1
|
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]
|
2
|
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]
|
3
|
Multistep antimicrobial stewardship intervention on antibiotic prescriptions and treatment duration in children with pneumonia. PLoS One 2021; 16:e0257993. [PMID: 34705849 PMCID: PMC8550372 DOI: 10.1371/journal.pone.0257993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The Italian antimicrobial prescription rate is one of the highest in Europe, and antibiotic resistance has become a serious problem with high costs and severe consequences, including prolonged illnesses, the increased period of hospitalization and mortality. Inadequate antibiotic prescriptions have been frequently reported, especially for lower respiratory tract infections (LRTI); many patients receive antibiotics for viral pneumonia or bronchiolitis or broad-spectrum antibiotics for not complicated community-acquired pneumonia. For this reason, healthcare organizations need to implement strategies to raise physicians' awareness about this kind of drug and their overall effect on the population. The implementation of antibiotic stewardship programs and the use of Clinical Pathways (CPs) are excellent solutions because they have proven to be effective tools at diagnostic and therapeutic levels. AIMS This study evaluates the impact of CPs implementation in a Pediatric Emergency Department (PED), analyzing antibiotic prescriptions before and after the publication in 2015 and 2019. The CP developed in 2019 represents an update of the previous one with the introduction of serum procalcitonin. The study aims to evaluate the antibiotic prescriptions in patients with community-acquired pneumonia (CAP) before and after both CPs (2015 and 2019). METHODS The periods analyzed are seven semesters (one before CP-2015 called PRE period, five post CP-2015 called POST 1-5 and 1 post CP-2019 called POST6). The patients have been split into two groups: (i) children admitted to the Pediatric Acute Care Unit (INPATIENTS), and (ii) patients evaluated in the PED and sent back home (OUTPATIENTS). We have analyzed all descriptive diagnosis of CAP (the assessment of episodes with a descriptive diagnosis were conducted independently by two pediatricians) and CAP with ICD9 classification. All antibiotic prescriptions for pediatric patients with CAP were analyzed. RESULTS A drastic reduction of broad-spectrum antibiotics prescription for inpatients has been noticed; from 100.0% in the PRE-period to 66.7% in POST1, and up to 38.5% in POST6. Simultaneously, an increase in amoxicillin use from 33.3% in the PRE-period to 76.1% in POST1 (p-value 0.078 and 0.018) has been seen. The outpatients' group's broad-spectrum antibiotics prescriptions decreased from 54.6% PRE to 17.4% in POST6. Both for outpatients and inpatients, there was a decrease of macrolides. The inpatient group's antibiotic therapy duration decreased from 13.5 days (PRE-period) to 7.0 days in the POST6. Antibiotic therapy duration in the outpatient group decreased from 9.0 days (PRE) to 7.0 days (POST1), maintaining the same value in subsequent periods. Overlapping results were seen in the ICD9 group for both inpatients and outpatients. CONCLUSIONS This study shows that CPs are effective tools for an antibiotic stewardship program. Indeed, broad-spectrum antibiotics usage has dropped and amoxicillin prescriptions have increased after implementing the CAP CP-2015 and the 2019 update.
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Donà D, Barbieri E, Daverio M, Lundin R, Giaquinto C, Zaoutis T, Sharland M. Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review. Antimicrob Resist Infect Control 2020; 9:3. [PMID: 31911831 PMCID: PMC6942341 DOI: 10.1186/s13756-019-0659-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.
Collapse
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
| |
Collapse
|
6
|
Shaw R, Popovsky E, Abo A, Jacobs M, Herrera N, Chamberlain J, Hahn A. Improving antibiotic prescribing in the emergency department for uncomplicated community-acquired pneumonia. World J Emerg Med 2020; 11:199-205. [PMID: 33014215 DOI: 10.5847/wjem.j.1920-8642.2020.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Pediatric Infectious Disease Society (PIDS) and Infectious Disease Society of America (IDSA) published an evidence-based guideline for the treatment of uncomplicated community-acquired pneumonia (CAP) in children, recommending aminopenicillins as the first-line therapy. Poor guideline compliance with 10%-50% of patients admitted to the hospital receiving narrow-spectrum antibiotics has been reported. A new clinical practice guideline (CPG) was implemented in our emergency department (ED) for uncomplicated CAP. The aim of this study was to examine baseline knowledge and ED provider prescribing patterns pre- and post-CPG implementation. METHODS Prior to CPG-implementation, an anonymous case-based survey was distributed to evaluate knowledge of the current PIDS/IDSA guideline. A retrospective chart review of patients treated in the ED for CAP from January 2015 to February 2017 was performed to assess prescribing patterns for intravenous (IV) antibiotics in the ED at Children's National Health System pre- and post-CPG implementation. RESULTS ED providers were aware of the PIDS/IDSA guideline recommendations, with 86.4% of survey responders selecting ampicillin as the initial antibiotic of choice. However, only 41.2% of patients admitted to the hospital with uncomplicated CAP pre-CPG received ampicillin (P<0.01). There was no statistically significant increase in ampicillin prescribing post-CPG (P=0.40). CONCLUSIONS Providers in the ED are aware of the PIDS/IDSA guideline regarding the first-line therapy for uncomplicated CAP; however, this knowledge does not translate into clinical practice. Implementation of a CPG in isolation did not significantly change prescribing patterns for uncomplicated CAP.
Collapse
Affiliation(s)
- Rebekah Shaw
- Division of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Erica Popovsky
- Division of Pediatrics, Children's National Health System, Washington, DC, USA
| | - Alyssa Abo
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Marni Jacobs
- Division of Biostatistics and Epidemiology, Children's National Health System, Washington, DC, USA
| | - Nicole Herrera
- Division of Biostatistics and Epidemiology, Children's National Health System, Washington, DC, USA
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Andrea Hahn
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Division of Infectious Diseases, Children's National Health System, Washington, DC, USA
| |
Collapse
|
7
|
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: 11] [Impact Index Per Article: 2.2] [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.
Collapse
Affiliation(s)
| | | | | | - Pascal Astagneau
- APHP University Hospital, Paris, France.,Sorbonne University, Paris France
| | | |
Collapse
|
8
|
The Influence of National Guidelines on the Management of Community-Acquired Pneumonia in Children. Do Pediatricians Follow the Recommendations? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1211:103-110. [PMID: 31144241 DOI: 10.1007/5584_2019_392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
This is a retrospective study whose main objective was to analyze the influence of the Polish Guidelines for the Management of Respiratory Tract Infections of 2010 (PGMRTI) on in-hospital treatment of children with community-acquired pneumonia (CAP). Files from four Warsaw hospitals were reviewed to identify children with uncomplicated CAP, treated before (2008-2009) (pre-PGMRTI) and after (2011-2012) (post-PGMRTI) publication of the guidelines. Predefined data on the management were compared. A cohort of 2,359 children (1,081 pre-PGMRTI and 1,278 post-PGMRTI) was included. We found that co-amoxiclav was the most common first-line therapy in children >3 months of age (34.6% and 40.4% pre- and post-PGMRTI, respectively), followed by cefuroxime (31.8% and 20.9% pre- and post-PGMRTI, respectively; p < 0.0001) and macrolides (17.4% and 24.5% pre- and post-PGMRTI, respectively; p < 0.0001). Amoxicillin was rarely used (5.4% and 4.9%, pre- and post-PGMRTI, respectively). The study revealed an overuse of inhaled bronchodilators, corticosteroids, and mucoactive drugs. Blood diagnostic tests were applied to a significant percentage of patients: blood cultures (41.2% and 44.5% pre-and post-PGMRTI, respectively) and serology for atypical pathogens (27.9% and 44.9% pre-and post-PGMRTI, respectively; p < 0.0001). The number of follow-up chest X-rays increased (30.5% and 53.8% pre- and post-PGMRTI, respectively; p < 0.0001). In conclusion, the study demonstrates an unsatisfactory influence of the guidelines on in-hospital management of CAP in children. Despite an explicit recommendation for the use of amoxicillin, it was still underused. Other methods of education and guideline dissemination are needed to optimize the prescribing of antibiotics.
