Multistep antimicrobial stewardship intervention on antibiotic prescriptions and treatment duration in children with pneumonia

Impact of a multifaceted antibiotic stewardship programme in a paediatric acute care unit over 8 years

Background

Antibiotics are the most prescribed drugs for children worldwide, but overuse and misuse have led to an increase in antibiotic resistance. Antimicrobial stewardship programmes (ASPs) have proven feasible in reducing inappropriate antimicrobial use. The study aimed at evaluating the impact and sustainability of an ASP with multiple interventions over 8 years.

Methods

This quasi-experimental study was conducted between 2014 and 2022 in the paediatric acute care unit of Padua University Hospital. Demographic and clinical data were retrieved from the electronic clinical records. Daily prescriptions were collected and analysed based on the AWaRe classification and using days of therapy (DOT) out of 1000 patient days (DOT/1000PDs). The primary outcome was to assess the change in overall antibiotic consumption and of access and watch antibiotics, stratifying patients with and without comorbidities. Trends in antibiotic consumption (DOTs/1000PD) were assessed using joinpoint regression analysis.

Findings

A total of 3118 children were included. Total antibiotic consumption remained stable and low in patients without comorbidities, ∼300 DOT/1000PDs, whereas a statistically significant constant reduction was observed in children with comorbidities, from almost 500 DOT/1000PPDs to <400 DOT/1000PDs. Access consumption increased in both groups of patients, whereas watch consumption constantly decreased, although statistically significant only in children with comorbidities.

Interpretation

Implementing a multistep ASP has proven feasible and sustainable in improving antibiotic prescriptions for previously healthy and fragile children. All the implemented interventions were low cost, and with efficient use of resources, ensuring an ASP that was effective, practical, and easily replicable and implementable in various healthcare settings.

Evaluation of the WHO standards to assess quality of care for children with acute respiratory infections: findings of a baseline multicentre assessment (CHOICE) in Italy

BACKGROUND

Experience is lacking on the implementation of the WHO standards for improving the quality of care (QOC) for children at facility level. We describe the use of 10 prioritised WHO standard-based quality measures to assess provision of care for children with acute respiratory infections (ARI) in Italy.

METHODS

In a multicentre observational study across 11 emergency departments with different characteristics, we collected 10 WHO standard-based quality measures related to case management of children with ARI and no emergency/priority signs. Univariate and multivariate analyses were conducted.

RESULTS

Data from 3145 children were collected. Major differences in QOC across facilities were observed: documentation of saturation level and respiratory rate varied from 34.3% to 100% and from 10.7% to 62.7%, respectively (p<0.001); antibiotic prescription rates ranged from 22.6% to 80.0% (p<0.001), with significant differences in the pattern of prescribed antibiotic; hospitalisations rates ranged between 2.3% and 30.6% (p<0.001). When corrected for children's individual sociodemographic and clinical characteristics, the variable more consistently associated with each analysed outcome was the individual facility where the child was managed. Higher rates of antibiotics prescription (+33.1%, p<0.001) and hospitalisation (+24.7%, p<0.001) were observed for facilities in Southern Italy, while university centres were associated with lower hospitalisation rates (-13.1%, p<0.001), independently from children's characteristics.

CONCLUSIONS

The use of 10 WHO standard-based measures can help quickly assess QOC for children with ARI. There is an urgent need to invest more in implementation research to identify sustainable and effective interventions to ensure that all children receive high QOC.

Accordance of Registered Drug Packages with Guideline-Recommended Treatment Durations for Community-Acquired Pneumonia-A New Antibiotic Stewardship Target?

In most countries, antibiotics for oral administration are put on the market in fixed packages. When there is no exact unit dispensing of antimicrobials, drug pack size may influence prescribers' choice of treatment duration. The aim of this study was to investigate the accordance of approved antibiotic packages with national guidelines for the treatment of community-acquired pneumonia (CAP). For the purpose of this study, criteria were developed to determine the accordance of approved antibiotic packages for treating CAP (criteria), which are based on recommendations from national guidelines for treating CAP. Subsequently, the accordance of approved antibiotic packages with the number of antibiotic doses resulting from the specified criteria was determined. Of 39 identified therapeutic option-package size combinations, 11 were found to be matched (28.2%), meaning there were no leftover medication units after completing therapy, and 28 were mismatched combinations (71.8%), indicating that there were excess doses of antibiotics remaining at the end of therapy. The results of this research showed a significant non-accordance of the approved antibiotic packages with the national guidelines for the treatment of CAP and, consequently, the creation of a large amount of residues of unit doses of antibiotics in the community.

Evaluation of a Pediatric Community-Acquired Pneumonia Antimicrobial Stewardship Intervention at an Academic Medical Center

(1) Background: Pneumonia is the leading diagnosis associated with antibiotic use in hospitalized children. The Infectious Diseases Society of America published pediatric community-acquired pneumonia (CAP) guidelines in 2011, but adherence to recommendations varies across institutions. The purpose of this study was to evaluate the impact of an antimicrobial stewardship intervention on antibiotic prescribing in pediatric patients admitted to an academic medical center. (2) Methods: This single-center pre/post-intervention evaluation included children admitted for CAP during three time periods (pre-intervention and post-intervention groups 1 and 2). The primary outcomes were changes in inpatient antibiotic selection and duration following the interventions. Secondary outcomes included discharge antibiotic regimens, length of stay, and 30-day readmission rates. (3) Results: A total of 540 patients were included in this study. Most patients were under five years of age (69%). Antibiotic selection significantly improved, with prescriptions for ceftriaxone decreasing (p < 0.001) and ampicillin increasing (p < 0.001) following the interventions. Antibiotic duration decreased from a median of ten days in the pre-intervention group and post-intervention group 1 to eight days in post-intervention group 2. (4) Conclusions: Our antibiotic stewardship intervention directed at pediatric CAP treatment resulted in improved antibiotic prescriptions and provides data that can be used to further educate providers at our institution.

