and quality of prescription (QOP) improvement. However, evidence of ASP impact in paediatrics is still limited. This study aims to assess a paediatric ASP long-term outcomes. METHODS A quality improvement study assessed by a interrupted time series analysis was conducted in a paediatric tertiary hospital. QOP expressed as proportion of adequate prescriptions, AMC measured by defined daily dose incidence per 1000 occupied bed days, incidence density of bloodstream infections (BSIs) and its related all-cause crude death rate (CDR) were compared between pre (from January 2013 to December 2015) and post (from January 2016 to December 2019) ASP activities intensification, which included a dedicated paediatric infectious diseases physician to actively perform educational interviews with prescribers. RESULTS Inappropriate prescribing showed a significant downward shift associated to the intervention with a -51.4% (-61.2% to -41.8%) reduction with respect to the expected values. Overall AMC showed no trend change after the intervention. For neonatology a28.8% (-36.8% to -20.9%) reduction was observed. Overall anti-pseudomonal cephalosporin use showed a -51.2% (-57.0% to -45.4%) reduction. Decreasing trends were observed for carbapenem use, with a quarterly per cent change (QPC) of -2.4% (-4.3% to -0.4%) and BSI-related CDR (QPC=-3.6%; -5.4% to -1.7%) through the study period. Healthcare-associated multi-drug-resistant BSI remained stable (QPC=2.1; -0.6 to 4.9). CONCLUSIONS Intensification of counselling educational activities within an ASP suggests to improve QOP and to partially reduce AMC in paediatric patients. The decreasing trends in mortality remained unchanged.
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Affiliation(s)
- Marta Aboza Garcia
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, UniversityHospital Virgen del Rocío, Institute of Biomedicine of Seville (IBIS)/ Universidad deSevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica, Seville, Spain
| | - Walter Goycochea-Valdivia
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, UniversityHospital Virgen del Rocío, Institute of Biomedicine of Seville (IBIS)/ Universidad deSevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica, Seville, Spain
| | - Germán Peñalva
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Lola Falcon Neyra
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, UniversityHospital Virgen del Rocío, Institute of Biomedicine of Seville (IBIS)/ Universidad deSevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica, Seville, Spain
| | - Marta Moleón Ruiz
- Department of Pharmacy, Hospital Universitario Virgen del Rocio, Seville, Spain
| | - Angel Rodriguez-Villodres
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Peter Olbrich
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, UniversityHospital Virgen del Rocío, Institute of Biomedicine of Seville (IBIS)/ Universidad deSevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica, Seville, Spain
| | | | - Francisco Jiménez
- Department of Neonatology, University Hospital Virgen del Rocío, Seville, Spain
| | - Maria Molina
- Department of Paediatric Surgery, University Hospital Virgen del Rocío, Seville, Spain
| | | | | | - Maria Victoria Gil Navarro
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pharmacy, Hospital Universitario Virgen del Rocio, Seville, Spain
| | - Jose Molina
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Olaf Neth
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, UniversityHospital Virgen del Rocío, Institute of Biomedicine of Seville (IBIS)/ Universidad deSevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica, Seville, Spain
| | - Jose Miguel Cisneros
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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13
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Gidey K, Aregawi SG, Hailu BY, Asgedom SW, Niriayo YL. Antimicrobial Use-Related Problems Among Hospitalized Pediatric Patients: A Prospective Observational Study. Infect Drug Resist 2024; 17:119-130. [PMID: 38234373 PMCID: PMC10792179 DOI: 10.2147/idr.s433677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 01/09/2024] [Indexed: 01/19/2024] Open
Abstract
Introduction Antimicrobials are among the most commonly misused medications, leading to antimicrobial resistance, and therefore demand more attention. There are limited studies documenting "antimicrobial use-related problems" in developing countries, especially in pediatric patients. Objectives This study aimed to evaluate the prevalence of antimicrobial use-related problems and risk factors among hospitalized pediatric patients. Materials and Methods A hospital-based prospective observational study was conducted in Ayder comprehensive specialized hospital (ACSH) in the Tigray region, Ethiopia. The participants of the study were pediatric patients aged ≤15 years who were admitted with a diagnosis of infectious disease between September 2019 and November 2019. Results A total of 232 pediatric patients were included in the study. Of these, 59.5% of the patients were male and the mean age (SD) of the patients was 5.8 (5.2) years. Of the 232 patients surveyed, a total of 177 antimicrobial use-related problems were identified. One or more antimicrobial use-related problems have occurred in more than half of the patients (53.9%). The commonest antimicrobial use problems were unnecessary antimicrobial therapy (22.8%) followed by need additional antimicrobial therapy (16.4%). In a multivariate logistic regression model, patients with comorbidities (Adjusted odds ratio (AOR): 1.84, 95% confidence interval (CI): 1.04-3.27) and hospital stays exceeding one week (AOR=1.88, 95% CI: 1.08-3.26) were predictors of antimicrobial use-related problems. Conclusion Antimicrobial use-related problems were found in a significant proportion of pediatric patients. Addressing these issues necessitates collaborative efforts, emphasizing targeted education, strengthened antimicrobial stewardship, ensuring responsible antimicrobial use and enhancing pediatric care.
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Affiliation(s)
- Kidu Gidey
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Solomon Girmay Aregawi
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Berhane Yohannes Hailu
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Solomon Weldegebreal Asgedom
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Yirga Legesse Niriayo
- Department of Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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14
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Alejandro AL, Leo WWC, Bruce M. Opportunities to Improve Awareness of Antimicrobial Resistance Through Social Marketing: A Systematic Review of Interventions Targeting Parents and Children. HEALTH COMMUNICATION 2023; 38:3376-3392. [PMID: 36437539 DOI: 10.1080/10410236.2022.2149132] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Lack of knowledge from parents concerning the appropriate use of antimicrobials leads to poor treatment choices and mismanagement of antimicrobials for their children. Social marketing (SM) strategies have the potential to help parents access useful information on the appropriate use of antimicrobials. Still, its application in interventions targeting antimicrobial/antibiotic resistance awareness is minimal. This study explores the use of SM in antimicrobial/antibiotic awareness campaigns (AACs) to identify opportunities for SM approaches in developing future communication interventions targeting parents and children. We conduct a systematic review of interventions targeting parents and children between 2000 and 2022. Articles meeting the selection criteria were assessed against social marketing benchmark criteria (SMBC). We identified 6978 original records, 16 of which were included in the final review. None of the articles explicitly identified SM as part of their interventions. Twelve interventions (75%) included 1 to 4 (out of 8) benchmark criteria, while four (25%) had 5-8 benchmarks in their interventions. Of the interventions with less than four benchmark criteria, six studies (50%) reported a positive effect direction outcome, and six studies (50%) reported negative/no change direction on the outcome of interests. Meanwhile, all interventions with five or more SMBC resulted in a positive effect direction in their outcomes. In this review, the use of SM has shown promising results, indicating opportunities for future antimicrobial resistance (AMR) interventions that incorporate social marketing benchmark criteria to improve intervention outcomes.
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Affiliation(s)
- Aaron Lapuz Alejandro
- Centre for Biosecurity and One Health, Harry Butler Institute, Murdoch University
- Department of Nursing, Fiona Stanley Hospital
| | | | - Mieghan Bruce
- Centre for Biosecurity and One Health, Harry Butler Institute, Murdoch University
- School of Veterinary Medicine, Murdoch University
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15
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Diggs DT, Tribble AC, Same RG, Newland JG, Lee BR. Appropriateness of antibiotic prescribing varies by clinical services at United States children's hospitals. Infect Control Hosp Epidemiol 2023; 44:1711-1717. [PMID: 37905378 PMCID: PMC10665883 DOI: 10.1017/ice.2023.56] [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: 11/30/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVE To describe patterns of inappropriate antibiotic prescribing at US children's hospitals and how these patterns vary by clinical service. DESIGN Serial, cross-sectional study using quarterly surveys. SETTING Surveys were completed in quarter 1 2019-quarter 3 2020 across 28 children's hospitals in the United States. PARTICIPANTS Patients at children's hospitals with ≥1 antibiotic order at 8:00 a.m. on institution-selected quarterly survey days. METHODS Antimicrobial stewardship physicians and pharmacists collected data on antibiotic orders and evaluated appropriateness of prescribing. The primary outcome was percentage of inappropriate antibiotics, stratified by clinical service and antibiotic class. Secondary outcomes included reasons for inappropriate use and association of infectious diseases (ID) consultation with appropriateness. RESULTS Of 13,344 orders, 1,847 (13.8%) were inappropriate; 17.5% of patients receiving antibiotics had ≥1 inappropriate order. Pediatric intensive care units (PICU) and hospitalists contributed the most inappropriate orders (n = 384 and n = 314, respectively). Surgical subspecialists had the highest percentage of inappropriate orders (22.5%), and 56.8% of these were for prolonged or unnecessary surgical prophylaxis. ID consultation in the previous 7 days was associated with fewer inappropriate orders (15% vs 10%; P < .001); this association was most pronounced for hospitalist, PICU, and surgical and medical subspecialty services. CONCLUSIONS Inappropriate antibiotic use for hospitalized children persists and varies by clinical service. Across 28 children's hospitals, PICUs and hospitalists contributed the most inappropriate antibiotic orders, and surgical subspecialists' orders were most often judged inappropriate. Understanding service-specific prescribing patterns will enable antimicrobial stewardship programs to better design interventions to optimize antibiotic use.
