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Klein E, Saheed M, Irvin N, Balhara KS, Badaki-Makun O, Poleon S, Kelen G, Cosgrove SE, Hinson J. Racial and Socioeconomic Disparities Evident in Inappropriate Antibiotic Prescribing in the Emergency Department. Ann Emerg Med 2024; 84:101-110. [PMID: 38260931 DOI: 10.1016/j.annemergmed.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/21/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024]
Abstract
STUDY OBJECTIVE Inappropriate antibiotic prescribing for acute respiratory tract infections is a common source of low-value care in the emergency department (ED). Racial and socioeconomic disparities have been noted in episodes of low-value care, particularly in children. We evaluated whether prescribing rates for acute respiratory tract infections when antibiotics would be inappropriate by guidelines differed by race and socioeconomics. METHODS A retrospective cross-sectional analysis of adult and pediatric patient encounters in the emergency department (ED) between 2015 and 2023 at 5 hospitals for acute respiratory tract infections that did not require antibiotics by guidelines. Multivariable regression was used to calculate the risk ratio between race, ethnicity, and area deprivation index and inappropriate antibiotic prescribing, controlling for patient age, sex, and relevant comorbidities. RESULTS A total of 147,401 ED encounters (55% pediatric, 45% adult) were included. At arrival, 4% patients identified as Asian, 50% as Black, 5% as Hispanic, and 23% as White. Inappropriate prescribing was noted in 7.6% of overall encounters, 8% for Asian patients, 6% for Black patients, 5% for Hispanic patients, and 12% for White patients. After adjusting for age, sex, comorbidities, and area deprivation index, White patients had a 1.32 (95% confidence interval, 1.26 to 1.38) higher likelihood of receiving a prescription compared with Black patients. Patients residing in areas of greater socioeconomic deprivation, regardless of race and ethnicity, had a 0.74 (95% confidence interval, 0.70 to 0.78) lower likelihood of receiving a prescription. CONCLUSION Our results suggest that although overall inappropriate prescribing was relatively low, White patients and patients from wealthier areas were more likely to receive an inappropriate antibiotic prescription.
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Affiliation(s)
- Eili Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; OneHealthTrust, Washington, DC.
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nathan Irvin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kamna S Balhara
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Oluwakemi Badaki-Makun
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeremiah Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Daley MF, Reifler LM, Sterrett AT, Poole NM, Winn DB, Steiner JF, Arnold Rehring SM. Improving Antibiotic Prescribing for Children with Community-acquired Pneumonia in Outpatient Settings. J Pediatr 2024; 274:114155. [PMID: 38897380 DOI: 10.1016/j.jpeds.2024.114155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/24/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE To assess whether a two-phase intervention was associated with improvements in antibiotic prescribing among nonhospitalized children with community-acquired pneumonia. STUDY DESIGN In a large health care organization, a first intervention phase was implemented in September 2020 directed at antibiotic choice and duration for children 2 months through 17 years of age with pneumonia. Activities included clinician education and implementation of a pneumonia-specific order set in the electronic health record. In October 2021, a second phase comprised additional education and order set revisions. A narrow spectrum antibiotic (eg, amoxicillin) was recommended in most circumstances. Electronic health record data were used to identify pneumonia cases and antibiotics ordered. Using interrupted time series analyses, antibiotic choice and duration after phase one (September 2020-September 2021) and after phase two (October 2021-October 2022) were compared with a preintervention prepandemic period (January 2016-early March 2020). RESULTS Overall, 3570 cases of community-acquired pneumonia were identified: 3246 cases preintervention, 98 post-phase one, and 226 post-phase two. The proportion receiving narrow spectrum monotherapy increased from 40.6% preintervention to 68.4% post-phase one to 69.0% post-phase two (P < .001). For children with an initial narrow spectrum antibiotic, duration decreased from preintervention (mean duration 9.9 days, SD 0.5 days) to post-phase one (mean 8.2, SD 1.9) to post-phase two (mean 6.8, SD 2.3) periods (P < .001). CONCLUSIONS A two-phase intervention with educational sessions combined with clinical decision support was associated with sustained improvements in antibiotic choice and duration among children with community-acquired pneumonia.
