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Aluisio YM, Sanchez AC, Norris KR, Waller J, Campbell CT. Impact of a Pediatric Emergency Medicine Pharmacist, Institutional Guideline, and Electronic Order Set on Empiric Antimicrobial Use for Febrile Neutropenia. Pediatr Emerg Care 2024; 40:151-155. [PMID: 37440312 DOI: 10.1097/pec.0000000000003009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
OBJECTIVES This study evaluated the difference in appropriateness of antimicrobial selection in pediatric patients with febrile neutropenia (FN) after implementation of an institutional guideline, a dedicated pediatric emergency medicine (EM) pharmacist, and an electronic order set. METHODS This was a retrospective cohort study that included febrile patients aged younger than 18 years who were at risk of neutropenia, as defined by our institutional algorithm. Charts were evaluated for inclusion by searching for patients who presented to the emergency department (ED) between February 2018 and January 2022 who had International Classification of Diseases, Tenth Revision (ICD-10) codes for patients at risk of FN. Three independent groups were compared before, during, and after interventions. A historical control group (group 1), postdedicated EM pharmacist and institutional guideline cohort (group 2), and postdedicated EM pharmacist, institutional guideline, and electronic order set cohort (group 3) were compared. Secondary outcomes included time from registration in the ED to administration of the first dose of empiric antimicrobials, days to defervescence, pediatric intensive care unit length of stay, and hospital length of stay. RESULTS Seventy-eight charts were reviewed for inclusion. Among those included (n = 38), there was an increase in appropriate use of antimicrobials from 71% to 92% to 100% ( P = 0.1534) between group 1, group 2, and group 3, respectively. In addition, the interventions in this study lead to an overall decrease in the median time from registration to first dose of antibiotics from 142 minutes to 72 minutes ( P = 0.1370). CONCLUSIONS This study demonstrated the positive impact a pediatric EM pharmacist along with an institutional guideline and an electronic order set have on appropriate antimicrobial selection in pediatric FN patients. Institutions should consider multipronged approaches to improve the selection and time to administration of appropriate empiric antimicrobials in the ED.
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Affiliation(s)
- Yancey M Aluisio
- From the Department of Pharmaceutical Services, Emory University Hospital Midtown/Winship Cancer Institute, Atlanta, GA
| | - Alicia C Sanchez
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA
| | - Kelley R Norris
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA
| | - Jennifer Waller
- Division of Biostatistics and Data Science, Department of Population Health Sciences, Augusta University, Augusta, GA
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Yarahuan JK, Kisvarday S, Kim E, Yan AP, Nakamura MM, Jones SB, Hron JD. An Algorithm to Assess Guideline Concordance of Antibiotic Choice in Community-Acquired Pneumonia. Hosp Pediatr 2024; 14:137-145. [PMID: 38287897 PMCID: PMC10823186 DOI: 10.1542/hpeds.2023-007418] [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] [Indexed: 01/31/2024]
Abstract
BACKGROUND AND OBJECTIVE This study aimed to develop and evaluate an algorithm to reduce the chart review burden of improvement efforts by automatically labeling antibiotic selection as either guideline-concordant or -discordant based on electronic health record data for patients with community-acquired pneumonia (CAP). METHODS We developed a 3-part algorithm using structured and unstructured data to assess adherence to an institutional CAP clinical practice guideline. The algorithm was applied to retrospective data for patients seen with CAP from 2017 to 2019 at a tertiary children's hospital. Performance metrics included positive predictive value (precision), sensitivity (recall), and F1 score (harmonized mean), with macro-weighted averages. Two physician reviewers independently assigned "actual" labels based on manual chart review. RESULTS Of 1345 patients with CAP, 893 were included in the training cohort and 452 in the validation cohort. Overall, the model correctly labeled 435 of 452 (96%) patients. Of the 286 patients who met guideline inclusion criteria, 193 (68%) were labeled as having received guideline-concordant antibiotics, 48 (17%) were labeled as likely in a scenario in which deviation from the clinical practice guideline was appropriate, and 45 (16%) were given the final label of "possibly discordant, needs review." The sensitivity was 0.96, the positive predictive value was 0.97, and the F1 was 0.96. CONCLUSIONS An automated algorithm that uses structured and unstructured electronic health record data can accurately assess the guideline concordance of antibiotic selection for CAP. This tool has the potential to improve the efficiency of improvement efforts by reducing the manual chart review needed for quality measurement.
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Affiliation(s)
- Julia K.W. Yarahuan
- />Department of Pediatrics, Divisions of General Pediatrics
- Department of Pediatrics, Emory University School of Medicine and Division of Hospital Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | | | - Adam P. Yan
- Hematology and Oncology
- Department of Pediatrics, The University of Toronto and Division of Hematology Oncology, The Hospital of Sick Children, Toronto, Ontario, Canada
| | | | - Sarah B. Jones
- Antimicrobial Stewardship Program
- Department of Pharmacy, Boston Children’s Hospital, Boston, Massachusetts
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TAFELSKI S, LANGE M, WEGENER F, GRATOPP A, SPIES C, WERNECKE KD, NACHTIGALL I. Pneumonia in pediatric critical care medicine and the adherence to guidelines. Minerva Pediatr (Torino) 2022; 74:447-454. [DOI: 10.23736/s2724-5276.19.05508-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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4
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The Current State and Future Directions of Inpatient Pediatric Antimicrobial Stewardship. Infect Dis Clin North Am 2022; 36:173-186. [DOI: 10.1016/j.idc.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Second-year Outcomes of Implementing Antimicrobial Stewardship Program in a Tertiary Pediatric Hospital. Jundishapur J Microbiol 2021. [DOI: 10.5812/jjm.118460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The increasing use of antimicrobial agents and resistance is becoming a serious problem in pediatric patients. Hence, antimicrobial stewardship program (ASP) is implemented to lessen the consequences. Objectives: This report aimed to demonstrate the impact of ASP on antimicrobials utilization in a referral and tertiary pediatric hospital in Isfahan, Iran. Methods: We launched an ASP for inpatients in March 2018 at the Imam Hussain Hospital, which is a 186-bed pediatrics hospital. Data was collected by ASP multidisciplinary team and using hospital records during February 2017-January 2018 (pre-intervention) and February 2019-January 2020 (post-intervention) periods. Consumption data were expressed as defined daily doses (DDDs) per 100 patient-days (PD). Independent sample t-test and paired t-test were used to assess the significance of differences. The rates of antimicrobials resistance for the most common hospital pathogens were also tracked. Results: Utilization of total antimicrobials decreased meaningfully by 12.41% (from 62.11 DDDs/100 PD in February 2017-January 2018 to 54.40 DDDs/100 PD in February 2019-January 2020; P = 0.024). The results showed that the reduction in non-restricted antimicrobials was less (5.43%) than restricted antimicrobials (27.6%). Conclusions: According to our results, the use of antimicrobials, especially the broad-spectrum ones, and the health burden costs significantly decreased after implementing ASP. Thus, continuous monitoring and educational programs are recommended to reduce the negative effects of using antimicrobials.
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Branstetter JW, Barker L, Yarbrough A, Ross S, Stultz JS. Challenges of Antibiotic Stewardship in the Pediatric and Neonatal Intensive Care Units. J Pediatr Pharmacol Ther 2021; 26:659-668. [PMID: 34588929 DOI: 10.5863/1551-6776-26.7.659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 07/01/2021] [Indexed: 12/14/2022]
Abstract
The goals of antimicrobial stewardship programs (ASPs) are to optimize antimicrobial prescribing habits in order to improve patient outcomes, reduce antimicrobial resistance, and reduce hospital costs. Multiple society-endorsed guidelines and government policies reinforce the importance of ASP implementation. Effective antimicrobial stewardship can impact unique patients, hospitals, and societal antibiotic-resistance burden. The role and subsequent success of these programs has largely been reported in the adult population. Pediatric and neonatal intensive care units present unique challenges for traditional antimicrobial stewardship approaches. The purpose of this review article is to explore the challenges of appropriate antibiotic use in the pediatric and neonatal intensive care units and to summarize strategies ASPs can use to overcome these challenges. These problems include non-specific disease presentations, limited evidence for definitive treatment durations in many pediatric infections, fewer pediatric-trained infectious disease physicians, and applicability of intensive laboratory obtainment, collection, and interpretation. Additionally, many ASP implementation studies evaluating the efficacy of ASPs exclude the PICU and NICU. Areas of focus for pediatric ASPs should likely include appropriate antibiotic initiation, appropriate antibiotic duration, and appropriate antibiotic de-escalation.
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Pediatric antimicrobial stewardship practices at discharge: A national survey. Infect Control Hosp Epidemiol 2021; 43:1686-1688. [PMID: 34269167 DOI: 10.1017/ice.2021.283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We surveyed pediatric antimicrobial stewardship program (ASP) site leaders within the Sharing Antimicrobial Reports for Pediatric Stewardship collaborative regarding discharge stewardship practices. Among 67 sites, 13 (19%) reported ASP review of discharge antimicrobial prescriptions. These findings highlight discharge stewardship as a potential opportunity for improvement during the hospital-to-home transition.
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Guideline Adherence and Registry Recruitment of Congenital Primary Hypothyroidism: Data from the German Registry for Congenital Hypothyroidism (HypoDok). Int J Neonatal Screen 2021; 7:ijns7010010. [PMID: 33673307 PMCID: PMC8006240 DOI: 10.3390/ijns7010010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/02/2021] [Accepted: 02/07/2021] [Indexed: 12/19/2022] Open
Abstract
Neonatal screening for congenital primary hypothyroidism (CH) is mandatory in Germany but medical care thereafter remains inconsistent. Therefore, the registry HypoDok of the German Society of Pediatric Endocrinology and Diabetology (DGKED) was analyzed to evaluate the implementation of evidence-based guidelines and to assess the number of included patients. Inclusion criteria were (i) date of birth between 10/2001 and 05/2020 and (ii) increased thyroid-stimulating hormone (TSH) at screening and/or confirmation. The cohort was divided into before (A) and after (B) guideline publication in 02/2011, to assess the guideline's influence on medical care. A total of 659 patients were analyzed as group A (n = 327) and group B (n = 332) representing 17.5% and 10.3% of CH patients identified in the German and Austrian neonatal screening program during the respective time period. Treatment start and thyroxine doses were similar in both groups and consistent with recommendations. Regular follow-ups were documented. In the first three years of life, less than half of the patients underwent audiometry; developmental assessment was performed in 49.3% (A) and 24.8% (B) (p < 0.01). Documentation of CH patient care by pediatric endocrinologists seemed to be established, however, it reflected only a minority of the affected patients. Therefore, comprehensive documentation as an important instrument of quality assurance and evidence-based medicine should be legally enforced and officially funded in order to record, comprehend, and optimize care and outcome in patients with rare diseases such as CH.
