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Ambroggio L, Cotter J, Hall M, Shapiro DJ, Lipsett SC, Hersh AL, Shah SS, Brogan TV, Gerber JS, Williams DJ, Blaschke AJ, Cogen JD, Neuman MI. Management of Pediatric Pneumonia: A Decade After the Pediatric Infectious Diseases Society and Infectious Diseases Society of America Guideline. Clin Infect Dis 2023; 77:1604-1611. [PMID: 37352841 DOI: 10.1093/cid/ciad385] [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: 04/11/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Incomplete uptake of guidelines can lead to nonstandardized care, increased expenditures, and adverse clinical outcomes. The objective of this study was to evaluate the impact of the 2011 Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) pediatric community-acquired pneumonia (CAP) guideline that emphasized aminopenicillin use and de-emphasized the use of chest radiographs (CXRs) in certain populations. METHODS This quasi-experimental study queried a national administrative database of children's hospitals to identify children aged 3 months-18 years with CAP who visited 1 of 28 participating hospitals from 2009 to 2021. PIDS/IDSA pediatric CAP guideline recommendations regarding antibiotic therapy, diagnostic testing, and imaging were evaluated. Segmented regression interrupted time series was used to measure guideline-concordant practices with interruptions for guideline publication and the Coronavirus Disease 2019 (COVID-19) pandemic. RESULTS Of 315 384 children with CAP, 71 804 (22.8%) were hospitalized. Among hospitalized children, there was a decrease in blood culture performance (0.5% per quarter) and increase in aminopenicillin prescribing (1.1% per quarter). Among children discharged from the emergency department (ED), there was an increase in aminopenicillin prescription (0.45% per quarter), whereas the rate of obtaining CXRs declined (0.12% per quarter). However, use of CXRs rebounded during the COVID-19 pandemic (increase of 1.56% per quarter). Hospital length of stay, ED revisit rates, and hospital readmission rates remained stable. CONCLUSIONS Guideline publication was associated with an increase of aminopenicillin prescribing. However, rates of diagnostic testing did not materially change, suggesting the need to consider implementation strategies to meaningfully change clinical practice for children with CAP.
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Affiliation(s)
- Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - Jillian Cotter
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - Matthew Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medicine Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Anne J Blaschke
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jonathan D Cogen
- Division of Pulmonary Medicine and Sleep Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Poluektova O, Robertson DA, Rafferty A, Cunney R, Lunn PD. A scoping review and behavioural analysis of factors underlying overuse of antimicrobials. JAC Antimicrob Resist 2023; 5:dlad043. [PMID: 37168837 PMCID: PMC10164659 DOI: 10.1093/jacamr/dlad043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
Background Overuse of antimicrobials is a challenging global issue that contributes to antimicrobial resistance. Despite widespread awareness of the problem among members of the medical community and various attempts to improve prescription practices, existing antimicrobial stewardship programmes are not always effective. In our view, this may reflect limited understanding of factors that influence prescription of antimicrobials as empirical therapy, implying a need to address the psychological mechanisms behind some of the specific behaviours involved. Objectives To identify factors that influence the antimicrobials prescription as empirical therapy, and to relate these factors to findings from behavioural science. Methods We conducted a scoping review of the literature on the factors underlying antimicrobial prescription decisions, following the protocol designed using PRISMA guidelines. Results and conclusions From a final sample of 90 sources, we identified ten factors important in antimicrobial prescription decisions. In the second stage of our analysis, we grouped them into five final categories: (1) nature of the decision, (2) social influences, (3) individual differences, (4) characteristics of the patient, (5) context. We analyse these categories using a behavioural science perspective.