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
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.
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Donà D, Zingarella S, Gastaldi A, Lundin R, Perilongo G, Frigo AC, Hamdy RF, Zaoutis T, Da Dalt L, Giaquinto C. Effects of clinical pathway implementation on antibiotic prescriptions for pediatric community-acquired pneumonia. PLoS One 2018; 13:e0193581. [PMID: 29489898 PMCID: PMC5831636 DOI: 10.1371/journal.pone.0193581] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 02/14/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Italian pediatric antimicrobial prescription rates are among the highest in Europe. As a first step in an Antimicrobial Stewardship Program, we implemented a Clinical Pathway (CP) for Community Acquired Pneumonia with the aim of decreasing overall prescription of antibiotics, especially broad-spectrum. MATERIALS AND METHODS The CP was implemented on 10/01/2015. We collected antibiotic prescribing and outcomes data from children aged 3 months-15 years diagnosed with CAP from 10/15/2014 to 04/15/2015 (pre-intervention period) and from 10/15/2015 to 04/15/2016 (post-intervention period). We assessed antibiotic prescription differences pre- and post-CP, including rates, breadth of spectrum, and duration of therapy. We also compared length of hospital stay for inpatients and treatment failure for inpatients and outpatients. Chi-square and Fisher's exact test were used to compare categorical variables and Wilcoxon rank sum test was used to compare quantitative outcomes. RESULTS 120 pre- and 86 post-intervention clinic visits were identified with a diagnosis of CAP. In outpatients, we observed a decrease in broad-spectrum regimens (50% pre-CP vs. 26.8% post-CP, p = 0.02), in particular macrolides, and an increase in narrow-spectrum (amoxicillin) post-CP. Post-CP children received fewer antibiotic courses (median DOT from 10 pre-CP to 8 post-CP, p<0.0001) for fewer days (median LOT from 10 pre-CP to 8 post-CP, p<0.0001) than their pre-CP counterparts. Physicians prescribed narrow-spectrum monotherapy more frequently than broad-spectrum combination therapy (DOT/LOT ratio 1.157 pre-CP vs. 1.065 post-CP). No difference in treatment failure was reported before and after implementation (2.3% pre-CP vs. 11.8% post-CP, p = 0.29). Among inpatients we also noted a decrease in broad-spectrum regimens (100% pre-CP vs. 66.7% post-CP, p = 0.02) and the introduction of narrow-spectrum regimens (0% pre-CP vs. 33.3% post-CP, p = 0.02) post-CP. Hospitalized patients received fewer antibiotic courses post-CP (median DOT from 18.5 pre-CP to 10 post-CP, p = 0.004), while there was no statistical difference in length of therapy (median LOT from 11 pre-CP to 10 post-CP, p = 0.06). Days of broad spectrum therapy were notably lower post-CP (median bsDOT from 17 pre-CP to 4.5 post-CP, p <0.0001). No difference in treatment failure was reported before and after CP implementation (16.7% pre-CP vs. 15.4% post-CP, p = 1). CONCLUSIONS Introduction of a CP for CAP in a Pediatric Emergency Department led to reduction of broad-spectrum antibiotic prescriptions, of combination therapy and of duration of treatment both for outpatients and inpatients.
Collapse
Affiliation(s)
- Daniele Donà
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Padua, Italy
- PENTA Foundation, Padua, Italy
| | - Silvia Zingarella
- Pediatric Emergency Department, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - Andrea Gastaldi
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Padua, Italy
| | | | - Giorgio Perilongo
- Department for Woman and Child Health, University of Padua, Padua, Italy
| | - Anna Chiara Frigo
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Rana F. Hamdy
- Department of Pediatrics, Children's National Health System, Washington DC, United States of America
| | - Theoklis Zaoutis
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Liviana Da Dalt
- Pediatric Emergency Department, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - Carlo Giaquinto
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Padua, Italy
- PENTA Foundation, Padua, Italy
| |
Collapse
|
13
|
Katz SE, Williams DJ. Pediatric Community-Acquired Pneumonia in the United States: Changing Epidemiology, Diagnostic and Therapeutic Challenges, and Areas for Future Research. Infect Dis Clin North Am 2017; 32:47-63. [PMID: 29269189 PMCID: PMC5801082 DOI: 10.1016/j.idc.2017.11.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Community-acquired pneumonia (CAP) is one of the most common serious infections in childhood. This review focuses on pediatric CAP in the United States and other industrialized nations, specifically highlighting the changing epidemiology of CAP, diagnostic and therapeutic challenges, and areas for further research.
Collapse
Affiliation(s)
- Sophie E Katz
- Division of Infectious Diseases, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, D-7235 Medical Center North, 1161 21st Avenue South, Nashville, TN 37232-2581, USA
| | - Derek J Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, CCC 5324 Medical Center North, 1161 21st Avenue South, Nashville, TN 37232, USA.
| |
Collapse
|
14
|
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]
|
15
|
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.
Collapse
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
| | | |
Collapse
|
16
|
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.
Collapse
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
| | | |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
|
19
|
Vicente M, Al-Nahedh M, Parsad S, Knoebel RW, Pisano J, Pettit NN. Impact of a clinical pathway on appropriate empiric vancomycin use in cancer patients with febrile neutropenia. J Oncol Pharm Pract 2016; 23:575-581. [PMID: 27609336 DOI: 10.1177/1078155216668672] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Febrile neutropenia management guidelines recommend the use of vancomycin as part of an empiric antimicrobial regimen when specific criteria are met. Often, vancomycin use among patients with febrile neutropenia is not indicated and may be over utilized for this indication. We sought to evaluate the impact of implementing a febrile neutropenia clinical pathway on empiric vancomycin use for febrile neutropenia and to identify predictors of vancomycin use when not indicated. Methods Adult febrile neutropenia patients who received initial therapy with an anti-pseudomonal beta-lactam with or without vancomycin were identified before (June 2008 to November 2010) and after (June 2012 to June 2013) pathway implementation. Patients were assessed for appropriateness of therapy based on whether the patient received vancomycin consistent with guideline recommendations. Using a comorbidity index used for risk assessment in high risk hematology/oncology patients, we evaluated whether specific comorbidities are associated with inappropriate vancomycin use in the setting of febrile neutropenia. Results A total of 206 patients were included in the pre-pathway time period with 35.9% of patients receiving vancomycin therapy that was inconsistent with the pathway. A total of 131 patients were included in the post-pathway time period with 11.4% of patients receiving vancomycin inconsistent with the pathway ( p = 0.001). None of the comorbidities assessed, nor the comorbidity index score were found to be predictors of vancomycin use inconsistent with guideline recommendations. Conclusion Our study has demonstrated that implementation of a febrile neutropenia pathway can significantly improve adherence to national guideline recommendations with respect to empiric vancomycin utilization for febrile neutropenia.