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Wacharachaisurapol N, Jitrungruengnij N, Janewongwirot P, Suchartlikitwong P, Chautrakarn S, Jantarabenjakul W, Anugulruengkitt S, Theerawit T, Sophonphan J, Deerojanawong J, Pancharoen C, Puthanakit T. High prescribing rates of third-generation cephalosporins in children hospitalized with acute lower respiratory infections at a university hospital. Int J Infect Dis 2020; 102:369-374. [PMID: 33186703 DOI: 10.1016/j.ijid.2020.10.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/28/2020] [Accepted: 10/31/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Antibiotics are frequently prescribed for the treatment of acute lower respiratory infections (ALRI) in children ≤5 years of age, even though viral aetiologies are the most common. The aim of this study was to describe antibiotic prescribing rates and patterns in children ≤5 years of age hospitalized with ALRI. METHODS A retrospective study was conducted involving patients aged 1 month to 5 years hospitalized with ALRI at a university hospital. Patient demographics, ALRI diagnosis, microbiological data, antibiotics prescribed, and treatment outcomes were recorded and analysed. RESULTS A total of 1283 patients were enrolled. Their median age was 1.6 years (interquartile range 0.8-2.8 years). Thirty-six percent had a co-morbidity. The diagnosis at discharge was viral ALRI in 81% and bacterial pneumonia in 19%. The mortality rate was 0.4%. The overall antibiotic prescribing rate was 46% (95% confidence interval 43-49%). Antibiotic prescribing rates were higher among children with co-morbidities (65% vs 35%, p < 0.001) and older children (57% for >2-5 years vs 39% for ≤2 years, p < 0.001). Parenteral third-generation cephalosporins were prescribed in up to 68% of all prescriptions. CONCLUSIONS Nearly-half of hospitalized children with ALRI were prescribed antibiotics. The majority of prescribed antibiotics were third-generation cephalosporins. An antimicrobial stewardship programme and antibiotic guidelines should be implemented to promote the judicious use of antibiotics.
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Affiliation(s)
- Noppadol Wacharachaisurapol
- Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Division of Paediatric Infectious Diseases, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Nattapong Jitrungruengnij
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Centre of Excellence for Paediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pakpoom Janewongwirot
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Centre of Excellence for Paediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pintip Suchartlikitwong
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Centre of Excellence for Paediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sineenart Chautrakarn
- Centre of Excellence for Paediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Watsamon Jantarabenjakul
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Centre of Excellence for Paediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Thai Red Cross Emerging Infectious Diseases Clinical Centre, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Suvaporn Anugulruengkitt
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Centre of Excellence for Paediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Tuangtip Theerawit
- Centre of Excellence for Paediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jiratchaya Sophonphan
- HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Jitladda Deerojanawong
- Division of Paediatric Pulmonary, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chitsanu Pancharoen
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Centre of Excellence for Paediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thanyawee Puthanakit
- Division of Paediatric Infectious Diseases, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Centre of Excellence for Paediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Rose MA, Barker M, Liese J, Adams O, Ankermann T, Baumann U, Brinkmann F, Bruns R, Dahlheim M, Ewig S, Forster J, Hofmann G, Kemen C, Lück C, Nadal D, Nüßlein T, Regamey N, Riedler J, Schmidt S, Schwerk N, Seidenberg J, Tenenbaum T, Trapp S, van der Linden M. [Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, pCAP) - Issued under the Responsibility of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Pulmonology (GPP)]. Pneumologie 2020; 74:515-544. [PMID: 32823360 DOI: 10.1055/a-1139-5132] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100 000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation > 92 % can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48 - 72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.
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Affiliation(s)
- M A Rose
- Fachbereich Medizin, Johann-Wolfgang-Goethe-Universität Frankfurt/Main und Zentrum für Kinder- und Jugendmedizin, Klinikum St. Georg Leipzig
| | - M Barker
- Klinik für Kinder- und Jugendmedizin, Helios Klinikum Emil von Behring, Berlin
| | - J Liese
- Kinderklinik und Poliklinik, Universitätsklinikum an der Julius-Maximilians-Universität Würzburg, Würzburg
| | - O Adams
- Institut für Virologie, Universitätsklinikum Düsseldorf
| | - T Ankermann
- Klinik für Kinder- und Jugendmedizin 1, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - U Baumann
- Pädiatrische Pneumologie, Allergologie und Neonatologie, Medizinische Hochschule Hannover
| | - F Brinkmann
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Ruhr-Universität Bochum
| | - R Bruns
- Zentrum für Kinder- und Jugendmedizin, Ernst-Moritz-Arndt-Universität Greifswald
| | - M Dahlheim
- Praxis für Kinderpneumologie und Allergologie, Mannheim
| | - S Ewig
- Kliniken für Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Bochum/Herne
| | - J Forster
- Kinderabteilung St. Hedwig, St. Josefskrankenhaus , Freiburg und Merzhausen
| | | | - C Kemen
- Katholisches Kinderkrankenhaus Wilhelmstift, Hamburg
| | - C Lück
- Institut für Medizinische Mikrobiologie und Hygiene, Technische Universität Dresden
| | - D Nadal
- Kinderspital Zürich, Schweiz
| | - T Nüßlein
- Klinik für Kinder- und Jugendmedizin, Gemeinschaftsklinikum Mittelrhein, Koblenz
| | - N Regamey
- Pädiatrische Pneumologie, Kinderspital Luzern, Schweiz
| | - J Riedler
- Kinder- und Jugendmedizin, Kardinal Schwarzenberg'sches Krankenhaus, Schwarzach, Österreich
| | - S Schmidt
- Zentrum für Kinder- und Jugendmedizin, Ernst-Moritz-Arndt-Universität Greifswald
| | - N Schwerk
- Pädiatrische Pneumologie, Allergologie und Neonatologie, Medizinische Hochschule Hannover
| | - J Seidenberg
- Klinik für pädiatrische Pneumologie und Allergologie, Neonatologie, Intensivmedizin und Kinderkardiologie, Klinikum Oldenburg
| | - T Tenenbaum
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Mannheim
| | | | - M van der Linden
- Institut für Medizinische Mikrobiologie, Universitätsklinikum Aachen
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Klatte JM. Pediatric Antimicrobial Stewardship Programs: Current Perspectives. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2020; 11:245-255. [PMID: 32801990 PMCID: PMC7383043 DOI: 10.2147/phmt.s224774] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/17/2020] [Indexed: 11/23/2022]
Abstract
With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.
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Affiliation(s)
- J Michael Klatte
- Division of Infectious Disease, Dayton Children's Hospital, Dayton, OH, USA
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12
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Le Saux NMA, Bowes J, Viel-Thériault I, Thampi N, Blackburn J, Buba M, Harrison MA, Barrowman N. Combined influence of practice guidelines and prospective audit and feedback stewardship on antimicrobial treatment of community-acquired pneumonia and empyema in children: 2012 to 2016. Paediatr Child Health 2020; 26:234-241. [PMID: 34136053 DOI: 10.1093/pch/pxaa066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/20/2020] [Indexed: 01/15/2023] Open
Abstract
Background Aminopenicillins are recommended empiric therapy for community-acquired pneumonia (CAP). The aim of the study was to assess treatment over a 5-year period after CAP guideline publication and introduction of an antimicrobial stewardship program (ASP). Methods Using ICD-10 discharge codes for pneumonia, children less than 18 years admitted to the Children's Hospital of Eastern Ontario January 1, 2012 and December 31, 2016 were identified. Children ≥ 2 months with consolidation were included. One day of therapy (DOT) was one or more doses of an antimicrobial given for 1 day. Results Of 1,707 patients identified, 713 met inclusion criteria. Eighteen (2.5%) had bacteria identified by culture and 79 of 265 (29.8%) had Mycoplasma pneumoniae detected. Mean DOT/1,000 patient days of aminopenicillins/penicillin (AAP) increased by 18.1% per year (95% confidence interval [CI] -0.2, 39.9%) and decreased by 37.6% per year (95% CI -56.1, -11.3%) for second- and third-generation cephalosporins in the post-ASP period. The duration of discharge antimicrobials decreased. Of 74 (10.4%) patients who had pleural fluid drained, 35 (47.3%) received more than 5 days of AAP and ≤ 5 days of second-/third-generation cephalosporins with no difference in median length of stay nor mean duration of antimicrobials. Conclusions Implementation of CAP management guidelines followed by prospective audit and feedback stewardship was associated with a sustained decrease in the use of broad-spectrum antibiotics in childhood CAP. Use of AAP should also be strongly considered in patients with effusions (even if no pathogen is identified), as clinical outcome appears similar to patients treated with broad-spectrum antimicrobials.
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Affiliation(s)
- Nicole M A Le Saux
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Jennifer Bowes
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Service d'Infectiologie, Département de Pédiatrie, Centre hospitalier université Laval et Centre mère-enfant Soleil, Québec, Québec
| | - Nisha Thampi
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Julie Blackburn
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Services de microbiologie et de maladies infectieuses, CHU Sainte-Justine, Montréal, Québec
| | - Melanie Buba
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Mary-Ann Harrison
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
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13
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Improving Antibiotic Use Through Quality Improvement Methods: Quality Improvement for Antibiotic Use. Jt Comm J Qual Patient Saf 2020; 45:787-788. [PMID: 31783950 DOI: 10.1016/j.jcjq.2019.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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14
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Synhorst DC, Johnson MB, Bettenhausen JL, Kyler KE, Richardson TE, Mann KJ, Fieldston ES, Hall M. Room Costs for Common Pediatric Hospitalizations and Cost-Reducing Quality Initiatives. Pediatrics 2020; 145:peds.2019-2177. [PMID: 32366609 DOI: 10.1542/peds.2019-2177] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Improvement initiatives promote safe and efficient care for hospitalized children. However, these may be associated with limited cost savings. In this article, we sought to understand the potential financial benefit yielded by improvement initiatives by describing the inpatient allocation of costs for common pediatric diagnoses. METHODS This study is a retrospective cross-sectional analysis of pediatric patients aged 0 to 21 years from 48 children's hospitals included in the Pediatric Health Information System database from January 1, 2017, to December 31, 2017. We included hospitalizations for 8 common inpatient pediatric diagnoses (seizure, bronchiolitis, asthma, pneumonia, acute gastroenteritis, upper respiratory tract infection, other gastrointestinal diagnoses, and skin and soft tissue infection) and categorized the distribution of hospitalization costs (room, clinical, laboratory, imaging, pharmacy, supplies, and other). We summarized our findings with mean percentages and percent of total costs and used mixed-effects models to account for disease severity and to describe hospital-level variation. RESULTS For 195 436 hospitalizations, room costs accounted for 52.5% to 70.3% of total hospitalization costs. We observed wide hospital-level variation in nonroom costs for the same diagnoses (25%-81% for seizure, 12%-51% for bronchiolitis, 19%-63% for asthma, 19%-62% for pneumonia, 21%-78% for acute gastroenteritis, 21%-63% for upper respiratory tract infection, 28%-69% for other gastrointestinal diagnoses, and 21%-71% for skin and soft tissue infection). However, to achieve a cost reduction equal to 10% of room costs, large, often unattainable reductions (>100%) in nonroom cost categories are needed. CONCLUSIONS Inconsistencies in nonroom costs for similar diagnoses suggest hospital-level treatment variation and improvement opportunities. However, individual improvement initiatives may not result in significant cost savings without specifically addressing room costs.