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Affiliation(s)
- Devin T. Diggs
- College of Science, University of Notre Dame, Notre Dame, Indiana
| | - Alison C. Tribble
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Rebecca G. Same
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason G. Newland
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Brian R. Lee
- Division of Health Services and Outcomes Research, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
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16
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Chitalia RA, Benscoter AL, Chlebowski MM, Hart KJ, Iliopoulos I, Misfeldt AM, Sawyer JE, Alten JA. Implementation of a 24-hour infection diagnosis protocol in the pediatric cardiac intensive care unit (CICU). Infect Control Hosp Epidemiol 2023; 44:1300-1307. [PMID: 36382469 DOI: 10.1017/ice.2022.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To reduce unnecessary antibiotic exposure in a pediatric cardiac intensive care unit (CICU). DESIGN Single-center, quality improvement initiative. Monthly antibiotic utilization rates were compared between 12-month baseline and 18-month intervention periods. SETTING A 25-bed pediatric CICU. PATIENTS Clinically stable patients undergoing infection diagnosis were included. Patients with immunodeficiency, mechanical circulatory support, open sternum, and recent culture-positive infection were excluded. INTERVENTIONS The key drivers for improvement were standardizing the infection diagnosis process, order-set creation, limitation of initial antibiotic prescription to 24 hours, discouraging indiscriminate vancomycin use, and improving bedside communication and situational awareness regarding the infection diagnosis protocol. RESULTS In total, 109 patients received the protocol; antibiotics were discontinued in 24 hours in 72 cases (66%). The most common reasons for continuing antibiotics beyond 24 hours were positive culture (n = 13) and provider preference (n = 13). A statistical process control analysis showed only a trend in monthly mean antibiotic utilization rate in the intervention period compared to the baseline period: 32.6% (SD, 6.1%) antibiotic utilization rate during the intervention period versus 36.6% (SD, 5.4%) during the baseline period (mean difference, 4%; 95% CI, -0.5% to -8.5%; P = .07). However, a special-cause variation represented a 26% reduction in mean monthly vancomycin use during the intervention period. In the patients who had antibiotics discontinued at 24 hours, delayed culture positivity was rare. CONCLUSIONS Implementation of a protocol limiting empiric antibiotic courses to 24 hours in clinically stable, standard-risk, pediatric CICU patients with negative cultures is feasible. This practice appears safe and may reduce harm by decreasing unnecessary antibiotic exposure.
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Affiliation(s)
- Reema A Chitalia
- Department of Pediatrics, The Heart Institute, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexis L Benscoter
- Department of Pediatrics, The Heart Institute, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Meghan M Chlebowski
- Department of Pediatrics, The Heart Institute, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kelsey J Hart
- Department of Pediatrics, The Heart Institute, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ilias Iliopoulos
- Department of Pediatrics, The Heart Institute, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrew M Misfeldt
- Department of Pediatrics, The Heart Institute, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jaclyn E Sawyer
- Department of Pediatrics, The Heart Institute, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey A Alten
- Department of Pediatrics, The Heart Institute, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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17
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Rudnick W, Conly J, Thirion DJG, Choi K, Pelude L, Cayen J, Bautista J, Beique L, Comeau JL, Dalton B, Delport J, Dhami R, Embree J, Émond Y, Evans G, Frenette C, Fryters S, Happe J, Katz K, Kibsey P, Langley JM, Lee BE, Lefebvre MA, Leis JA, McGeer A, McKenna S, Neville HL, Slayter K, Suh KN, Tse-Chang A, Weiss K, Science M. Antimicrobial use among paediatric inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program, 2017/2018. Antimicrob Resist Infect Control 2023; 12:35. [PMID: 37072874 PMCID: PMC10111695 DOI: 10.1186/s13756-023-01219-x] [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: 05/11/2022] [Accepted: 02/16/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Antimicrobial resistance threatens the ability to successfully prevent and treat infections. While hospital benchmarks regarding antimicrobial use (AMU) have been well documented among adult populations, there is less information from among paediatric inpatients. This study presents benchmark rates of antimicrobial use (AMU) for paediatric inpatients in nine Canadian acute-care hospitals. METHODS Acute-care hospitals participating in the Canadian Nosocomial Infection Surveillance Program submitted annual AMU data from paediatric inpatients from 2017 and 2018. All systemic antimicrobials were included. Data were available for neonatal intensive care units (NICUs), pediatric ICUs (PICUs), and non-ICU wards. Data were analyzed using days of therapy (DOT) per 1000 patient days (DOT/1000pd). RESULTS Nine hospitals provided paediatric AMU data. Data from seven NICU and PICU wards were included. Overall AMU was 481 (95% CI 409-554) DOT/1000pd. There was high variability in AMU between hospitals. AMU was higher on PICU wards (784 DOT/1000pd) than on non-ICU (494 DOT/1000pd) or NICU wards (333 DOT/1000pd). On non-ICU wards, the antimicrobials with the highest use were cefazolin (66 DOT/1000pd), ceftriaxone (59 DOT/1000pd) and piperacillin-tazobactam (48 DOT/1000pd). On PICU wards, the antimicrobials with the highest use were ceftriaxone (115 DOT/1000pd), piperacillin-tazobactam (115 DOT/1000pd), and cefazolin (111 DOT/1000pd). On NICU wards, the antimicrobials with the highest use were ampicillin (102 DOT/1000pd), gentamicin/tobramycin (78 DOT/1000pd), and cefotaxime (38 DOT/1000pd). CONCLUSIONS This study represents the largest collection of antimicrobial use data among hospitalized paediatric inpatients in Canada to date. In 2017/2018, overall AMU was 481 DOT/1000pd. National surveillance of AMU among paediatric inpatients is necessary for establishing benchmarks and informing antimicrobial stewardship efforts.
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Affiliation(s)
- Wallis Rudnick
- Public Health Agency of Canada, 130 Colonnade Rd, Ottawa, ON, K2E 7L9, Canada
| | - John Conly
- University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Foothills Medical Centre, Alberta Health Services, 3330 Hospital Dr. NW, Calgary, AB, T2N 2T9, Canada
| | - Daniel J G Thirion
- Université de Montréal, 2900 Boulevard Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada
- McGill University Health Centre, 1001 Boulevard Décarie, Montréal, QC, H4A 3J1, Canada
| | - Kelly Choi
- Public Health Agency of Canada, 130 Colonnade Rd, Ottawa, ON, K2E 7L9, Canada
| | - Linda Pelude
- Public Health Agency of Canada, 130 Colonnade Rd, Ottawa, ON, K2E 7L9, Canada
| | - Joelle Cayen
- Public Health Agency of Canada, 130 Colonnade Rd, Ottawa, ON, K2E 7L9, Canada
| | - John Bautista
- Central Newfoundland Regional Health Centre, 50 Union, Grand Falls-Windsor, NL, A2A 2E1, Canada
| | - Lizanne Beique
- Public Health Agency of Canada, 130 Colonnade Rd, Ottawa, ON, K2E 7L9, Canada
| | | | - Bruce Dalton
- Alberta Health Services, 1620 29 St NW, Calgary, AB, T2N 4L7, Canada
| | - Johan Delport
- London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
| | - Rita Dhami
- London Health Sciences Centre, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada
- University of Waterloo, 200 University Ave W, Waterloo, ON, N2L 3G1, Canada
- University of Western Ontario, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Joanne Embree
- University of Manitoba, Winnipeg, MB, R3T 2N2, Canada
- Shared Health Manitoba, Winnipeg, MB, R3T 2N2, Canada
- Children's Hospital Winnipeg, 840 Sherbrook St, Winnipeg, MB, R3E 0Z3, Canada
| | - Yannick Émond
- Hôpital Maisonneuve-Rosemont, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Gerald Evans
- Kingston Health Sciences Centre, 76 Stuart St, Kingston, ON, K7L 2V7, Canada
| | - Charles Frenette
- McGill University Health Centre, 1001 Boulevard Décarie, Montréal, QC, H4A 3J1, Canada
| | - Susan Fryters
- Alberta Health Services, 10240 Kingsway Avenue, Edmonton, AB, T5H 3V9, Canada
| | - Jennifer Happe
- Infection Prevention and Control Canada, Red Deer, AB, T4N 6R2, Canada
| | - Kevin Katz
- North York General Hospital, 4001 Leslie St, North York, ON, M2K 1E1, Canada
| | - Pamela Kibsey
- Royal Jubilee Hospital, 1952 Bay St, Victoria, BC, V8R 1J8, Canada
| | - Joanne M Langley
- IWK Health Centre, 5980 University Ave, Halifax, NS, B3K 6R8, Canada
- Dalhousie University, 6299 South St, Halifax, NS, B3H 4R2, Canada
| | - Bonita E Lee
- Stollery Children's Hospital, Edmonton, AB, T6G 2B7, Canada
- University of Alberta, Edmonton, AB, T6G 2R7, Canada
| | - Marie-Astrid Lefebvre
- McGill University Health Centre, 1001 Boulevard Décarie, Montréal, QC, H4A 3J1, Canada
| | - Jerome A Leis
- Department of Medicine, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada
- Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Allison McGeer
- Sinai Health System, 600 University Ave, Toronto, ON, M5G 1X5, Canada
- University of Toronto, 27 King's College Cir, Toronto, ON, M5S 1A1, Canada
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3M7, Canada
| | - Susan McKenna
- Kingston Health Sciences Centre, 76 Stuart St, Kingston, ON, K7L 2V7, Canada
| | - Heather L Neville
- Nova Scotia Health, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Kathryn Slayter
- IWK Health Centre, 5980 University Ave, Halifax, NS, B3K 6R8, Canada
| | - Kathryn N Suh
- The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada
| | - Alena Tse-Chang
- Stollery Children's Hospital, Edmonton, AB, T6G 2B7, Canada
- University of Alberta, Edmonton, AB, T6G 2R7, Canada
| | - Karl Weiss
- SMBD-Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1E2, Canada
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Mintz I, Chowers M, Obolski U. Prediction of ciprofloxacin resistance in hospitalized patients using machine learning. COMMUNICATIONS MEDICINE 2023; 3:43. [PMID: 36977789 PMCID: PMC10050086 DOI: 10.1038/s43856-023-00275-z] [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: 11/03/2022] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Ciprofloxacin is a widely used antibiotic that has lost efficiency due to extensive resistance. We developed machine learning (ML) models that predict the probability of ciprofloxacin resistance in hospitalized patients. METHODS Data were collected from electronic records of hospitalized patients with positive bacterial cultures, during 2016-2019. Susceptibility results to ciprofloxacin (n = 10,053 cultures) were obtained for Escherichia coli, Klebsiella pneumoniae, Morganella morganii, Pseudomonas aeruginosa, Proteus mirabilis and Staphylococcus aureus. An ensemble model, combining several base models, was developed to predict ciprofloxacin resistant cultures, either with (gnostic) or without (agnostic) information on the infecting bacterial species. RESULTS The ensemble models' predictions are well-calibrated, and yield ROC-AUCs (area under the receiver operating characteristic curve) of 0.737 (95%CI 0.715-0.758) and 0.837 (95%CI 0.821-0.854) on independent test-sets for the agnostic and gnostic datasets, respectively. Shapley additive explanations analysis identifies that influential variables are related to resistance of previous infections, where patients arrived from (hospital, nursing home, etc.), and recent resistance frequencies in the hospital. A decision curve analysis reveals that implementing our models can be beneficial in a wide range of cost-benefits considerations of ciprofloxacin administration. CONCLUSIONS This study develops ML models to predict ciprofloxacin resistance in hospitalized patients. The models achieve high predictive ability, are well calibrated, have substantial net-benefit across a wide range of conditions, and rely on predictors consistent with the literature. This is a further step on the way to inclusion of ML decision support systems into clinical practice.