Factors Influencing Inappropriate Use of Antibiotics in Infants under 3 Years of Age in Primary Care: A Qualitative Study of the Paediatricians' Perceptions

Antibiotic consumption in infants of less than three years is higher than average the average consumption for general population. The aim of this study was to explore paediatricians' opinions regarding factors influencing inappropriate use of antibiotics in early infancy in primary care. A qualitative study based on the grounded theory using convenience sampling was conducted in Murcia Region, Spain. Three focal discussion groups were developed with 25 participants from 9 health areas (HA) of Murcia Region. Paediatricians perceived that health care pressure was an influential factor in the prescribing behaviour, forcing them to prescribe antibiotics for a rapid cure in unjustified circumstances. Participants believed that antibiotic consuming was related to parents' self-medication due to their perceptions about the curative potential of antibiotics together with facilities to obtain these agents from pharmacies without prescription. The misuse of antibiotics by paediatricians was associated to the lack of education on antibiotic prescription and the limited use of clinical guidelines. Not prescribing an antibiotic in the presence of a potentially severe disease generated more fear than an unnecessary prescription. The clinical interaction asymmetry was more evident, when paediatricians use trapping risk strategies as a mechanism to justify a restrictive prescribing behaviour. The rational model of clinical decision-making in antibiotic prescribing among paediatricians was determined by factors associated with health care management, social awareness and knowledge of the population and pressure of families' demands. The present findings have contributed to the design and implementation of health interventions in the community for improving awareness of the appropriate use of antibiotics, as well as for a better quality of prescription by peadiatricians.

Improving Duration of Antibiotics for Skin and Soft-tissue Infections in Pediatric Urgent Cares

BACKGROUND AND OBJECTIVES

National guidelines recommend a 5- to 7-day course of antibiotics for most skin and soft-tissue infections (SSTIs). Our aim was to increase the percentage of pediatric patients receiving 5 to 7 days of oral antibiotics for SSTIs in our pediatric urgent care clinics (UCCs) from 60% to 75% by December 31, 2021.

METHODS

We performed cause-and-effect analysis and surveyed UCC providers to uncover reasons for hesitation with short antibiotic courses for SSTIs. Plan- Do-Study-Act (PDSA) cycle 1 provided an update on current guidelines for UCC providers and addressed providers' concerns. PDSA cycle 2 modified the electronic health record to display antimicrobial prescription sentences from shortest to longest duration. PDSA cycle 3 provided project outcome and balancing measure updates to UCC providers at regular intervals. We created a monthly report of patients 90 days and older in UCCs with a final diagnosis of SSTIs. We used a Shewhart control chart to identify special cause variations.

RESULTS

After completing our PDSA cycles, we found that the percentage of children receiving 5 to 7 days of oral antibiotics for SSTIs exceeded 85%. The improvement was sustained over multiple months. There was no increase in the proportion of patients returning to the UCCs with an SSTI diagnosis within 14 days.

CONCLUSIONS

By addressing primary drivers uncovered through quality improvement methodology, we shortened the antibiotic course for children seen in our UCCs with SSTIs. Outpatient antimicrobial stewardship programs may apply similar methods to other diagnoses to further improve duration of antibiotic prescriptions.

Antimicrobial stewardship for surgical antibiotic prophylaxis and surgical site infections: a systematic review

Background Surgical site infections account for 14-17% of all healthcare-associated infections. Antimicrobial stewardship (AMS) are complementary strategies developed to optimize the use of antimicrobials. Aim to evaluate the effectiveness of AMS in promoting adherence to surgical antibiotic prophylaxis protocols in hospitalized patients, reducing surgical site infection rate and cost-benefit ratio. Method This systematic review of randomized clinical trials, non-randomized clinical trials and before and after studies was performed using Pubmed, Cochrane, Web of Science, Scopus, Embase, Google Scholar and ClinicalTrials.gov, in addition to reference lists of included studies. The risk of bias of studies was measured by the ROBINS-I checklist and the quality of the evidence synthesis by GRADE. Results Fourteen before and after design studies were included. In 85.7% of the studies, AMS was effective in increasing adherence to surgical antibiotic prophylaxis protocols and in 28.5%, there was reduction in surgical site infection rate. Three studies evaluated cost-benefit ratio and found a favorable impact. Eight (57%) studies were at risk of moderate bias and six had severe bias. The evaluation of the synthesis of evidence showed quality ranging from low to very low. Conclusion AMS, such as audit, feedback, education, implementation of a protocol, and a computer-assisted decision support methodology, appear to be effective in promoting adherence to surgical antibiotic prophylaxis protocols, reducing surgical site infection rate with a positive economic impact. However, more studies, particularly randomized clinical trials, are needed to improve the level of evidence of available information on AMS in order to favor decision-making.