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Kono M, Murakami D, Sakatani H, Okuda K, Kinoshita T, Hijiya M, Iyo T, Shiga T, Morita Y, Itahashi K, Sasagawa Y, Iwama Y, Yamaguchi T, Hotomi M. Factors affecting the antimicrobial changes during treatment for acute otitis media in Japan: A retrospective cohort study using classification and regression trees (CART) analysis. J Infect Chemother 2024; 30:832-837. [PMID: 38417479 DOI: 10.1016/j.jiac.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/15/2024] [Accepted: 02/25/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVES Factors that affect the change of first-line antimicrobial agents were investigated to further promote their appropriate use. METHODS This descriptive study used an electronic medical records database. Total 16,353 of the 199,896 patients enrolled between 1996 and 2019 met the inclusion criteria and formed the overall pediatric acute otitis media (AOM) cohort. The factors leading to the change in first-line antimicrobial agents within 14 days were analyzed using classification and regression trees (CART) analysis. RESULTS This antimicrobial treatment cohort, involved 4860 cases of AOM alone and 9567 cases of AOM with other diseases. The size of the medical facility based on number of beds and historical duration of patient registration impacted on antimicrobial changes. CONCLUSIONS The current results show that hospital-wide or nation-wide antimicrobial stewardship promotion could be the most influencing factor for antimicrobial changes. Particularly in cases of AOM where other diseases coexist, a more accurate diagnosis and definition of treatment failure of first-line drug are suggested to be important while establishing future treatment strategies. The current study is important to promote appropriate antimicrobial use for AOM treatment.
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Affiliation(s)
- Masamitsu Kono
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, Wakayama, 641-8510, Japan
| | - Daichi Murakami
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, Wakayama, 641-8510, Japan
| | - Hideki Sakatani
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, Wakayama, 641-8510, Japan
| | - Katsuya Okuda
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, Wakayama, 641-8510, Japan
| | - Tetsuya Kinoshita
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, Wakayama, 641-8510, Japan
| | - Masayoshi Hijiya
- Department of Otorhinolaryngology, Head and Neck Surgery, Kinan Hospital, 46-70 Shinjyo-Cho, Tanabe-shi, Wakayama, 646-8588, Japan
| | - Takuro Iyo
- Department of Otorhinolaryngology, Head and Neck Surgery, Kinan Hospital, 46-70 Shinjyo-Cho, Tanabe-shi, Wakayama, 646-8588, Japan
| | - Tatsuya Shiga
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, Wakayama, 641-8510, Japan
| | - Yohei Morita
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, Wakayama, 641-8510, Japan
| | - Koju Itahashi
- Medical Affairs Department, Meiji Seika Pharma Co., Ltd., 2-4-16 Kyobashi, Chuo-ku, Tokyo, 104-8002, Japan
| | - Yuji Sasagawa
- Clinical Development Department, Meiji Seika Pharma Co., Ltd., 2-4-16 Kyobashi, Chuo-ku, Tokyo, 104-8002, Japan
| | - Yasuhiro Iwama
- Clinical Development Department, Meiji Seika Pharma Co., Ltd., 2-4-16 Kyobashi, Chuo-ku, Tokyo, 104-8002, Japan
| | - Tomohisa Yamaguchi
- Medical Affairs Department, Meiji Seika Pharma Co., Ltd., 2-4-16 Kyobashi, Chuo-ku, Tokyo, 104-8002, Japan
| | - Muneki Hotomi
- Department of Otorhinolaryngology Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama-shi, Wakayama, Wakayama, 641-8510, Japan.
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Dillen H, Wouters J, Snijders D, Wynants L, Verbakel JY. Factors associated with inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries: a systematic review and meta-analysis. J Antimicrob Chemother 2024; 79:498-511. [PMID: 38113395 PMCID: PMC10904728 DOI: 10.1093/jac/dkad383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Acutely ill children are at risk of unwarranted antibiotic prescribing. Data on the appropriateness of antibiotic prescriptions provide insights into potential tailored interventions to promote antibiotic stewardship. OBJECTIVES To examine factors associated with the inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries. METHODS On 8 September 2022, we systematically searched articles published since 2002 in MEDLINE, Embase, CENTRAL, Web of Science, and grey literature databases. We included studies with acutely ill children presenting to ambulatory care settings in high-income countries reporting on the appropriateness of antibiotic prescriptions. The quality of the studies was evaluated using the Appraisal tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale. Pooled ORs were calculated using random-effects models. Meta-regression, sensitivity and subgroup analysis were also performed. RESULTS We included 40 articles reporting on 30 different factors and their association with inappropriate antibiotic prescribing. 'Appropriateness' covered a wide range of definitions. The following factors were associated with increased inappropriate antibiotic prescribing: acute otitis media diagnosis [pooled OR (95% CI): 2.02 (0.54-7.48)], GP [pooled OR (95% CI) 1.38 (1.00-1.89)] and rural setting [pooled OR (95% CI) 1.47 (1.08-2.02)]. Older patient age and a respiratory tract infection diagnosis have a tendency to be positively associated with inappropriate antibiotic prescribing, but pooling of studies was not possible. CONCLUSIONS Prioritizing acute otitis media, GPs, rural areas, older children and respiratory tract infections within antimicrobial stewardship programmes plays a vital role in promoting responsible antibiotic prescribing. The implementation of a standardized definition of appropriateness is essential to evaluate such programmes.