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Affiliation(s)
- Igor Mintz
- School of Public Health, Tel Aviv University, Tel Aviv, Israel
- Porter School of the Environment and Earth Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Michal Chowers
- Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Obolski
- School of Public Health, Tel Aviv University, Tel Aviv, Israel.
- Porter School of the Environment and Earth Sciences, Tel Aviv University, Tel Aviv, Israel.
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Papan C, Reifenrath K, Last K, Attarbaschi A, Graf N, Groll AH, Hübner J, Laws HJ, Lehrnbecher T, Liese JG, Martin L, Tenenbaum T, Vieth S, von Both U, Wagenpfeil G, Weichert S, Hufnagel M, Simon A, Baier J, Balzer S, Behr Ü, Bernbeck B, Beutel K, Blattmann C, Bochennek K, Cario H, Eggert A, Ehlert K, Göpner S, Kontny U, Körholz D, Kramm C, Lauten M, Lessel L, Linderkamp C, Lobitz S, Maas V, Misgeld R, Mücke U, Neubert J, Nonnenmacher L, Queudeville M, Redlich A, Rodehüser M, Schober S, Siepermann M, Simon T, Souliman H, Stiefel M, Wiegering V, Winkler B. Antimicrobial use in pediatric oncology and hematology in Germany and Austria, 2020/2021: a cross-sectional, multi-center point-prevalence study with a multi-step qualitative adjudication process. Lancet Reg Health Eur 2023; 28:100599. [PMID: 37180743 PMCID: PMC10173264 DOI: 10.1016/j.lanepe.2023.100599] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/31/2023] [Accepted: 02/08/2023] [Indexed: 03/05/2023] Open
Abstract
Background Due to the high risk of severe infection among pediatric hematology and oncology patients, antimicrobial use is particularly high. With our study, we quantitatively and qualitatively evaluated, based on institutional standards and national guidelines, antimicrobial usage by employing a point-prevalence survey with a multi-step, expert panel approach. We analyzed reasons for inappropriate antimicrobial usage. Methods This cross-sectional study was conducted at 30 pediatric hematology and oncology centers in 2020 and 2021. Centers affiliated to the German Society for Pediatric Oncology and Hematology were invited to join, and an existing institutional standard was a prerequisite to participate. We included hematologic/oncologic inpatients under 19 years old, who had a systemic antimicrobial treatment on the day of the point prevalence survey. In addition to a one-day, point-prevalence survey, external experts individually assessed the appropriateness of each therapy. This step was followed by an expert panel adjudication based upon the participating centers' institutional standards, as well as upon national guidelines. We analyzed antimicrobial prevalence rate, along with the rate of appropriate, inappropriate, and indeterminate antimicrobial therapies with regard to institutional and national guidelines. We compared the results of academic and non-academic centers, and performed a multinomial logistic regression using center- and patient-related data to identify variables that predict inappropriate therapy. Findings At the time of the study, a total of 342 patients were hospitalized at 30 hospitals, of whom 320 were included for the calculation of the antimicrobial prevalence rate. The overall antimicrobial prevalence rate was 44.4% (142/320; range 11.1-78.6%) with a median antimicrobial prevalence rate per center of 44.5% (95% confidence interval [CI] 35.9-49.9). Antimicrobial prevalence rate was significantly higher (p < 0.001) at academic centers (median 50.0%; 95% CI 41.2-55.2) compared to non-academic centers (median 20.0%; 95% CI 11.0-32.4). After expert panel adjudication, 33.8% (48/142) of all therapies were labelled inappropriate based upon institutional standards, with a higher rate (47.9% [68/142]) when national guidelines were taken into consideration. The most frequent reasons for inappropriate therapy were incorrect dosage (26.2% [37/141]) and (de-)escalation/spectrum-related errors (20.6% [29/141]). Multinomial, logistic regression yielded the number of antimicrobial drugs (odds ratio, OR, 3.13, 95% CI 1.76-5.54, p < 0.001), the diagnosis febrile neutropenia (OR 0.18, 95% CI 0.06-0.51, p = 0.0015), and an existing pediatric antimicrobial stewardship program (OR 0.35, 95% CI 0.15-0.84, p = 0.019) as predictors of inappropriate therapy. Our analysis revealed no evidence of a difference between academic and non-academic centers regarding appropriate usage. Interpretation Our study revealed there to be high levels of antimicrobial usage at German and Austrian pediatric oncology and hematology centers with a significant higher number at academic centers. Incorrect dosing was shown to be the most frequent reason for inappropriate usage. Diagnosis of febrile neutropenia and antimicrobial stewardship programs were associated with a lower likelihood of inappropriate therapy. These findings suggest the importance of febrile neutropenia guidelines and guidelines compliance, as well as the need for regular antibiotic stewardship counselling at pediatric oncology and hematology centers. Funding European Society of Clinical Microbiology and Infectious Diseases, Deutsche Gesellschaft für Pädiatrische Infektiologie, Deutsche Gesellschaft für Krankenhaushygiene, Stiftung Kreissparkasse Saarbrücken.
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20
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Chiotos K, Blumenthal J, Boguniewicz J, Palazzi DL, Stalets EL, Rubens JH, Tamma PD, Cabler SS, Newland J, Crandall H, Berkman E, Kavanagh RP, Stinson HR, Gerber JS. Antibiotic Indications and Appropriateness in the Pediatric Intensive Care Unit: A 10-Center Point Prevalence Study. Clin Infect Dis 2023; 76:e1021-e1030. [PMID: 36048543 PMCID: PMC10169439 DOI: 10.1093/cid/ciac698] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/04/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antibiotics are prescribed to most pediatric intensive care unit (PICU) patients, but data describing indications and appropriateness of antibiotic orders in this population are lacking. METHODS We performed a multicenter point prevalence study that included children admitted to 10 geographically diverse PICUs over 4 study days in 2019. Antibiotic orders were reviewed for indication, and appropriateness was assessed using a standardized rubric. RESULTS Of 1462 patients admitted to participating PICUs, 843 (58%) had at least 1 antibiotic order. A total of 1277 antibiotic orders were reviewed. Common indications were empiric therapy for suspected bacterial infections without sepsis or septic shock (260 orders, 21%), nonoperative prophylaxis (164 orders, 13%), empiric therapy for sepsis or septic shock (155 orders, 12%), community-acquired pneumonia (CAP; 118 orders, 9%), and post-operative prophylaxis (94 orders, 8%). Appropriateness was assessed for 985 orders for which an evidence-based rubric for appropriateness could be created. Of these, 331 (34%) were classified as inappropriate. Indications with the most orders classified as inappropriate were empiric therapy for suspected bacterial infection without sepsis or septic shock (78 orders, 24%), sepsis or septic shock (55 orders, 17%), CAP (51 orders, 15%), ventilator-associated infections (47 orders, 14%), and post-operative prophylaxis (44 orders, 14%). The proportion of antibiotics classified as inappropriate varied across institutions (range, 19%-43%). CONCLUSIONS Most PICU patients receive antibiotics. Based on our study, we estimate that one-third of antibiotic orders are inappropriate. Improved antibiotic stewardship and research focused on strategies to optimize antibiotic use in critically ill children are needed.
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Affiliation(s)
- Kathleen Chiotos
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Blumenthal
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Juri Boguniewicz
- Section of Infectious Diseases and Epidemiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Debra L Palazzi
- Infectious Diseases Division, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jessica H Rubens
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pranita D Tamma
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephanie S Cabler
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jason Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Emily Berkman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert P Kavanagh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Hannah R Stinson
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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21
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Characteristics of antifungal utilization for hospitalized children in the United States. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e190. [PMID: 36505943 PMCID: PMC9726632 DOI: 10.1017/ash.2022.338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 12/05/2022]
Abstract
Objective To characterize antifungal prescribing patterns, including the indication for antifungal use, in hospitalized children across the United States. Design We analyzed antifungal prescribing data from 32 hospitals that participated in the SHARPS Antibiotic Resistance, Prescribing, and Efficacy among Children (SHARPEC) study, a cross-sectional point-prevalence survey conducted between June 2016 and December 2017. Methods Inpatients aged <18 years with an active systemic antifungal order were included in the analysis. We classified antifungal prescribing by indication (ie, prophylaxis, empiric, targeted), and we compared the proportion of patients in each category based on patient and antifungal characteristics. Results Among 34,927 surveyed patients, 2,095 (6%) received at least 1 systemic antifungal and there were 2,207 antifungal prescriptions. Most patients had an underlying oncology or bone marrow transplant diagnosis (57%) or were premature (13%). The most prescribed antifungal was fluconazole (48%) and the most common indication for antifungal use was prophylaxis (64%). Of 2,095 patients receiving antifungals, 79 (4%) were prescribed >1 antifungal, most often as targeted therapy (48%). The antifungal prescribing rate ranged from 13.6 to 131.2 antifungals per 1,000 patients across hospitals (P < .001). Conclusions Most antifungal use in hospitalized children was for prophylaxis, and the rate of antifungal prescribing varied significantly across hospitals. Potential targets for antifungal stewardship efforts include high-risk, high-utilization populations, such as oncology and bone marrow transplant patients, and specific patterns of utilization, including prophylactic and combination antifungal therapy.
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22
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Zhang J, Zhang W, Ma X, Tang L, Tian D, Wu K, Zheng Y, Shen K, Deng J, Yang Y. Antimicrobial prescribing for children in China: data from point prevalence surveys in 18 tertiary centres in China in 2016-2017. BMJ Open 2022; 12:e059244. [PMID: 36691159 PMCID: PMC9442487 DOI: 10.1136/bmjopen-2021-059244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 08/09/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES The reports on evaluating the classification of antibiotic agents prescribed for Chinese children by combining WHO's and China's administrative categories were rare. This study aimed to investigate the pattern of antimicrobial agents prescribing for Chinese children in 2016. SETTINGS 18 tertiary centres from nine provinces located in northern, southern, eastern and western China. PARTICIPANTS The antimicrobial prescribing data from the children admitted in medical wards, surgical wards and intensive care units were collected and analysed. A total of 3680 antibiotic prescriptions for Chinese children were included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES One-day point-prevalence surveys (PPSs) on antimicrobial prescribing were conducted among hospitalised children in China between 1 February 2016 and 28 February 2017. Five hospitals participated in the first PPS, 13 hospitals in the second PPS, 17 hospitals in the third PPS and 18 hospitals in the fourth PPS. Patterns of antibiotic use with a drug utilisation of 90%, Anatomical Therapeutical Chemical Classification, WHO Access, Watch and Reserve (AWaRe) (version 2019) and antibiotic classification in China were described retrospectively. RESULTS A total of 4442 children and 3680 antibiotic prescriptions for Chinese children were included in the analysis. 2900 (65.3%) children received at least one ongoing antibiotic during the survey days. On the basis of WHO AWaRe classification, the proportion of antibiotics in the Watch group was 76.5% (2814/3680). According to the Management of Antibiotic Classification in China, 56.8% (2089/3680) and 16.1% (594/3680) of antibiotic prescriptions in the Restricted group and the Special group, respectively, were included into broad-spectrum antibiotics. The most common indication for antibiotics was bacterial lower respiratory tract infection (2044/3680, 55.5%). CONCLUSIONS The use of broad-spectrum antibiotics was frequent and excessive in hospitalised children in China in 2016.