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Affiliation(s)
- Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Andrew T Sterrett
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Nicole M Poole
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Epidemiology, University of Colorado School of Medicine, Aurora, CO
| | - D Brian Winn
- Department of Medicine, Colorado Permanente Medical Group, Denver, CO; Department of Medical Informatics, Colorado Permanente Medical Group, Denver, CO
| | - John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Department of Medical Education, Colorado Permanente Medical Group, Denver, CO; Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Sharisse M Arnold Rehring
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Department of Medical Education, Colorado Permanente Medical Group, Denver, CO
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Bekdas M, Saygi B, Kilinc YB, Kilinc E. Plasma levels of neurogenic inflammation related neuropeptides in pediatric patients with community-acquired pneumonia and their potential diagnostic value in distinguishing viral and bacterial pneumonia. Eur J Pediatr 2024; 183:1619-1627. [PMID: 38183438 PMCID: PMC11001734 DOI: 10.1007/s00431-023-05417-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/16/2023] [Accepted: 12/30/2023] [Indexed: 01/08/2024]
Abstract
Neurogenic inflammation is involved in the development and progression of respiratory inflammatory diseases. However, its role in community-acquired pneumonia (CAP) remains unclear. We therefore aimed to investigate plasma levels of neurogenic inflammation-related neuropeptides, calcitonin gene-related peptide (CGRP), substance P (SP), vasoactive intestinal peptide (VIP) and neuropeptide Y (NPY), and procalcitonin (PCT) in pediatric patients with CAP and to assess their diagnostic value in viral and bacterial/mixed pneumonia. A total of 124 pediatric patients with CAP (1 month-18 years old) and 56 healthy children of similar ages were prospectively enrolled. The patients were classified as viral (n = 99) and bacterial/mixed (n = 25) pneumonia. Plasma levels of the peptides were quantified by ELISA. ROC analysis was performed to evaluate possible diagnostic value of the peptides. While plasma levels of CGRP, VIP and PCT were significantly higher in patients with CAP than in the control group, respectively, NPY levels were significantly lower. Moreover, plasma levels of all neuropeptides and PCT were significantly higher in bacterial pneumonia patients compared to viral pneumonia patients. ROC analysis revealed that CGRP, SP and NPY had a diagnostic value in distinguishing viral and bacterial/mixed pneumonia. CONCLUSIONS Our findings suggest that these neuropeptides may be implicated in pediatric CAP. CGRP, SP and NPY together may be a promising candidate in distinguishing viral and bacterial/mixed pneumonia, however, for this, further studies are needed. WHAT IS KNOWN • Neurogenic inflammation contributes to the development and progression of respiratory inflammatory diseases such as chronic obstructive pulmonary disease and bronchial asthma. WHAT IS NEW • Plasma levels of neurogenic inflammation related neuropeptides calcitonin gene-related peptide, substance P, vasoactive intestinal peptide and neuropeptide Y are changed in pediatric community-acquired pneumonia. Calcitonin gene-related peptide, substance P and neuropeptide Y are promising candidates in distinguishing viral and bacterial/mixed pneumonia.
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Affiliation(s)
- Mervan Bekdas
- Department of Pediatrics, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey
| | - Bilgi Saygi
- Department of Pediatrics, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey
| | | | - Erkan Kilinc
- Department of Physiology, Faculty of Medicine, Bolu Abant Izzet Baysal University, Bolu, Turkey.
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Cheng X, Wang H, Sun L, Ge W, Liu R, Qin H, Zhang Y, Li C. Construction and external validation of a scoring prediction model for mortality risk within 30 days of community-acquired pneumonia in children admitted to the pediatric intensive care unit: A multicenter retrospective case-control study. Medicine (Baltimore) 2024; 103:e37419. [PMID: 38457576 PMCID: PMC10919472 DOI: 10.1097/md.0000000000037419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 03/10/2024] Open
Abstract
In this study, we constructed and validated a scoring prediction model to identify children admitted to the pediatric intensive care unit (PICU) with community-acquired pneumonia (CAP) at risk for early death. Children with CAP who were admitted to the PICU were included in the training set and divided into death and survival groups according to whether they died within 30 days of admission. For univariate and multifactorial analyses, demographic characteristics, vital signs at admission, and laboratory test results were collected separately from the 2 groups, and independent risk factors were derived to construct a scoring prediction model. The ability of the scoring model to predict CAP-related death was validated by including children with CAP hospitalized at 3 other centers during the same period in the external validation set. Overall, the training and validation sets included 296 and 170 children, respectively. Univariate and multifactorial analyses revealed that procalcitonin (PCT), lactate dehydrogenase (LDH), activated partial thromboplastin time (APTT), and fibrinogen (Fib) were independent risk factors. The constructed scoring prediction model scored 2 points each for PCT ≥ 0.375 ng/mL, LDH ≥ 490 U/L, and APTT ≥ 31.8 s and 1 point for Fib ≤ 1.78 g/L, with a total model score of 0-7 points. When the score was ≥ 5 points, the sensitivity and specificity of mortality diagnosis in children with CAP were 72.7% and 87.5%, respectively. In the external validation set, the sensitivity, specificity, and accuracy of the scoring model for predicting the risk of CAP-related death were 64.0%, 92.4%, and 88.2%, respectively. Constructing a scoring prediction model is worth promoting and can aid pediatricians in simply and rapidly evaluating the risk of death in children with CAP, particularly those with complex conditions.