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Affiliation(s)
- Hannelore Dillen
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
| | - Jo Wouters
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Daniëlle Snijders
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Laure Wynants
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht University, 1 Peter Debyeplein, Maastricht, 6229 HA, The Netherlands
- Department of Development and Regeneration, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- NIHR Community Healthcare MedTech and IVD cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
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Miller KM, Barnett TC, Cadarette D, Bloom DE, Carapetis JR, Cannon JW. Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study. EBioMedicine 2023; 98:104864. [PMID: 37950997 PMCID: PMC10663680 DOI: 10.1016/j.ebiom.2023.104864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Antibiotic consumption can lead to antimicrobial resistance and microbiome imbalance. We sought to estimate global antibiotic consumption for sore throat, and the potential reduction in consumption due to effective vaccination against group A Streptococcus (Strep A). METHODS We reviewed and analysed articles published between January 2000 and February 2022, identified though Clarivate Analytics' Web of Science search platform, with reference to antibiotic prescribing or consumption, sore throat, pharyngitis, or tonsillitis. We then used those analyses, combined with assumptions for the effectiveness, duration of protection, and coverage of a vaccine, to calculate the estimated reduction in antibiotic prescribing due to the introduction of Strep A vaccines. FINDINGS We identified 101 studies covering 38 countries. The mean prescribing rate for sore throat was approximately 5 courses per 100 population per year, accounting for approximately 5% of all antibiotic consumption. Based on 2020 population estimates for countries with empiric prescribing rates, antibiotic consumption for sore throat was estimated to exceed 37 million courses annually, of which half could be attributable to treatment for Strep A. A vaccine that reduces rates of Strep A infection by 80%, with 80% coverage and 10 year's duration of protection, could avert 2.8 million courses of antibiotics prescribed for sore throat treatment among 5-14 year-olds in countries with observed prescribing rates, increasing to an estimated 7.5 million averted if an effective vaccination program also reduced precautionary prescribing. INTERPRETATION A vaccine that prevents Strep A throat infections in children may reduce antibiotic prescribing for sore throat by 32-87% depending on changes to prescribing and consumption behaviours. FUNDING The Wellcome Trust, grant agreement number 215490/Z/19/Z.
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Affiliation(s)
- Kate M Miller
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Timothy C Barnett
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Marshall Centre for Infectious Diseases Research and Training, School of Biomedical Sciences, University of Western Australia, Nedlands, Western Australia, Australia
| | - Daniel Cadarette
- Harvard Kennedy School, Harvard University, Cambridge, MA, United States
| | - David E Bloom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Jonathan R Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Jeffrey W Cannon
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Centre for Child Health Research, Medical School, University of Western Australia, Nedlands, Western Australia, Australia.
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Pellegrino R, Timitilli E, Verga MC, Guarino A, Iacono ID, Scotese I, Tezza G, Dinardo G, Riccio S, Pellizzari S, Iavarone S, Lorenzetti G, Simeone G, Bergamini M, Donà D, Pierantoni L, Garazzino S, Esposito S, Venturini E, Gattinara GC, Lo Vecchio A, Marseglia GL, Di Mauro G, Principi N, Galli L, Chiappini E. Acute pharyngitis in children and adults: descriptive comparison of current recommendations from national and international guidelines and future perspectives. Eur J Pediatr 2023; 182:5259-5273. [PMID: 37819417 PMCID: PMC10746578 DOI: 10.1007/s00431-023-05211-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 10/13/2023]
Abstract
This study aims to provide a comparison of the current recommendations about the management of acute pharyngitis. A literature search was conducted from January 2009 to 2023. Documents reporting recommendations on the management of acute pharyngitis were included, pertinent data were extracted, and a descriptive comparison of the different recommendations was performed. The quality of guidelines was assessed through the AGREE II instrument. Nineteen guidelines were included, and an overall moderate quality was found. Three groups can be distinguished: one group supports the antibiotic treatment of group A β-hemolytic Streptococcus (GABHS) to prevent acute rheumatic fever (ARF); the second considers acute pharyngitis a self-resolving disease, recommending antibiotics only in selected cases; the third group recognizes a different strategy according to the ARF risk in each patient. An antibiotic course of 10 days is recommended if the prevention of ARF is the primary goal; conversely, some guidelines suggest a course of 5-7 days, assuming the symptomatic cure is the goal of treatment. Penicillin V and amoxicillin are the first-line options. In the case of penicillin allergy, first-generation cephalosporins are a suitable choice. In the case of beta-lactam allergy, clindamycin or macrolides could be considered according to local resistance rates. Conclusion: Several divergencies in the management of acute pharyngitis were raised among guidelines (GLs) from different countries, both in the diagnostic and therapeutic approach, allowing the distinction of 3 different strategies. Since GABHS pharyngitis could affect the global burden of GABHS disease, it is advisable to define a shared strategy worldwide. It could be interesting to investigate the following issues further: cost-effectiveness analysis of diagnostic strategies in different healthcare systems; local genomic epidemiology of GABHS infection and its complications; the impact of antibiotic treatment of GABHS pharyngitis on its complications and invasive GABHS infections; the role of GABHS vaccines as a prophylactic measure. The related results could aid the development of future recommendations. What is Known: • GABHS disease spectrum ranges from superficial to invasive infections and toxin-mediated diseases. • GABHS accounts for about 25% of sore throat in children and its management is a matter of debate. What is New: • Three strategies can be distinguished among current GLs: antibiotic therapy to prevent ARF, antibiotics only in complicated cases, and a tailored strategy according to the individual ARF risk. • The impact of antibiotic treatment of GABHS pharyngitis on its sequelae still is the main point of divergence; further studies are needed to achieve a global shared strategy.
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Affiliation(s)
- Roberta Pellegrino
- Department of Health Sciences, Postgraduate School of Pediatrics, University of Florence, Florence, Italy
| | - Edoardo Timitilli
- Department of Health Sciences, Postgraduate School of Pediatrics, University of Florence, Florence, Italy
| | | | - Alfredo Guarino
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Iride Dello Iacono
- Unit of Allergology, Division of Internal Medicine, Fatebenefratelli Hospital, Benevento, Italy
| | | | - Giovanna Tezza
- Department of Pediatrics, Ospedale San Maurizio, Bolzano, Italy
| | - Giulio Dinardo
- Department of Woman, Child and of General and Specialized Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Simona Riccio
- Department of Woman, Child and of General and Specialized Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Sofia Pellizzari
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Pediatric Clinic, University of Verona, Verona, Italy
| | - Sonia Iavarone
- Department of Maternal, Infantile, and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Giulia Lorenzetti
- Residency School of Pediatrics, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Luca Pierantoni
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Silvia Garazzino
- Department of Paediatrics, Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Susanna Esposito
- Paediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | | | - Andrea Lo Vecchio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Gian Luigi Marseglia
- Department of Pediatrics, Foundation IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Giuseppe Di Mauro
- Pediatric Primary Care, National Pediatric Health Care System, Caserta, Italy
| | - Nicola Principi
- Professor Emeritus of Pediatrics, University of Milan, Milan, Italy
| | - Luisa Galli
- Infectious Diseases Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Viale Pieraccini 24, 50139, Firenze, Italy
| | - Elena Chiappini
- Infectious Diseases Unit, Meyer Children's Hospital IRCCS, Florence, Italy.