Collapse
Affiliation(s)
- Mildred Vicente
- 1 Department of Pharmacy Services, Rush University Medical Center, Chicago, IL, USA
| | - Mohammad Al-Nahedh
- 2 Pharmaceutical Care Division, King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Sandeep Parsad
- 3 Department of Pharmacy Services, The University of Chicago Medical Center, Chicago, IL, USA
| | - Randall W Knoebel
- 3 Department of Pharmacy Services, The University of Chicago Medical Center, Chicago, IL, USA
| | - Jennifer Pisano
- 4 Infectious Diseases and Global Health, The University of Chicago Medicine, Chicago, IL, USA
| | - Natasha N Pettit
- 3 Department of Pharmacy Services, The University of Chicago Medical Center, Chicago, IL, USA
| |
Collapse
|
20
|
Launay E, Levieux K, Levy C, Dubos F, Martinot A, Vrignaud B, Lepage F, Cohen R, Grimprel E, Hanf M, Angoulvant F, Gras-Le Guen C. Compliance with the current recommendations for prescribing antibiotics for paediatric community-acquired pneumonia is improving: data from a prospective study in a French network. BMC Pediatr 2016; 16:126. [PMID: 27520057 PMCID: PMC4983061 DOI: 10.1186/s12887-016-0661-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/02/2016] [Indexed: 11/10/2022] Open
Abstract
Background Lower respiratory tract infection is a common cause of consultation and antibiotic prescription in paediatric practice. The misuse of antibiotics is a major cause of the emergence of multidrug-resistant bacteria. The aim of this study was to evaluate the frequency, changes over time, and determinants of non-compliance with antibiotic prescription recommendations for children admitted in paediatric emergency department (PED) with community-acquired pneumonia (CAP). Methods We conducted a prospective two-period study using data from the French pneumonia network that included all children with CAP, aged one month to 15 years old, admitted to one of the ten participating paediatric emergency departments. In the first period, data from children included in all ten centres were analysed. In the second period, we analysed children in three centers for which we collected additional data. Two experts assessed compliance with the current French recommendations. Independent determinants of non-compliance were evaluated using a logistic regression model. The frequency of non-compliance was compared between the two periods for the same centres in univariate analysis, after adjustment for confounding factors. Results A total of 3034 children were included during the first period (from May 2009 to May 2011) and 293 in the second period (from January to July 2012). Median ages were 3.0 years [1.4–5] in the first period and 3.6 years in the second period. The main reasons for non-compliance were the improper use of broad-spectrum antibiotics or combinations of antibiotics. Factors that were independently associated with non-compliance with recommendations were younger age, presence of risk factors for pneumococcal infection, and hospitalization. We also observed significant differences in compliance between the treatment centres during the first period. The frequency of non-compliance significantly decreased from 48 to 18.8 % between 2009 and 2012. The association between period and non-compliance remained statistically significant after adjustment for confounding factors. Amoxicillin was prescribed as the sole therapy significantly more frequently in the second period (71 % vs. 54.2 %, p < 0.001). Conclusions We observed a significant increase in the compliance with recommendations, with a reduction in the prescription of broad-spectrum antibiotics, efforts to improve antibiotic prescriptions must continue. Electronic supplementary material The online version of this article (doi:10.1186/s12887-016-0661-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Elise Launay
- GPIP, Groupe de Pathologie Infectieuse Pédiatrique, Société Française de Pédiatrie, Paris, France. .,Paediatric Department, CHU Nantes, Hôpital Mère-Enfant, 7 quai Moncousu, 44093, Nantes cedex 1, France.
| | - Karine Levieux
- Paediatric Emergency Department, CHU Nantes, Hôpital Mère-Enfant, Nantes, France
| | - Corinne Levy
- GPIP, Groupe de Pathologie Infectieuse Pédiatrique, Société Française de Pédiatrie, Paris, France.,ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Saint-Maur des Fossés, France.,Centre Hospitalier Intercommunal de Créteil, Centre de Recherche Clinique, Créteil, France
| | - François Dubos
- GPIP, Groupe de Pathologie Infectieuse Pédiatrique, Société Française de Pédiatrie, Paris, France.,Paediatric Emergency Unit & Infectious Diseases, Lille-2 Nord-de-France University & CHRU Lille, Lille, France
| | - Alain Martinot
- GPIP, Groupe de Pathologie Infectieuse Pédiatrique, Société Française de Pédiatrie, Paris, France.,Paediatric Emergency Unit & Infectious Diseases, Lille-2 Nord-de-France University & CHRU Lille, Lille, France
| | - Bénédicte Vrignaud
- Paediatric Department, CHU Nantes, Hôpital Mère-Enfant, 7 quai Moncousu, 44093, Nantes cedex 1, France
| | - Flora Lepage
- Paediatric Department, CHU Nantes, Hôpital Mère-Enfant, 7 quai Moncousu, 44093, Nantes cedex 1, France
| | - Robert Cohen
- GPIP, Groupe de Pathologie Infectieuse Pédiatrique, Société Française de Pédiatrie, Paris, France.,ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Saint-Maur des Fossés, France.,Centre Hospitalier Intercommunal de Créteil, Centre de Recherche Clinique, Créteil, France
| | - Emmanuel Grimprel
- GPIP, Groupe de Pathologie Infectieuse Pédiatrique, Société Française de Pédiatrie, Paris, France.,Paediatric Department, AP-HP, Trousseau University Hospital, Paris, France
| | - Matthieu Hanf
- Centre d'Investigation Clinique, CHU Nantes, Nantes, France
| | - François Angoulvant
- GPIP, Groupe de Pathologie Infectieuse Pédiatrique, Société Française de Pédiatrie, Paris, France.,INSERM CIE5, Clinical Epidemiology Unit, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,Paediatric Emergency Department, AP-HP, Hôpital Robert Debré, Paris, France
| | - Christèle Gras-Le Guen
- GPIP, Groupe de Pathologie Infectieuse Pédiatrique, Société Française de Pédiatrie, Paris, France.,Paediatric Department, CHU Nantes, Hôpital Mère-Enfant, 7 quai Moncousu, 44093, Nantes cedex 1, France
| | | |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Bedi N, Gupta P. Antimicrobial stewardship in pediatrics: An Indian perspective. Indian Pediatr 2016; 53:293-8. [DOI: 10.1007/s13312-016-0839-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
24
|
Reduction of Broad-Spectrum Antimicrobial Use in a Tertiary Children's Hospital Post Antimicrobial Stewardship Program Guideline Implementation. Pediatr Crit Care Med 2016; 17:187-93. [PMID: 26669645 DOI: 10.1097/pcc.0000000000000615] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The core strategies recommended for antimicrobial stewardship programs, formulary restriction with preauthorization and prospective audit and feedback, can be difficult to implement with limited resources; therefore, we took an approach of guideline development and education with the goal of reducing overall antibiotic use and unwarranted use of broad-spectrum antimicrobials. DESIGN Retrospective chart review before and after intervention. SETTING Le Bonheur Children's Hospital pediatric, neonatal, and cardiac ICUs. PATIENTS All patients in our pediatric, neonatal, and cardiac ICUs within the time frame of the study. INTERVENTIONS Baseline review in our ICUs revealed excessive use of broad-spectrum antibiotics and inconsistency in managing common pediatric infections. Guidelines were developed and implemented using cycles of education, retrospective review, and feedback. Purchasing and antibiotic use data were obtained to assess changes before and after guideline implementation. Unit-specific days of therapy were measured using periodic chart audit. Segmented regression analysis was used to assess changes in purchasing and broad-spectrum antibiotic days of therapy. The change in median monthly purchases was assessed using 2-tail Student t test. MEASUREMENTS AND MAIN RESULTS Hospital-wide targeted broad-spectrum antibiotic days of therapy/1,000 patient-days during the preimplementation year averaged 105 per month and decreased 33% to 70 per month during the postimplementation year. The overall antibiotic days of therapy decreased 41%, 21%, and 18%, and targeted broad-spectrum antibiotic days of therapy decreased by 99%, 75%, and 61% in the cardiac, pediatric, and neonatal ICUs, respectively, after guideline implementation. Yearly purchases of our most common broad-spectrum antibiotics decreased 62% from $230,059 to $86,887 after guideline implementation. Median monthly purchases of these drugs before implementation were $19,389 and $11,043 after implementation (p < 0.001). CONCLUSIONS Guideline implementation was successful in reducing targeted broad-spectrum antibiotic use and acquisition cost. Programs with very limited resources may find similar implementation of guidelines effective to provide initial success, so that putting into practice one of the more resource intensive core strategies, such as prospective audit and feedback, may be feasible.