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Affiliation(s)
- Olga Poluektova
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, School of Social Science and Philosophy, Department of Sociology (Visiting Research Fellow), Dublin, Ireland
| | - Deirdre A Robertson
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, School of Psychology, Dublin, Ireland
| | - Aisling Rafferty
- Children’s Health Ireland, Department of Pharmacy, Dublin, Ireland
- University of Birmingham, School of Pharmacy, Institute of Clinical Sciences,Birmingham, UK
| | - Robert Cunney
- Children’s Health Ireland, Irish Meningitis and Sepsis Reference Laboratory, Dublin, Ireland
- Royal College of Surgeons in Ireland, Department of Microbiology, Dublin, Ireland
- Children’s Health Ireland, Department of Microbiology, Dublin, Ireland
| | - Peter D Lunn
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, Department of Economics, Dublin, Ireland
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Cotter JM, Florin TA, Moss A, Suresh K, Navanandan N, Ramgopal S, Shah SS, Ruddy R, Kempe A, Ambroggio L. Antibiotic use and outcomes among children hospitalized with suspected pneumonia. J Hosp Med 2022; 17:975-983. [PMID: 36380654 PMCID: PMC9722550 DOI: 10.1002/jhm.13002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although viral etiologies predominate, antibiotics are frequently prescribed for community-acquired pneumonia (CAP). OBJECTIVE We evaluated the association between antibiotic use and outcomes among children hospitalized with suspected CAP. DESIGNS, SETTINGS AND PARTICIPANTS We performed a secondary analysis of a prospective cohort of children hospitalized with suspected CAP. INTERVENTION The exposure was the receipt of antibiotics in the emergency department (ED). MAIN OUTCOME AND MEASURES Clinical outcomes included length of stay (LOS), care escalation, postdischarge treatment failure, 30-day ED revisit, and quality-of-life (QoL) measures from a follow-up survey 7-15 days post discharge. To minimize confounding by indication (e.g., radiographic CAP), we performed inverse probability treatment weighting with propensity analyses. RESULTS Among 523 children, 66% were <5 years, 88% were febrile, 55% had radiographic CAP, and 55% received ED antibiotics. The median LOS was 41 h (IQR: 25, 54). After propensity analyses, there were no differences in LOS, escalated care, treatment failure, or revisits between children who received antibiotics and those who did not. Seventy-one percent of patients completed follow-up surveys after discharge. Among 16% of patients with fevers after discharge, the median fever duration was 2 days, and those who received antibiotics had a 37% decrease in the mean number of days with fever (95% confidence interval: 20% and 51%). We found no statistical differences in other QoL measures.
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Affiliation(s)
- Jillian M Cotter
- Section of Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Todd A Florin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
| | - Krithika Suresh
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Nidhya Navanandan
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Sriram Ramgopal
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Richard Ruddy
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Allison Kempe
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
| | - Lilliam Ambroggio
- Section of Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
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Cotter JM, Hall M, Shah SS, Molloy MJ, Markham JL, Aronson PL, Stephens JR, Steiner MJ, McCoy E, Collins M, Tchou MJ. Variation in bacterial pneumonia diagnoses and outcomes among children hospitalized with lower respiratory tract infections. J Hosp Med 2022; 17:872-879. [PMID: 35946482 PMCID: PMC11366396 DOI: 10.1002/jhm.12940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Current diagnostics do not permit reliable differentiation of bacterial from viral causes of lower respiratory tract infection (LRTI), which may lead to over-treatment with antibiotics for possible bacterial community-acquired pneumonia (CAP). OBJECTIVES We sought to describe variation in the diagnosis and treatment of bacterial CAP among children hospitalized with LRTIs and determine the association between CAP diagnosis and outcomes. DESIGN, SETTING AND PARTICIPANTS This multicenter cross-sectional study included children hospitalized between 2017 and 2019 with LRTIs at 42 children's hospitals. MAIN OUTCOME AND METHODS We calculated the proportion of children with LRTIs who were diagnosed with and treated for bacterial CAP. After adjusting for confounders, hospitals were grouped into high, moderate, and low CAP diagnosis groups. Multivariable regression was used to examine the association between high and low CAP diagnosis groups and outcomes. RESULTS We identified 66,581 patients hospitalized with LRTIs and observed substantial variation across hospitals in the proportion diagnosed with and treated for bacterial CAP (median 27%, range 12%-42%). Compared with low CAP diagnosing hospitals, high diagnosing hospitals had higher rates of CAP-related revisits (0.6% [95% confidence interval: 0.5, 0.7] vs. 0.4% [0.4, 0.5], p = .04), chest radiographs (58% [53, 62] vs. 46% [41, 51], p = .02), and blood tests (43% [33, 53] vs. 26% [19, 35], p = .046). There were no significant differences in length of stay, all-cause revisits or readmissions, CAP-related readmissions, or costs. CONCLUSION There was wide variation across hospitals in the proportion of children with LRTIs who were treated for bacterial CAP. The lack of meaningful differences in clinical outcomes among hospitals suggests that some institutions may over-diagnose and overtreat bacterial CAP.
