Impact of a Best Practice Advisory for Pediatric Patients With Staphylococcus aureus Bacteremia

Implementation of a Best Practice Advisory to Improve Infection Screening Prior to New Prescriptions of Biologics and Targeted Synthetic Drugs

OBJECTIVE

Use of biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in patients with preexisting tuberculosis (TB), hepatitis B virus (HBV), or hepatitis C virus (HCV) infection can have serious consequences. Although various society guidelines recommend routine screening for these infections before initiating certain b/tsDMARDs, adherence to these recommendations varies widely. This quality improvement initiative evaluated local compliance with screening and assessed whether an automated computerized decision support system in the form of a best practice advisory (BPA) in the electronic health record could improve patient screening.

METHODS

Established patients with autoimmune rheumatic disease (ARD) aged 18 years or older with at least one visit to our rheumatology practice between October 1, 2017, and March 3, 2022, were included. When prescribing a new b/tsDMARD, clinicians were alerted via a BPA that showed the most recent results for TB, HBV, and HCV. Screening proportions for TB, HBV, and HCV before BPA initiation were compared with those of eligible patients after the BPA implementation.

RESULTS

A total of 711 patients pre-BPA and 257 patients post-BPA implementation were included in the study. The BPA implementation was associated with statistically significant improvement in screening for TB from 66% to 82% (P ≤ 0.001), HCV from 60% to 79% (P ≤ 0.001), hepatitis B core antibody 32% to 51% (P ≤ 0.001), and hepatitis B surface antigen from 51% to 70% (P ≤ 0.001).

CONCLUSION

Implementation of a BPA can improve infectious disease screening for patients with ARD who are started on b/tsDMARDs and has potential to improve patient safety.

The impact of infectious diseases consultation for children with Staphylococcus aureus bacteremia

BACKGROUND

Despite clear benefit of improved outcomes in adults, the impact of infectious diseases (ID) consultation for Staphylococcus aureus bacteremia in children remains understudied.

METHODS

To assess the impact of pediatric ID consultation on management and outcomes, we conducted a cohort study of children with S. aureus bacteremia at St. Louis Children's Hospital from 2011 to 2018. We assessed adherence to six established quality-of-care indicators (QCIs). We applied propensity score methodology to examine the impact of ID consultation on risk of treatment failure, a composite of all-cause mortality or hospital readmission within 90 days.

RESULTS

Of 306 patients with S. aureus bacteremia, 193 (63%) received ID consultation. ID consultation was associated with increased adherence to all QCIs, including proof-of-cure blood cultures, indicated laboratory studies, echocardiography, source control, targeted antibiotic therapy, and antibiotic duration. Obtaining proof-of-cure blood cultures and all indicated laboratory studies were associated with improved outcomes. In propensity score-weighted analyses, risk of treatment failure was similar among patients who did and did not receive ID consultation. However, the number of events was small and risk estimates were imprecise.

CONCLUSIONS

For children with S. aureus bacteremia, ID consultation improved adherence to QCIs, some of which were associated with improved clinical outcomes.

IMPACT

In children with Staphylococcus aureus bacteremia, consultation by an infectious diseases (ID) physician improved adherence to established quality-of-care indicators (QCIs). The current literature regarding ID consultation in pediatric S. aureus bacteremia is sparse. Three prior international studies demonstrated improved quality of care with ID consultation, though results were disparate regarding clinical outcomes. This article impacts the current literature by strengthening the evidence that ID consultation in children improves adherence to QCIs, and demonstrates that adherence to QCIs improves clinical outcomes.

Increasing Pediatric Infectious Diseases Consultation Rates for Staphylococcus aureus Bacteremia

Introduction

Staphylococcus aureus bacteremia (SAB) in children is associated with significant mortality and morbidity, including recurrent bacteremia. Infectious disease consultation (IDC) improves SAB outcomes in adult patients. However, increasing IDC and impact for pediatric patients with SAB is not well described.

Methods

This quality improvement project aimed to increase IDC for SAB events at a quaternary pediatric medical center. First, we evaluated the local practices regarding pediatric SAB and engaged stakeholders (July 2018-August 2020). We added an advisory comment supporting IDC for SAB to all blood culture results in September 2020. Using statistical process control charts, we monitored the number of SAB events with IDC before a SAB event without IDC. Finally, we evaluated SAB recurrences before and after initiating the advisory comment.

Results

In the baseline period, 30 of 49 (61%) SAB events received an IDC with a mean of 1.4 SAB events with IDC before a SAB event without IDC. Postintervention, 22 of 23 (96%) SAB events received IDC with a mean of 14 events with IDC before 1 event without IDC. The SAB recurrence rate was 8%, with 6 events in 4 children; none of the index cases resulting in recurrence received an IDC (P = 0.0002), and all occurred before any intervention.

Conclusions

An electronic advisory comment supporting IDC for SAB significantly increased the rate of pediatric IDC with no further SAB recurrence episodes following intervention. This low-resource intervention may be considered in other pediatric centers to optimize SAB management.