Collapse
|
25
|
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.
Collapse
|
26
|
Wright H, Skinner AC, Jhaveri R. Evaluating Guideline-Recommended Antibiotic Practices for Childhood Respiratory Infections: Is It Time to Consider Case-Based Formats? Clin Pediatr (Phila) 2016; 55:118-21. [PMID: 25986442 DOI: 10.1177/0009922815587091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We sought to better understand barriers to adherence to published guidelines for respiratory infections among community providers. METHODS A case-based survey was developed and emailed to all members of the state pediatric society. Providers chose their preferred management for acute otitis media, acute bacterial sinusitis, and community-acquired pneumonia. An "answer key" and a follow-up questionnaire were distributed to assess reevaluation of current practices. RESULTS We received 173 completed surveys (15% response rate). While most responders followed guideline recommendations (6 of the 10 questions with ≥ 65% choosing recommended antibiotic), discrepancies existed in several cases. After receiving the answer key, respondents said they reviewed the guidelines (69%), adjusted their practice (26%), used cases for teaching (9%), and discussed guidelines with colleagues (21%). CONCLUSIONS The majority of respondents followed published guidelines, but there was a tendency to overuse azithromycin in certain cases. Future guidelines including case-based discussions may enhance adherence.
Collapse
Affiliation(s)
- Heather Wright
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | | | - Ravi Jhaveri
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| |
Collapse
|
27
|
Spyridis N, Syridou G, Goossens H, Versporten A, Kopsidas J, Kourlaba G, Bielicki J, Drapier N, Zaoutis T, Tsolia M, Sharland M. Variation in paediatric hospital antibiotic guidelines in Europe. Arch Dis Child 2016; 101:72-6. [PMID: 26416900 DOI: 10.1136/archdischild-2015-308255] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 09/08/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the availability and source of guidelines for common infections in European paediatric hospitals and determine their content and characteristics. DESIGN Participating hospitals completed an online questionnaire on the availability and characteristics of antibiotic prescribing guidelines and on empirical antibiotic treatment including duration of therapy for 5 common infection syndromes: respiratory tract, urinary tract, skin and soft tissue, osteoarticular and sepsis in neonates and children. RESULTS 84 hospitals from 19 European countries participated in the survey of which 74 confirmed the existence of guidelines. Complete guidelines (existing guidelines for all requested infection syndromes) were reported by 20% of hospitals and the majority (71%) used a range of different sources. Guidelines most commonly available were those for urinary tract infection (UTI) (74%), neonatal sepsis (71%) and sepsis in children (65%). Penicillin and amoxicillin were the antibiotics most commonly recommended for respiratory tract infections (RTIs) (up to 76%), cephalosporin for UTI (up to 50%) and for skin and soft tissue infection (SSTI) and bone infection (20% and 30%, respectively). Antistaphylococcal penicillins were recommended for SSTIs and bone infections in 43% and 36%, respectively. Recommendations for neonatal sepsis included 20 different antibiotic combinations. Duration of therapy guidelines was mostly available for RTI and UTI (82%). A third of hospitals with guidelines for sepsis provided recommendations for length of therapy. CONCLUSIONS Comprehensive antibiotic guideline recommendations are generally lacking from European paediatric hospitals. We documented multiple antibiotics and combinations for most infections. Considerable improvement in the quality of guidelines and their evidence base is required, linking empirical therapy to resistance rates.
Collapse
Affiliation(s)
- N Spyridis
- Department of Paediatric Infectious Diseases, Aglaia Kyriakou Children's Hospital, University of Athens, Athens, Greece
| | - G Syridou
- Department of Paediatric Infectious Diseases, Aglaia Kyriakou Children's Hospital, University of Athens, Athens, Greece
| | - H Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - A Versporten
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - J Kopsidas
- Stavros Niarchos Foundation-Collaborative Center for Clinical Epidemiology and Outcomes Research and Division of Infectious Diseases (CLEO), University of Athens School of Medicine, Athens, Greece
| | - G Kourlaba
- Stavros Niarchos Foundation-Collaborative Center for Clinical Epidemiology and Outcomes Research and Division of Infectious Diseases (CLEO), University of Athens School of Medicine, Athens, Greece
| | - J Bielicki
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - N Drapier
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - T Zaoutis
- Stavros Niarchos Foundation-Collaborative Center for Clinical Epidemiology and Outcomes Research and Division of Infectious Diseases (CLEO), University of Athens School of Medicine, Athens, Greece The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - M Tsolia
- Department of Paediatric Infectious Diseases, Aglaia Kyriakou Children's Hospital, University of Athens, Athens, Greece
| | - M Sharland
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | | |
Collapse
|
28
|
Zhang H, Wang Y, Gao P, Hu J, Chen Y, Zhang L, Shen X, Xu H, Xu Q. Pharmacokinetic Characteristics and Clinical Outcomes of Vancomycin in Young Children With Various Degrees of Renal Function. J Clin Pharmacol 2015; 56:740-8. [PMID: 26440302 DOI: 10.1002/jcph.653] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/28/2015] [Accepted: 09/30/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Huanian Zhang
- Department of Clinical Pharmacology; Wuhan Children's Hospital; Hubei China
| | - Yang Wang
- Department of Clinical Pharmacology; Wuhan Children's Hospital; Hubei China
| | - Ping Gao
- Department of Clinical Pharmacology; Wuhan Children's Hospital; Hubei China
| | - Jiasheng Hu
- Department of Pediatric Neurology; Wuhan Children's Hospital; Hubei China
| | - Yujun Chen
- Department of Clinical Pharmacology; Wuhan Children's Hospital; Hubei China
| | - Long Zhang
- Department of ICU; Wuhan Children's Hospital; Hubei China
| | - Xiantao Shen
- Department of Orthopedics; Wuhan Children's Hospital; Hubei China
| | - Hua Xu
- Department of Clinical Pharmacology; Wuhan Children's Hospital; Hubei China
| | - Qiong Xu
- Department of Clinical Pharmacology; Wuhan Children's Hospital; Hubei China
| |
Collapse
|
29
|
Smith MJ, Gerber JS, Hersh AL. Inpatient Antimicrobial Stewardship in Pediatrics: A Systematic Review. J Pediatric Infect Dis Soc 2015; 4:e127-35. [PMID: 26582880 DOI: 10.1093/jpids/piu141] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 12/12/2014] [Indexed: 11/13/2022]
Abstract
BACKGROUND The clinical and economic outcomes associated with pediatric antimicrobial stewardship programs (ASPs) and other supplemental antimicrobial stewardship (AS) interventions have not been well described or reviewed. METHODS We performed a systematic review using PubMed to identify studies with any of the following terms in the title or abstract: "antimicrobial stewardship," "antimicrobial control," "antibiotic control," or "antibiotic stewardship." Studies were further limited to inpatient studies in the United States that contained the terms: "child," "children," "pediatric*" ("*" includes all terms with the same stem), "paediatric,*" "newborn," "infant," or "neonat,*" in the title or abstract. Clinical and economic outcomes from each relevant study were summarized. RESULTS Nine original studies reported outcomes related to formal pediatric ASPs. An additional 8 studies focused on specific AS interventions; 3 on management of community-acquired pneumonia, 2 on vancomycin-specific initiatives, and 1 each on clinical support, antibiotic restriction, and antibiotic rotation. Reported outcomes include decreases in antimicrobial utilization (11 studies), prescribing errors (3 studies), and drug costs (3 studies). Five studies assessed the potential adverse effects of AS interventions on patient safety and found none. Data to support an association between pediatric AS interventions and antimicrobial resistance are limited. CONCLUSIONS A small number of pediatric studies evaluating ASPs or other AS strategies have been published. These studies demonstrate reductions in antimicrobial utilization, cost, and prescribing errors with no apparent negative impact on patient safety. Although the studies are promising, the current evidence base is limited. Additional studies focusing on the appropriateness and outcomes of antimicrobial prescribing practices as well as more formalized economic evaluations are needed.