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Affiliation(s)
- Jillian M. Cotter
- Department of Pediatrics, Section of Hospital Medicine, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas, USA
| | - Samir S. Shah
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew J. Molloy
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jessica L. Markham
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John R. Stephens
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Michael J. Steiner
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Pediatrics and Medicine, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Megan Collins
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Michael J. Tchou
- Department of Pediatrics, Section of Hospital Medicine, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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Cotter JM, Florin TA, Moss A, Suresh K, Ramgopal S, Navanandan N, Shah SS, Ruddy RM, Ambroggio L. Factors Associated With Antibiotic Use for Children Hospitalized With Pneumonia. Pediatrics 2022; 150:e2021054677. [PMID: 35775330 PMCID: PMC9727820 DOI: 10.1542/peds.2021-054677] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Antibiotics are frequently used for community-acquired pneumonia (CAP), although viral etiologies predominate. We sought to determine factors associated with antibiotic use among children hospitalized with suspected CAP. METHODS We conducted a prospective cohort study of children who presented to the emergency department (ED) and were hospitalized for suspected CAP. We estimated risk factors associated with receipt of ≥1 dose of inpatient antibiotics and a full treatment course using multivariable Poisson regression with an interaction term between chest radiograph (CXR) findings and ED antibiotic use. We performed a subgroup analysis of children with nonradiographic CAP. RESULTS Among 477 children, 60% received inpatient antibiotics and 53% received a full course. Factors associated with inpatient antibiotics included antibiotic receipt in the ED (relative risk 4.33 [95% confidence interval, 2.63-7.13]), fever (1.66 [1.22-2.27]), and use of supplemental oxygen (1.29 [1.11-1.50]). Children with radiographic CAP and equivocal CXRs had an increased risk of inpatient antibiotics compared with those with normal CXRs, but the increased risk was modest when antibiotics were given in the ED. Factors associated with a full course were similar. Among patients with nonradiographic CAP, 29% received inpatient antibiotics, 21% received a full course, and ED antibiotics increased the risk of inpatient antibiotics. CONCLUSIONS Inpatient antibiotic utilization was associated with ED antibiotic decisions, CXR findings, and clinical factors. Nearly one-third of children with nonradiographic CAP received antibiotics, highlighting the need to reduce likely overuse. Antibiotic decisions in the ED were strongly associated with decisions in the inpatient setting, representing a modifiable target for future interventions.