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Affiliation(s)
- Jiaosheng Zhang
- Department of Infectious Diseases, Shenzhen Children's Hospital, Shenzhen, China
| | - Wenshuang Zhang
- Department of Respiratory, Tianjin Children's Hospital, Tianjin, China
| | - Xiang Ma
- Department of Respiratory, Children's Hospital Affiliated to Shandong University & Jinan Children's Hospital, Ji'nan, China
| | - Lanfang Tang
- Department of Respiratory, Children's Hospital Zhejiang University School of Medicine, Hangzhou, China
| | - Daiyin Tian
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing, Chongqing, China
| | - Keye Wu
- Department of Cardiothoracic Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Yuejie Zheng
- Department of Respiratory, Shenzhen Children's Hospital, Shenzhen, China
| | - Kunling Shen
- Department of Respiration, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing, China
| | - Jikui Deng
- Department of Infectious Diseases, Shenzhen Children's Hospital, Shenzhen, China
| | - Yonghong Yang
- Department of Infectious Diseases, Shenzhen Children's Hospital, Shenzhen, China
- Beijing Pediatric Research Institute, Beijing Children's Hospital Affiliated to Capital Medical University, National Center for Children's Health, Beijing, China
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23
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Use of broad-spectrum antibiotics in children diagnosed with multisystem inflammatory syndrome temporarily associated with SARS-CoV-2 infection in Poland: the MOIS-CoR study. Int J Infect Dis 2022; 122:703-709. [PMID: 35830922 PMCID: PMC9271354 DOI: 10.1016/j.ijid.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Multisystem inflammatory syndrome in children (MIS-C) is the result of an immune response triggered by a previous exposure to SARS-CoV-2. The clinical presentation of MIS-C overlaps with other life-threatening bacterial infections, in which antimicrobials are the mainstay therapy. The aim of study was to describe the use of antibiotics in children with MIS-C in Poland. METHODS The analysis of 345 children reported from 42 Polish cities to the national MultiOrgan Inflammatory Syndromes COVID-19 Related Study (MOIS-CoR Study) from June 2020 to April 2021. RESULTS At least one antibiotic was used in 310 (90%) children, mainly third-generation cephalosporin (251/310). Broad-spectrum antibiotics were used in 258 (75%) children and 224 (87%) received this treatment for more than 3 days. Concentrations of serum procalcitonin >2 µg/l and the presence of lower respiratory symptoms were associated with increased odds of receiving any antibiotic. CONCLUSION Although bacterial infections in patients with MIS-C are uncommon, we show that MIS-C poses a challenge to clinicians who are faced with the decision to start, continue, or stop antimicrobial therapy. Antibiotic stewardship in patients with MIS-C should be improved to ensure that likely pathogens are treated and that antimicrobials are stopped when bacterial infections are excluded and the diagnosis of MIS-C is made.
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Novel expansion of a well-established antimicrobial stewardship program: Enhancing program efficiency and reach. Infect Control Hosp Epidemiol 2022:1-6. [DOI: 10.1017/ice.2022.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objective:
To evaluate efficiency and impact of a novel antimicrobial stewardship program (ASP) prospective-audit-with-feedback (PAF) review process using the Cerner Multi-Patient Task List (MPTL).
Design:
Retrospective cohort study.
Setting:
A 367-bed free-standing, pediatric academic medical center.
Methods:
The ASP PAF review process expanded to monitor all systemic and inhaled antibiotics through use of the MPTL on July 23, 2020. Average number of daily ASP reviews, absolute number of monthly interventions, and time to conduct ASP reviews were compared between the preimplementation period and the postimplementation period following expansion. Antibiotic days of therapy (DOT) per 1,000 patient days for overall and select antibiotics were compared between periods. ASP intervention characteristics were assessed.
Results:
Average daily ASP reviews significantly increased following program expansion (9 vs 14 reviews; P < .0001), and the absolute number of ASP interventions each month also increased (34 vs 52 interventions; P ≤ .0001). Time to conduct daily ASP reviews increased in the postimplementation period (1.03 vs 1.32 hours). Overall antibiotic DOT per 1,000 patient days significantly decreased in the postimplementation period (457.9 vs 427.9; P < .0001) as well as utilization of select, narrow-spectrum antibiotics such as ampicillin and clindamycin. Intervention type and antibiotics were similar between periods. The ASP documented 128 “nonantibiotic interventions” in the postimplementation period, including culture and/or susceptibility testing (32.8%), immunizations (25.8%), and additional diagnostic testing (22.7%).
Conclusions:
Implementation of an ASP PAF review process using the MPTL allowed for efficient expansion of a pre-existing ASP and a decrease in overall antibiotic utilization. ASP documentation was enhanced to fully track the impact of the program.
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Marti D, Hamdy RF, Broniatowski DA. Gist Representations and Decision-Making Processes Affecting Antibiotic Prescribing for Children with Acute Otitis Media. MDM Policy Pract 2022; 7:23814683221115416. [PMID: 35911174 PMCID: PMC9335473 DOI: 10.1177/23814683221115416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 07/01/2022] [Indexed: 11/25/2022] Open
Abstract
Objective. To test the predictions of fuzzy-trace theory regarding pediatric clinicians’ decision-making processes and risk perceptions about antibiotics for children with acute otitis media (AOM). Methods. We conducted an online survey experiment administered to a sample of 260 pediatric clinicians. We measured their risk perceptions and prescribing decisions across 3 hypothetical AOM treatment scenarios. Participants were asked to choose among the following options: prescribe antibiotics immediately, watchful waiting (“hedging”), or not prescribing antibiotics. Results. We identified 4 gists based on prior literature: 1) “why not take a risk?” 2) “antibiotics might not help but can hurt,” 3) “antibiotics do not have harmful side effects,” and 4) “antibiotics might have harmful side effects.” All 4 gists predicted risky choice (P < 0.001), and gist endorsements varied significantly between scenarios when antibiotics were indicated, F(2, 255) = 8.53, P < 0.001; F(2, 255) = 5.14, P < .01; and F(2, 255) = 3.56, P < 0.05 for the first 3 factors, respectively. In a logistic regression, more experienced clinicians were less likely to hedge (B = −0.05; P < 0.01). Conclusion. As predicted by fuzzy-trace theory, pediatric clinicians’ prescription decisions are associated with gist representations, which are distinct from verbatim risk estimates. Implications. Antibiotic stewardship programs can benefit by communicating the appropriate gists to clinicians who prescribe antibiotics for pediatric patients.
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Affiliation(s)
| | - Rana F. Hamdy
- Department of Pediatrics, Children’s National Health System, Washington DC, USA
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Alsaedi AA, El-Saed A, Althaqafi A, Bhutta MJ, Abukhzam B, Alshamrani M. Antimicrobial therapy, resistance, and appropriateness in healthcare-associated and community-associated infections; a point prevalence survey. J Infect Chemother 2022; 28:1358-1363. [PMID: 35760663 DOI: 10.1016/j.jiac.2022.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Data examining differences in antimicrobial therapy and its appropriateness between healthcare-associated infections (HAIs) and community-associated infections (CAIs) are limited. The objective was to compare antimicrobial therapy, resistance, and appropriateness between CAIs and HAIs. METHODS One-day point prevalence survey targeting admitted patients with active infections was conducted in six tertiary care hospitals. Antimicrobial appropriateness was decided based on hospital antimicrobial guidelines, clinical assessment, culture results, and other relevant investigations. RESULTS Out of 1666 patient records reviewed, 240 (14.4%) infection events were identified. Prevalence of infections treated with antimicrobials were 6.5% for HAIs and 7.1% for CAIs. The most commonly prescribed antimicrobials were carbapenems (19.6%), cephalosporins (14.8%), and vancomycin (13.2%), with some differences between HAIs and CAIs. The overall contribution of MDR pathogens to both HAIs and CAIs was similar (34.0% versus 34.3%, p = 0.969). ESBL was significantly associated with CAIs while other gram-negative MDR pathogens significantly associated with HAIs. Overall appropriateness of antimicrobial therapy was similar in HAI and CAI events (64.2% versus 64.7%, p = 0.934). However, it was highest in aminoglycosides (78.6%) and lowest in vancomycin (40.8%). It was lowest in bloodstream infections than other infections (48.5% versus 61% to 78%, p = 0.044). CONCLUSION Although the overall burden of MDR pathogens and appropriateness of antimicrobial therapy were similar in HAI and CAI events, there were some differences related to the type of MDR, type of antimicrobials, and type of infection. The current finding can guide training and educational activities of local antimicrobial stewardship initiatives aiming to improve antimicrobial therapy in hospital setting.