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Affiliation(s)
- David C Synhorst
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri;
| | - Matthew B Johnson
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Jessica L Bettenhausen
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Kathryn E Kyler
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Troy E Richardson
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas
| | - Keith J Mann
- American Board of Pediatrics, Chapel Hill, North Carolina; and
| | - Evan S Fieldston
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas
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15
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Klatte JM, Knee A, Szczerba F, Horton ER, Kopcza K, Fisher DJ. Identification of High-Yield Targets for Antimicrobial Stewardship Program Efforts Within a Nonfreestanding Children's Hospital. Hosp Pediatr 2020; 9:355-364. [PMID: 31003995 DOI: 10.1542/hpeds.2018-0254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Identify diagnoses with the highest likelihood of prompting antimicrobial stewardship program (ASP) recommendations and lowest probability of recommendation acceptance, investigate the impact of provider years in practice on recommendation receipt and acceptance, and simultaneously assess the influence of patient and provider-level variables associated with recommendations within a nonfreestanding children's hospital. METHODS Retrospective cohort study of antibiotic courses reviewed by the ASP staff from December 1, 2014 to November 30, 2016. Poisson regression was used to detect associations between diagnoses, provider years in practice, and the probability of recommendation receipt and acceptance. Multivariable logistic regression was used to simultaneously examine the influence of patient and provider-level characteristics on recommendation probability. RESULTS A total of 938 inpatient encounters and 1170 antibiotic courses were included. Diagnoses were associated with provider receipt (P < .001) and acceptance (P < .001) of recommendations, with ear, nose, and throat and/or sinopulmonary diagnoses most likely to prompt recommendations (56%; 95% confidence interval [CI], 48-64) and recommendations for neonatal and/or infant diagnoses accepted least often (67%; 95% CI, 58-76). No associations were initially found between provider experience and recommendation receipt or acceptance, although multivariable analysis revealed a trend between increasing years in practice and recommendation likelihood (P = .001). Vancomycin usage (64%; 95% CI, 56-72) and ear, nose, and throat and/or sinopulmonary diagnoses (56%; 95% CI, 47-65) had the highest probability of a recommendation. Sensitivity analyses revealed that use of diagnosis-related clinical practice guidelines decreased recommendations and increased acceptance rates, especially for the surgery diagnosis category. CONCLUSIONS High-yield targets for ASP activities at our nonfreestanding children's hospital were identified. Clinical practice guidelines have the potential to decrease ASP workload, and their development should be particularly encouraged for ASPs with limited resources.
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Affiliation(s)
- J Michael Klatte
- Department of Pediatrics, Division of Infectious Diseases, .,University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Alexander Knee
- University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.,Office of Research, Baystate Medical Center, Springfield, Massachusetts.,Department of Medicine, and
| | - Frank Szczerba
- Department of Pharmacy Services, Baystate Health, Springfield, Massachusetts; and
| | - Evan R Horton
- Department of Pharmacy Services, Baystate Health, Springfield, Massachusetts; and.,Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
| | - Kathleen Kopcza
- Department of Pharmacy Services, Baystate Health, Springfield, Massachusetts; and
| | - Donna J Fisher
- Department of Pediatrics, Division of Infectious Diseases.,University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
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16
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Schefft M, Lee C, Munoz J. Discharge Criteria Decrease Variability and Improve Efficiency. Hosp Pediatr 2020; 10:318-324. [PMID: 32179570 DOI: 10.1542/hpeds.2019-0244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES To determine the effect of discharge criteria on discharge readiness and length of stay (LOS). Discharge inefficiency is a common barrier to hospital flow, affecting admissions, discharges, cost, patient satisfaction, and quality of care. Our center identified increasing discharge efficiency as a method to improve flow and better meet the needs of our patients. METHODS A multidisciplinary team was assembled to examine discharge efficiency and flow. Discharge criteria were created for the 3 most common diagnoses on the hospital medicine service then expanded to 10 diagnoses 4 months into the project. Discharge workflow was evaluated through swim lane mapping, and barriers were evaluated through fishbone diagrams and a key driver diagram. Progress was assessed every 2 weeks through statistical process control charts. Additional interventions included provider education, daily review of criteria, and autotext added to daily notes. Our primary aim was to increase the percentage of patients discharged within 3 hours of meeting discharge criteria from 44% to 75% within 12 months of project implementation. RESULTS Discharge within 3 hours as well as 2 hours of meeting criteria improved significantly, from 44% to 87% and from 33% to 78%, respectively. LOS for the 10 diagnoses decreased from 2.89 to 1.47 days, with greatest gains seen for patients with asthma, pneumonia, and bronchiolitis without a change in the 30-day readmission rate. CONCLUSIONS Discharge criteria for common diagnoses may be an effective way to decrease variability and improve LOS for hospitalized children.
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Affiliation(s)
- Matthew Schefft
- Department of Pediatrics, School of Medicine, Virginia Commonwealth University, Children's Hospital of Richmond, Richmond, Virginia
| | - Clifton Lee
- Department of Pediatrics, School of Medicine, Virginia Commonwealth University, Children's Hospital of Richmond, Richmond, Virginia
| | - Jose Munoz
- Department of Pediatrics, School of Medicine, Virginia Commonwealth University, Children's Hospital of Richmond, Richmond, Virginia
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17
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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: 80] [Impact Index Per Article: 20.0] [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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18
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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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19
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Grammatico-Guillon L, Abdurrahim L, Shea K, Astagneau P, Pelton S. Scope of Antibiotic Stewardship Programs in Pediatrics. Clin Pediatr (Phila) 2019; 58:1291-1301. [PMID: 31179745 DOI: 10.1177/0009922819852985] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This review of pediatric antibiotic stewardship programs (ASPs) summarized the antibiotic prescribing interventions and their impact on antibiotic use and antimicrobial resistance. We reviewed studies of pediatric ASP, including the search terms "antimicrobial stewardship," "antibiotic stewardship," "children," and "pediatric." The articles' selection and review were performed independently by 2 investigators, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Twenty-one studies were included, from the past 15 years, increasing after the 2007 IDSA (Infectious Diseases Society of America) guidelines for ASP with a large variability of the programs, and the virtual exclusive focus on inpatient settings (90%): 16 formalized ASP and 5 non-ASP actions. A reduction in antibiotic prescribing in ASP has been demonstrated in the studies reporting pediatric ASP, but only one ASP showed a significant impact on antimicrobial resistance. However, the impact on antibiotic consumption in pediatrics demonstrated the important contribution of these strategies to improve antibiotic use in children, without complications or negative issues.
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Affiliation(s)
| | | | | | - Pascal Astagneau
- APHP University Hospital, Paris, France.,Sorbonne University, Paris France
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20
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Sonda TB, Horumpende PG, Kumburu HH, van Zwetselaar M, Mshana SE, Alifrangis M, Lund O, Aarestrup FM, Chilongola JO, Mmbaga BT, Kibiki GS. Ceftriaxone use in a tertiary care hospital in Kilimanjaro, Tanzania: A need for a hospital antibiotic stewardship programme. PLoS One 2019; 14:e0220261. [PMID: 31381579 PMCID: PMC6681960 DOI: 10.1371/journal.pone.0220261] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/11/2019] [Indexed: 12/12/2022] Open
Abstract
Excessive use of antibiotics, especially watch group antibiotics such as ceftriaxone leads to emergence and spread of antimicrobial resistance (AMR). In low and middle-income countries (LMICs), antibiotics are overused but data on consumption is scarcely available. We aimed at determining the extent and predictors of ceftriaxone use in a tertiary care university teaching hospital in Kilimanjaro, Tanzania. A hospital-based cross-sectional study was conducted from August 2013 through August 2015. Patients admitted in the medical, surgical wards and their respective intensive care units, receiving antimicrobials and other medications for various ailments were enrolled. Socio-demographic and clinical data were recorded in a structured questionnaire from patients' files and logistic regression was performed to determine the predictors for ceftriaxone use. Out of the 630 patients included in this study, 322 (51.1%) patients were on ceftriaxone during their time of hospitalization. Twenty-two patients out of 320 (6.9%) had been on ceftriaxone treatment without evidence of infection. Ceftriaxone use for surgical prophylaxis was 44 (40.7%), of which 32 (72.7%) and 9 (20.5%) received ceftriaxone prophylaxis before and after surgery, respectively. Three (6.8%) received ceftriaxone prophylaxis during surgery. Predicting factors for that the health facility administered ceftriaxone were identified as history of any medication use before referral to hospital [OR = 3.4, 95% CI (1.0-11.4), p = 0.047], bacterial infection [OR = 18.0, 95% CI (1.4-225.7, p = 0.025)], surgical ward [OR = 2.9, 95% CI (0.9-9.4), p = 0.078] and medical wards [OR = 5.0, 95% CI (0.9-28.3), p = 0.070]. Overall, a high ceftriaxone use at KCMC hospital was observed. Antimicrobial stewardship programs are highly needed to monitor and regulate hospital antimicrobial consumption, which in turn could help in halting the rising crisis of antimicrobial resistance.
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Affiliation(s)
- Tolbert B. Sonda
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Pius G. Horumpende
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Biochemistry and Molecular Biology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Lugalo General Military Hospital, Military College of Medical Sciences, Dar es Salaam, Tanzania
| | - Happiness H. Kumburu
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Marco van Zwetselaar
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Michael Alifrangis
- Centre for Medical Parasitology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Lund
- Centre for Biological Sequence Analysis, Technical University of Denmark; Copenhagen, Denmark
| | - Frank M. Aarestrup
- Centre for Genomic Epidemiology, Technical University of Denmark; Copenhagen, Denmark
| | - Jaffu O. Chilongola
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Biochemistry and Molecular Biology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Blandina T. Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Biochemistry and Molecular Biology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
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21
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Nava Lara RA, Aguilera-Mendoza L, Brizuela CA, Peña A, Del Rio G. Heterologous Machine Learning for the Identification of Antimicrobial Activity in Human-Targeted Drugs. Molecules 2019; 24:molecules24071258. [PMID: 30935109 PMCID: PMC6479866 DOI: 10.3390/molecules24071258] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/09/2019] [Accepted: 03/14/2019] [Indexed: 12/13/2022] Open
Abstract
The emergence of microbes resistant to common antibiotics represent a current treat to human health. It has been recently recognized that non-antibiotic labeled drugs may promote antibiotic-resistance mechanisms in the human microbiome by presenting a secondary antibiotic activity; hence, the development of computer-assisted procedures to identify antibiotic activity in human-targeted compounds may assist in preventing the emergence of resistant microbes. In this regard, it is worth noting that while most antibiotics used to treat human infectious diseases are non-peptidic compounds, most known antimicrobials nowadays are peptides, therefore all computer-based models aimed to predict antimicrobials either use small datasets of non-peptidic compounds rendering predictions with poor reliability or they predict antimicrobial peptides that are not currently used in humans. Here we report a machine-learning-based approach trained to identify gut antimicrobial compounds; a unique aspect of our model is the use of heterologous training sets, in which peptide and non-peptide antimicrobial compounds were used to increase the size of the training data set. Our results show that combining peptide and non-peptide antimicrobial compounds rendered the best classification of gut antimicrobial compounds. Furthermore, this classification model was tested on the latest human-approved drugs expecting to identify antibiotics with broad-spectrum activity and our results show that the model rendered predictions consistent with current knowledge about broad-spectrum antibiotics. Therefore, heterologous machine learning rendered an efficient computational approach to classify antimicrobial compounds.