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Affiliation(s)
- Jillian M Cotter
- Section of Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics
| | - Todd A Florin
- Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Angela Moss
- Adult and Child Center for Outcomes Research and Delivery Science
| | - Krithika Suresh
- Adult and Child Center for Outcomes Research and Delivery Science
- Department of Biostatistics and Informatics, Colorado School of Public Health
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Nidhya Navanandan
- Section of Emergency Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Richard M Ruddy
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Section of Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics
- Section of Emergency Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
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Geanacopoulos AT, Lipsett SC, Hirsch AW, Monuteaux MC, Neuman MI. Impact of Viral Radiographic Features on Antibiotic Treatment for Pediatric Pneumonia. J Pediatric Infect Dis Soc 2022; 11:207-213. [PMID: 35020928 DOI: 10.1093/jpids/piab132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/14/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND/OBJECTIVES Chest radiograph (CXR) is routinely performed among children with suspected pneumonia, though it is not clear how specific radiographic findings impact antibiotic treatment for pneumonia. We evaluated the impact of viral radiographic features on antibiotic treatment among children undergoing pneumonia evaluation in the emergency department (ED). METHODS Children presenting to a pediatric ED who underwent a CXR for pneumonia evaluation were prospectively enrolled. Prior to CXR performance, physicians indicated their level of suspicion for pneumonia. The CXR report was reviewed to assess for the presence of viral features (peribronchial cuffing, perihilar markings, and interstitial infiltrate) as well as radiographic features suggestive of pneumonia (consolidation, infiltrate, and opacity). The relationship between viral radiographic features and antibiotic treatment was assessed based on the level of clinical suspicion for pneumonia prior to CXR. RESULTS Patients with normal CXRs (n = 400) and viral features alone (n = 370) were managed similarly, with 8.0% and 8.6% of patients receiving antibiotic treatment, respectively (P = .75). Compared with children with radiographic pneumonia (n = 174), patients with concurrent viral features and radiographic pneumonia (n = 177) were treated with antibiotics less frequently (86.2% vs 54.3%, P < .001). Among children with isolated viral features on CXR, antibiotic treatment rates were correlated with pre-CXR level of suspicion for pneumonia. CONCLUSIONS Among children with suspected pneumonia, the presence of viral features alone on CXR is not associated with increased rates of antibiotic use. Among children with radiographic pneumonia, the addition of viral features on CXR is associated with lower rates of antibiotic use, as compared to children with radiographic pneumonia alone.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Susan C Lipsett
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexander W Hirsch
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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Covino M, Buonsenso D, Gatto A, Morello R, Curatole A, Simeoni B, Franceschi F, Chiaretti A. Determinants of antibiotic prescriptions in a large cohort of children discharged from a pediatric emergency department. Eur J Pediatr 2022; 181:2017-2030. [PMID: 35118518 PMCID: PMC8813572 DOI: 10.1007/s00431-022-04386-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/03/2022] [Accepted: 01/21/2022] [Indexed: 01/26/2023]
Abstract
While there is evidence of high use of wide-spectrum antibiotics in children evaluated in the pediatric emergency departments, determinants of this behavior are still unclear. This study was aimed at defining the demographic, social, clinical, and laboratory factors that affect antibiotic prescriptions in children discharged from the emergency department. We performed a retrospective observational study of children aged younger than 18 years discharged from a pediatric university hospital between Jan. 1, 2015 and Dec. 31, 2020. We determined the proportion and type of antibiotic prescription according to demographic, social, clinical, laboratory, and imaging data, as well as doctor's expertise. Fifty-one thousand six hundred thirty-three children were included, and 13,167 (25.5%) received an antibiotic prescription. Amoxicilline/clavulanate (Am/Cl) was the most prescribed antibiotic (8453, 64.2% of all prescriptions). Factors independently associated with an antibiotic prescription were older age (OR = 1.62 [1.53-1.73] for age 2-5 years, OR = 1.77 [1.64-1.91] for age 6-10 years, OR = 1.36 [1.25-1.49] for age 11-18 years, p < 0.001 for all groups); being evaluated by a physician with > 3 years of pediatric expertise (OR = 1.22 [1.13-1.31], p < 0.001); fever peak higher than 40 °C (OR = 1.37 [1.21-1.54], p < 0.001); abnormal findings on auscultation (OR = 1.95 [1.75-2.17], p < 0.001), CRP values (OR = 1.63 [1.26-2.10] for CRP < 50 mg/L, and OR = 3.78 (2.75-5.21) for CRP ≥ 50 mg/L with respect to CRP not requested; p < 0.01); CXR results whatever positive (OR = 4.47 [3.62-5.52], p < 0.001) or negative (1.82 [1.62-2.04], p < 0.001); being diagnosed with upper respiratory tract infections (OR = 4.27 [4.04-4.51], p < 0.001), lower respiratory tract infections (OR = 5.35 [4.88-5.85]; p < 0.001), and UTI (OR = 9.33 [8.14-10.71], p < 0.001). Conclusions: Overprescription of antibiotics, including Am/Cl, is relevant in pediatric emergency departments. Factors associated with overprescription are not limited to the clinical characteristics of the treated patients. These findings highlight the need for a new and comprehensive approach to ensure successful antibiotic stewardship initiatives in the emergency departments. What is Known: • Antibiotic resistance is a growing problem in medical practice, including in pediatrics. • Antibiotics are overprescribed in children assessed in the emergency department, but comprehensive and large studies are lacking. What is New: • Factors associated with overprescription are not limited to the clinical characteristics of the patients. • Non-clinical factors such as environmental variables, doctor's expertise, and attitudes to laboratory and radiological examinations affect prescription.