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Affiliation(s)
- Asim A Alsaedi
- Infection Prevention and Control Department, Ministry of National Guard Health Affairs (MNGHA), Jeddah, Saudi Arabia; King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Aiman El-Saed
- Infection Prevention and Control Department, MNGHA, Riyadh, Saudi Arabia; King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Community Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Muhammad Javid Bhutta
- Infection Prevention and Control Department, Ministry of National Guard Health Affairs (MNGHA), Jeddah, Saudi Arabia
| | - Bassem Abukhzam
- Infection Prevention and Control Department, MNGHA, Riyadh, Saudi Arabia
| | - Majid Alshamrani
- Infection Prevention and Control Department, MNGHA, Riyadh, Saudi Arabia; King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
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Battini V, Mari A, Gringeri M, Casini F, Bergamaschi F, Mosini G, Guarnieri G, Pozzi M, Nobile M, Zuccotti G, Clementi E, Radice S, Fabiano V, Carnovale C. Antibiotic-Induced Neutropenia in Pediatric Patients: New Insights From Pharmacoepidemiological Analyses and a Systematic Review. Front Pharmacol 2022; 13:877932. [PMID: 35721197 PMCID: PMC9201445 DOI: 10.3389/fphar.2022.877932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/19/2022] [Indexed: 12/04/2022] Open
Abstract
Aim: to characterize pediatric cases of antibiotic-associated neutropenia through a multidisciplinary approach, focusing on the temporal association between the wide spectrum of treatment options and the occurrence of this relatively uncommon but potentially clinically relevant adverse event. Methods: we carried out a pharmacoepidemiological analysis based on the FDA Adverse Event Reporting System (FAERS) database, a retrospective chart review and a systematic review of the literature, focusing on the time to onset (TTO) of this side effect, in the pediatric clinical setting. Results: A total of 281 antibiotic-related neutropenia events, involving 11 categories of antibiotics, were included in the time to onset analysis. The median TTO ranged from 4 to 60 days after the start of the therapy. A shorter median TTO was found from the retrospective chart review [16 patients: median days (25th-75th percentiles) = 4 (3–5)], compared to 15 (9–18) vs. 10 (6–18) for literature (224 patients) and FAERS (41 cases), respectively. The Anatomical Therapeutic Chemical classes, J01X, J01F, J01E and J04A, and the median TTOs retrieved from more than one source revealed high accordance (p > 0.05), with J01X causing neutropenia in less than a week and J01F/J01E/J04A in more than 10 days. Antibiotics were discontinued in nearly 34% of cases. In FDA Adverse Event Reporting System reports, half of the patients experiencing neutropenia were hospitalized. Conclusion: Whereas antibiotic associated neutropenia is benign in the majority of cases, yet it should not be neglected as, even if rarely, it may put children at higher risk of clinical consequences. Clinicians’ awareness of antibiotic-associated neutropenia and its mode of presentation contributes to the continuous process of monitoring safety of antibiotics.
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Affiliation(s)
- Vera Battini
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Alessandra Mari
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Michele Gringeri
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Francesca Casini
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Francesco Bergamaschi
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Giulia Mosini
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Greta Guarnieri
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Marco Pozzi
- Scientific Institute IRCCS E. Medea, Bosisio Parini, Lecco, Italy
| | - Maria Nobile
- Scientific Institute IRCCS E. Medea, Bosisio Parini, Lecco, Italy
| | - Gianvincenzo Zuccotti
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Emilio Clementi
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy.,Scientific Institute IRCCS E. Medea, Bosisio Parini, Lecco, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Valentina Fabiano
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
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Daniels EA, McPherson CC, Newland JG, Lee BR. Variation in ampicillin dosing for lower respiratory tract infections and neonatal bacterial infections in US children's hospitals. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e85. [PMID: 36483411 PMCID: PMC9726562 DOI: 10.1017/ash.2022.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE We examined ampicillin dosing in pediatric patients across 3 conditions: (1) bacterial lower respiratory tract infections (LRTIs) in infants and children >3 months, (2) neonates with suspected or proven sepsis, and (3) neonates with suspected central nervous system (CNS) infections. We compared our findings to dosing guidance for these specific indications. DESIGN Retrospective cohort study. SETTING The study included data from 32 children's hospitals in the United States. METHODS We reviewed prescriptions from the SHARPS study of antimicrobials, a survey of antibiotic prescribing from July 2016 to December 2017. Prescriptions were analyzed for indication, total daily dose per kilogram, and presence of antimicrobial stewardship program (ASP) review. LRTI prescriptions were compared to IDSA recommendations for community-acquired pneumonia. Neonatal prescriptions were compared to recommendations from the American Academy of Pediatrics (AAP). Prescriptions were categorized as "optimal" (80%-120% of recommended dosing), "suboptimal" (<80% of recommended dosing), or "excessive" (>120% of recommended dosing). RESULTS Among 1,038 ampicillin prescriptions, we analyzed 88 prescriptions for LRTI, 499 prescriptions for neonatal sepsis, and 27 prescriptions for neonatal CNS infection. Of the LRTI prescriptions, 77.3%were optimal. Of prescriptions for neonatal sepsis, 81.6% were excessive compared to AAP bacteremia recommendations but 78.8% were suboptimal compared to AAP meningitis guidelines. Also, 48.1% of prescriptions for neonatal CNS infection were suboptimal, and 50.6% of prescriptions were not reviewed by the ASP. CONCLUSIONS LRTI dosing is generally within the IDSA-recommended range. However, dosing for neonatal sepsis often exceeds the recommendation for bacteremia but is below the recommendation for meningitis. This variability points to an important opportunity for future antimicrobial stewardship efforts.
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Affiliation(s)
- Elizabeth A. Daniels
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | | | - Jason G. Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Brian R. Lee
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
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Liu YX, Yang Y, Le KJ, Zhang ZL, Cui M, Zhong H, Gu ZC. Antimicrobial Stewardship in Surgery: A Literature Bibliometric Analysis. Front Public Health 2022; 10:847420. [PMID: 35462840 PMCID: PMC9021645 DOI: 10.3389/fpubh.2022.847420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/16/2022] [Indexed: 01/03/2023] Open
Abstract
Background Antimicrobial resistance and the dwindling antibiotic development pipeline have resulted in a looming post-antibiotic era. Research related to antimicrobial stewardship (AMS) has grown rapidly in the past decade, especially in the field of surgery. We conducted a bibliometric analysis of these publications. In addition, we aimed to identify research hotspots and infer future research trends. Methods We screened global publications on AMS in the surgical field over ten years (between 2011 and 2020) from the Web of Science core collection database. The keywords “antimicrobial or antibiotic”, “stewardship”, “management”, “management strategies”, “programme”, “surgery” and “surgical” were used to search for related papers. VOS viewer, R software, and other machine learning and visualization tools were used to conduct the bibliometric analysis of the publications. Results We identified 674 publications on AMS in surgical fields; “antimicrobial stewardship” (with total link strength of 1,096) was the most frequent keyword, and had strong links to “antimicrobial resistance” and “guidelines”. The top 100 most cited papers had a mean citation count of 47.21 (range: 17–1155) citations, which were cited by survey research studies, clinical trials, and observational studies. The highest-ranking and most cited journal was Clinical Infectious Diseases with eight publications. Jason G. Newland from Washington University wrote seven papers and was cited 1,282 times. The University of Washington published 17 papers and was cited 1,258 times, with the largest number of publications by author and organization. The USA published 198 papers and cooperated with 21 countries, mainly partnering with Italy, the UK, and Canada. Published articles mainly focused on the current clinical situation regarding surgical AMS management, antibiotic prescription, and antibiotic resistance. Conclusions Publications on surgical AMS management have increased in recent decades, with the USA being the most prolific. Epidemiological investigations of surgical-related infections, antibiotic prescriptions, and antibiotic resistance are fast-developing research trends. However, further improvements are still needed according to the recommendations gained from the bibliometric analysis.
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Affiliation(s)
- Yang-Xi Liu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ya Yang
- Department of Infection Control, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ke-Jia Le
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zai-Li Zhang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Cui
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Han Zhong
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Han Zhong
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Zhi-Chun Gu
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Chiotos K, Fitzgerald JC, Hayes M, Dashefsky H, Metjian TA, Woods-Hill C, Biedron L, Stinson H, Ku BC, Robbins Tighe S, Weiss SL, Balamuth F, Schriver E, Gerber JS. Improving Vancomycin Stewardship in Critically Ill Children. Pediatrics 2022; 149:185402. [PMID: 35362066 PMCID: PMC9647566 DOI: 10.1542/peds.2021-052165] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Inappropriate vancomycin use is common in children's hospitals. We report a quality improvement (QI) intervention to reduce vancomycin use in our tertiary care PICU. METHODS We retrospectively quantified the prevalence of infections caused by organisms requiring vancomycin therapy, including methicillin-resistant Staphylococcus aureus (MRSA), among patients with suspected bacterial infections. Guided by these data, we performed 3 QI interventions over a 3-year period, including (1) stakeholder education, (2) generation of a consensus-based guideline for empiric vancomycin use, and (3) implementation of this guideline through clinical decision support. Vancomycin use in days of therapy (DOT) per 1000 patient days was measured by using statistical process control charts. Balancing measures included frequency of bacteremia due to an organism requiring vancomycin not covered with empiric therapy, 30-day mortality, and cardiovascular, respiratory, and renal organ dysfunction. RESULTS Among 1276 episodes of suspected bacterial infection, a total of 19 cases of bacteremia (1.5%) due to organisms requiring vancomycin therapy were identified, including 6 MRSA bacteremias (0.5%). During the 3-year QI project, overall vancomycin DOT per 1000 patient days in the PICU decreased from a baseline mean of 182 DOT per 1000 patient days to 109 DOT per 1000 patient days (a 40% reduction). All balancing measures were unchanged, and all cases of MRSA bacteremia were treated empirically with vancomycin. CONCLUSION Our interventions reduced overall vancomycin use in the PICU without evidence of harm. Provider education and consensus building surrounding indications for empiric vancomycin use were key strategies.
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Affiliation(s)
- Kathleen Chiotos
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Division of Infectious Diseases, Department of Pediatrics,Antimicrobial Stewardship Program,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Address correspondence to Kathleen Chiotos, MD, MSCE, 3401 Civic Center Blvd, Wood Building, 6 Floor Room 6029, Philadelphia, PA 19104. E-mail:
| | - Julie C. Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hannah Dashefsky
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Charlotte Woods-Hill
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren Biedron
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hannah Stinson
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brandon C. Ku
- Division of Emergency Medicine,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sheila Robbins Tighe
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Scott L. Weiss
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fran Balamuth
- Division of Emergency Medicine,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Jeffrey S. Gerber
- Antimicrobial Stewardship Program,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Imburgia TA, Kussin ML. A Review of Extended and Continuous Infusion Beta-Lactams in Pediatric Patients. J Pediatr Pharmacol Ther 2022; 27:214-227. [PMID: 35350159 DOI: 10.5863/1551-6776-27.3.214] [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: 05/13/2021] [Accepted: 10/29/2021] [Indexed: 11/11/2022]
Abstract
Intravenous beta-lactam antibiotics are the most prescribed antibiotic class in US hospitalized patients of all ages; therefore, optimizing their dosing is crucial. Bactericidal killing is best predicted by the time in which beta-lactam drug concentrations are maintained above the organism's minimum inhibitory concentration (MIC), rather than achievement of a high peak concentration. As such, administration of beta-lactam antibiotics via extended or continuous infusions over a minimum of 3 hours, rather than standard infusions over approximately 30 minutes, has been associated with improved achievement of pharmacodynamic targets and improved clinical outcomes in adult medical literature. This review summarizes the pediatric medical literature. Applicable studies include pharmacodynamic models, case series, retrospective analyses, and prospective studies on the use of extended infusion and continuous infusion penicillins, cephalosporins, carbapenems, and monobactams in neonates, infants, children, and adolescents. Specialized patient populations with unique pharmacokinetics and high-risk infections (neonates, critically ill, febrile neutropenia, cystic fibrosis) are also reviewed. While more studies are needed to confirm prospective clinical outcomes, the current body of evidence suggests extended and continuous infusions of beta-lactam antibiotics are well tolerated in children and improve achievement of pharmacokineticpharmacodynamic targets with similar or superior clinical outcomes, particularly in infections associated with high MICs.