- Department of Health Sciences, University of Florence, Viale Pieraccini 24, 50139, Firenze, Italy.
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Grubenhoff JA, Bakel LA, Dominguez F, Leonard J, Widmer K, Sanders JS, Spencer SP, Stein JM, Searns JB. Clinical Pathway Adherence and Missed Diagnostic Opportunities Among Children with Musculoskeletal Infections. Jt Comm J Qual Patient Saf 2023; 49:547-556. [PMID: 37495472 DOI: 10.1016/j.jcjq.2023.06.011] [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: 02/10/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Clinical care pathways (CPs) integrate best evidence into the local care delivery context to promote efficiency and patient safety. However, the impact of CPs on diagnostic performance remains poorly understood. The objectives of this study were to evaluate adherence to a musculoskeletal infection (MSKI) diagnostic CP and identify recurrent failure points leading to missed diagnostic opportunities (MDOs). METHODS Retrospective chart review was performed from January 2018 to February 2022 for children 6 months to 18 years of age who had an unplanned admission for MSKI after being evaluated and discharged from the pediatric emergency department (PED) for related complaints within the previous 10 days. MDOs were identified using the Revised Safer Dx. Demographic and clinical characteristics of children with and without MDOs were compared using bivariate descriptive statistics. An improvement team reviewed the diagnostic trajectories of MDOs for deviations from the MSKI CP and developed a fishbone diagram to describe contributing factors to CP deviations. RESULTS The study identified 21 children with and 13 children without MSKI-associated MDOs. Children with MDOs were more likely to have an initial C-reactive protein value > 2 mg/dL (90.0% vs. 0%, p = 0.01) and returned to care earlier than children without MDOs (median 2.8 days vs. 6.7 days, p = 0.004). Factors contributing to MDOs included failure to obtain screening laboratory tests, misinterpretation of laboratory values, failure to obtain orthopedic consultation, and failure to obtain definitive imaging. CONCLUSION Several recurrent deviations from an MSKI diagnostic CP were found to be associated with MDOs. Future quality improvement efforts to improve adherence to this MSKI CP may prevent MDOs.
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Brigadoi G, Rossin S, Visentin D, Barbieri E, Giaquinto C, Da Dalt L, Donà D. The impact of Antimicrobial Stewardship Programmes in paediatric emergency departments and primary care: a systematic review. Ther Adv Infect Dis 2023; 10:20499361221141771. [PMID: 36654872 PMCID: PMC9841878 DOI: 10.1177/20499361221141771] [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: 03/08/2022] [Accepted: 11/07/2022] [Indexed: 01/14/2023] Open
Abstract
Background Antibiotics remain the most prescribed medicine in children worldwide, but half of the prescriptions are unnecessary or inappropriate, leading to an increase in antibiotic resistance. This study aims to systemically review the effects of different Antimicrobial Stewardship Programmes (ASPs) on reducing the rates of both antibiotic prescriptions and changes in antimicrobial resistance, and on the economic impact in paediatric emergency departments (PED) and primary care settings. Materials and methods Embase, MEDLINE, and Cochrane Library were systematically searched, combining Medical Subject Heading and free-text terms for 'children' and 'antimicrobial' and 'stewardship'. The search strategy involved restrictions on dates (from 1 January 2007 to 30 December 2020) but not on language. Randomized controlled trials, controlled and non-controlled before and after studies, controlled and non-controlled interrupted time series, and cohort studies were included for review. The review protocol was registered at the PROSPERO International Prospective Register of Systematic Reviews: Registration Number CRD42021270630. Results Of the 47,158 articles that remained after removing duplicates, 59 were eligible for inclusion. Most of the studies were published after 2015 (37/59, 62.7%) and in high-income countries (51/59, 86.4%). Almost half of the studies described the implementation of an ASP in the primary care setting (28/59, 47.5%), while 15 manuscripts described the implementation of ASPs in EDs (15/59, 25.4%). More than half of the studies (43/59, 72.9%) described the implementation of multiple interventions, whereas few studies considered the implementation of a single intervention. Antibiotic prescriptions and compliance with guidelines were the most frequent outcomes (47/59, 79.7% and 20/59, 33.9%, respectively). Most of the articles reported an improvement in these outcomes after implementing an ASP. Meanwhile, only very few studies focused on health care costs (6/59, 10.2%) and antimicrobial resistance (3/59 5.1%). Conclusion The implementation of ASPs has been proven to be feasible and valuable, even in challenging settings such as Emergency Departments and Primary care.
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Affiliation(s)
- Giulia Brigadoi
- Paediatric Emergency Department, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
- Division of Paediatric Infectious Diseases, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Sara Rossin
- Paediatric Emergency Department, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Davide Visentin
- Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Elisa Barbieri
- Division of Paediatric Infectious Diseases, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Carlo Giaquinto
- Division of Paediatric Infectious Diseases, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Liviana Da Dalt
- Paediatric Emergency Department, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department of Woman’s and Children’s Health, University of Padua, Via Giustiani 3, 35141 Padua, Italy
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Hamdy RF, Nedved A, Fung M, Fleming-Dutra KE, Liu CM, Obremskey J, Montalbano A. Pediatric Urgent Care Providers' Approach to Antibiotic Stewardship: A National Survey. Pediatr Emerg Care 2022; 38:e1446-e1448. [PMID: 35766867 DOI: 10.1097/pec.0000000000002788] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Outpatient antibiotic prescribing for acute respiratory conditions is highest in urgent care settings; however, this has not been studied among pediatric urgent cares. The objective of this study was to evaluate pediatric urgent care providers' perceptions of antibiotic stewardship. METHODS Members of the Society for Pediatric Urgent Care were recruited via email to participate in a quality improvement antibiotic stewardship project. A preimplementation survey was sent to participants via email in March 2019 to evaluate perceptions on antibiotic stewardship. Descriptive statistics were used to analyze the survey responses. RESULTS A total of 156 providers completed the survey; 83% were board-certified pediatricians. Almost all (98%) indicated that antibiotic stewardship interventions are important for optimizing antibiotic use in urgent care. More than half (53%) indicated that their urgent care provided guidelines for prescribing antibiotics for acute respiratory tract infections. Treating patients with an underlying complex medical condition was the most common reason (21%) providers would deviate from guidelines. The most commonly cited barriers to appropriate prescribing for acute respiratory infections were patient expectations (93%), psychosocial barriers (40%), lack of clear evidence-based recommendations (15%), and lack of access to guidelines on prescribing (15%). CONCLUSIONS Parental expectation of receiving antibiotics was viewed as the most common barrier to appropriate prescribing. These findings should be used to target directed interventions such as shared decision making and communication training to support appropriate antibiotic prescribing in pediatric urgent care.