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Affiliation(s)
- Rodrigo A Nava Lara
- Department of biochemistry and structural biology, Instituto de Fisiología Celular, UNAM, Mexico City 04510, Mexico.
| | | | - Carlos A Brizuela
- Computer Science Department, CICESE Research Center, Ensenada, Baja California 22860, Mexico.
| | - Antonio Peña
- Department of genetics, Instituto de Fisiología Celular, UNAM, Mexico City 04510, Mexico.
| | - Gabriel Del Rio
- Department of biochemistry and structural biology, Instituto de Fisiología Celular, UNAM, Mexico City 04510, Mexico.
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22
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Mostaghim M, Snelling T, McMullan B, Ewe YH, Bajorek B. Impact of clinical decision support on empirical antibiotic prescribing for children with community-acquired pneumonia. J Paediatr Child Health 2019; 55:305-311. [PMID: 30161269 DOI: 10.1111/jpc.14191] [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] [Received: 12/26/2017] [Revised: 06/08/2018] [Accepted: 07/08/2018] [Indexed: 12/13/2022]
Abstract
AIM To assess the impact of a computerised clinical decision support system (CDSS) on antibiotic use in hospitalised children with a presumptive diagnosis of uncomplicated community-acquired pneumonia (CAP). METHODS Codes associated with lower respiratory tract infection were used to identify cases of presumed uncomplicated CAP requiring admission to a tertiary paediatric hospital. Random sampling of the periods between 1 October 2010 and 30 September 2012 (pre-CDSS) and 1 October 2012 and 30 September 2014 (post-CDSS) determined the sequence of case assessment by two independent investigators. Initial antibiotic therapy, associated CDSS approvals and documented signs of clinical deterioration prior to antibiotic decision-making were recorded. RESULTS Statistically significant differences between cases pre- and post-CDSS implementation were minimal. High fever was observed in 57.5% (77/134) cases pre-CDSS and 45.8% (49/107) cases post-CDSS (P = 0.07). Supplemental oxygen was used in 30.6% pre-CDSS and 54.2% post-CDSS cases (P < 0.001). Narrow-spectrum penicillins were prescribed most often, with no statistically significant change post-CDSS implementation (81.3% pre-CDSS, 77.6% post-CDSS, P = 0.47). Macrolides were used consistently throughout the study period (53.7% pre-CDSS, 61.7% post-CDSS; P = 0.21). CONCLUSION CDSS implementation did not reduce already low rates of broad-spectrum antibiotic use for uncomplicated CAP.
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Affiliation(s)
- Mona Mostaghim
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia.,Pharmacy Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Tom Snelling
- Department of Infectious Diseases, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Brendan McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Yean H Ewe
- Junior Medical Unit, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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23
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Gold J, Hametz P, Sen AI, Maykowski P, Leone N, Lee DS, Gagliardo C, Hymes S, Biller R, Saiman L. Provider Knowledge, Attitudes, and Practices Regarding Bronchiolitis and Pneumonia Guidelines. Hosp Pediatr 2019; 9:87-91. [PMID: 30610012 DOI: 10.1542/hpeds.2018-0211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Practice guidelines have been published for bronchiolitis and community-acquired pneumonia (CAP), but little is known about pediatricians' knowledge of and attitudes toward these guidelines since their publication. METHODS We surveyed pediatric providers at 6 children's hospitals in the New York City area. Two vignettes, an infant with bronchiolitis and a child with CAP, were provided, and respondents were asked about management. Associations between respondent characteristics and their reported practices were examined using χ2 and Fisher's exact tests. Associations between questions probing knowledge and attitude barriers relevant to guideline adherence and reported practices were examined using Cochran-Mantel-Haenszel relative risk estimates. RESULTS Of 283 respondents, 58% were trainees; 57% of attending physician respondents had finished training within 10 years. Overall, 76% and 45% of respondents reported they had read the bronchiolitis and CAP guidelines, respectively. For the bronchiolitis vignette, 40% reported ordering a chest radiograph (CXR), and 38% prescribed bronchodilators (neither recommended). For the CAP vignette, 38% prescribed ceftriaxone (not recommended). Study site, level of training, and practice locations were associated with nonrecommended practices. Site-adjusted knowledge and attitude barriers were used to identify that those who agreed CXRs were useful in managing bronchiolitis were more likely to order CXRs, and those who felt bronchodilators shortened length of stay were more likely to prescribe them. Concerns about ampicillin resistance and lack of confidence using local susceptibility patterns to guide prescribing were associated with ordering ceftriaxone. CONCLUSIONS Provider-level factors and knowledge gaps were associated with ordering nonrecommended treatments for bronchiolitis and CAP.
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Affiliation(s)
- Jessica Gold
- Morgan Stanley Children's Hospital, Columbia University Medical Center and
| | - Patricia Hametz
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York
| | - Anita I Sen
- Morgan Stanley Children's Hospital, Columbia University Medical Center and
| | - Philip Maykowski
- College of Medicine-Phoenix, University of Arizona, Phoenix, Arizona
| | - Nicole Leone
- Cohen Children's Medical Center, Northwell Health, Queens, New York
| | - Diana S Lee
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York
| | - Christina Gagliardo
- Goryeb Children's Hospital, Morristown Medical Center, Morristown, New Jersey
| | - Saul Hymes
- Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, New York; and
| | - Rachel Biller
- Department of Pediatrics, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, New York
| | - Lisa Saiman
- Morgan Stanley Children's Hospital, Columbia University Medical Center and.,Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York City, New York
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24
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Metz J, Oehler P, Burggraf M, Burdach S, Behrends U, Rieber N. Improvement of Guideline Adherence After the Implementation of an Antibiotic Stewardship Program in a Secondary Care Pediatric Hospital. Front Pediatr 2019; 7:478. [PMID: 31799227 PMCID: PMC6865353 DOI: 10.3389/fped.2019.00478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/30/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction: The accelerating threat of multidrug-resistant bacteria (MRB) forces health care providers to use antibiotics more rationally. Antibiotic stewardship programs (ASP) are a proven and safe way to achieve that goal. They have been comprehensively studied in adults but data from secondary care pediatric hospitals are lacking. Material and Methods: In our study an ASP with standard operating procedures (SOPs), audits, a weekly ward round with experts in pediatric infectious diseases and an antibiotic pocket-card for selected infectious diseases was established in July 2017 in a Munich municipal secondary care children's hospital. All antibiotic prescriptions on general pediatric wards were reviewed each in the first quarter of 2017 and 2018. The primary outcome was adherence to treatment guidelines. Secondary outcomes were substance consumption, duration of therapy and death. Results: After the ASP was implemented guideline adherence increased significantly from 33 to 63%. The consumption of cephalosporins decreased significantly (-60%), whereas aminopenicillin use increased accordingly (+120%). Neither in the pre- nor in the post-intervention group deaths occurred. Discussion: Data on ASP in pediatric secondary care hospitals are scarce. Most previous studies have been performed at tertiary care/university children's hospitals. We demonstrate a significant improvement in guideline adherence regarding antibiotic treatments after the implementation of an ASP. Cephalosporin consumption decreased which might be relevant for the selection of MRB (e.g., vancomycin-resistant enterococci). Results are limited by the single-center design and the short observation period. The study encourages the implementation of ASPs in secondary care children's hospitals.
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Affiliation(s)
- Jakob Metz
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany
| | - Philipp Oehler
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany
| | - Manuela Burggraf
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany
| | - Stefan Burdach
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany
| | - Uta Behrends
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany.,German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Nikolaus Rieber
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany.,Children's Hospital, University of Tübingen, Tübingen, Germany
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25
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Ambroggio L, Schondelmeyer A, Hoefgen E, Brady P, Shaughnessy E. Quality Improvement Feature Series Article 4: Advanced Designs for Quality Improvement Studies. J Pediatric Infect Dis Soc 2018; 7:335-337. [PMID: 29045666 DOI: 10.1093/jpids/pix082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/28/2017] [Indexed: 11/12/2022]
Abstract
Each quality improvement (QI) project has an implicit study design, although these designs are not discussed as commonly as they are in clinical research. Most QI projects fall under the quasi-experimental study category, in which observations are made before and after the implementation of an intervention(s). The simplest and most commonly used for QI studies is the pre-post design, in which observations are made before and after each intervention that was implemented over a specified period. More sophisticated designs for QI studies enable a study team to draw stronger inferences about the system that is being changed and the individual effects of the interventions that are implemented. In the final commentary in this QI series, we discuss these study designs and focus on the strengths and weaknesses of more sophisticated designs, including cluster randomized, stepped-wedge, and factorial designs.
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Affiliation(s)
- Lilliam Ambroggio
- Division of Hospital Medicine, Cincinnati Children's Hospital, Ohio; and Department of Pediatrics, University of Cincinnati, Ohio
| | - Amanda Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital, Ohio; and Department of Pediatrics, University of Cincinnati, Ohio
| | - Erik Hoefgen
- Division of Hospital Medicine, Cincinnati Children's Hospital, Ohio; and Department of Pediatrics, University of Cincinnati, Ohio
| | - Patrick Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital, Ohio; and Department of Pediatrics, University of Cincinnati, Ohio
| | - Erin Shaughnessy
- Division of Hospital Medicine, Cincinnati Children's Hospital, Ohio; and Department of Pediatrics, University of Cincinnati, Ohio
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From paper to practice: Strategies for improving antibiotic stewardship in the pediatric ambulatory setting. Curr Probl Pediatr Adolesc Health Care 2018; 48:289-305. [PMID: 30322711 DOI: 10.1016/j.cppeds.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Antibiotic stewardship aims to better patient outcomes, reduce antibiotic resistance, and decrease unnecessary health care costs by improving appropriate antibiotic use. More than half of annual antibiotic expenditures for antibiotics in the United States are prescribed in the ambulatory setting. This review provides a summary of evidence based strategies shown to improve antibiotic prescribing in ambulatory care settings including: providing education to patients and their families, providing education to clinicians regarding best practices for specific conditions, providing communications training to clinicians, implementing disease-specific treatment algorithms, implementing delayed prescribing for acute otitis media, supplying prescribing feedback to providers with peer comparisons, using commitment letters, and prompting providers to justify antibiotic prescribing for diagnoses for which antibiotics are not typically recommended. These various mechanisms to improve stewardship can be tailored to a specific practice's work flow and culture. Interventions should be used in combination to maximize impact. The intent with this review is to provide an overview of strategies that pediatric providers can take from paper to practice.