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Affiliation(s)
- Taylor A Imburgia
- Department of Pharmacy (TAI), WVU Medicine Children's, Morgantown, WV
| | - Michelle L Kussin
- Department of Pharmacy (MLK), Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, IN
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The Current State and Future Directions of Inpatient Pediatric Antimicrobial Stewardship. Infect Dis Clin North Am 2022; 36:173-186. [DOI: 10.1016/j.idc.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Oo WT, Carr SD, Marchello CS, San MM, Oo AT, Oo KM, Lwin KT, Win HH, Crump JA. Point-prevalence surveys of antimicrobial consumption and resistance at a paediatric and an adult tertiary referral hospital in Yangon, Myanmar. Infect Prev Pract 2022; 4:100197. [PMID: 35005602 PMCID: PMC8717234 DOI: 10.1016/j.infpip.2021.100197] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/08/2021] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND Antimicrobial resistance is increasingly prevalent worldwide. The inappropriate use of antimicrobials, including in the hospital setting, is considered a major driver of antimicrobial resistance. AIM To inform improvements in antimicrobial stewardship, we undertook point prevalence surveys of antimicrobial prescribing at Yangon Children's Hospital and Yangon General Hospital in Yangon, Myanmar. METHODS We conducted our surveys using the Global Point-Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) method. All inpatients who were prescribed an antimicrobial on the day of the survey were included in the analysis. FINDINGS We evaluated a total of 1,980 patients admitted to two hospitals during December 2019. Of these, 1,255 (63.4%) patients were prescribed a total of 2,108 antimicrobials. Among antimicrobials prescribed, 722 (34.3%) were third-generation cephalosporins, the most commonly prescribed antimicrobial class. A total of 940 (44.6%) antimicrobials were prescribed for community-acquired infection, and 724 (34.3%) for surgical prophylaxis. Of 2,108 antimicrobials, 317 (15.0%) were prescribed for gastrointestinal tract prophylaxis, 305 (14.5%) for skin, soft tissue, bone and joint prophylaxis, and 303 (14.4%) for pneumonia treatment. A stop or review date was documented for 350 (16.6%) antimicrobial prescriptions, 673 (31.9%) antimicrobial prescriptions were guideline compliant, and 1,335 (63.3%) antimicrobials were administered via the parenteral route. Of 1,083 antimicrobials prescribed for a therapeutic use, 221 (20.4%) were targeted therapy. CONCLUSION Our findings underscore the need to update and expand evidence-based guidelines for antimicrobial use, promote the benefits of targeted antimicrobial therapy, and support the implementation of hospital-based antimicrobial stewardship programmes at the hospitals surveyed.
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Affiliation(s)
- Win Thandar Oo
- Centre for International Health, University of Otago, Dunedin, New Zealand
- Department of Microbiology, University of Medicine 1, Yangon, Myanmar
| | - Samuel D. Carr
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | | | - Moe Moe San
- Department of Tropical and Infectious Diseases Medicine, Yangon General Hospital, Yangon, Myanmar
| | | | - Khine Mar Oo
- Department of Microbiology, University of Medicine 1, Yangon, Myanmar
| | - Kay Thi Lwin
- Department of Preventive and Social Medicine, University of Medicine 1, Yangon, Myanmar
| | - Hla Hla Win
- University of Public Health, Yangon, Myanmar
| | - John A. Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
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Woods-Hill CZ, Xie A, Lin J, Wolfe HA, Plattner AS, Malone S, Chiotos K, Szymczak JE. Numbers and narratives: how qualitative methods can strengthen the science of paediatric antimicrobial stewardship. JAC Antimicrob Resist 2022; 4:dlab195. [PMID: 35098126 PMCID: PMC8794647 DOI: 10.1093/jacamr/dlab195] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents' perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 E Pratt St., Baltimore, MD 21202, USA
| | - John Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Heather A. Wolfe
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Alex S. Plattner
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Sara Malone
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Kathleen Chiotos
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Julia E. Szymczak
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
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35
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Poole NM, Frost H. Targets and Methods to Improve Outpatient Antibiotic Prescribing for Pediatric Patients. Infect Dis Clin North Am 2022; 36:187-202. [DOI: 10.1016/j.idc.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Grewer-Katona G, Hüebner J, Pecar A, Wolf GK. Opportunities for Antibiotic Stewardship Interventions in a Pediatric Hospital. J PEDIAT INF DIS-GER 2022. [DOI: 10.1055/s-0042-1744559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Objective This study's objective was to assess an antibiotic stewardship intervention, compare pediatric antibiotic usage in a non-university hospital (Children's Hospital Traunstein [TS]) with a university hospital (Dr. von Hauner Children's Hospital, Ludwig Maximilians University Munich [MUC]), and assess adherence to national guidelines.
Methods Antibiotic usage pre- and post-antibiotic stewardship (ABS) intervention was compared, and antibiotic prescriptions over 4 months were prospectively recorded. ABS intervention consisted of weekly teaching sessions, antibiotic pocket cards, and rounds with pediatric infectious disease staff. Medical records were reviewed to describe antibiotic consumption, antibiotic dosages and length of use, and adherence to national guidelines. Pediatric antibiotic usage was compared between hospitals and patient groups.
Results After the ABS intervention, the use of second-generation cephalosporins decreased, while penicillin with β-lactamase inhibitors (BLI) increased. Survey of antibiotic prescriptions over the 4 months study period in the non-university hospital showed a high administration rate of second-generation cephalosporins and extended-spectrum penicillins in the non-intensive care units (ICU) wards (48.53 and 38.93 days of therapy [DoT]/1,000 patient days [PD], respectively) and a high rate of third-generation cephalosporins in the ICU ward (110.33 DoT/1,000PD). A high prescriptions rate was seen in the neonatal intensive care unit (NICU) wards (DoT/ length of therapy [LoT] ratio of 2.185). Reserve group antibiotics were only given in the ICU. Adherence to national guidelines was highest in the NICU and pediatric ICU wards. Striking was the relatively high rate of incorrect usage of second-generation cephalosporins. Comparing the pediatric wards of the non-university hospital (TS) and the university hospital (MUC), the prescription ratio was 11.1% (TS) versus 30.6% (MUC), and DoT/1,000PD 198.9 (TS) versus 483.6 (MUC), p = 0.02. ABS intervention changed the choice of described antibiotics, but not the overall frequency.
Conclusion Adherence to national guidelines was highest in fields with standardized therapy recommendations, like in the NICU. In MUC, antibiotics, in particular restricted ones, were prescribed more frequently, probably due to higher severity of illness.These data indicate that the usage of antibiotics and adherence to national guidelines show a wide variety, but ABS interventions were effective in changing prescription behavior.
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Affiliation(s)
- Gabor Grewer-Katona
- Department of Pediatric Cardiology, Center for Pediatrics, University of Bonn Medical Center, Bonn, Germany
| | - Johannes Hüebner
- Dr. Von Hauner Children's Hospital, Ludwig Maximilians University Munich, Germany
| | - Alenka Pecar
- Department of Pharmacy, University Hospital, Ludwig Maximilians University Munich, Germany
| | - Gerhard K. Wolf
- Department of Pediatrics, Children's Hospital Traunstein, Germany
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Rungsitsathian K, Wacharachaisurapol N, Nakaranurack C, Usayaporn S, Sakares W, Kawichai S, Jantarabenjakul W, Puthanakit T, Anugulruengkitt S. Acceptance and outcome of interventions in a meropenem de-escalation antimicrobial stewardship program in pediatrics. Pediatr Int 2021; 63:1458-1465. [PMID: 33740838 DOI: 10.1111/ped.14703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/04/2021] [Accepted: 03/16/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Prospective audit and feedback is a method that allows the antimicrobial stewardship program (ASP) team to interact with attending physicians to tailor antibiotic therapy, including de-escalation, as appropriate. This study aimed to evaluate the acceptance and outcomes of ASP de-escalation recommendations in children who received meropenem. METHODS A prospective cohort study was conducted in children aged 1 month to 18 years who received meropenem in a tertiary-care teaching hospital. The ASP team gave recommendation between 72 and 120 h after initiating meropenem therapy. Acceptance of de-escalation recommendations among primary physicians was evaluated within 24 h of recommendation. Outcomes included clinical success rate on the 7th day and incidence rate of acquisition of carbapenem-resistant gram-negative bacteria (CR-GNB) within 30 days. RESULTS From March to December 2019, 217 children with a median (interquartile range) age of 2.1 (0.6, 9.5) years received meropenem. The ASP team gave recommendations in 127 (58.5%) of cases for continuation of meropenem therapy and 90 (41.5%) of cases for de-escalation. The overall acceptance of ASP de-escalation recommendations was 57.8% (95%CI: 46.9-68.1%). Clinical success rates were 85.2% in the accepted group compared to 77.5% in the rejected group (P = 0.06). The incidence rate of acquisition of CR-GNB within 30 days after treatment was 5.8% in the accepted group and 15.8% in the rejected group (P = 0.03). CONCLUSIONS About half of the recommendations to de-escalate meropenem prescriptions were accepted through the ASP intervention. Carbapenem-resistant gram-negative bacteria acquisitions was less likely in the de-escalation group. A robust de-escalation strategy 72 h following carbapenem initiation should be encouraged to combat multidrug-resistant organisms.