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Affiliation(s)
| | - Amanda Nedved
- Division of Urgent Care, Children's Mercy Kansas City; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Melody Fung
- Antibiotic Resistance Action Center, Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | | | - Cindy M Liu
- Antibiotic Resistance Action Center, Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | | | - Amanda Montalbano
- Division of Urgent Care, Children's Mercy Kansas City; University of Missouri-Kansas City School of Medicine, Kansas City, MO
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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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Marom T, Gluck O, Ovnat Tamir S. Treatment failure in pediatric acute otitis media: How do you define? Int J Pediatr Otorhinolaryngol 2021; 150:110888. [PMID: 34416438 DOI: 10.1016/j.ijporl.2021.110888] [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: 02/21/2021] [Revised: 06/26/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Reaching the point of treatment failure in the management of pediatric acute otitis media (AOM) is decision-changing, and is often associated with switching to a broader coverage antibiotic with/without middle ear surgical drainage. Yet, still there is no consensus on the definition of what is treatment failure, which may lead to confusion for clinical decision-making purposes. We sought to review the heterogeneity of treatment failure definitions in AOM. METHODS We searched for relevant English language manuscripts using the following key-words: ['otitis media' (OM) or (AOM)] AND ['treatment failure' or 'failure' or 'response failure' or 'response'] AND 'human' in various electronic databases from 1/1/2005 through 10/31/2020. RESULTS In the 60 retrieved papers, treatment failure was considered only when antibiotics had been prescribed beforehand, but not when watchful waiting had been adopted. We categorized the manuscripts into 5 major treatment failure definition subgroups, which occasionally overlapped: unimprovement or worsening of symptoms or signs of failure in otoscopy (n = 36), specialist(s) referral or hospital admission (n = 12), changing or adding antibiotic treatment (n = 22), failure to eradicate causative bacteria (n = 7) and failure as perceived by parents (n = 4). CONCLUSIONS We suggest a broader definition of AOM treatment failure including physical examination findings and degree of initial treatment response, which will enable an unbiased, uniform comparison of treatments for pediatric AOM.
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Affiliation(s)
- Tal Marom
- Department of Otolaryngology-Head and Neck Surgery, Samson Assuta Ashdod University Hospital, Ben Gurion University Faculty of Health Sciences, Ashdod, Israel.
| | - Ofer Gluck
- Department of Otolaryngology-Head and Neck Surgery, Samson Assuta Ashdod University Hospital, Ben Gurion University Faculty of Health Sciences, Ashdod, Israel
| | - Sharon Ovnat Tamir
- Department of Otolaryngology-Head and Neck Surgery, Samson Assuta Ashdod University Hospital, Ben Gurion University Faculty of Health Sciences, Ashdod, Israel
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Bianco A, Licata F, Nobile CG, Napolitano F, Pavia M. Pattern and appropriateness of antibiotic prescriptions for upper respiratory tract infections in primary care paediatric patients. Int J Antimicrob Agents 2021; 59:106469. [PMID: 34757133 DOI: 10.1016/j.ijantimicag.2021.106469] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/12/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this cross-sectional study was to investigate the pattern of antibiotic prescriptions for upper respiratory tract infections (URTIs) in children seen by primary care paediatricians (PCPs). METHODS Data were collected from face-to-face interviews administered to a sample of parents of outpatient children aged 0-14 years in two regions in Southern Italy. To be eligible, children had to be diagnosed with sinusitis, pharyngotonsillitis, otitis media, bronchitis, influenza or a common cold. The presence of an indication of antibiotic therapy was evaluated according to national and international guidelines. RESULTS An antibiotic prescription was indicated in 57 (10.1%) of the sampled patients, of whom 33.3% did not receive an antibiotic prescription; among the 508 patients for whom an antibiotic prescription was not indicated, 27.4% received a prescription. Of all PCP consultations, 72% were appropriate (an antibiotic was prescribed when indicated and not prescribed when not indicated), whilst an antibiotic prescription not indicated by guidelines was given to 24.6% of the participants, and 3.4% of the sample did not receive an antibiotic prescription when indicated. The most frequently prescribed antibiotic was amoxicillin with clavulanic acid. A rapid microbiological examination was performed in two patients. CONCLUSIONS The study findings highlight a high rate of sub-optimal antibiotic therapeutic profile. Over-prescription of antibiotic therapy and the use of broad-spectrum molecules are widespread in children with URTIs. Antibiotic under-prescription, which may deprive paediatric patients of an effective treatment when indicated, also occurs.