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Affiliation(s)
- Xingfeng Cheng
- Department of Pediatric Intensive Care Unit, Wuhan Children’s Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huizhen Wang
- Department of Neonatal Intensive Care Unit, Wuhan Children’s Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lingli Sun
- Department of Child Health, Wuhan Children’s Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Ge
- Department of Pediatrics, Tongcheng People’s Hospital, Xianning, China
| | - Rui Liu
- Department of Pediatrics, Macheng People’s Hospital, Huanggang, China
| | - Hua Qin
- Department of Pediatrics, Jingmen Second People’s Hospital, Jingmen, China
| | - Yong Zhang
- Department of Cardiology, Wuhan Children’s Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Changjian Li
- Department of Cardiology, Wuhan Children’s Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Saatchi A, Haverkate MR, Reid JN, Shariff SZ, Povitz M, Patrick DM, Silverman M, Morris AM, McCormack J, Marra F. Quality of antibiotic prescribing for pediatric community-acquired Pneumonia in outpatient care. BMC Pediatr 2023; 23:542. [PMID: 37898747 PMCID: PMC10612244 DOI: 10.1186/s12887-023-04355-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/10/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Antibiotics remain the primary treatment for community acquired pneumonia (CAP), however rising rates of antimicrobial resistance may jeopardize their future efficacy. With higher rates of disease reported in the youngest populations, effective treatment courses for pediatric pneumonia are of paramount importance. This study is the first to examine the quality of pediatric antibiotic use by agent, dose and duration. METHODS A retrospective cohort study included all outpatient/primary care physician visits for pediatric CAP (aged < 19 years) between January 1 2014 to December 31 2018. Relevant practice guidelines were identified, and treatment recommendations extracted. Amoxicillin was the primary first-line agent for pediatric CAP. Categories of prescribing included: guideline adherent, effective but unnecessary (excess dose and/or duration), under treatment (insufficient dose and/or duration), and not recommended. Proportions of attributable-antibiotic use were examined by prescribing category, and then stratified by age and sex. RESULT(S) A total of 42,452 episodes of pediatric CAP were identified. Of those, 31,347 (76%) resulted in an antibiotic prescription. Amoxicillin accounted for 51% of all prescriptions. Overall, 27% of prescribing was fully guideline adherent, 19% effective but unnecessary, 10% under treatment, and 44% not recommended by agent. Excessive duration was the hallmark of effective but unnecessary prescribing (97%) Macrolides accounted for the majority on non-first line agent use, with only 32% of not recommended prescribing preceded by a previous course of antibiotics. CONCLUSION(S) This study is the first in Canada to examine prescribing quality for pediatric CAP by agent, dose and duration. Utilizing first-line agents, and shorter-course treatments are targets for stewardship.
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Affiliation(s)
- Ariana Saatchi
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Manon R Haverkate
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Jennifer N Reid
- London Health Sciences Centre, ICES Western, Lawson Health Research Institute, London, ON, Canada
| | - Salimah Z Shariff
- London Health Sciences Centre, ICES Western, Lawson Health Research Institute, London, ON, Canada
| | - Marcus Povitz
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - David M Patrick
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Michael Silverman
- Faculty of Medicine, University of Western Ontario, London, ON, Canada
| | - Andrew M Morris
- Sinai Health System, University Health Network and University of Toronto, Toronto, ON, Canada
| | - James McCormack
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
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Pierantoni L, Lasala V, Dondi A, Cifaldi M, Corsini I, Lanari M, Zama D. Antibiotic Prescribing for Lower Respiratory Tract Infections and Community-Acquired Pneumonia: An Italian Pediatric Emergency Department's Real-Life Experience. Life (Basel) 2023; 13:1922. [PMID: 37763325 PMCID: PMC10532937 DOI: 10.3390/life13091922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/01/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Lower respiratory tract infections (LRTIs) and community-acquired pneumonia (CAP) are among the most frequent reasons for referrals to the pediatric emergency department (PED). The aim of this study is to describe the management of antibiotic prescription in febrile children with LRTI or CAP admitted to a third-level PED and to investigate the different variables that can guide physicians in this decision-making. METHODS This is an observational, retrospective, monocentric study including patients < 14 years old who were presented to the PED for a febrile LRTI or CAP during the first six months of the year 2017. Demographic and clinical data, PED examinations, recommended therapy, and discharge modality were considered. Two multivariate logistic regression analyses were performed on patients with complete profiles to investigate the impact of demographic, laboratory, and clinical variables on antibiotic prescription and hospital admission. RESULTS This study included 584 patients with LRTI (n = 368) or CAP (n = 216). One hundred and sixty-eight individuals (28.7%) were admitted to the hospital. Lower age, higher heart rate, and lower SpO2 were associated with an increased risk of hospitalization. Antibiotics were prescribed to 495 (84.8%) patients. According to the multivariate logistic regression, the diagnosis and duration of fever were substantially linked with antibiotic prescription. CONCLUSIONS The present study reports real-life data about our PED experience. A high rate of antibiotic prescription was noted. In the future, it is necessary to improve antibiotic stewardship programs to increase clinical adherence to guidelines.