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Affiliation(s)
- Kanokporn Rungsitsathian
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Noppadol Wacharachaisurapol
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chotirat Nakaranurack
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Sang Usayaporn
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Watchara Sakares
- Pharmaceuticals Care Unit Inpatient, Department of Pharmacy, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Surinda Kawichai
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Watsamon Jantarabenjakul
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Suvaporn Anugulruengkitt
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Outpatient antimicrobial stewardship programs in pediatric institutions in 2020: Status, needs, barriers. Infect Control Hosp Epidemiol 2021; 43:1396-1402. [PMID: 34674785 DOI: 10.1017/ice.2021.416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess current resources, interventions, and obstacles of pediatric outpatient antimicrobial stewardship programs (ASP). DESIGN Cross-sectional study. SETTING Institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient collaborative (SHARPS-OP). PARTICIPANTS Antimicrobial stewardship leaders from the above institutions. METHODS An investigator-developed survey was deployed online in September 2020 to antimicrobial stewardship leaders in SHARPS-OP institutions. The survey was divided into 4 sections: (1) basic information, (2) status of pediatric outpatient ASP in the institutions including financial support, (3) outpatient ASP interventions undertaken by the institutions, and (4) needs and SHARPS-OP collaborative goals. RESULTS Of 56 invited institutions, 45 participated, achieving an 80% response rate. Only 5 sites (11%) had allocated financial support for an outpatient ASP, compared to 42 (95.6%) for their inpatient ASP. The most widely used outpatient ASP interventions included antimicrobial guidance (57.8%), education (46.7%), and quality improvement projects (37.8%). Time was identified as the biggest barrier to expanding outpatient ASPs (91.1%), followed by financial support (53.3%), development of meaningful reports (51.1%), and administrative support (44.4%). Important goals of the collaborative included seeking learning opportunities and developing clear metrics for pediatric outpatient ASP benchmarking. Program needs included securing operational support (35.8%) and strengthening data analysis (31.6%). CONCLUSIONS Very few pediatric institutions with robust inpatient ASPs have devoted time and financial support to advance outpatient efforts. To promote appropriate antibiotic prescribing in the outpatient arena, time and resource funding by administrative leaders are necessary to develop a robust, sustainable stewardship infrastructure.
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Lu H, Thurnherr E, Meaney CJ, Fusco NM. Incidence and Risk Factors for Acute Kidney Injury in Hospitalized Children Receiving Piperacillin-Tazobactam. J Pediatr Pharmacol Ther 2021; 26:597-602. [PMID: 34421409 DOI: 10.5863/1551-6776-26.6.597] [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: 09/28/2020] [Accepted: 12/30/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Drug-induced kidney injury contributes to morbidity and mortality in hospitalized children. Antibiotics such as TZP have been implicated in the development of acute kidney injury (AKI) in adults; however, data are limited in children. The purpose of this study was to determine the incidence of AKI in hospitalized children receiving TZP. METHODS This was a retrospective cohort study of hospitalized children between 2 months and 19 years of age who received TZP for at least 48 hours. Acute kidney injury was defined as a 50% increase from the initial serum creatinine (SCr) prior to TZP initiation. Serum creatinine values were adjusted for fluid balance using a validated approach. Severity of AKI was characterized using the Pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease (pRIFLE) criteria. Descriptive and inferential statistics were used to describe the incidence and risk factors of AKI, with an alpha = 0.05. RESULTS A total of 65 subjects were included. Twenty-five (38.5%) required PICU admission. The incidence of AKI was 7.7% (n = 5) using adjusted SCr (13.37 cases/1000 patient-days). According to pRIFLE, 6.15% (n = 4) subjects met criteria for Risk (n = 3) or Injury (n = 1), and none developed Failure, Loss, or End-Stage (10.70 cases/1000 patient-days for Risk and Injury categories). No risk factors were identified. Hospital length of stay was longer in subjects who experienced AKI compared with those who did not (p = 0.04). CONCLUSIONS The incidence of AKI in hospitalized children exposed to TZP was low. In those who did develop AKI, peak SCr occurred approximately 1 week after TZP initiation.
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Pediatric antimicrobial stewardship practices at discharge: A national survey. Infect Control Hosp Epidemiol 2021; 43:1686-1688. [PMID: 34269167 DOI: 10.1017/ice.2021.283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We surveyed pediatric antimicrobial stewardship program (ASP) site leaders within the Sharing Antimicrobial Reports for Pediatric Stewardship collaborative regarding discharge stewardship practices. Among 67 sites, 13 (19%) reported ASP review of discharge antimicrobial prescriptions. These findings highlight discharge stewardship as a potential opportunity for improvement during the hospital-to-home transition.
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Boone K, Morris SK, Doshi S, Black J, Mohsin M, Ahmed T, Al Mahmud A, Roth DE. Antimicrobial Prescribing during Infant Hospital Admissions in a Birth Cohort in Dhaka, Bangladesh. J Trop Pediatr 2021; 67:5998440. [PMID: 33221898 PMCID: PMC8319631 DOI: 10.1093/tropej/fmaa093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Empirical antimicrobial use is common in hospitalized infants and may contribute to antimicrobial resistance in low- and middle-income countries. In this observational birth cohort study nested in a randomized controlled trial in Dhaka, Bangladesh, inpatient antimicrobial prescription data were extracted from serious adverse event forms completed for hospitalizations of infants (0-12 months of age). The primary outcome was the proportion of inpatient admissions where systemic antimicrobials were prescribed. Infant and hospitalization-related factors associated with antimicrobial prescriptions were determined. Among 1254 infants, there were 448 admissions to 32 facilities from 2014 to 2016. Antimicrobials were prescribed in 73% of admissions with a mean antimicrobial exposure rate of 0.25 antimicrobials per day of admission [95% confidence intervals (95% CIs): 0.24-0.27]. The most common antibiotics were aminoglycosides (29%), penicillins (26%) and third-generation cephalosporins (25%). In all, 58% of antibiotics were classified as 'access', 38% 'watch' and 1% 'reserve' using the World Health Organization (WHO) Essential Medicines List classification. WHO-recommended antimicrobial regimens were used in 68% of neonatal sepsis and 9% of lower respiratory tract infection (LRTI) admissions. 'Watch' antimicrobials were used in 26% of neonatal sepsis and 76% of LRTI admissions. Compared with private facilities, antimicrobial prescription rates were lower at government [rate ratio (RR) 0.71; 95% CI: 0.61-0.83] and charitable facilities (RR 0.39; 95% CI: 0.28-0.53), after adjustment for household wealth index and parental education. Younger infant age, older maternal age and longer admission were associated with higher prescription rates. These findings highlight the need for paediatric antimicrobial stewardship programs in Bangladesh.
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Affiliation(s)
- Katherine Boone
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON M5G 1X8, Canada.,Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Shaun K Morris
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON M5G 1X8, Canada.,Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.,Division of Infectious Diseases, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Sejal Doshi
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Jason Black
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Minhazul Mohsin
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Abdullah Al Mahmud
- Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
| | - Daniel E Roth
- Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON M5G 1X8, Canada.,Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
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Whitney E. Antibiotic stewardship-Basic principles in urinary tract infections, community acquired pneumonia, and skin and soft tissue infections. Curr Probl Pediatr Adolesc Health Care 2021; 51:101002. [PMID: 34053849 DOI: 10.1016/j.cppeds.2021.101002] [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: 11/25/2022]
Abstract
Antimicrobial stewardship is vital to prevent the deleterious effects of inappropriate antibiotic use: increasing antibiotic resistance, drug adverse effects, selection of pathogenic organisms, and unnecessary costs. This article reviews basic elements of antibiotic stewardship and applies them to three common infectious diseases for which patients are often hospitalized.
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Affiliation(s)
- Eric Whitney
- Dayton Children's Hospital, United States of America; Integrated Pediatric Residency Training Program, Boonshoft School of Medicine at Wright State University, United States of America; Boonshoft School of Medicine at Wright State University, United States of America.
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Malone S, McKay VR, Krucylak C, Powell BJ, Liu J, Terrill C, Saito JM, Rangel SJ, Newland JG. A cluster randomized stepped-wedge trial to de-implement unnecessary post-operative antibiotics in children: the optimizing perioperative antibiotic in children (OPerAtiC) trial. Implement Sci 2021; 16:29. [PMID: 33741048 PMCID: PMC7980649 DOI: 10.1186/s13012-021-01096-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic-resistant infections have become a public health crisis that is driven by the inappropriate use of antibiotics. In the USA, antibiotic stewardship programs (ASP) have been established and are required by regulatory agencies to help combat the problem of antibiotic resistance. Post-operative antibiotic use in surgical cases deemed low-risk for infection is an area with significant overuse of antibiotics in children. Consensus among leading public health organizations has led to guidelines eliminating post-operative antibiotics in low-risk surgeries. However, the best strategies to de-implement these inappropriate antibiotics in this setting are unknown. METHODS/DESIGN A 3-year stepped wedge cluster randomized trial will be conducted at nine US Children's Hospitals to assess the impact of two de-implementation strategies, order set change and facilitation training, on inappropriate post-operative antibiotic prescribing in low risk (i.e., clean and clean-contaminated) surgical cases. The facilitation training will amplify order set changes and will involve a 2-day workshop with antibiotic stewardship teams. This training will be led by an implementation scientist expert (VRM) and a pediatric infectious diseases physician with antibiotic stewardship expertise (JGN). The primary clinical outcome will be the percentage of surgical cases receiving unnecessary post-operative antibiotics. Secondary clinical outcomes will include the rate of surgical site infections and the rate of Clostridioides difficile infections, a common negative consequence of antibiotic use. Monthly semi-structured interviews at each hospital will assess the implementation process of the two strategies. The primary implementation outcome is penetration, which will be defined as the number of order sets changed or developed by each hospital during the study. Additional implementation outcomes will include the ASP team members' assessment of the acceptability, appropriateness, and feasibility of each strategy while they are being implemented. DISCUSSION This study will provide important information on the impact of two potential strategies to de-implement unnecessary post-operative antibiotic use in children while assessing important clinical outcomes. As more unnecessary medical practices are identified, de-implementation strategies, including facilitation, need to be rigorously evaluated. Along with this study, other rigorously designed studies evaluating additional strategies are needed to further advance the burgeoning field of de-implementation. TRIAL REGISTRATION NCT04366440. Registered April 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04366440 .
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Affiliation(s)
- Sara Malone
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.,Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University in St. Louis School of Medicine, Campus Box 8116, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Virginia R McKay
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Christina Krucylak
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University in St. Louis School of Medicine, Campus Box 8116, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Byron J Powell
- Brown School, Washington University in St. Louis, St. Louis, MO, USA.,Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St Louis, MO, USA
| | - Cindy Terrill
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University in St. Louis School of Medicine, Campus Box 8116, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Jacqueline M Saito
- Division of Pediatric Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MO, USA
| | - Jason G Newland
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University in St. Louis School of Medicine, Campus Box 8116, 660 S. Euclid Ave, St. Louis, MO, 63110, USA.