Collapse
Affiliation(s)
- Michael J Smith
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Jeffrey S Gerber
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| |
Collapse
|
30
|
Moreno-Pérez D, Martín AA, García AT, Montaner AE, Mulet JF, García JG, Moreno-Galdó A, de Liria CRG, Contreras JR, Lozano JS. Community acquired pneumonia in children: Outpatient treatment and prevention. An Pediatr (Barc) 2015. [DOI: 10.1016/j.anpede.2014.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
31
|
Magsarili HK, Girotto JE, Bennett NJ, Nicolau DP. Making a Case for Pediatric Antimicrobial Stewardship Programs. Pharmacotherapy 2015; 35:1026-36. [PMID: 26598095 DOI: 10.1002/phar.1647] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although antimicrobials are commonly used in children, it is important to remember that they can have a profound impact on this unique patient population. Inadvertent consequences of antiinfective use in children include antimicrobial resistance, infection caused by Clostridium difficile, increased risk of obesity, and adverse drug events. In addition, compared with adults, children have different dosing requirements, antimicrobial formulation needs, pharmacokinetics, and antimicrobial susceptibility profiles. Therefore, pediatric-specific antimicrobial stewardship efforts are needed to promote appropriate use of antimicrobials in children. The primary purposes of this review article are to provide a rationale behind pediatric-focused antimicrobial stewardship and to describe currently available evidence regarding the initiatives of pediatric antimicrobial stewardship programs (ASPs). A literature search of the Medline database was performed (from inception through March 2015). The studies included in this review focus on antimicrobial stewardship interventions in inpatient pediatric settings. Ten inpatient studies involving pediatric-focused antimicrobial stewardship interventions were identified from the published literature. Four studies used the core strategy of prospective audit with feedback; two used prior approval. The remaining four used supplemental antimicrobial stewardship strategies (guidelines, clinical pathways, and computerized decision support tools). In general, the interventions resulted in decreased antimicrobial use, reduced antimicrobial costs, and fewer prescribing errors. Children have unique medical needs related to antimicrobials and deserve focused ASP efforts. The literature regarding pediatric antimicrobial stewardship interventions is limited, but published interventions may serve as paradigms for developing pediatric ASPs as demonstrated by the general success of these interventions.
Collapse
Affiliation(s)
- Heather K Magsarili
- Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Jennifer E Girotto
- Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut.,Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, Hartford, Connecticut.,Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs, Connecticut
| | - Nicholas J Bennett
- Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, Hartford, Connecticut
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut
| |
Collapse
|
32
|
Williams DJ, Edwards KM, Self WH, Zhu Y, Ampofo K, Pavia AT, Hersh AL, Arnold SR, McCullers JA, Hicks LA, Bramley AM, Jain S, Grijalva CG. Antibiotic Choice for Children Hospitalized With Pneumonia and Adherence to National Guidelines. Pediatrics 2015; 136:44-52. [PMID: 26101356 PMCID: PMC4485005 DOI: 10.1542/peds.2014-3047] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The 2011 national guidelines for the management of childhood community-acquired pneumonia (CAP) recommended narrow-spectrum antibiotics (eg, ampicillin) for most children hospitalized with CAP. We assessed the impact of these guidelines on antibiotic prescribing at 3 children's hospitals. METHODS Children hospitalized with clinical and radiographic CAP were enrolled from January 1, 2010, through June 30, 2012, at 3 hospitals in Tennessee and Utah as part of the Centers for Disease Control and Prevention Etiology of Pneumonia in the Community study. Antibiotic selection was determined by the treating provider. The impact of the guidelines and hospital-level implementation efforts was determined by assessing the monthly percentage of enrolled children receiving third-generation cephalosporins or penicillin/ampicillin. Segmented linear regression was used to compare observed antibiotic selection in the postguideline period with expected antibiotic use projected from preguideline months. RESULTS Overall, 2121 children were included. During the preguideline period, 52.8% (interquartile range 47.8-56.6) of children with CAP received third-generation cephalosporins, whereas 2.7% (2.1, 7.0) received penicillin/ampicillin. By 9 months postguidelines, third-generation cephalosporin use declined (absolute difference -12.4% [95% confidence interval -19.8% to -5.1%]), whereas penicillin/ampicillin use increased (absolute difference 11.3% [4.3%-18.3%]). The most substantial changes were noted at those institutions that implemented guideline-related dissemination activities. CONCLUSIONS After publication of national guidelines, third-generation cephalosporin use declined and penicillin/ampicillin use increased among children hospitalized with CAP. Changes were more apparent among those institutions that proactively disseminated the guidelines, suggesting that targeted, hospital-based efforts are important for timely implementation of guideline recommendations.
Collapse
Affiliation(s)
- Derek J. Williams
- Divisions of Hospital Medicine and,Department of Pediatrics, Vanderbilt University School of Medicine, Vanderbilt Vaccine Research Program, Nashville, Tennessee
| | - Kathryn M. Edwards
- Infectious Diseases, Monroe Carell Jr. Children’s Hospital, and,Department of Pediatrics, Vanderbilt University School of Medicine, Vanderbilt Vaccine Research Program, Nashville, Tennessee
| | | | | | - Krow Ampofo
- Division of Infectious Diseases, and ,Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Andrew T. Pavia
- Division of Infectious Diseases, and ,Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Adam L. Hersh
- Division of Infectious Diseases, and ,Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Sandra R. Arnold
- Division of Infectious Diseases, LeBonheur Children’s Hospital, and ,Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee; and
| | - Jonathan A. McCullers
- Division of Infectious Diseases, LeBonheur Children’s Hospital, and ,Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee; and
| | - Lauri A. Hicks
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anna M. Bramley
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Seema Jain
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carlos G. Grijalva
- Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| |
Collapse
|
33
|
Moreno-Pérez D, Andrés Martín A, Tagarro García A, Escribano Montaner A, Figuerola Mulet J, García García JJ, Moreno-Galdó A, Rodrigo Gonzalo de Lliria C, Ruiz Contreras J, Saavedra Lozano J. [Community acquired pneumonia in children: Outpatient treatment and prevention]. An Pediatr (Barc) 2014; 83:439.e1-7. [PMID: 25488029 DOI: 10.1016/j.anpedi.2014.10.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/29/2014] [Indexed: 11/17/2022] Open
Abstract
There have been significant changes in community acquired pneumonia (CAP) in children in the last decade. These changes relate to epidemiology and clinical presentation. Resistance to antibiotics is also a changing issue. These all have to be considered when treating CAP. In this document, two of the main Spanish pediatric societies involved in the treatment of CAP in children, propose a consensus concerning therapeutic approach. These societies are the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases. The Advisory Committee on Vaccines of the Spanish Association of Paediatrics (CAV-AEP) has also been involved in the prevention of CAP. An attempt is made to provide up-to-date guidelines to all paediatricians. The first part of the statement presents the approach to ambulatory, previously healthy children. We also review the prevention with currently available vaccines. In a next second part, special situations and complicated forms will be addressed.