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Affiliation(s)
- Luca Pierantoni
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.P.); (I.C.); (M.L.); (D.Z.)
| | - Valentina Lasala
- Specialty School of Paediatrics, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy;
| | - Arianna Dondi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.P.); (I.C.); (M.L.); (D.Z.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Marina Cifaldi
- Pediatric Clinic, Department of Medicine and Surgery, Azienda Ospedaliero-Universitaria of Parma, 43126 Parma, Italy;
| | - Ilaria Corsini
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.P.); (I.C.); (M.L.); (D.Z.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.P.); (I.C.); (M.L.); (D.Z.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Daniele Zama
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.P.); (I.C.); (M.L.); (D.Z.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
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Chang TH, Liu YC, Lin SR, Chiu PH, Chou CC, Chang LY, Lai FP. Clinical characteristics of hospitalized children with community-acquired pneumonia and respiratory infections: Using machine learning approaches to support pathogen prediction at admission. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:772-781. [PMID: 37246060 DOI: 10.1016/j.jmii.2023.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 04/03/2023] [Accepted: 04/25/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Acute respiratory infections (ARIs) are common in children. We developed machine learning models to predict pediatric ARI pathogens at admission. METHODS We included hospitalized children with respiratory infections between 2010 and 2018. Clinical features were collected within 24 h of admission to construct models. The outcome of interest was the prediction of 6 common respiratory pathogens, including adenovirus, influenza virus types A and B, parainfluenza virus (PIV), respiratory syncytial virus (RSV), and Mycoplasma pneumoniae (MP). Model performance was estimated using area under the receiver operating characteristic curve (AUROC). Feature importance was measured using Shapley Additive exPlanation (SHAP) values. RESULTS A total of 12,694 admissions were included. Models trained with 9 features (age, event pattern, fever, C-reactive protein, white blood cell count, platelet count, lymphocyte ratio, peak temperature, peak heart rate) achieved the best performance (AUROC: MP 0.87, 95% CI 0.83-0.90; RSV 0.84, 95% CI 0.82-0.86; adenovirus 0.81, 95% CI 0.77-0.84; influenza A 0.77, 95% CI 0.73-0.80; influenza B 0.70, 95% CI 0.65-0.75; PIV 0.73, 95% CI 0.69-0.77). Age was the most important feature to predict MP, RSV and PIV infections. Event patterns were useful for influenza virus prediction, and C-reactive protein had the highest SHAP value for adenovirus infections. CONCLUSION We demonstrate how artificial intelligence can assist clinicians identify potential pathogens associated with pediatric ARIs upon admission. Our models provide explainable results that could help optimize the use of diagnostic testing. Integrating our models into clinical workflows may lead to improved patient outcomes and reduce unnecessary medical costs.
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Affiliation(s)
- Tu-Hsuan Chang
- Department of Pediatrics, Chi Mei Medical Center, Tainan City, Taiwan
| | - Yun-Chung Liu
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Siang-Rong Lin
- Institute of Applied Mechanics, National Taiwan University, Taipei City, Taiwan
| | - Pei-Hsin Chiu
- Institute of Applied Mechanics, National Taiwan University, Taipei City, Taiwan
| | - Chia-Ching Chou
- Institute of Applied Mechanics, National Taiwan University, Taipei City, Taiwan.
| | - Luan-Yin Chang
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan.