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Affiliation(s)
- Aida Bianco
- Department of Health Sciences, School of Medicine, University of Catanzaro "Magna Græcia", Catanzaro, Italy
| | - Francesca Licata
- Department of Health Sciences, School of Medicine, University of Catanzaro "Magna Græcia", Catanzaro, Italy
| | - Carmelo Ga Nobile
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Cosenza, Italy
| | - Francesco Napolitano
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Pavia
- Department of Health Sciences, School of Medicine, University of Catanzaro "Magna Græcia", Catanzaro, Italy; Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
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Multistep antimicrobial stewardship intervention on antibiotic prescriptions and treatment duration in children with pneumonia. PLoS One 2021; 16:e0257993. [PMID: 34705849 PMCID: PMC8550372 DOI: 10.1371/journal.pone.0257993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The Italian antimicrobial prescription rate is one of the highest in Europe, and antibiotic resistance has become a serious problem with high costs and severe consequences, including prolonged illnesses, the increased period of hospitalization and mortality. Inadequate antibiotic prescriptions have been frequently reported, especially for lower respiratory tract infections (LRTI); many patients receive antibiotics for viral pneumonia or bronchiolitis or broad-spectrum antibiotics for not complicated community-acquired pneumonia. For this reason, healthcare organizations need to implement strategies to raise physicians' awareness about this kind of drug and their overall effect on the population. The implementation of antibiotic stewardship programs and the use of Clinical Pathways (CPs) are excellent solutions because they have proven to be effective tools at diagnostic and therapeutic levels. AIMS This study evaluates the impact of CPs implementation in a Pediatric Emergency Department (PED), analyzing antibiotic prescriptions before and after the publication in 2015 and 2019. The CP developed in 2019 represents an update of the previous one with the introduction of serum procalcitonin. The study aims to evaluate the antibiotic prescriptions in patients with community-acquired pneumonia (CAP) before and after both CPs (2015 and 2019). METHODS The periods analyzed are seven semesters (one before CP-2015 called PRE period, five post CP-2015 called POST 1-5 and 1 post CP-2019 called POST6). The patients have been split into two groups: (i) children admitted to the Pediatric Acute Care Unit (INPATIENTS), and (ii) patients evaluated in the PED and sent back home (OUTPATIENTS). We have analyzed all descriptive diagnosis of CAP (the assessment of episodes with a descriptive diagnosis were conducted independently by two pediatricians) and CAP with ICD9 classification. All antibiotic prescriptions for pediatric patients with CAP were analyzed. RESULTS A drastic reduction of broad-spectrum antibiotics prescription for inpatients has been noticed; from 100.0% in the PRE-period to 66.7% in POST1, and up to 38.5% in POST6. Simultaneously, an increase in amoxicillin use from 33.3% in the PRE-period to 76.1% in POST1 (p-value 0.078 and 0.018) has been seen. The outpatients' group's broad-spectrum antibiotics prescriptions decreased from 54.6% PRE to 17.4% in POST6. Both for outpatients and inpatients, there was a decrease of macrolides. The inpatient group's antibiotic therapy duration decreased from 13.5 days (PRE-period) to 7.0 days in the POST6. Antibiotic therapy duration in the outpatient group decreased from 9.0 days (PRE) to 7.0 days (POST1), maintaining the same value in subsequent periods. Overlapping results were seen in the ICD9 group for both inpatients and outpatients. CONCLUSIONS This study shows that CPs are effective tools for an antibiotic stewardship program. Indeed, broad-spectrum antibiotics usage has dropped and amoxicillin prescriptions have increased after implementing the CAP CP-2015 and the 2019 update.
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Spoială EL, Stanciu GD, Bild V, Ababei DC, Gavrilovici C. From Evidence to Clinical Guidelines in Antibiotic Treatment in Acute Otitis Media in Children. Antibiotics (Basel) 2021; 10:52. [PMID: 33419114 PMCID: PMC7825459 DOI: 10.3390/antibiotics10010052] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/29/2020] [Accepted: 01/05/2021] [Indexed: 12/30/2022] Open
Abstract
Acute otitis media (AOM) in children represents a public health concern, being one of the leading causes of health care visits and antibiotic prescriptions worldwide. The overall aim of this paper is to unravel the major current insights into the antibiotic treatment of AOM in children. Our approach is three-fold: 1. a preclinical evaluation of antibiotics in animal models of AOM stressing on the advantages of different species when testing for different schemes of antibiotics; 2. an overview on the new antimicrobial agents whose efficacy has been demonstrated in refractory cases of AOM in children; and 3. an analysis of the different guidelines stressing on the differences and similarities between the various schemes of antibiotic treatment. The preferred therapeutic agents remain amoxicillin and the amoxicillin-clavulanate combination for AOM caused by Streptococcus pneumoniae, whereas oral cephalosporin is preferred in AOM due to Moraxella catarrhalis and Haemophilus influenzae. As for the second and third line antimicrobial treatments, there is a wide variety of suggested antibiotic classes with variations in duration and posology. The decision to prescribe antimicrobial treatment as a first-line choice is based on the severity of the symptoms in 16 of the guidelines included in this review.
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Affiliation(s)
- Elena Lia Spoială
- Pediatrics Department, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (E.L.S.); (C.G.)
| | - Gabriela Dumitrita Stanciu
- Center for Advanced Research and Development in Experimental Medicine (CEMEX), Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania;
| | - Veronica Bild
- Center for Advanced Research and Development in Experimental Medicine (CEMEX), Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania;
- Pharmacodynamics and Clinical Pharmacy Department, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Daniela Carmen Ababei
- Pharmacodynamics and Clinical Pharmacy Department, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Cristina Gavrilovici
- Pediatrics Department, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania; (E.L.S.); (C.G.)
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Barbieri E, De Luca M, Minute M, D’Amore C, Ciofi Degli Atti ML, Martelossi S, Giaquinto C, Da Dalt L, Zaoutis T, Dona D. Impact and Sustainability of Antibiotic Stewardship in Pediatric Emergency Departments: Why Persistence Is the Key to Success. Antibiotics (Basel) 2020; 9:antibiotics9120867. [PMID: 33291565 PMCID: PMC7761799 DOI: 10.3390/antibiotics9120867] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/23/2020] [Accepted: 11/30/2020] [Indexed: 02/06/2023] Open
Abstract
Antibiotic stewardship programs proved to be effective in improving prescribing appropriateness. This multicenter quasi-experimental study, aimed to assesses the stewardship impact on antibiotics prescribing in different semesters from 2014 to 2019 in three pediatric emergency departments (Center A, B, and C) in Italy. All consecutive patients diagnosed with acute otitis media or pharyngitis were evaluated for inclusion. Two different stewardship were adopted: for Center A and B, clinical pathways were implemented and disseminated, and yearly lectures were held, for Center C, only pathways were implemented. Broad-spectrum prescription rates decreased significantly by 80% for pharyngitis and 29.5 to 55.2% for otitis after the implementation. In Center C, rates gradually increased from the year after the implementation. Amoxicillin dosage adjusted to pharyngitis recommendations in Center C (53.7 vs. 51.6 mg/kg/die; p = 0.011) and otitis recommendations in Center A increasing from 50.0 to 75.0 mg/kg/die (p < 0.001). Days of therapy in children < 24 months with otitis increased from 8.0 to 10.0 in Center A, while in older children decreased in Center A (8.0 vs. 7.0; p < 0.001) and Center B (10.0 vs. 8.0; p < 0.001). Clinical pathways combined with educational lectures is a feasible and sustainable program in reducing broad-spectrum antibiotic prescribing with stable rates over time.
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Affiliation(s)
- Elisa Barbieri
- Division of Pediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padova, 35131 Padova, Italy; (C.G.); (D.D.)