Collapse
Affiliation(s)
- D Moreno-Pérez
- Infectología Pediátrica e Inmunodeficiencias, Unidad de Gestión Clínica de Pediatría, Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Grupo de Investigación IBIMA, Departamento de Pediatría y Farmacología, Facultad de Medicina, Universidad de Málaga, Málaga, España.
| | - A Andrés Martín
- Sección de Neumología Pediátrica, Servicio de Pediatría, Hospital Universitario Virgen Macarena, Departamento de Farmacología, Pediatría y Radiología, Facultad de Medicina, Universidad de Sevilla, Sevilla, España
| | - A Tagarro García
- Servicio de Pediatría, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, España
| | - A Escribano Montaner
- Unidad de Neumología Pediátrica y Fibrosis Quística, Servicio de Pediatría, Hospital Clínico Universitario, Universitat de València, Valencia, España
| | - J Figuerola Mulet
- Unidad de Neumología y Alergia Pediátrica, Servicio de Pediatría, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, España
| | - J J García García
- Servicio de Pediatría, Hospital San Joan de Dèu, Universitat de Barcelona, Barcelona, España
| | - A Moreno-Galdó
- Sección de Neumología Pediátrica y Fibrosis Quística, Hospital Universitario Vall d́Hebron, Barcelona, Universitat Autònoma de Barcelona, Barcelona, España
| | - C Rodrigo Gonzalo de Lliria
- Unidad de Enfermedades Infecciosas e Inmunología Clínica, Servicio de Pediatría, Hospital Universitario Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, Barcelona, España
| | - J Ruiz Contreras
- Servicio de Pediatría, Hospital 12 de Octubre, Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - J Saavedra Lozano
- Unidad de Infectología Pediátrica, Servicio de Pediatría, Hospital General Universitario Gregorio Marañón, Madrid, España
| |
Collapse
|
34
|
Leyenaar JK, Lagu T, Shieh MS, Pekow PS, Lindenauer PK. Variation in resource utilization for the management of uncomplicated community-acquired pneumonia across community and children's hospitals. J Pediatr 2014; 165:585-91. [PMID: 24973795 PMCID: PMC4158451 DOI: 10.1016/j.jpeds.2014.04.062] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 04/09/2014] [Accepted: 04/29/2014] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To describe patterns of diagnostic testing and antibiotic management of uncomplicated pneumonia in general community hospitals and children's hospitals within hospitals and to determine the association between diagnostic testing and length of hospital stay. STUDY DESIGN We conducted a retrospective cohort study of children 1-17 years of age hospitalized with the diagnosis of pneumonia from 2007 to 2010 to hospitals contributing data to Perspective Database Warehouse, assessing patterns of diagnostic testing and antibiotic management. We constructed logistic regression models of log-transformed length of stay (LOS) and grouped treatment models to ascertain whether performance of blood cultures and viral respiratory testing were associated with LOS. RESULTS A total of 17 299 pneumonia cases occurred at 125 hospitals, with considerable variability in pneumonia management. Only 40 (0.2%) received ampicillin/penicillin G alone or in combination with other antibiotics, and 1318 (7.4%) received macrolide monotherapy as initial antibiotic management. Performance of blood culture and testing for respiratory viruses was associated with a statistically significant longer LOS, but these differences did not persist in grouped treatment models. CONCLUSIONS We observed greater rates of diagnostic testing in this cohort of structurally diverse hospitals than previously reported at freestanding children's hospitals, with extremely low rates of narrow-spectrum antibiotic use. Tailored antibiotic stewardship initiatives at these hospitals are needed to achieve adherence to national guideline recommendations.
Collapse
Affiliation(s)
- JoAnna K Leyenaar
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston, MA.
| | - Tara Lagu
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA; Division of General Internal Medicine, Baystate Medical Center, Springfield, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Meng-Shiou Shieh
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA
| | - Penelope S Pekow
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA; Department of Public Health, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA; Division of General Internal Medicine, Baystate Medical Center, Springfield, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA
| |
Collapse
|
35
|
Cantor SL, Khan MA, Gupta A. Development and optimization of taste-masked orally disintegrating tablets (ODTs) of clindamycin hydrochloride. Drug Dev Ind Pharm 2014; 41:1156-64. [DOI: 10.3109/03639045.2014.935392] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
36
|
Hester G, Nelson K, Mahant S, Eresuma E, Keren R, Srivastava R. Methodological quality of national guidelines for pediatric inpatient conditions. J Hosp Med 2014; 9:384-90. [PMID: 24677729 PMCID: PMC4043870 DOI: 10.1002/jhm.2187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 02/11/2014] [Accepted: 02/28/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Guidelines help inform standardization of care for quality improvement (QI). The Pediatric Research in Inpatient Settings network published a prioritization list of inpatient conditions with high prevalence, cost, and variation in resource utilization across children's hospitals. The methodological quality of guidelines for priority conditions is unknown. OBJECTIVE To rate the methodological quality of national guidelines for 20 priority pediatric inpatient conditions. DESIGN We searched sources including PubMed for national guidelines published from 2002 to 2012. Guidelines specific to 1 organism, test or treatment, or institution were excluded. Guidelines were rated by 2 raters using a validated tool (Appraisal of Guidelines for Research and Evaluation) with an overall rating on a 7-point scale (7 = the highest). Inter-rater reliability was measured with a weighted kappa coefficient. RESULTS Seventeen guidelines met inclusion criteria for 13 conditions; 7 conditions yielded no relevant national guidelines. The highest methodological-quality guidelines were for asthma, tonsillectomy, and bronchiolitis (mean overall rating 7, 6.5, and 6.5, respectively); the lowest were for sickle cell disease (2 guidelines) and dental caries (mean overall rating 4, 3.5, and 3, respectively). The overall weighted kappa was 0.83 (95% confidence interval 0.78-0.87). CONCLUSIONS We identified a group of moderate to high methodological-quality national guidelines for priority pediatric inpatient conditions. Hospitals should consider these guidelines to inform QI initiatives.
Collapse
Affiliation(s)
| | | | - Sanjay Mahant
- Department of Pediatrics, SickKids, University of Toronto
- For the Pediatric Research in Inpatient Settings (PRIS) Network
| | | | - Ron Keren
- Department of Pediatrics, Children's Hospital of Philadelphia
- For the Pediatric Research in Inpatient Settings (PRIS) Network
| | - Rajendu Srivastava
- Department of Pediatrics, University of Utah
- For the Pediatric Research in Inpatient Settings (PRIS) Network
| |
Collapse
|
37
|
Elemraid MA, Rushton SP, Thomas MF, Spencer DA, Eastham KM, Gennery AR, Clark JE. Changing clinical practice: management of paediatric community-acquired pneumonia. J Eval Clin Pract 2014; 20:94-9. [PMID: 24118607 PMCID: PMC4291095 DOI: 10.1111/jep.12091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2013] [Indexed: 11/04/2022]
Abstract
RATIONALE AND AIM To compare clinical features and management of paediatric community-acquired pneumonia (PCAP) following the publication of UK pneumonia guidelines in 2002 with data from a similar survey at the same hospitals in 2001-2002 (pre-guidelines). METHODS A prospective survey of 11 hospitals in Northern England was undertaken during 2008-2009. Clinical and laboratory data were recorded on children aged ≤16 years who presented with clinical and radiological features of pneumonia. RESULTS 542 children were included. There was a reduction in all investigations performed (P < 0.001) except C-reactive protein (P = 0.448) between surveys. These included full blood count (76% to 61%); blood culture (70% to 53%) and testing of respiratory secretions for viruses (24% to 12%) and bacteria (18% to 8%). Compared to pre-guidelines, there was a reduction in the use of intravenous antibiotics as a proportion of the total prescribed from 47% to 36% (P < 0.001) and a change in the route of antibiotic administration with increasing preference for oral alone (16% pre-compared to 50% post-guidelines, P < 0.001). CONCLUSION Apart from the acute phase reactants that should not be measured routinely, these changes are in line with the guideline recommendations. Improvements in antibiotic use are possible and have implications for future antimicrobial stewardship programmes. Further work using cost-effectiveness analysis may also demonstrate a financial benefit to health services from adoption of guidelines.