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Ambroggio L, Mangeot C, Murtagh Kurowski E, Graham C, Korn P, Strasser M, Cavallo C, Brady K, Campanella S, Clohessy C, Brinkman WB, Shah SS. Guideline Adoption for Community-Acquired Pneumonia in the Outpatient Setting. Pediatrics 2018; 142:peds.2018-0331. [PMID: 30254038 DOI: 10.1542/peds.2018-0331] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/02/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Pediatric Infectious Diseases Society and Infectious Diseases Society of America national childhood community-acquired pneumonia (CAP) guideline encouraged the standard evaluation and treatment of children who were managed as outpatients. Our objectives were to (1) increase adherence to guideline-recommended diagnostics and antibiotic treatment of CAP at 5 pediatric primary care practices (PPCPs) by using quality-improvement methods and (2) evaluate the association between guideline adherence and unscheduled follow-up visits. METHODS Immunocompetent children >3 months of age with no complex chronic conditions and who were diagnosed with CAP were eligible for inclusion in this stepped-wedge study. Interventions were focused on education, knowledge of colleagues' prescribing practices, and feedback sessions. Statistical process control charts were used to assess changes in recommendations and antibiotic treatment. Unscheduled follow-up visits were compared across time by using generalized estimating equations that were clustered by PPCP. RESULTS CAP was diagnosed in 1906 children. Guideline recommended therapy and pulse oximetry use increased from a mean baseline of 24.9% to a mean of 68.0% and from 4.3% to 85.0%, respectively, over the study period. Among children >5 years of age, but not among those who were younger, the receipt of guideline recommended antibiotics, as compared with nonguideline therapy, was associated with the increased likelihood of unscheduled follow-up (adjusted odds ratio, 2.12; 95% confidence interval: 1.31-3.43). Chest radiographs and complete blood cell counts were rarely performed at baseline. CONCLUSIONS Recommendations for limited use of chest radiographs and complete blood cell counts and standardized antibiotic therapy in children is supported at PPCPs. However, the guideline may need to include macrolide monotherapy as appropriate antibiotic therapy for older children.
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Affiliation(s)
- Lilliam Ambroggio
- Divisions of Hospital Medicine, .,Biostatistics and Epidemiology.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Eileen Murtagh Kurowski
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Emergency Medicine
| | - Camille Graham
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,General and Community Pediatrics, and.,Mid City Pediatrics, Cincinnati, Ohio
| | | | | | | | | | | | | | - William B Brinkman
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,General and Community Pediatrics, and
| | - Samir S Shah
- Divisions of Hospital Medicine.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Kronman MP, Banerjee R, Duchon J, Gerber JS, Green MD, Hersh AL, Hyun D, Maples H, Nash CB, Parker S, Patel SJ, Saiman L, Tamma PD, Newland JG. Expanding Existing Antimicrobial Stewardship Programs in Pediatrics: What Comes Next. J Pediatric Infect Dis Soc 2018; 7:241-248. [PMID: 29267871 PMCID: PMC7107461 DOI: 10.1093/jpids/pix104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/08/2017] [Indexed: 02/06/2023]
Abstract
The prevalence of pediatric antimicrobial stewardship programs (ASPs) is increasing in acute care facilities across the United States. Over the past several years, the evidence base used to inform effective stewardship practices has expanded, and regulatory interest in stewardship programs has increased. Here, we review approaches for established, hospital-based pediatric ASPs to adapt and report standardized metrics, broaden their reach to specialized populations, expand to undertake novel stewardship initiatives, and implement rapid diagnostics to continue their evolution in improving antimicrobial use and patient outcomes.
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Affiliation(s)
- Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Ritu Banerjee
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Jennifer Duchon
- Division of Infectious Diseases, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael D Green
- Division of Infectious Diseases, Department of Pediatrics, University of Pittsburgh, Pennsylvania
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Holly Maples
- Department of Pharmacy, University of Arkansas, Little Rock, Arkansas
| | - Colleen B Nash
- Division of Infectious Diseases, Department of Pediatrics, University of Chicago, Illinois
| | - Sarah Parker
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Sameer J Patel
- Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lisa Saiman
- Division of Infectious Diseases, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Pranita D Tamma
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University, St. Louis, Missouri
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Foolad F, Nagel JL, Eschenauer G, Patel TS, Nguyen CT. Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management. J Antimicrob Chemother 2018; 72:3232-3244. [PMID: 29177489 DOI: 10.1093/jac/dkx266] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.
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Affiliation(s)
- Farnaz Foolad
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Jerod L Nagel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Gregory Eschenauer
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.,College of Pharmacy, University of Michigan, 428 Church St., Ann Arbor, MI 48109, USA
| | - Twisha S Patel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Cynthia T Nguyen
- Department of Pharmacy, University of Chicago Medicine, 5841 S. Maryland Ave. MC0010, Chicago, IL 60637, USA
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A Comprehensive Approach to Pediatric Pneumonia: Relationship Between Standardization, Antimicrobial Stewardship, Clinical Testing, and Cost. J Healthc Qual 2018; 39:e59-e69. [PMID: 27811579 DOI: 10.1097/jhq.0000000000000048] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In September 2012, our institution implemented an emergency department (ED) and inpatient pathway for community-acquired pneumonia (CAP) based on national guideline recommendations. The objective of this study was to determine the relationship between standardizing ED and inpatient care for CAP and antimicrobial stewardship, clinical testing, and cost. METHODS We used descriptive statistics, statistical process control, and interrupted time series analysis to analyze measures 12 months before and after implementation. RESULTS Six hundred thirty-two patients were included. We found an immediate sustained increase in narrow-spectrum antibiotic (ampicillin) use from a baseline of 8-54%. There was a shift toward more guideline-recommended diagnostic testing with an increase in blood cultures and respiratory viral testing among admitted patients (35-63% and 52-84%, respectively). We identified no significant change in ED chest radiography use, mean ED length of stay (LOS), percentage of CAP admissions, or mean inpatient LOS. Costs of care for admitted patients and for patients discharged from the ED were unchanged. CONCLUSIONS Standardizing care for ED and inpatient management of CAP led to immediate and sustained improvements in antimicrobial stewardship and guideline-recommended testing without significantly affecting costs.
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McDaniel CE, Haaland W, Parlaman J, Zhou C, Desai AD. A Multisite Intervention for Pediatric Community-acquired Pneumonia in Community Settings. Acad Emerg Med 2018; 25:870-879. [PMID: 29513362 DOI: 10.1111/acem.13405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/01/2018] [Accepted: 03/01/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The majority of children with community-acquired pneumonia (CAP) are primarily evaluated in community hospital emergency departments (EDs); however, studies on the management of pediatric CAP have largely targeted care provided in freestanding children's hospital EDs or inpatient settings. The objectives of this study were to examine whether implementation of a CAP pathway within three community hospital EDs and inpatient units improved process measures related to appropriate laboratory testing and antibiotic prescribing and to compare performance on these measures between the community hospitals and a freestanding children's hospital. METHODS Through a multidisciplinary approach (including general emergency medicine [EM] providers, pediatric fellowship-trained EM providers, and pediatric hospitalists), a CAP pathway was designed and implemented at three community hospitals in January and February 2016. Diagnostic and therapeutic process measures were collected using administrative data and medical record abstraction 1 year pre- and postintervention. Chi-square statistics and statistical process control P-charts were used to examine adherence to these process measures. RESULTS Across the community hospitals, 544 patients preintervention and 321 patients postintervention met inclusion criteria, with 290 children's hospital patients meeting criteria in the postintervention period. Adherence to process measures increased postintervention for appropriate laboratory testing, narrow-spectrum antibiotic stewardship and macrolide stewardship by 10.8% (95% confidence interval [CI] = 4.7% to 16.9%), 8.3% (95% CI = 21.5% to 15.2%), and 3.1% (95% CI = -4.3% to 10.4%), respectively. Statistical process control P-charts demonstrated special cause variation immediately after implementation of the intervention in regards to appropriate laboratory testing. CONCLUSION Implementation of a CAP pathway through a multisite community hospital intervention improved adherence to evidence-based recommendations for laboratory testing and antibiotic stewardship. Similar interventions may improve the quality of care for children with CAP on a population level, as community hospitals are where these patients are seen most frequently.
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Affiliation(s)
| | - Wren Haaland
- Seattle Children's Research Institute Seattle WA
| | - Joshua Parlaman
- Department of Pediatrics University of Washington Seattle WA
| | - Chuan Zhou
- Seattle Children's Research Institute Seattle WA
| | - Arti D. Desai
- Department of Pediatrics University of Washington Seattle WA
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Quaak CH, Cové E, Driessen GJ, Tramper-Stranders GA. Trends in paediatric inpatient antibiotic therapy in a secondary care setting. Eur J Pediatr 2018; 177:1271-1278. [PMID: 29948254 PMCID: PMC6061058 DOI: 10.1007/s00431-018-3185-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/18/2018] [Accepted: 05/29/2018] [Indexed: 11/30/2022]
Abstract
UNLABELLED There is growing attention for antimicrobial stewardship in paediatrics. Currently, little is known about secondary care antibiotic practice. We analysed trends in time with respect to inpatient antibiotic use in a secondary paediatric care setting. Total inpatient antibiotic consumption per year (2010-2015) and antibiotic prescriptions for urinary tract infection (UTI) and lower respiratory tract infection (LRTI) were analysed. Variables were total, antibiotic-specific, and intravenous days of therapy (DOT/100PD) and for UTI/LRTI treatment type, route and duration. Third-generation cephalosporin use decreased (DOT/100PD 11.6 in 2011 vs. 5.1 in 2015; p < 0.001); intravenous antibiotics were prescribed less often (p = 0.06). These findings were confirmed for the specific diseases: third-generation cephalosporin use decreased for both UTI (93% vs. 45%; p = 0.002) and LRTI (14% vs. 6%; p = 0.18); the duration of intravenous therapy decreased (UTI p = 0.02; LRTI p < 0.001). Median LRTI treatment duration was 9.2 days in 2008 and 6.6 in 2015 (p < 0.001); penicillin prescriptions were more narrow in spectrum (p = 0.02). CONCLUSION A decrease in third-generation cephalosporin use and intravenous route was identified. LRTI treatment was significantly shorter and more narrow in spectrum. This could be explained by awareness and interventions in the context of antimicrobial stewardship. A decrease in antibiotic use is also feasible and important in non-tertiary paediatric wards. What is Known: • Antimicrobial stewardship programmes are effective in reduction of total and broad-spectrum antibiotic use in tertiary paediatric hospitals • The majority of hospitalised paediatric patients are admitted at general, secondary care wards, often for infectious diseases What is New: • Antimicrobial stewardship interventions in secondary care are also effective in establishing a reduction in broad-spectrum antibiotic use, intravenous route and days on antibiotic therapy.