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Magill SS, O’Leary E, Ray SM, Kainer MA, Evans C, Bamberg WM, Johnston H, Janelle SJ, Oyewumi T, Lynfield R, Rainbow J, Warnke L, Nadle J, Thompson DL, Sharmin S, Pierce R, Zhang AY, Ocampo V, Maloney M, Greissman S, Wilson LE, Dumyati G, Edwards JR, Chea N, Neuhauser MM. Assessment of the Appropriateness of Antimicrobial Use in US Hospitals. JAMA Netw Open 2021; 4:e212007. [PMID: 33734417 PMCID: PMC7974639 DOI: 10.1001/jamanetworkopen.2021.2007] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
IMPORTANCE Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited. OBJECTIVE To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020. EXPOSURE Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin. MAIN OUTCOMES AND MEASURES The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration. RESULTS Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.6%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]). CONCLUSIONS AND RELEVANCE The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally.
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Affiliation(s)
- Shelley S. Magill
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erin O’Leary
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- Lantana Consulting Group, Thetford, Vermont
| | - Susan M. Ray
- Department of Medicine, Emory University, Atlanta, Georgia
- Georgia Emerging Infections Program, Decatur
| | - Marion A. Kainer
- Tennessee Department of Health, Nashville
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Infectious Diseases, Western Health, Melbourne, Victoria, Australia
| | | | - Wendy M. Bamberg
- Colorado Department of Public Health and Environment, Denver
- Medical Epidemiology Consulting, Denver, Colorado
| | - Helen Johnston
- Colorado Department of Public Health and Environment, Denver
| | | | - Tolulope Oyewumi
- Colorado Department of Public Health and Environment, Denver
- Department of Healthcare Management, University of Denver, Colorado
| | | | | | - Linn Warnke
- Minnesota Department of Health, St Paul
- Hennepin County Public Health, Minneapolis, Minnesota
| | | | - Deborah L. Thompson
- New Mexico Department of Health, Santa Fe
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Shamima Sharmin
- New Mexico Department of Health, Santa Fe
- Infection Prevention and Control Department, University of New Mexico Hospital, Albuquerque
| | | | | | | | - Meghan Maloney
- Connecticut Emerging Infections Program, Hartford and New Haven
| | - Samantha Greissman
- Connecticut Emerging Infections Program, Hartford and New Haven
- Department of Medicine, Columbia–New York Presbyterian Hospital
| | - Lucy E. Wilson
- Maryland Department of Health, Baltimore
- University of Maryland Baltimore County, Baltimore
| | - Ghinwa Dumyati
- New York Emerging Infections Program, Rochester
- University of Rochester Medical Center, Rochester, New York
| | - Jonathan R. Edwards
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nora Chea
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Melinda M. Neuhauser
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Aguilera-Alonso D. It is time for pediatric antimicrobial stewardship programs. Enferm Infecc Microbiol Clin 2021; 39:113-114. [DOI: 10.1016/j.eimc.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 12/11/2020] [Indexed: 11/26/2022]
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Ferguson RA, Herigon JC, Lee BR, Nakamura MM, Newland JG. Variability in Ceftriaxone Dosing Across 32 US Acute Care Children's Hospitals. J Pediatric Infect Dis Soc 2021; 10:677-681. [PMID: 33528009 PMCID: PMC8163046 DOI: 10.1093/jpids/piab004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/11/2021] [Indexed: 11/14/2022]
Abstract
Ceftriaxone is one of the most common antibiotics prescribed for hospitalized children in the United States. However, ceftriaxone is not dosed consistently. Sepsis/serious bacterial infection had high dosing variability. Dosing for central nervous system infection was frequently suboptimal. Future efforts should focus on optimizing and standardizing ceftriaxone dosing.
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Affiliation(s)
- Rina A Ferguson
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri, USA
| | - Joshua C Herigon
- Department of Pediatrics, Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Brian R Lee
- Health Services and Outcomes Research, Children’s Mercy Kansas City, Kansas City, Missouri, USA
| | - Mari M Nakamura
- Department of Pediatrics, Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA,Antimicrobial Stewardship Program, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Jason G Newland
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri, USA,Corresponding Author: Jason G. Newland, MD, MEd, 660 S. Euclid Ave., Campus Box 8116, St. Louis, MO 63110-1093, USA. E-mail:
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Enane LA, Christenson JC. Global emerging resistance in pediatric infections with TB, HIV, and gram-negative pathogens. Paediatr Int Child Health 2021; 41:65-75. [PMID: 33305992 PMCID: PMC8243638 DOI: 10.1080/20469047.2020.1853350] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/13/2020] [Indexed: 12/28/2022]
Abstract
Infants, children and adolescents are at risk of life-threatening, antimicrobial-resistant infections. Global burdens of drug-resistant TB, HIV and gram-negative pathogens have a particular impact on paediatric age groups, necessitating a paediatric-focused agenda to address emerging resistance. Dedicated approaches are needed to find, successfully treat and prevent resistant infections in paediatric populations worldwide. Challenges include the diagnosis and identification of resistant infections, limited access to novel antimicrobials or to paediatric-friendly formulations, limited access to research and clinical trials and implementation challenges related to prevention and successful completion of treatment. In this review, the particular complexities of emerging resistance in TB, HIV and gram-negative pathogens in children, with attention to both clinical and public health challenges, are highlighted. Key principles of a paediatric-focused agenda to address antimicrobial resistance are outlined. They include quality of care, increasing equitable access to key diagnostics, expanding antimicrobial stewardship and infection prevention across global settings, and health system strengthening. Increased access to research studies, including clinical trials, is needed. Further study and implementation of care models and strategies for child- or adolescent-centred management of infections such as HIV and TB can critically improve outcome and avoid development of resistance. As the current global pandemic of a novel coronavirus, SARS-CoV-2, threatens to disrupt health systems and services for vulnerable populations, this is a critical time to mitigate against a potential surge in the incidence of resistant infections.
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Affiliation(s)
- Leslie A Enane
- Department of Pediatrics Indiana University School of Medicine, Ryan White Center for Pediatric Infectious Disease and Global Health, Indianapolis, IN, USA
| | - John C Christenson
- Department of Pediatrics Indiana University School of Medicine, Ryan White Center for Pediatric Infectious Disease and Global Health, Indianapolis, IN, USA
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Same RG, Hsu AJ, Cosgrove SE, Klein EY, Amoah J, Hersh AL, Kronman MP, Tamma PD. Antibiotic-Associated Adverse Events in Hospitalized Children. J Pediatric Infect Dis Soc 2021; 10:622-628. [PMID: 33452808 PMCID: PMC8162628 DOI: 10.1093/jpids/piaa173] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antibiotic-associated adverse events (AEs) in hospitalized children have not been comprehensively characterized. METHODS We conducted a retrospective observational study of children hospitalized at The Johns Hopkins Hospital receiving ≥24 hours of systemic antibiotics. Consensus regarding antibiotic-associated AE definitions was established by 5 infectious diseases specialists prior to data collection. Two physicians reviewed potential AEs and determined whether they were more likely than not related to antibiotics after comprehensive manual chart review. Inpatient and post-discharge AEs were identified using the Epic Care Everywhere network. AEs evaluated from the initiation of antibiotics until 30 days after antibiotic completion included gastrointestinal, hematologic, hepatobiliary, renal, neurologic, dermatologic, cardiac, myositis, vascular access device-related events, and systemic reactions. Ninety-day AEs included Clostridioides difficile infections, multidrug-resistant organism infections, and clinically significant candidal infections. The impact of AEs was categorized as necessitating additional diagnostic testing, changes in medications, unplanned medical encounters, prolonged or new hospitalizations, or death. RESULTS Among 400 antibiotic courses, 21% were complicated by at least one AE and 30% occurred post-discharge. Each additional day of antibiotics was associated with a 7% increased odds of an AE. Of courses complicated by an AE, 66% required further intervention. Hematologic, gastrointestinal, and renal AEs were the most common, accounting for 31%, 15%, and 11% of AEs, respectively. AEs complicated 35%, 35%, 19%, and 18% of courses of piperacillin-tazobactam, tobramycin, ceftazidime, and vancomycin, respectively. CONCLUSIONS More than 1 in 5 courses of antibiotics administered to hospitalized children are complicated by AEs. Clinicians should weigh the risk of harm against expected benefit when prescribing antibiotics.
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Affiliation(s)
- Rebecca G Same
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Corresponding Author: Rebecca G. Same, MD, Department of Pediatrics, Washington University School of Medicine in St. Louis, Campus Box 8116, One Children’s Place, St. Louis, MO 63110, USA. E-mail:
| | - Alice J Hsu
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joe Amoah
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adam L Hersh
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Matthew P Kronman
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Pranita D Tamma
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Dantuluri KL, Bruce J, Edwards KM, Banerjee R, Griffith H, Howard LM, Grijalva CG. Rurality of Residence and Inappropriate Antibiotic Use for Acute Respiratory Infections Among Young Tennessee Children. Open Forum Infect Dis 2020; 8:ofaa587. [PMID: 33511228 PMCID: PMC7814393 DOI: 10.1093/ofid/ofaa587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background Antibiotic use is common for acute respiratory infections (ARIs) in children, but much of this use is inappropriate. Few studies have examined whether rurality of residence is associated with inappropriate antibiotic use. We examined whether rates of ARI-related inappropriate antibiotic use among children vary by rurality of residence. Methods We conducted a retrospective cohort study of children aged 2 months-5 years enrolled in Tennessee Medicaid between 2007 and 2017 and diagnosed with ARI in the outpatient setting. Study outcomes included ARI, ARI-related antibiotic use, and ARI-related inappropriate antibiotic use. Multivariable Poisson regression was used to measure associations between rurality of residence, defined by the US Census Bureau, and the rate of study outcomes, while accounting for other factors including demographics and underling comorbidities. Results A total of 805 332 children met selection criteria and contributed 1 840 048 person-years (p-y) of observation. Children residing in completely rural, mostly rural, and mostly urban counties contributed 70 369 (4%) p-y, 479 121 (26%) p-y, and 1 290 558 p-y (70%), respectively. Compared with children in mostly urban counties (238 per 1000 p-y), children in mostly rural (450 per 1000 p-y) and completely rural counties (468 per 1000 p-y) had higher rates of inappropriate antibiotic use (adjusted incidence rate ratio [aIRR] = 1.34, 95% confidence interval [CI] = 1.33-1.35 and aIRR = 1.33, 95% CI = 1.32-1.35, respectively). Conclusions Inappropriate antibiotic use is common among young children with ARI, with higher rates in rural compared with urban counties. These differences should inform targeted outpatient antibiotic stewardship efforts.
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Affiliation(s)
- Keerti L Dantuluri
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jean Bruce
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn M Edwards
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ritu Banerjee
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hannah Griffith
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leigh M Howard
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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