| | - Fei-Pei Lai
- Graduate Institute of Biomedical Electronics and Bioinformatics, Taipei City, National Taiwan University, Taiwan; Department of Computer Science and Information Engineering, National Taiwan University, Taipei City, Taiwan; Department of Electrical Engineering, National Taiwan University, Taipei City, Taiwan
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Poluektova O, Robertson DA, Rafferty A, Cunney R, Lunn PD. A scoping review and behavioural analysis of factors underlying overuse of antimicrobials. JAC Antimicrob Resist 2023; 5:dlad043. [PMID: 37168837 PMCID: PMC10164659 DOI: 10.1093/jacamr/dlad043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
Background Overuse of antimicrobials is a challenging global issue that contributes to antimicrobial resistance. Despite widespread awareness of the problem among members of the medical community and various attempts to improve prescription practices, existing antimicrobial stewardship programmes are not always effective. In our view, this may reflect limited understanding of factors that influence prescription of antimicrobials as empirical therapy, implying a need to address the psychological mechanisms behind some of the specific behaviours involved. Objectives To identify factors that influence the antimicrobials prescription as empirical therapy, and to relate these factors to findings from behavioural science. Methods We conducted a scoping review of the literature on the factors underlying antimicrobial prescription decisions, following the protocol designed using PRISMA guidelines. Results and conclusions From a final sample of 90 sources, we identified ten factors important in antimicrobial prescription decisions. In the second stage of our analysis, we grouped them into five final categories: (1) nature of the decision, (2) social influences, (3) individual differences, (4) characteristics of the patient, (5) context. We analyse these categories using a behavioural science perspective.
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Affiliation(s)
| | - Deirdre A Robertson
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, School of Psychology, Dublin, Ireland
| | - Aisling Rafferty
- Children’s Health Ireland, Department of Pharmacy, Dublin, Ireland
- University of Birmingham, School of Pharmacy, Institute of Clinical Sciences,Birmingham, UK
| | - Robert Cunney
- Children’s Health Ireland, Irish Meningitis and Sepsis Reference Laboratory, Dublin, Ireland
- Royal College of Surgeons in Ireland, Department of Microbiology, Dublin, Ireland
- Children’s Health Ireland, Department of Microbiology, Dublin, Ireland
| | - Peter D Lunn
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, Department of Economics, Dublin, Ireland
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9
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Rynkiewich K, Gole S, Won S, Schwartz DN. Cultures of antibiotic prescribing in medical intensive care. Soc Sci Med 2023; 324:115834. [PMID: 37003024 DOI: 10.1016/j.socscimed.2023.115834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 04/03/2023]
Abstract
Antimicrobial resistance (AMR) continues to present a challenge to international healthcare systems and structures of public health. The focus on optimizing antibiotic prescribing in human populations has challenged healthcare systems charged with making responsible their physician-prescribers. In the United States, physicians in almost every specialty and role use antibiotics as part of their therapeutic armamentariums. In United States hospitals, most patients are administered antibiotics during their stay. Therefore, antibiotic prescribing and utilization is a commonly accepted part of medical practice. In this paper, we utilize social science work on antibiotic prescribing to examine a critical space of care in United States hospital settings. From March to August 2018, we used ethnographic methods to study hospital-based medical intensive care unit physicians at the offices and hospital floors they frequent in two urban United States teaching hospitals. We focused on eliciting the interactions and discussions surrounding antibiotic decision-making that are uniquely influenced by the context of medical intensive care units. We argue that antibiotic use in the medical intensive care units under study was shaped by urgency, hierarchy, and uncertainty representative of the medical intensive care unit's role within the larger hospital system. We conclude that by studying the culture of antibiotic prescribing in medical intensive care units, we can see more clearly both the vulnerability of the looming antimicrobial resistance crisis and by contrast the perceived insignificance of stewarding antibiotic use when considered alongside the fragility of life amidst acute medical concerns regularly experienced in the unit.
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Affiliation(s)
| | - Sarin Gole
- Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, NB5, Cleveland, OH 44195, USA
| | - Sarah Won
- Department of Internal Medicine, Rush Medical College, USA
| | - David N Schwartz
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, USA
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10
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Al Okla S, Prashanth GP, Kurbet S, Al Attraqchi Y, Asaad A. Emergent "Bloody Diarrhea" Associated with the Use of Oral Cefdinir in Young Children: A Brief Report and Review of Literature. J Emerg Med 2023; 64:220-223. [PMID: 36822986 DOI: 10.1016/j.jemermed.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/08/2022] [Accepted: 12/13/2022] [Indexed: 02/23/2023]
Abstract
BACKGROUND Cefdinir is an extended-spectrum, third-generation, oral cephalosporin widely used in pediatric population to treat common bacterial infections, including otitis media and streptococcal pharyngitis. It is considered a safe and well-tolerated alternative to penicillin and macrolides. CASE REPORT This report describes a case series of 3 infants presenting to the emergency department for evaluation of "bloody diarrhea." The parents noticed red stools when their children were started on oral cefdinir when they were previously receiving iron-containing preparations. Reddish-colored heme-negative stools observed in all cases were due to the interaction of the drug with supplemental iron or iron-containing formula feeds. This adverse effect was reversible on discontinuation of cefdinir. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Red stools due to cefdinir is an underreported benign adverse drug reaction with fewer than 10 cases described in the literature. Thorough history taking with an appropriate focus on diet and drug history are essential to avoid parental anxiety, unnecessary patient workup, and economic burden to the caregivers in these cases. Awareness of this unusual adverse effect among emergency physicians could prevent further inconvenience for already overburdened health systems.