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Affiliation(s)
- C. H. Quaak
- Erasmus University, Rotterdam, the Netherlands
| | - E. Cové
- Erasmus University, Rotterdam, the Netherlands
| | - G. J. Driessen
- ErasmusMC-Sophia Children’s Hospital, Rotterdam and Haga teaching hospital-Juliana Children’s Hospital, The Hague, the Netherlands
| | - G. A. Tramper-Stranders
- Department of Pediatrics, Franciscus Gasthuis, Kleiweg 500, 3045 PM Rotterdam, the Netherlands ,Department of Neonatology, ErasmusMC-Sophia Children’s Hospital, Rotterdam, the Netherlands
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Messinger AI, Kupfer O, Hurst A, Parker S. Management of Pediatric Community-acquired Bacterial Pneumonia. Pediatr Rev 2017; 38:394-409. [PMID: 28864731 DOI: 10.1542/pir.2016-0183] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Amanda Hurst
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO
| | - Sarah Parker
- Infectious Diseases, Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO
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Turner RB, Valcarlos E, Loeffler AM, Gilbert M, Chan D. Impact of an Antimicrobial Stewardship Program on Antibiotic Use at a Nonfreestanding Children's Hospital. J Pediatric Infect Dis Soc 2017; 6:e36-e40. [PMID: 28903514 DOI: 10.1093/jpids/piw059] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 09/12/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pediatric stewardship programs have been successful at reducing unnecessary antibiotic use. Data from nonfreestanding children's hospitals are currently limited. This study is an analysis of antibiotic use after implementation of an antimicrobial stewardship program at a community nonfreestanding children's hospital. METHODS In April 2013, an antimicrobial stewardship program that consisted of physician-group engagement and pharmacist prospective auditing and feedback was initiated. We compared antibiotic use in the preintervention period (April 2012 to March 2013) with that in the postintervention period (April 2013 to March 2015) in all units except the neonatal intensive care unit and the emergency department. In addition, drug-acquisition costs, antibiotic-specific use, death, length of stay, and case-mix index were examined. RESULTS Antibiotic use decreased by 16.8% (95% confidence interval, 18.0% to -9.2%; P < .001) in the postintervention period. Vancomycin use decreased by 38% (P = .001), whereas antipseudomonal β-lactam use was unaltered. Drug-acquisition cost savings were estimated to be $67 000/year over the 2-year postintervention period. Lengths of stay and mortality rates were unchanged in the postintervention period after adjusting for case-mix index. CONCLUSIONS Implementation of a simple stewardship initiative with limited resources at a community nonfreestanding children's hospital effectively reduced antibiotic use without an overt negative impact on overall clinical outcomes. The results of this study suggest that nonfreestanding children's hospitals can achieve substantial reductions in antibiotic use despite limited resources.
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Affiliation(s)
- R Brigg Turner
- Department of Pharmacy, Legacy Health, Portland.,School of Pharmacy, Pacific University, Hillsboro
| | | | - Ann M Loeffler
- Department of Pediatrics, Randall Children's Hospital at Legacy Emanuel, Portland, Oregon
| | - Michael Gilbert
- Department of Pediatrics, Randall Children's Hospital at Legacy Emanuel, Portland, Oregon
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Shukla PJ, Behnam-Terneus M, Cunill-De Sautu B, Perez GF. Antibiotic Use by Pediatric Residents: Identifying Opportunities and Strategies for Antimicrobial Stewardship. Hosp Pediatr 2017; 7:553-558. [PMID: 28814443 DOI: 10.1542/hpeds.2017-0059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine the antibiotic prescribing practices of pediatric residents and assess how they acquire knowledge leading to prescribing behaviors. METHODS We performed a cross-sectional electronic survey of all pediatric residents at the Children's National Medical Center and Nicklaus Children's Hospital, assessing antibiotic prescribing patterns for common pediatric infections, use of antibiograms, and factors influencing antibiotic choice. RESULTS Eighty-five surveys (45%) were returned complete and included in the analysis. Increased deviations from clinical guideline recommendations were observed for antibiotic treatments of sinusitis and community-acquired pneumonia as compared with otitis media and group A streptococcal pharyngitis. Only 57% of residents reported having used antibiograms. General pediatric inpatient attending physicians were identified as the most influential source for house staff antibiotic knowledge. CONCLUSIONS Results illustrate the need for better promotion and integration of clinical guidelines with antibiograms when developing antibiotic education programs for residents in training. In addition, pediatric hospitalists should play an active role in the implementation of these programs and can provide valuable insight into the development of educational programs in conjunction with graduate medical education divisions.
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Affiliation(s)
| | - Maria Behnam-Terneus
- Miami Children's Health System, Nicklaus Children's Hospital, Miami, Florida; and
| | | | - Geovanny F Perez
- Division of Pulmonary and Sleep Medicine, .,Department of Pediatrics, School of Medicine and Health Sciences, and.,Department of Integrative Systems Biology, George Washington University, Washington, District of Columbia.,Center for Genetic Research Medicine, Children's National Medical Center, Washington, District of Columbia
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Araujo da Silva AR, Albernaz de Almeida Dias DC, Marques AF, Biscaia di Biase C, Murni IK, Dramowski A, Sharland M, Huebner J, Zingg W. Role of antimicrobial stewardship programmes in children: a systematic review. J Hosp Infect 2017; 99:117-123. [PMID: 28807835 DOI: 10.1016/j.jhin.2017.08.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
Abstract
The United Nations and the World Health Organization have designated antimicrobial resistance (AMR) as a major health priority and developed action plans to reduce AMR in all healthcare settings. Establishment of institutional antimicrobial stewardship programmes (ASPs) is advocated as a key intervention to reduce antibiotic consumption in hospitals and address high rates of multi-drug-resistant (MDR) bacteria. PUBMED and the Cochrane Database of Systematic Reviews (January 2007-March 2017) were searched to identify studies reporting the effectiveness of ASPs in general paediatric wards and paediatric intensive care units (PICUs) for reducing antibiotic consumption, use of broad-spectrum/restricted antibiotics, and antibiotic resistance and healthcare-associated infections (HAIs). Neonatal units and antifungal agents were excluded. Of 2509 titles and abstracts, nine articles were eligible for inclusion in the final analysis. All studies reported a reduction in the use of broad-spectrum/restricted antibiotics or antibiotic consumption. One study reported a reduction in HAIs in a PICU, and another study evaluated bacterial resistance, showing no effect following ASP implementation. Prospective audit on antibiotic use was the most common ASP core component (eight of nine studies). Antibiotic pre-authorization was described in two studies. Other described interventions were the provision of guidelines or written information (five of nine studies), and training of healthcare professionals (one study). There is limited evidence for a reduction in antibiotic consumption and use of broad-spectrum/restricted agents following ASP implementation specifically in PICUs. Data evaluating the impact of ASPs on HAIs and AMR in PICUs are lacking. In addition, there is limited information on effective components of a successful ASP in PICUs.
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Affiliation(s)
- A R Araujo da Silva
- Laboratory of Teaching of Prevention and Control of Healthcare-Associated Infections, Federal Fluminense University, Rio de Janeiro, Brazil.
| | - D C Albernaz de Almeida Dias
- Laboratory of Teaching of Prevention and Control of Healthcare-Associated Infections, Federal Fluminense University, Rio de Janeiro, Brazil
| | - A F Marques
- Laboratory of Teaching of Prevention and Control of Healthcare-Associated Infections, Federal Fluminense University, Rio de Janeiro, Brazil
| | - C Biscaia di Biase
- Laboratory of Teaching of Prevention and Control of Healthcare-Associated Infections, Federal Fluminense University, Rio de Janeiro, Brazil
| | - I K Murni
- Department of Paediatrics, Dr Sardjito Hospital/Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - A Dramowski
- Department of Paediatrics and Child Health, Division of Paediatric Infectious Diseases, Stellenbosch University, Stellenbosch, South Africa
| | - M Sharland
- Paediatric Infectious Diseases Research Group, St George's University, London, UK
| | - J Huebner
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - W Zingg
- Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
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Development and Application of an Antibiotic Spectrum Index for Benchmarking Antibiotic Selection Patterns Across Hospitals. Infect Control Hosp Epidemiol 2017; 38:993-997. [PMID: 28560946 DOI: 10.1017/ice.2017.94] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Standard metrics for antimicrobial use consider volume but not spectrum of antimicrobial prescribing. We developed an antibiotic spectrum index (ASI) to classify commonly used antibiotics based on activity against important pathogens. The application of this index to hospital antibiotic use reveals how this tool enhances current antimicrobial stewardship metrics. Infect Control Hosp Epidemiol 2017;38:993-997.
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38
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Hyman D, Neiman J, Rannie M, Allen R, Swietlik M, Balzer A. Innovative Use of the Electronic Health Record to Support Harm Reduction Efforts. Pediatrics 2017; 139:peds.2015-3410. [PMID: 28557714 DOI: 10.1542/peds.2015-3410] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Awareness of the impact of preventable harm on patients and families has resulted in extensive efforts to make our health care systems safer. We determined that, in our hospital, patients experienced 1 of 9 types of preventable harm approximately every other day. In an effort to expedite early identification of patients at risk and provide timely intervention, we used the electronic health record's (EHR) documentation to enable decision support, data capture, and auditing and implemented reporting tools to reduce rates of harm. METHODS Harm reduction strategies included aggregating data to generate a risk profile for hospital-acquired conditions (HACs) for all inpatients. The profile includes links to prevention bundles and available care guidelines. Additionally, lists of patients at risk for HACs autopopulate electronic audit tools contained within Research Electronic Data Capture, and data from observational audits and EHR documentation populate real-time dashboards of bundle compliance. Patient population summary reports promote the discussion of relevant HAC prevention measures during patient care and unit leadership rounds. RESULTS The hospital has sustained a >30% reduction in harm for 9 types of HAC since 2012. In 2014, the number of HACs with >80% bundle adherence doubled coincident with the progressive rollout of these EHR-based interventions. CONCLUSIONS Existing EHR documentation and reporting tools may be effective adjuncts to harm reduction initiatives. Additional study should include an evaluation of scalability across organizations, ongoing bundle adherence, and individual tests of change to isolate interventions with the highest impact on our results.