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Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Danilo Buonsenso
- Dipartimento Di Scienze Di Laboratorio E Infettivologiche, Fondazione Policlinico Universitario A. 8 Gemelli, IRCCS, Rome, Italy
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario 10 A. Gemelli, IRCCS, Rome, Italy
- Global Health Research Institute, Istituto Di Igiene, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Gatto
- Dipartimento Di Scienze Di Laboratorio E Infettivologiche, Fondazione Policlinico Universitario A. 8 Gemelli, IRCCS, Rome, Italy
| | - Rosa Morello
- Dipartimento Di Scienze Di Laboratorio E Infettivologiche, Fondazione Policlinico Universitario A. 8 Gemelli, IRCCS, Rome, Italy
| | - Antonietta Curatole
- Dipartimento Di Scienze Di Laboratorio E Infettivologiche, Fondazione Policlinico Universitario A. 8 Gemelli, IRCCS, Rome, Italy
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Chiaretti
- Dipartimento Di Scienze Di Laboratorio E Infettivologiche, Fondazione Policlinico Universitario A. 8 Gemelli, IRCCS, Rome, Italy
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Lipshaw MJ, Eckerle M, Florin TA, Crotty EJ, Lipscomb J, Jacobs J, Rattan MS, Ruddy RM, Shah SS, Ambroggio L. Antibiotic Use and Outcomes in Children in the Emergency Department With Suspected Pneumonia. Pediatrics 2020; 145:peds.2019-3138. [PMID: 32179662 PMCID: PMC7111492 DOI: 10.1542/peds.2019-3138] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Antibiotic therapy is often prescribed for suspected community-acquired pneumonia (CAP) in children despite a lack of knowledge of causative pathogen. Our objective in this study was to investigate the association between antibiotic prescription and treatment failure in children with suspected CAP who are discharged from the hospital emergency department (ED). METHODS We performed a prospective cohort study of children (ages 3 months-18 years) who were discharged from the ED with suspected CAP. The primary exposure was antibiotic receipt or prescription. The primary outcome was treatment failure (ie, hospitalization after being discharged from the ED, return visit with antibiotic initiation or change, or antibiotic change within 7-15 days from the ED visit). The secondary outcomes included parent-reported quality-of-life measures. Propensity score matching was used to limit potential bias attributable to treatment selection between children who did and did not receive an antibiotic prescription. RESULTS Of 337 eligible children, 294 were matched on the basis of propensity score. There was no statistical difference in treatment failure between children who received antibiotics and those who did not (odds ratio 1.0; 95% confidence interval 0.45-2.2). There was no difference in the proportion of children with return visits with hospitalization (3.4% with antibiotics versus 3.4% without), initiation and/or change of antibiotics (4.8% vs 6.1%), or parent-reported quality-of-life measures. CONCLUSIONS Among children with suspected CAP, the outcomes were not statistically different between those who did and did not receive an antibiotic prescription.
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Affiliation(s)
| | - Michelle Eckerle
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Todd A. Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois; and
| | - Eric J. Crotty
- Radiology,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Mantosh S. Rattan
- Radiology,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Richard M. Ruddy
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Samir S. Shah
- Hospital Medicine, and,Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado Denver and Sections of Emergency Medicine and Hospital Medicine, Children’s Hospital Colorado, Denver, Colorado
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