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Affiliation(s)
- Souad Al Okla
- College of Medicine and Health Sciences, National University of Science and Technology, Muscat, Oman
| | | | - Santosh Kurbet
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education, Belagavi, India
| | - Yahya Al Attraqchi
- College of Medicine and Health Sciences, National University of Science and Technology, Muscat, Oman
| | - Alhasan Asaad
- College of Medicine and Health Sciences, National University of Science and Technology, Muscat, Oman
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11
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Cohen HA, Gerstein M, Loewenberg Weisband Y, Richenberg Y, Jacobson E, Cohen M, Shkalim Zemer V, Machnes MD. Pediatric Antibiotic Stewardship for Community-Acquired Pneumonia: A Pre-Post Intervention Study. Clin Pediatr (Phila) 2022; 61:795-801. [PMID: 35673872 DOI: 10.1177/00099228221102827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We aimed to investigate the effectiveness of an antibiotic stewardship program (ASP) on antibiotic prescription in children with community-acquired pneumonia (CAP). Antibiotic purchasing data were collected for children aged 3 months to 18 years diagnosed with CAP from November 2016 to April 2017 (pre-intervention period) and from November 2017 to April 2018 (post-intervention period). The intervention was a 1-day seminar for primary care pediatricians on the diagnosis and treatment of CAP in children according to national guidelines. There was a substantial decrease in the use of azithromycin after the intervention. In younger children, there was a 42% decrease, alongside an increased use of amoxicillin (P < .001). In older children, there was a smaller, non-statistically significant decrease in the use of azithromycin (P = .45). Our data demonstrate that the implementation of an ASP was associated with a reduction in the use of broad-spectrum antibiotics and macrolides and increased guideline adherence for the safe treatment of CAP.
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Affiliation(s)
- Herman Avner Cohen
- Pediatric Ambulatory Community Clinic, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya Gerstein
- Pediatric Ambulatory Community Clinic, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Eyal Jacobson
- Clalit Health Services, Dan-Petach Tikva District, Israel
| | | | - Vered Shkalim Zemer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Clalit Health Services, Petach Tikva, Israel
| | - Maayan Diti Machnes
- Pediatric Ambulatory Community Clinic, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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12
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Ramgopal S, Lorenz D, Navanandan N, Cotter JM, Shah SS, Ruddy RM, Ambroggio L, Florin TA. Validation of Prediction Models for Pneumonia Among Children in the Emergency Department. Pediatrics 2022; 150:e2021055641. [PMID: 35748157 PMCID: PMC11127179 DOI: 10.1542/peds.2021-055641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Several prediction models have been reported to identify patients with radiographic pneumonia, but none have been validated or broadly implemented into practice. We evaluated 5 prediction models for radiographic pneumonia in children. METHODS We evaluated 5 previously published prediction models for radiographic pneumonia (Neuman, Oostenbrink, Lynch, Mahabee-Gittens, and Lipsett) using data from a single-center prospective study of patients 3 months to 18 years with signs of lower respiratory tract infection. Our outcome was radiographic pneumonia. We compared each model's area under the receiver operating characteristic curve (AUROC) and evaluated their diagnostic accuracy at statistically-derived cutpoints. RESULTS Radiographic pneumonia was identified in 253 (22.2%) of 1142 patients. When using model coefficients derived from the study dataset, AUROC ranged from 0.58 (95% confidence interval, 0.52-0.64) to 0.79 (95% confidence interval, 0.75-0.82). When using coefficients derived from original study models, 2 studies demonstrated an AUROC >0.70 (Neuman and Lipsett); this increased to 3 after deriving regression coefficients from the study cohort (Neuman, Lipsett, and Oostenbrink). Two models required historical and clinical data (Neuman and Lipsett), and the third additionally required C-reactive protein (Oostenbrink). At a statistically derived cutpoint of predicted risk from each model, sensitivity ranged from 51.2% to 70.4%, specificity 49.9% to 87.5%, positive predictive value 16.1% to 54.4%, and negative predictive value 83.9% to 90.7%. CONCLUSIONS Prediction models for radiographic pneumonia had varying performance. The 3 models with higher performance may facilitate clinical management by predicting the risk of radiographic pneumonia among children with lower respiratory tract infection.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky
| | - Nidhya Navanandan
- Sections of Emergency Medicine, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Jillian M. Cotter
- Pediatric Hospital Medicine, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Samir S. Shah
- Divisions of Hospital Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Richard M. Ruddy
- Emergency Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Sections of Emergency Medicine, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Pediatric Hospital Medicine, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Todd A. Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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13