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Affiliation(s)
- Daniel Hyman
- Quality and Patient Safety Department; Children's Hospital Colorado, Aurora, Colorado; .,Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Jenae Neiman
- Quality and Patient Safety Department; Children's Hospital Colorado, Aurora, Colorado
| | - Michael Rannie
- Quality and Patient Safety Department; Children's Hospital Colorado, Aurora, Colorado
| | - Renee Allen
- Quality and Patient Safety Department; Children's Hospital Colorado, Aurora, Colorado
| | - Marguerite Swietlik
- Division of Nursing, Clinical Informatics; Virginia Mason Medical Center, Seattle, Washington; and
| | - Andrea Balzer
- Lean Resource Office, Children's Minnesota, Minneapolis, Minnesota
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Kreitmeyr K, von Both U, Pecar A, Borde JP, Mikolajczyk R, Huebner J. Pediatric antibiotic stewardship: successful interventions to reduce broad-spectrum antibiotic use on general pediatric wards. Infection 2017; 45:493-504. [DOI: 10.1007/s15010-017-1009-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 03/14/2017] [Indexed: 01/07/2023]
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Williams DJ, Hall M, Gerber JS, Neuman MI, Hersh AL, Brogan TV, Parikh K, Mahant S, Blaschke AJ, Shah SS, Grijalva CG. Impact of a National Guideline on Antibiotic Selection for Hospitalized Pneumonia. Pediatrics 2017; 139:peds.2016-3231. [PMID: 28275204 PMCID: PMC5369677 DOI: 10.1542/peds.2016-3231] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND We evaluated the impact of the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America pneumonia guideline and hospital-level implementation efforts on antibiotic prescribing for children hospitalized with pneumonia. METHODS We assessed inpatient antibiotic prescribing for pneumonia at 28 children's hospitals between August 2009 and March 2015. Each hospital was also surveyed regarding local implementation efforts targeting antibiotic prescribing and organizational readiness to adopt guideline recommendations. To estimate guideline impact, we used segmented linear regression to compare the proportion of children receiving penicillins in March 2015 with the expected proportion at this same time point had the guideline not been published based on a projection of a preguideline trend. A similar approach was used to estimate the short-term (6-month) impact of local implementation efforts. The correlations between organizational readiness and the impact of the guideline were estimated by using Pearson's correlation coefficient. RESULTS Before guideline publication, penicillin prescribing was rare (<10%). After publication, an absolute increase in penicillin use was observed (27.6% [95% confidence interval: 23.7%-31.5%]) by March 2015. Among hospitals with local implementation efforts (n = 20, 71%), the median increase was 29.5% (interquartile range: 19.6%-39.1%) compared with 20.1% (interquartile rage: 9.5%-44.5%) among hospitals without such activities (P = .51). The independent, short-term impact of local implementation efforts was similar in magnitude to that of the national guideline. Organizational readiness was not correlated with prescribing changes. CONCLUSIONS The publication of the Pediatric Infectious Diseases Society/Infectious Diseases Society of America guideline was associated with sustained increases in the use of penicillins for children hospitalized with pneumonia. Local implementation efforts may have enhanced guideline adoption and appeared more relevant than hospitals' organizational readiness to change.
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Affiliation(s)
- Derek J. Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt,,Departments of Pediatrics, and
| | - Matthew Hall
- Children’s Hospital Association, Overland Park, Kansas
| | - Jeffrey S. Gerber
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard University School of Medicine, Boston, Massachusetts
| | - Adam L. Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Thomas V. Brogan
- Division of Critical Care Medicine, Seattle Children’s Hospital, Seattle, Washington;,Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Kavita Parikh
- Division of Hospital Medicine, Children’s National Medical Center, Washington, DC;,Department of Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Sanjay Mahant
- Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada;,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Anne J. Blaschke
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Samir S. Shah
- Divisions of Infectious Diseases, and,Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Carlos G. Grijalva
- Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
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Parikh K, Biondi E, Nazif J, Wasif F, Williams DJ, Nichols E, Ralston S. A Multicenter Collaborative to Improve Care of Community Acquired Pneumonia in Hospitalized Children. Pediatrics 2017; 139:peds.2016-1411. [PMID: 28148730 DOI: 10.1542/peds.2016-1411] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The Value in Inpatient Pediatrics Network sponsored the Improving Care in Community Acquired Pneumonia collaborative with the goal of increasing evidence-based management of children hospitalized with community acquired pneumonia (CAP). Project aims included: increasing use of narrow-spectrum antibiotics, decreasing use of macrolides, and decreasing concurrent treatment of pneumonia and asthma. METHODS Data were collected through chart review across emergency department (ED), inpatient, and discharge settings. Sites reviewed up to 20 charts in each of 6 3-month cycles. Analysis of means with 3-σ control limits was the primary method of assessment for change. The expert panel developed project measures, goals, and interventions. A change package of evidence-based tools to promote judicious use of antibiotics and raise awareness of asthma and pneumonia codiagnosis was disseminated through webinars. Peer coaching and periodic benchmarking were used to motivate change. RESULTS Fifty-three hospitals enrolled and 48 (91%) completed the 1-year project (July 2014-June 2015). A total of 3802 charts were reviewed for the project; 1842 during baseline cycles and 1960 during postintervention cycles. The median before and after use of narrow-spectrum antibiotics in the collaborative increased by 67% in the ED, 43% in the inpatient setting, and 25% at discharge. Median before and after use of macrolides decreased by 22% in the ED and 27% in the inpatient setting. A decrease in asthma and CAP codiagnosis was noted, but the change was not sustained. CONCLUSIONS Low-cost strategies, including collaborative sharing, peer benchmarking, and coaching, increased judicious use of antibiotics in a diverse range of hospitals for pediatric CAP.
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Affiliation(s)
- Kavita Parikh
- Division of Hospital Medicine, Children's National Health System, and George Washington University School of Medicine, Washington, District of Columbia;
| | - Eric Biondi
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Joanne Nazif
- Children's Hospital at Montefiore, Bronx, New York
| | - Faiza Wasif
- American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Derek J Williams
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Elizabeth Nichols
- Dartmouth Institute for Health Policy and Clinical Effectiveness, Lebanon, New Hampshire; and
| | - Shawn Ralston
- Department of Pediatrics, Geisel School of Medicine at Children's Hospital at Dartmouth, Lebanon, New Hampshire
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Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, Gould IM, Ramsay CR, Michie S. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2:CD003543. [PMID: 28178770 PMCID: PMC6464541 DOI: 10.1002/14651858.cd003543.pub4] [Citation(s) in RCA: 397] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. OBJECTIVES To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. MAIN RESULTS This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias.More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention.The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence).Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence).There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomesWe analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. AUTHORS' CONCLUSIONS We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions.
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Affiliation(s)
- Peter Davey
- University of DundeePopulation Health SciencesMackenzie BuildingKirsty Semple WayDundeeScotlandUKDD2 4BF
| | - Charis A Marwick
- University of DundeePopulation Health Sciences Division, Medical Research InstituteDundeeUK
| | - Claire L Scott
- NHS Education for ScotlandScottish Dental Clinical Effectiveness ProgrammeDundee Dental Education CentreSmall's WyndDundeeUKDD1 4HN
| | - Esmita Charani
- Imperial College LondonNIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial ResistanceDu Cane RoadLondonUKW12 OHS
| | - Kirsty McNeil
- University of DundeeSchool of Medicine147 Forth CrescentDundeeScotlandUKDD2 4JA
| | - Erwin Brown
- No affiliation31 Park CrescentFrenchayBristolUKBS16 1NZ
| | - Ian M Gould
- Aberdeen Royal InfirmaryDepartment of Medical MicrobiologyForesterhillAberdeenUKAB25 2ZN
| | - Craig R Ramsay
- University of AberdeenHealth Services Research Unit, Division of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Susan Michie
- University College LondonResearch Department of Primary Care and Population HealthUpper Floor 3, Royal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Jeon YH, Kim JH. Treatment of community-acquired pneumonia in Korean children. ALLERGY ASTHMA & RESPIRATORY DISEASE 2017. [DOI: 10.4168/aard.2017.5.4.177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- You Hoon Jeon
- Department of Pediatrics, Hallym University Dongtan Sacred Heart Hospital, Hwasung, Korea
| | - Jeong Hee Kim
- Department of Pediatrics, Inha University Hospital, Incheon, Korea
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Rutman L, Atkins RC, Migita R, Foti J, Spencer S, Lion KC, Wright DR, Leu MG, Zhou C, Mangione-Smith R. Modification of an Established Pediatric Asthma Pathway Improves Evidence-Based, Efficient Care. Pediatrics 2016; 138:peds.2016-1248. [PMID: 27940683 DOI: 10.1542/peds.2016-1248] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In September 2011, an established pediatric asthma pathway at a tertiary care children's hospital underwent significant revision. Modifications included simplification of the visual layout, addition of evidence-based recommendations regarding medication use, and implementation of standardized admission criteria. The objective of this study was to determine the impact of the modified asthma pathway on pathway adherence, percentage of patients receiving evidence-based care, length of stay, and cost. METHODS Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were analyzed for 24 months before and after pathway modification. Statistical process control was used to examine changes in processes of care, and interrupted time series was used to examine outcome measures, including length of stay and cost in the premodification and postmodification periods. RESULTS A total of 5584 patients were included (2928 premodification; 2656 postmodification). Pathway adherence was high (79%-88%) throughout the study period. The percentage of patients receiving evidence-based care improved after pathway modification, and the results were sustained for 2 years. There was also improved efficiency, with a 30-minute (10%) decrease in emergency department length of stay for patients admitted with asthma (P = .006). There was a nominal (<10%) increase in costs of asthma care for patients in the emergency department (P = .04) and no change for those admitted to the hospital. CONCLUSIONS Modification of an existing pediatric asthma pathway led to sustained improvement in provision of evidence-based care and patient flow without adversely affecting costs. Our results suggest that continuous re-evaluation of established clinical pathways can lead to changes in provider practices and improvements in patient care.
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Affiliation(s)
- Lori Rutman
- University of Washington, Seattle, Washington; .,Seattle Children's Hospital, Seattle, Washington; and
| | | | - Russell Migita
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Jeffrey Foti
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | | | - K Casey Lion
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Davene R Wright
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Michael G Leu
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
| | - Chuan Zhou
- University of Washington, Seattle, Washington
| | - Rita Mangione-Smith
- University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington; and
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da Fonseca Lima EJ, Lima DEP, Serra GHC, Abreu e Lima MAZS, de Mello MJG. Prescription of antibiotics in community-acquired pneumonia in children: are we following the recommendations? Ther Clin Risk Manag 2016; 12:983-8. [PMID: 27366076 PMCID: PMC4913964 DOI: 10.2147/tcrm.s101709] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To assess the adequacy of antibiotic prescription in children hospitalized for pneumonia in a reference pediatric hospital in Brazil. METHODS This was a cross-sectional study involving children aged between 1 month and 5 years who were hospitalized between October 2010 and September 2013. The classification of community-acquired pneumonia (CAP) was based on the clinical and radiological criteria of the World Health Organization (WHO). The analysis of antibiotic adequacy was performed according to the main guidelines on CAP treatment, which include the WHO guidelines, Brazilian Society of Pediatrics guidelines, and international guidelines (Pediatrics Infectious Diseases Society, the Infectious Disease Society of America, British Thoracic Society, and Consenso de la Sociedad latinoamericana de Infectología). A multivariate analysis was performed including variables that have statistical significance of P≤0.25 in the bivariate analysis. RESULTS The majority of the 452 hospitalized children were classified as having severe or very severe CAP (85.18%), and inadequate empiric antimicrobial therapy was started in 26.10% (118/452) of them. Ampicillin was the most used empiric antibiotic therapy (62.17%) for pneumonia, followed by a combination of ampicillin and associated with gentamicin. The initially proposed regimen was modified in 29.6% of the patients, and the most frequent change was the replacement of ampicillin by oxacillin combined with chloramphenicol. The median hospitalization time was 8.5 days, and the lethality rate was 1.55%. There was no statistical difference in adequacy in relation to the severity of pneumonia or degree of malnutrition. In the bivariate analysis, inadequacy of antibiotic therapy regimen was higher in patients undergoing oxygen therapy (P<0.05), which was given to 219 patients (48.45%). Pleural effusion was observed in 118 patients (26.11%) and was associated with higher prescription inadequacy, and it was the only factor that remained in the multivariate analysis (odds ratio =8.89; 95% confidence interval 5.20-15.01). CONCLUSION Adherence to the main guidelines for antimicrobial therapy according to the childhood CAP was unsatisfactory. Compliance with the guidelines is essential for both the management of pneumonia cases and the decrease in bacterial resistance and it is one of the cornerstone of WHO police of controlling antibiotic resistance.