- Correspondence:
| | - Maia De Luca
- Unit of Immune and Infectious Diseases, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Marta Minute
- Pediatric Unit, Ca’ Foncello’s Hospital, 31100 Treviso, Italy; (M.M.); (S.M.)
| | - Carmen D’Amore
- Unit of Clinical Epidemiology, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (C.D.); (M.L.C.D.A.)
| | | | - Stefano Martelossi
- Pediatric Unit, Ca’ Foncello’s Hospital, 31100 Treviso, Italy; (M.M.); (S.M.)
| | - Carlo Giaquinto
- Division of Pediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padova, 35131 Padova, Italy; (C.G.); (D.D.)
| | - Liviana Da Dalt
- Pediatric Emergency Department, Department of Women’s and Children’s Health, University Hospital of Padua, 2-35128 Padova, Italy;
| | - Theoklis Zaoutis
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Daniele Dona
- Division of Pediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padova, 35131 Padova, Italy; (C.G.); (D.D.)
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14
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Kullgren KA, Klein EJ, Sturza J, Hutton D, Monroe K, Pardon A, Sroufe N, Malas N. Standardizing Pediatric Somatic Symptom and Related Disorders Care: Clinical Pathway Reduces Health Care Cost and Use. Hosp Pediatr 2020; 10:867-876. [PMID: 32978209 DOI: 10.1542/hpeds.2020-0004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pediatric somatic symptom and related disorders (SSRDs) are common with high health care costs and use because of lack of standardized, evidence-based practice. Our hospital implemented a clinical pathway (CP) for SSRD evaluation and management. Our study objective was to evaluate health care cost and use associated with the organization's SSRD CP in the emergency department (ED) and inpatient settings hypothesizing lower cost and use in the CP group relative to controls. METHODS We conducted a retrospective analysis of costs and use before and after implementation of the SSRD CP. Data were collected from the hospital's electronic health record and the Pediatric Health Information System database. Participants included pediatric patients on the CP ("P" group) and control groups with an SSRD diagnosis and mental health consultation either the year before the CP ("C" group) or during the CP study period ("T" group). Primary outcomes included costs, length of stay, diagnostic testing, imaging, subspecialty consultation, and readmission rates. RESULTS The ED P group had more lower-cost imaging, whereas the inpatient T group greater higher-cost imaging than other groups. The inpatient P group had significantly shorter length of stay, fewer subspecialty consults, and lower costs. There were no significant group differences in readmission rates. The CP reduced median total costs per patient encounter by $51 433 for the inpatient group and $6075 for the ED group. CONCLUSIONS The CP group showed significant reductions in health care cost and use after implementation of a CP for SSRD care. In future work, researchers should explore patient and practitioner experience with the SSRD CP and long-term outcomes.
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15
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Silver GH, Kearney JA, Bora S, De Souza C, Giles L, Hrycko S, Jenkins W, Malas N, Namerow L, Ortiz-Aguayo R, Russell R, Pao M, Plioplys S, Brahmbhatt K. A Clinical Pathway to Standardize Care of Children With Delirium in Pediatric Inpatient Settings. Hosp Pediatr 2020; 9:909-916. [PMID: 31662421 DOI: 10.1542/hpeds.2019-0115] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pediatric delirium is an important comorbidity of medical illness in inpatient pediatric care that has lacked a consistent approach for detection and management. A clinical pathway (CP) was developed to address this need. Pediatric delirium contributes significantly to morbidity, mortality, and costs of inpatient care of medically ill children and adolescents. Screening for delirium in hospital settings with validated tools is feasible and effective in reducing delirium and improving outcomes; however, multidisciplinary coordination is required for implementation. The workgroup, composed of international experts in child and adolescent consultation psychiatry, reviewed the literature and developed a flowchart for feasible screening and management of pediatric delirium. When evidence was lacking, expert consensus was reached; stakeholder feedback was included to create the final pathway. A CP expert collaborated with the workgroup. Two sequential CPs were created: (1) "Prevention and Identification of Pediatric Delirium" emphasizes the need for systematic preventive measures and screening, and (2) "Diagnosis and Management of Pediatric Delirium" recommends an urgent and ongoing search for the underlying causes to reverse the syndrome while providing symptomatic management focused on comfort and safety. Detailed accompanying documents explain the supporting literature and the rationale for recommendations and provide resources such as screening tools and implementation guides. Additionally, the role of the child and adolescent consultation-liaison psychiatrist as a resource for collaborative care of patients with delirium is discussed.
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Affiliation(s)
- Gabrielle H Silver
- NewYork-Presbyterian/Weill Cornell Medical Center, Weill Cornell Medicine, Cornell University, New York, New York;
| | | | - Sonali Bora
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Claire De Souza
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Giles
- Departments of Pediatrics and Psychiatry, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Sophia Hrycko
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
| | - Willough Jenkins
- Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, California
| | - Nasuh Malas
- Division of Child and Adolescent Psychiatry, Departments of Psychiatry and Pediatrics, C.S. Mott Children's Hospital, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Lisa Namerow
- Institute of Living and Hartford Hospital, School of Medicine, University of Connecticut, Hartford, Connecticut
| | | | - Ruth Russell
- McGill University Health Centre and Montreal Children's Hospital, Montréal, Canada
| | - Maryland Pao
- National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | - Sigita Plioplys
- Department of Psychiatry and Behavioral Sciences, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois; and
| | - Khyati Brahmbhatt
- Department of Psychiatry, Langley Porter Psychiatric Institute, Weill Institute for Neurosciences, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
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16
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Donà D, Barbieri E, Daverio M, Lundin R, Giaquinto C, Zaoutis T, Sharland M. Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review. Antimicrob Resist Infect Control 2020; 9:3. [PMID: 31911831 PMCID: PMC6942341 DOI: 10.1186/s13756-019-0659-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.