Collapse
Affiliation(s)
- Mohamed A Elemraid
- Department of Paediatric Infectious Disease and Immunology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | | | | | | | | | | | | | | |
Collapse
|
38
|
Ross RK, Hersh AL, Kronman MP, Newland JG, Metjian TA, Localio AR, Zaoutis TE, Gerber JS. Impact of Infectious Diseases Society of America/Pediatric Infectious Diseases Society guidelines on treatment of community-acquired pneumonia in hospitalized children. Clin Infect Dis 2014; 58:834-8. [PMID: 24399088 DOI: 10.1093/cid/ciu013] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
We examined the impact of the Pediatric Infectious Diseases Society/Infectious Diseases Society of America guidelines that recommend ampicillin or amoxicillin for children hospitalized with community-acquired pneumonia. Prescribing of ampicillin/amoxicillin increased following guideline publication, but remains low. Cephalosporin and macrolide prescribing decreased but remains common. Further studies exploring outcomes of and reasons for compliance with guidelines are warranted.
Collapse
Affiliation(s)
- Rachael K Ross
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Pennsylvania
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Brady PW, Brinkman WB, Simmons JM, Yau C, White CM, Kirkendall ES, Schaffzin JK, Conway PH, Vossmeyer MT. Oral antibiotics at discharge for children with acute osteomyelitis: a rapid cycle improvement project. BMJ Qual Saf 2013; 23:499-507. [PMID: 24347649 DOI: 10.1136/bmjqs-2013-002179] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Substantial evidence demonstrates comparable cure rates for oral versus intravenous therapy for routine osteomyelitis. Evidence adoption is often slow and in our centre virtually all patients with osteomyelitis were discharged on intravenous therapy. OBJECTIVE For patients with acute osteomyelitis admitted to the hospital medicine service, we aimed to increase the proportion of cases discharged on oral antibiotics to at least 70%. METHODS The setting for our observational time series study was a large academic children's hospital. The model for improvement and plan-do-study-act cycles were used to test, refine and implement interventions identified through our key driver diagram. Our multifaceted intervention included a shared decision-making tool, an order set in our electronic health record, and education to faculty and trainees. We also included an identify and mitigate intervention to target providers caring for children with osteomyelitis in near-real time and reinforce the evidence-based recommendations. Data were analysed on an annotated g-chart of osteomyelitis cases between patients discharged on intravenous antibiotics. Structured chart review was used to identify treatment failures as well as length of stay and hospital charges in preintervention and postintervention groups. RESULTS The osteomyelitis cases between patients discharged on intravenous antibiotics increased from a median of 0 preintervention to a maximum of 9 cases following our identify and mitigate intervention. The direction and magnitude of successive improvements observed satisfied criteria for special cause variation. Improvement has been sustained for 1 year. Treatment failure and complications were uncommon in preintervention and postintervention phases. No significant differences in length of stay or charges were detected. CONCLUSIONS Even for uncommon conditions, rapid and sustained evidence adoption is possible using quality improvement methods.
Collapse
Affiliation(s)
- Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA The James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - William B Brinkman
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA The James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey M Simmons
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Connie Yau
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christine M White
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eric S Kirkendall
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joshua K Schaffzin
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick H Conway
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Centers for Medicare and Medicaid Services, Baltimore, Maryland, USA
| | - Michael T Vossmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
40
|
Maltezou HC, Mougkou K, Iosifidis E, Katerelos P, Roilides E, Theodoridou M. Prescription of antibiotics and awareness of antibiotic costs by paediatricians in two hospitals in Greece. J Chemother 2013; 26:26-31. [PMID: 24410189 DOI: 10.1179/1973947813y.0000000096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Our aim was to study the antibiotic prescription practices and the knowledge about antibiotic costs, brand and generic drugs of paediatricians working in two hospitals in Greece. The 2007 national guidelines were used as the gold standard for antibiotic prescription. A total of 126 paediatricians participated in the study (50.4% response rate). The mean compliance rate with the guidelines was 50.1% (range per infection: 10.6-84.7%). The mean scores of knowledge about antibiotic costs and about brand name and generic drugs were 35.6 and 60.3%, respectively. Linear regression analysis found a significant association between the mean compliance rate with the national guidelines and the paediatricians' age (mean compliance rates were 49.1, 53.0, and 43.0% in the ≤ 30, 31-40, and > 40 years age-groups, respectively; P = 0.003). In conclusion, five years after the first national guidelines were issued in Greece only half of the paediatricians working in hospitals comply fully with them.
Collapse
|
41
|
Brett A, Bielicki J, Newland JG, Rodrigues F, Schaad UB, Sharland M. Neonatal and pediatric antimicrobial stewardship programs in Europe-defining the research agenda. Pediatr Infect Dis J 2013; 32:e456-65. [PMID: 23958812 DOI: 10.1097/inf.0b013e31829f0460] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The relationship between suboptimal use of antimicrobials and antimicrobial resistance has become increasingly clear. Despite significant international effort aimed at reducing inappropriate antimicrobial prescribing in hospitals, antimicrobial resistance remains a major public health threat. Antimicrobial Stewardship Programs (ASPs) comprise a series of measures aimed at optimizing the use of antimicrobials, while improving the quality of patient care and promoting cost-effectiveness. This discussion article aims to summarize some of the approaches that have been used in neonatal and pediatric ASPs, with a particular focus on the European healthcare setting. Current evidence demonstrates neonatal and pediatric ASPs to be safe, practical to implement, generally cost-effective and possibly associated with a reduction in antimicrobial resistance rates. This review identified that, despite the recognized need for additional evidence and information on implementation, published data on pediatric ASPs derives mainly from the United States, with very few published reports on formal ASPs in European children's hospitals. Consequently, the optimal method of implementation remains unknown within a European setting. Future research needs to include novel study designs on how best to introduce ASPs, monitoring of clinically relevant outcomes and cost-effectiveness with improved measurement of the impact on antimicrobial resistance.