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Baša M, Sovtić A. Treatment of the most common respiratory infections in children. ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-37857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Acute respiratory infections are the most common group of infective diseases in the pediatric population. Although the improvement of health care and vaccination program has led to a significant reduction in the incidence of certain respiratory infections, the combination of a high prevalence in vulnerable pediatric categories and uncritical prescription of antibiotics, due to the inability to adequately distinguish between viruses and bacterial etiology, still represents a significant challenge for the public health system. In order to promote rational antibiotic therapy with an overall improvement of both diagnostic and therapeutic principles, acute respiratory diseases have been the subject of consideration in numerous publications and national guidelines. Nonspecific clinical manifestations with pathogen heterogeneity and both anatomical and physiological characteristics of the child's respiratory system during growth and development have created the need for individualized therapy. Since the guidelines emphasize the undoubtful and crucial benefits of symptomatic therapy (e.g. analgesics in acute otitis media, supplemental oxygen in lower respiratory tract infections with hypoxemia), the use of antibiotics and corticosteroids is indicated in selected cases with a severe clinical picture. The choice of antibiotic depends on the clinical condition, presumed causative agent, and local epidemiologic circumstances. Respiratory support (oxygen therapy and/or artificial ventilation) is reserved for inpatient treatment of cases with a particularly severe clinical picture and associated complications.
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14
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Monsees EA, Burns AN, Lee BR, Wirtz A, El Feghaly RE. Considerations for implementation: Pediatric outpatient antimicrobial stewardship program. Am J Infect Control 2021; 49:1543-1546. [PMID: 34358544 DOI: 10.1016/j.ajic.2021.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 11/15/2022]
Abstract
It is encouraging that most acute care centers have formal antimicrobial stewardship (AS) programs; though, most antibiotic use occurs in outpatient settings where access to infectious diseases specialists are limited. Stewardship programs often target dichotomous populations (adult or pediatric), but most children receive care in nonacademic, community outpatient settings. We propose 3 considerations for adult providers and infection preventionists seeking to incorporate outpatient AS elements and implement quality improvement initiatives that optimize pediatric care.
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Affiliation(s)
- Elizabeth A Monsees
- Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO
| | - Alaina N Burns
- Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO
| | - Brian R Lee
- Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO
| | - Ann Wirtz
- Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO
| | - Rana E El Feghaly
- Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO.
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15
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Lipshaw MJ, Florin TA, Krueger S, Belsky MA, Epperson T, Crotty EJ, Lipscomb J, Jacobs J, Rattan MS, Ruddy RM, Shah SS, Ambroggio L. Factors Associated With Antibiotic Prescribing and Outcomes for Pediatric Pneumonia in the Emergency Department. Pediatr Emerg Care 2021; 37:e1033-e1038. [PMID: 31290801 PMCID: PMC6946906 DOI: 10.1097/pec.0000000000001892] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Chest radiographs (CXRs) are often performed in children with respiratory illness to inform the decision to prescribe antibiotics. Our objective was to determine the factors associated with clinicians' plans to treat with antibiotics prior to knowledge of CXR results and the associations between preradiograph plans with antibiotic prescription and return to medical care. METHODS Previously healthy children aged 3 months to 18 years with a CXR for suspected pneumonia were enrolled in a prospective cohort study in the emergency department. Our primary outcomes were antibiotic prescription or administration in the emergency department and medical care sought within 7 to 15 days after discharge. Inverse probability treatment weighting was used to limit bias due to treatment selection. Inverse probability treatment weighting was included in a logistic regression model estimating the association between the intention to give antibiotics and outcomes. RESULTS Providers planned to prescribe antibiotics prior to CXR in 68 children (34.9%). There was no difference in the presence of radiographic pneumonia between those with and without a plan for antibiotics. Children who had a plan for antibiotics were more likely to receive antibiotics than those without (odds ratio [OR], 6.39; 95% confidence interval [CI], 3.7-11.0). This association was stronger than the association between radiographic pneumonia and antibiotic receipt (OR, 3.49; 95% CI, 1.98-6.14). Children prescribed antibiotics were more likely to seek care after discharge than children who were not (OR, 1.85; 95% CI, 1.13-3.05). CONCLUSIONS Intention to prescribe antibiotics based on clinical impression was the strongest predictor of antibiotic prescription in our study. Prescribing antibiotics may lead to subsequent medical care after controlling for radiographic pneumonia.