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Affiliation(s)
- D. Donà
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
- Pediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
- Fondazione Penta ONLUS, Padua, Italy
| | - E. Barbieri
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
| | - M. Daverio
- Pediatric intensive care unit, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - R. Lundin
- Fondazione Penta ONLUS, Padua, Italy
| | - C. Giaquinto
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
- Fondazione Penta ONLUS, Padua, Italy
| | - T. Zaoutis
- Fondazione Penta ONLUS, Padua, Italy
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - M. Sharland
- Pediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
- Fondazione Penta ONLUS, Padua, Italy
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Islam S, Mannix MK, Breuer RK, Hassinger AB. Guideline Adherence and Antibiotic Utilization by Community Pediatricians, Private Urgent Care Centers, and a Pediatric Emergency Department. Clin Pediatr (Phila) 2020; 59:21-30. [PMID: 31609128 DOI: 10.1177/0009922819879462] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Pediatric antibiotic prescriptions originate from an increasingly broad range of ambulatory settings. In this retrospective study, pharyngitis, otitis media, sinusitis, pneumonia, and upper respiratory infection cases, at 11 primary care offices, 2 independent urgent care centers (UCCs), and a pediatric emergency department in Western New York, were analyzed relative to medical society practice guidelines and antibiotic utilization. Of 2358 eligible visits across all sites, 25% were for study diagnoses, with 38% at UCC (P < .01). Across all sites, 26% of pharyngitis cases given antibiotics did not have diagnostic evidence of bacterial infection. At primary care offices and UCCs, guideline recommended first-line agents for pharyngitis and otitis media were used in only 58% and 63% of treated cases, respectively. Overall, an estimated 9855 to 12 045 avoidable antibiotic and 8030 non-guideline antibiotic courses annually are represented by the 14 sites studied. These and other study findings highlight numerous opportunities for outpatient pediatric antibiotic stewardship.
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Affiliation(s)
- Shamim Islam
- Pediatric Infectious Diseases, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Mary Kathryn Mannix
- Pediatric Infectious Diseases, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Ryan K Breuer
- John R. Oishei Children's Hospital, Buffalo, NY, USA.,Department of Pediatrics, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Amanda B Hassinger
- John R. Oishei Children's Hospital, Buffalo, NY, USA.,Department of Pediatrics, University at Buffalo, State University of New York, Buffalo, NY, USA
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18
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Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Treatment. Pediatr Infect Dis J 2019; 38:S10-S21. [PMID: 31876601 DOI: 10.1097/inf.0000000000002452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND New insights into the diagnosis, treatment and prevention of acute otitis media (AOM) have been gained in recent years. For this reason, the Italian Paediatric Society has updated its 2010 guidelines. METHODS A literature search was carried out on PubMed. Only pediatric studies published between January 1, 2010 and December 31, 2018 in English or Italian were included. Each included study was assessed according to the GRADE methodology. The quality of the systematic reviews was assessed using AMSTAR 2. The recommendations were formulated by a multidisciplinary panel of experts. RESULTS Prompt antibiotic treatment is recommended for children with otorrhea, intracranial complications and/or a history of recurrence and for children under the age of 6 months. For children 6 months to 2 years of age, prompt antibiotic treatment is recommended for all forms of unilateral and bilateral AOM, whether mild or severe. Prompt antibiotic treatment is also recommended for children over 2 years with severe bilateral AOM. A watchful-waiting approach can be applied to children over 2 years with mild or severe unilateral AOM or mild bilateral AOM. High doses of amoxicillin, or amoxicillin-clavulanic acid for patients with a high risk of infection by Beta-lactamase producing strains, remain the first-line antibiotics. CONCLUSIONS AOM should be managed on a case-by-case basis that takes account of the child's age, the severity of the episode and whether it is unilateral or bilateral. In patients under 2 years, prompt antibiotic treatment is always recommended.
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Cole KA, Rivard KR, Dumkow LE. Antimicrobial Stewardship Interventions to Combat Antibiotic Resistance: an Update on Targeted Strategies. Curr Infect Dis Rep 2019; 21:33. [PMID: 31473861 DOI: 10.1007/s11908-019-0689-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Overutilization of antimicrobials is a known contributor to the development of antimicrobial resistance, which is a threat to global health. The goal of antimicrobial stewardship programs (ASPs) is to implement targeted interventions to reduce inappropriate antimicrobial prescribing and prevent development of antimicrobial resistance. We aim to review recently published literature focused on five categories of ASP interventions that have demonstrated success in optimizing appropriate antimicrobial use, improving patient outcomes, and fighting antimicrobial resistance. RECENT FINDINGS In the past year, ASP interventions in the published literature have focused on minimizing duration of antimicrobial therapy for infectious syndromes, implementing novel methods for performing prospective audit and feedback, utilizing microbiology laboratory or rapid diagnostic tests to expedite diagnosis, leveraging clinical decision support and electronic medical record tools, and performing penicillin allergy assessment. While the majority of studies assessing ASP interventions do not assess changes in antimicrobial resistance, outcomes demonstrating improved appropriate antibiotic use have been used as a surrogate. Successful ASPs should seek to implement and evaluate novel interventions targeting improvement in antimicrobial prescribing. Such interventions are of critical importance to prevent further growth of antimicrobial resistance.
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Affiliation(s)
- Kelli A Cole
- Department of Pharmacy Services, University of Toledo Medical Center, 3000 Arlington Ave. MS 1013, Toledo, OH, 43614, USA.
| | - Kaitlyn R Rivard
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue (Hb-105), Cleveland, OH, 44195, USA
| | - Lisa E Dumkow
- Department of Pharmacy Services, Mercy Health Saint Mary's, 200 Jefferson SE, Grand Rapids, MI, 49503, USA.