Collapse
Affiliation(s)
- Ana Brett
- From the *Infectious Diseases Unit and Emergency Service, Hospital Pediátrico, Centro, Hospitalar e Universitário de Coimbra, Coimbra, Portugal; †Paediatric Infectious Diseases Research Group, St George's University London, London, United Kingdom; ‡Division of Pediatric Infectious Diseases, Children's Mercy Hospital and Clinics, University of Missouri-Kansas City, MO; and §Paediatric Infectious Diseases Division, University Children's Hospital, Basel, Switzerland
| | | | | | | | | | | |
Collapse
|
42
|
Williams DJ, Hall M, Shah SS, Parikh K, Tyler A, Neuman MI, Hersh AL, Brogan TV, Blaschke AJ, Grijalva CG. Narrow vs broad-spectrum antimicrobial therapy for children hospitalized with pneumonia. Pediatrics 2013; 132:e1141-8. [PMID: 24167170 PMCID: PMC4530302 DOI: 10.1542/peds.2013-1614] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America community-acquired pneumonia (CAP) guideline recommends narrow-spectrum antimicrobial therapy for most children hospitalized with CAP. However, few studies have assessed the effectiveness of this strategy. METHODS Using data from 43 children's hospitals, we conducted a retrospective cohort study to compare outcomes and resource utilization among children hospitalized with CAP between 2005 and 2011 receiving either parenteral ampicillin/penicillin (narrow spectrum) or ceftriaxone/cefotaxime (broad spectrum). Children with complex chronic conditions, interhospital transfers, recent hospitalization, or the occurrence of any of the following during the first 2 calendar days of hospitalization were excluded: pleural drainage procedure, admission to intensive care, mechanical ventilation, death, or hospital discharge. RESULTS Overall, 13,954 children received broad-spectrum therapy (89.7%) and 1610 received narrow-spectrum therapy (10.3%). The median length of stay was 3 days (interquartile range 3-4) in the broad- and narrow-spectrum therapy groups (adjusted difference 0.12 days, 95% confidence interval [CI]: -0.02 to 0.26). One hundred fifty-six children (1.1%) receiving broad-spectrum therapy and 13 children (0.8%) receiving narrow-spectrum therapy were admitted to intensive care (adjusted odds ratio 0.85, 95% CI: 0.27 to 2.73). Readmission occurred for 321 children (2.3%) receiving broad-spectrum therapy and 39 children (2.4%) receiving narrow-spectrum therapy (adjusted odds ratio 0.85, 95% CI: 0.45 to 1.63). Median costs for the hospitalization were $3992 and $4375 (adjusted difference -$14.4, 95% CI: -177.1 to 148.3). CONCLUSIONS Clinical outcomes and costs for children hospitalized with CAP are not different when treatment is with narrow- compared with broad-spectrum therapy.
Collapse
Affiliation(s)
- Derek J Williams
- 1161 21st Ave South, CCC 5311 Medical Center North, Nashville, TN 37232.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Ambroggio L, Thomson J, Murtagh Kurowski E, Courter J, Statile A, Graham C, Sheehan B, Iyer S, Shah SS, White CM. Quality improvement methods increase appropriate antibiotic prescribing for childhood pneumonia. Pediatrics 2013; 131:e1623-31. [PMID: 23589819 PMCID: PMC3639461 DOI: 10.1542/peds.2012-2635] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In August 2011, the Pediatric Infectious Disease Society and Infectious Disease Society of America published an evidence-based guideline for the management of community-acquired pneumonia (CAP) in children ≥3 months. Our objective was to evaluate if quality improvement (QI) methods could improve appropriate antibiotic prescribing in a setting without a formal antimicrobial stewardship program. METHODS At a tertiary children's hospital, QI methods were used to rapidly implement the Pediatric Infectious Disease Society/Infectious Disease Society of America guideline recommendations for appropriate first-line antibiotic therapy in children with CAP. QI interventions focused on 4 key drivers and were tested separately in the emergency department and on the hospital medicine resident teams, using multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed weekly to determine the success of prescribing recommended antibiotic therapy. The impact of these interventions on our outcome was tracked over time on run charts. RESULTS Appropriate first-line antibiotic prescribing for children admitted with the diagnosis of CAP increased in the emergency department from a median baseline of 0% to 100% and on the hospital medicine resident teams from 30% to 100% within 6 months of introducing the guidelines locally at Cincinnati Children's Hospital Medical Center and has been sustained for 3 months. CONCLUSIONS Our study demonstrates that QI methods can rapidly improve adherence to national guidelines even in settings without a formal antimicrobial stewardship program to encourage judicious antibiotic prescribing for CAP.
Collapse
Affiliation(s)
- Lilliam Ambroggio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA.
| | | | - Eileen Murtagh Kurowski
- Emergency Medicine,,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Angela Statile
- Divisions of Hospital Medicine,,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Camille Graham
- Divisions of Hospital Medicine,,General and Community Pediatrics
| | | | - Srikant Iyer
- Emergency Medicine,,James M. Anderson Center for Health Systems Excellence, and,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Samir S. Shah
- Divisions of Hospital Medicine,,James M. Anderson Center for Health Systems Excellence, and,Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christine M. White
- Divisions of Hospital Medicine,,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
44
|
Abstract
Viral pathogens are commonly isolated from children with community-acquired pneumonia (CAP). Viruses like respiratory syncytial virus, human rhinovirus, human metapneumovirus, parainfluenza viruses, and influenza may act as sole pathogens or may predispose to bacterial pneumonia by a variety of mechanisms. New, emerging, or reemerging viral pathogens occasionally cause outbreaks of severe respiratory tract infection in children. The 2009–2010 H1N1 influenza virus pandemic resulted in increased rates of influenza-related hospitalizations and deaths in children. Rapid viral diagnostic tests based on antigen detection or nucleic acid amplification are increasingly available for clinical use and confirm the importance of viral infection in children hospitalized with CAP. Recently published guidelines for the management of CAP in children note that positive viral test results can modify clinical decision making in children with suspected pneumonia by allowing antibacterial therapy to be withheld in the absence of clinical, laboratory, or radiographic findings that suggest bacterial coinfection.
Collapse
Affiliation(s)
- Charles R Woods
- Pediatric Infectious Diseases, University of Louisville School of Medicine, 571 South Floyd Street, Suite 321, Louisville, KY, 40202, USA,
| | | |
Collapse
|
45
|
|
46
|
Neuman MI, Shah SS, Shapiro DJ, Hersh AL. Emergency department management of childhood pneumonia in the United States prior to publication of national guidelines. Acad Emerg Med 2013; 20:240-6. [PMID: 23517255 DOI: 10.1111/acem.12088] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 09/18/2012] [Accepted: 09/19/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent publication of national guidelines by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) provide recommendations around diagnostic testing and antibiotic treatment for children with community-acquired pneumonia (CAP). These guidelines emphasize limited use of chest radiograph (CXR) and complete blood count (CBC) and routinely performing viral testing and use of narrow-spectrum antibiotics. OBJECTIVES The objective was to estimate the rate of emergency department (ED) visits for pediatric CAP in the United States and to describe management of patients prior to publication of consensus national guidelines. METHODS Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for ED visits from 2001 through 2009 for children with CAP. RESULTS During the study period there were an estimated 375,000 ED visits for CAP annually; 85% occurred within a general, rather than pediatric, ED. Overall, 20% of children with CAP were hospitalized. Among children discharged from EDs with CAP, CBC was performed during 30% of visits, CXR during 83%, and viral testing in only 13%. Twelve percent of children discharged from EDs with CAP had blood cultures obtained. No major differences were observed in the rates of laboratory testing or antibiotic administration between children treated in general versus pediatric EDs. During the study period, only 21% of children discharged from EDs with CAP received amoxicillin, the guideline-recommended antibiotic. CONCLUSIONS Most ED visits for CAP in the United States occur in general EDs. To encourage care that is consistent with national guidelines, efforts should be made to reduce the performance of certain diagnostic testing, such as CBC and CXR, among children discharged from EDs with CAP. Additionally, the use of narrow-spectrum antibiotics should be encouraged.
Collapse
Affiliation(s)
- Mark I. Neuman
- Division of Emergency Medicine; Boston Children's Hospital; Department of Pediatrics; Harvard Medical School; Boston MA
| | - Samir S. Shah
- Divisions of Infectious Diseases and Hospital Medicine; Cincinnati Children's Hospital Medical Center; Department of Pediatrics; University of Cincinnati College of Medicine; Cincinnati OH
| | - Daniel J. Shapiro
- Division of General Pediatrics; University of California; San Francisco CA
| | - Adam L. Hersh
- Division of Pediatric Infectious Diseases; University of Utah School of Medicine; Salt Lake City UT
| |
Collapse
|
47
|
Campos J. [Antibiotic use in the community--the prevalence as a starting point]. Enferm Infecc Microbiol Clin 2012; 30:589-90. [PMID: 22955003 DOI: 10.1016/j.eimc.2012.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/09/2012] [Indexed: 10/27/2022]
|