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Affiliation(s)
- Eduardo Jorge da Fonseca Lima
- Instituto de Medicina Integral Professor Fernando Figueira – IMIP, Recife, PE, Brazil
- Faculdade Pernambucana de Saúde – FPS, Recife, PE, Brazil
| | | | | | | | - Maria Júlia Gonçalves de Mello
- Instituto de Medicina Integral Professor Fernando Figueira – IMIP, Recife, PE, Brazil
- Faculdade Pernambucana de Saúde – FPS, Recife, PE, Brazil
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Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Samore MH, Seo SK, Trivedi KK. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62:e51-77. [PMID: 27080992 PMCID: PMC5006285 DOI: 10.1093/cid/ciw118] [Citation(s) in RCA: 1826] [Impact Index Per Article: 228.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 12/11/2022] Open
Abstract
Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
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Affiliation(s)
- Tamar F Barlam
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lilian M Abbo
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Conan MacDougall
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco
| | - Audrey N Schuetz
- Department of Medicine, Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Edward J Septimus
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Houston
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Timothy H Dellit
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle
| | - Yngve T Falck-Ytter
- Department of Medicine, Case Western Reserve University and Veterans Affairs Medical Center, Cleveland, Ohio
| | - Neil O Fishman
- Department of Medicine, University of Pennsylvania Health System, Philadelphia
| | | | | | - Pamela A Lipsett
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland
| | - Preeti N Malani
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor
| | - Larissa S May
- Department of Emergency Medicine, University of California, Davis
| | - Gregory J Moran
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Sylmar
| | | | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Missouri
| | - Christopher A Ohl
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew H Samore
- Department of Veterans Affairs and University of Utah, Salt Lake City
| | - Susan K Seo
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, New York
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Parikh K, Hall M, Blaschke A, Grijalva CG, Brogan TV, Neuman MI, Williams D, Gerber JS, Hersh AL, Shah SS. Aggregate and hospital-level impact of national guidelines on diagnostic resource utilization for children with pneumonia at children's hospitals. J Hosp Med 2016; 11:317-23. [PMID: 26762571 PMCID: PMC5103701 DOI: 10.1002/jhm.2534] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 11/23/2015] [Accepted: 12/04/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND National guidelines for the management of community-acquired pneumonia (CAP) in children were published in 2011. These guidelines discourage most diagnostic testing for outpatients, as well as repeat testing for hospitalized patients who are improving. We sought to evaluate the temporal trends in diagnostic testing associated with guideline implementation among children with CAP. METHODS Children 1 to 18 years old who were discharged with pneumonia after emergency department (ED) evaluation or hospitalization from January 1, 2008 to June 30, 2014 at any of 32 children's hospitals participating in the Pediatric Health Information System were included. We excluded children with complex chronic conditions and those requiring intensive care or who underwent early pleural drainage. We compared use of diagnostic testing (blood culture, complete blood count [CBC], C-reactive protein [CRP], and chest radiography [CXR]) before and after release of the guidelines, and assessed for temporal trends using interrupted time series analysis. We also calculated the cost impact of these changes on diagnostic utilization and evaluated the variability of the guideline's impact across hospitals. RESULTS Overall, 220,539 patients were included; 53% were male and the median age was 4 years (interquartile range, 2-7). For patients discharged from the ED with CAP, diagnostic utilization rates for blood culture, CBC, CRP, and CXR were higher after guideline publication compared with expected utilization rates without guidelines. In contrast, initial testing and repeat testing among patients hospitalized with CAP was lower after guideline publication. There were modest reductions in estimated costs associated with these changes. However, wide variability was observed in the impact of the guidelines across hospitals. CONCLUSIONS Publication of national pneumonia guidelines in 2011 was associated with modest changes in diagnostic testing for children with CAP. However, the changes varied across hospitals, and the financial impact was modest. Local implementation efforts are warranted to ensure widespread guideline adherence. Journal of Hospital Medicine 2016;11:317-323. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Kavita Parikh
- Children’s National Medical Center and George Washington School of Medicine, Washington DC
| | - Matt Hall
- Children’s Hospital Association, Overland Park, KS
| | - Anne Blaschke
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Carlos G. Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Thomas V. Brogan
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Derek Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt and the Department of Pediatrics, Vanderbilt University School of Medicine
| | - Jeffrey S. Gerber
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Adam L. Hersh
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children’s Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Lion KC, Wright DR, Spencer S, Zhou C, Del Beccaro M, Mangione-Smith R. Standardized Clinical Pathways for Hospitalized Children and Outcomes. Pediatrics 2016; 137:peds.2015-1202. [PMID: 27002007 PMCID: PMC5531174 DOI: 10.1542/peds.2015-1202] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2015] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Clinical pathways standardize care for common health conditions. We sought to assess whether institution-wide implementation of multiple standardized pathways was associated with changes in utilization and physical functioning after discharge among pediatric inpatients. METHODS Interrupted time series analysis of admissions to a tertiary care children's hospital from December 1, 2009 through March 30, 2014. On the basis of diagnosis codes, included admissions were eligible for 1 of 15 clinical pathways implemented during the study period; admissions from both before and after implementation were included. Postdischarge physical functioning improvement was assessed with the Pediatric Quality of Life Inventory 4.0 Generic Core or Infant Scales. Average hospitalization costs, length of stay, readmissions, and physical functioning improvement scores were calculated by month relative to pathway implementation. Segmented linear regression was used to evaluate differences in intercept and trend over time before and after pathway implementation. RESULTS There were 3808 and 2902 admissions in the pre- and postpathway groups, respectively. Compared with prepathway care, postpathway care was associated with a significant halt in rising costs (prepathway vs postpathway slope difference -$155 per month [95% confidence interval -$246 to -$64]; P = .001) and significantly decreased length of stay (prepathway vs post-pathway slope difference -0.03 days per month [95% confidence interval -0.05 to -0.02]; P = .02), without negatively affecting patient physical functioning improvement or readmissions. CONCLUSIONS Implementation of multiple evidence-based, standardized clinical pathways was associated with decreased resource utilization without negatively affecting patient physical functioning improvement. This approach could be widely implemented to improve the value of care provided.
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Affiliation(s)
- K. Casey Lion
- Department of Pediatrics, University of Washington, Seattle, Washington;,Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington; and,Address correspondence to K. Casey Lion, MD, MPH, University of Washington, and Center for Child Health, Behavior and Development, Seattle Children’s Research Institute; M/S CW8-6, PO Box 5371, Seattle, WA 98145-5005. E-mail:
| | - Davene R. Wright
- Department of Pediatrics, University of Washington, Seattle, Washington;,Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington; and
| | | | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington;,Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington; and
| | - Mark Del Beccaro
- Department of Pediatrics, University of Washington, Seattle, Washington;,Seattle Children’s Hospital, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington;,Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington; and
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Characteristics of Antimicrobial Stewardship Programs at Veterans Affairs Hospitals: Results of a Nationwide Survey. Infect Control Hosp Epidemiol 2016; 37:647-54. [PMID: 26905338 DOI: 10.1017/ice.2016.26] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) are variably implemented. OBJECTIVE To characterize variations of antimicrobial stewardship structure and practices across all inpatient Veterans Affairs facilities in 2012 and correlate key characteristics with antimicrobial usage. DESIGN A web-based survey regarding stewardship activities was administered to each facility's designated contact. Bivariate associations between facility characteristics and inpatient antimicrobial use during 2012 were determined. SETTING Total of 130 Veterans Affairs facilities with inpatient services. RESULTS Of 130 responding facilities, 29 (22%) had a formal policy establishing an ASP, and 12 (9%) had an approved ASP business plan. Antimicrobial stewardship teams were present in 49 facilities (38%); 34 teams included a clinical pharmacist with formal infectious diseases (ID) training. Stewardship activities varied across facilities, including development of yearly antibiograms (122 [94%]), formulary restrictions (120 [92%]), stop orders for antimicrobial duration (98 [75%]), and written clinical pathways for specific conditions (96 [74%]). Decreased antimicrobial usage was associated with having at least 1 full-time ID physician (P=.03), an ID fellowship program (P=.003), and a clinical pharmacist with formal ID training (P=.006) as well as frequency of systematic patient-level reviews of antimicrobial use (P=.01) and having a policy to address antimicrobial use in the context of Clostridium difficile infection (P=.01). Stop orders for antimicrobial duration were associated with increased use (P=.03). CONCLUSIONS ASP-related activities varied considerably. Decreased antibiotic use appeared related to ID presence and certain select practices. Further statistical assessments may help optimize antimicrobial practices. Infect Control Hosp Epidemiol 2016;37:647-654.
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Le Saux N, Robinson JL. Uncomplicated pneumonia in healthy Canadian children and youth: Practice points for management. Paediatr Child Health 2016; 20:441-50. [PMID: 26744558 DOI: 10.1093/pch/20.8.441] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Although immunization has decreased the incidence of bacterial pneumonia in vaccinated children, pneumonia remains common in healthy children. Symptoms of bacterial pneumonia frequently overlap those present with viral infections or reactive airway disease. Optimally, the diagnosis of bacterial pneumonia should be supported by a chest radiograph before starting antimicrobials. Factors such as age, vital signs and other measures of illness severity are critical when deciding whether to admit a patient to hospital. Because Streptococcus pneumoniae continues to be the most common cause of bacterial pneumonia in children, prescribing amoxicillin or ampicillin for seven to 10 days remains the mainstay of empirical therapy for nonsevere pneumonia. If improvement does not occur, consideration should be given to searching for complications (empyema or lung abscess). Routine chest radiographs at the end of therapy are not recommended unless clinically indicated.
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