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20
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Barbieri E, Donà D, Cantarutti A, Lundin R, Scamarcia A, Corrao G, Cantarutti L, Giaquinto C. Antibiotic prescriptions in acute otitis media and pharyngitis in Italian pediatric outpatients. Ital J Pediatr 2019; 45:103. [PMID: 31420054 PMCID: PMC6697973 DOI: 10.1186/s13052-019-0696-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 08/06/2019] [Indexed: 11/25/2022] Open
Abstract
Background Acute otitis media (AOM) and pharyngitis are very common infections in children and adolescents. Italy is one of the European countries with the highest rate of antibiotic prescriptions. The aim of this study is to describe first-line treatment approaches for AOM and pharyngitis in primary care settings in Italy over six years, including the prevalence of ‘wait and see’ for AOM, where prescription of antibiotics is delayed 48 h from presentation, and differences in prescribing for pharyngitis when diagnostic tests are used. Methods The study is a secondary data analysis using Pedianet, a database including data at outpatient level from children aged 0–14 in Italy. Prescriptions per antibiotic group, per age group and per calendar year were described as percentages. “Wait and see” approach rate was described for AOM and pharyngitis prescriptions were further grouped according to the diagnostic test performed and test results. Results We identified 120,338 children followed by 125 family pediatricians between January 2010 and December 2015 for a total of 923,780 person-years of follow-up. Among them 30,394 (mean age 44 months) had at least one AOM diagnosis (n = 54,943) and 52,341 (mean age 5 years) had at least one pharyngitis diagnosis (n = 126,098). 82.5% of AOM diagnoses were treated with an antibiotic within 48 h (mainly amoxicillin and amoxicillin/clavulanate) and the “wait and see” approach was adopted only in 17.5% of cases. The trend over time shows an increase in broad spectrum antibiotic prescriptions in the last year (2015). 79,620 (63%) cases of pharyngitis were treated and among GABHS pharyngitis confirmed by rapid test 56% were treated with amoxicillin. The ones not test confirmed were treated mainly with broad spectrum antibiotics. Conclusions Despite guidance to use the ‘wait and see’ approach in the age group analyzed, this strategy is not often used for AOM, as previously noted in other studies in hospital settings. Broad-spectrum antibiotic prescription was more frequent when pharyngitis was not confirmed by rapid test, in keeping with evidence from other studies that diagnostic uncertainty leads to overuse of antibiotics. Electronic supplementary material The online version of this article (10.1186/s13052-019-0696-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- E Barbieri
- Department for Woman and Child Health, University of Padua, Padua, Italy.
| | - D Donà
- Division of Paediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141, Padua, Italy.,PENTA Foundation, Padua, Italy
| | - A Cantarutti
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,Department of Statistics and Quantitative Methods, Unit of Biostatistics Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | | | | | - G Corrao
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,Department of Statistics and Quantitative Methods, Unit of Biostatistics Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | | | - C Giaquinto
- Division of Paediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141, Padua, Italy.,PENTA Foundation, Padua, Italy.,National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.,Pedianet Project, Padua, Italy
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21
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Malmgren A, Biswanger K, Lundqvist A, Zaoutis T. Education, decision support, feedback and a minor reward: a novel antimicrobial Stewardship intervention in a Swedish paediatric emergency setting. Infect Dis (Lond) 2019; 51:559-569. [PMID: 31088317 DOI: 10.1080/23744235.2019.1606933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Sweden enjoys a favourable situation with regard to antimicrobial resistance. However, healthcare costs are expected to increase exponentially, along with increased morbidity and mortality, due to the emergence of resistant bacterial strains. Our aim was to design an antimicrobial stewardship programme suitable for Scandinavian settings. Methods: A quasi-experimental pre-post study was conducted in a Swedish paediatric emergency department, evaluating adherence to national guidelines for acute otitis media and acute tonsillitis. The programme consisted of educational outreach, decision support, feedback, and a minor reward upon reaching a pre-defined adherence rate. Results: The largest impact, significant for both diagnoses, was on the practice of refraining from antibiotic use when recommended. The other variables evaluated showed no significant improvement for either condition; however, in most cases, pre-interventional adherence was already high. Conclusions: This relatively easily implementable ASP intervention showed a significant effect on correctly refraining from the use of antibiotics. Previous interventions in Scandinavia either failed to accomplish this or have been more logistically difficult. The combination of education, decision support, email-based feedback and a minor reward, offers an alternative. Future research will be needed to assess whether the result is sustainable, as well as to identify additional barriers to the judicious use of antibiotics not addressed in this study.
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Affiliation(s)
- Annika Malmgren
- a Department of Pediatric Medicine , Queen Silvia Children's Hospital , Gothenburg , Sweden
| | - Karin Biswanger
- b Department of Pediatric Medicine , Södra Älvsborg Hospital , Borås , Sweden
| | - Anders Lundqvist
- c Department of Infectious Diseases , Södra Älvsborg Hospital , Borås , Sweden
| | - Theoklis Zaoutis
- d Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness , Children's Hospital of Philadelphia , Philadelphia , PA , USA
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22
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Messina F, Clavenna A, Cartabia M, Piovani D, Bortolotti A, Fortino I, Merlino L, Bonati M. Antibiotic prescription in the outpatient paediatric population attending emergency departments in Lombardy, Italy: a retrospective database review. BMJ Paediatr Open 2019; 3:e000546. [PMID: 31909220 PMCID: PMC6937000 DOI: 10.1136/bmjpo-2019-000546] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 10/29/2019] [Accepted: 11/09/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This study aimed to assess the appropriateness of antibiotic prescription in children seen in emergency departments (EDs) and to compare prescription profiles in ED and primary care. DESIGN This is a retrospective analysis of healthcare administrative databases. SETTING The study analysed data collected in emergency departments (EDs) and primary care practices (PCPs) in Lombardy, Italy. PARTICIPANTS Children and adolescents between 1 and 13 years old with an ED access and/or an antibiotic prescription in the first semester of 2012 participated in the study. Only those with an index event (ie, without ED access, hospital admissions or antibiotic prescriptions in the previous 60 days) were included. MAIN OUTCOME MEASURES The main outcomes are percentage of subjects receiving amoxicillin (first-choice antibiotic) and percentages receiving macrolides/cephalosporins (second-choice therapies). RESULTS During the observation period, 133 275 children had one ED access, and 26 087 (19.6%) received an antibiotic prescription. In all, 56.1% of children seen for upper respiratory tract infections (URTIs) received an antibiotic, with a prevalence of 67.8% for otitis media and 56.4% for pharyngotonsillitis; 22.3% of children were given amoxicillin after a visit for URTIs, with no differences among infections, and 19.6% received macrolides and cephalosporins. Few differences were found when comparing the index antibiotic prescriptions in ED and PCP settings. A higher prescription of second-choice antibiotics was observed among children cared for by PCPs compared with children attending EDs (31.3% vs 23.4%, χ2 M-H=720, p<0.001). The place of residence was the main determinant of the qualitative profile of prescriptions. CONCLUSIONS More must be done to improve rational use of antibiotics in the ED and PCP setting, and educational interventions including physicians in both setting are strongly needed.
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Affiliation(s)
- Francesco Messina
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Antonio Clavenna
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Massimo Cartabia
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Daniele Piovani
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | | | - Ida Fortino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - Luca Merlino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - Maurizio Bonati
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
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