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Affiliation(s)
- Matthew J Lipshaw
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Todd A Florin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Sara Krueger
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Michael A Belsky
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Thomas Epperson
- Department of Pediatrics, University of Cincinnati College of Medicine
| | | | | | | | | | | | | | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, CO
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16
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Abstract
OBJECTIVES Although community-acquired pneumonia (CAP) is one of the most common infections in children, no standardized risk classification exists to guide management. The objective of this study was to develop expert consensus for factors associated with various degrees of disease severity in pediatric CAP. METHODS Using a web-based classical Delphi process, a multidisciplinary panel of 10 childhood pneumonia experts rated the degree of severity (mild, moderate, or severe) of clinical, radiographic, and laboratory factors, as well as outcomes relevant to pediatric pneumonia. Round 1 was open-ended, with panelists freely stating all characteristics they felt determined pneumonia severity. In rounds 2 to 4, panelists used a 9-point Likert scale (1-3, mild; 4-6, moderate; 7-9, severe) to rate severity for each item. Consensus was defined as 70% or greater agreement in ranking mild, moderate, or severe. RESULTS Panelists identified 318 factors or outcomes in round 1; the panel reached consensus for 286 (90%). The majority of items without consensus straddled levels of severity (eg, mild-moderate). Notable clinical factors with consensus included age, oxygen saturation, age-based respiratory rate, and gestational age. Severity classification consensus was also reached for specific imaging and laboratory findings. Need for and duration of hospitalization, supplemental oxygen/respiratory support, and intravenous fluids/medications were considered important outcomes in classifying severity. CONCLUSIONS This study presents factors deemed important for risk stratification in pediatric CAP by consensus of a multidisciplinary expert panel. This initial step toward identifying and formalizing severity criteria for CAP informs critical knowledge gaps and can be leveraged in future development of clinically meaningful risk stratification scores.
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Affiliation(s)
- Preston Dean
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center
| | - Daniel Schumacher
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Todd A. Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
- Department of Pediatrics, North-western University Feinberg School of Medicine, Chicago, IL
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17
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Chiotos K, Gerber JS. Does procalcitonin have clinical utility in the management of paediatric community-acquired pneumonia? A PRO/CON debate. JAC Antimicrob Resist 2021; 3:dlab153. [PMID: 34704033 PMCID: PMC8531865 DOI: 10.1093/jacamr/dlab153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Although the overwhelming majority of community-acquired pneumonia (CAP) in children is caused by viral infections, treatment of CAP is among the most common indications for antibiotic use in children. This is largely driven by the imprecision of clinical diagnostic tools to differentiate viral from bacterial pneumonia and highlights the need for improved approaches to optimizing management of CAP in children. In this issue of JAC-Antimicrobial Resistance, we present a PRO/CON debate that discusses the clinical utility of procalcitonin in children with CAP.
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Affiliation(s)
- Kathleen Chiotos
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey S Gerber
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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18
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McLaren SH, Mistry RD, Neuman MI, Florin TA, Dayan PS. Guideline Adherence in Diagnostic Testing and Treatment of Community-Acquired Pneumonia in Children. Pediatr Emerg Care 2021; 37:485-493. [PMID: 30829848 DOI: 10.1097/pec.0000000000001745] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to determine emergency department (ED) physician adherence with the 2011 Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) guidelines for outpatient management of children with mild-to-moderate community-acquired pneumonia (CAP). METHODS A cross-sectional survey of physicians on the American Academy of Pediatrics Section on Emergency Medicine Survey listserv was conducted. We evaluated ED physicians' reported adherence with the PIDS/IDSA guidelines through presentation of 4 clinical vignettes representing mild-to-moderate CAP of presumed viral (preschool-aged child), bacterial (preschool and school-aged child), and atypical bacterial (school-aged child) etiology. RESULTS Of 120 respondents with analyzable data (31.4% response rate), use of chest radiograph (CXR) was nonadherent to the guidelines in greater than 50% of respondents for each of the 4 vignettes. Pediatric emergency medicine fellowship training was independently associated with increased CXR use in all vignettes, except for school-aged children with bacterial CAP. Guideline-recommended amoxicillin was selected to treat bacterial CAP by 91.7% of the respondents for preschool-aged children and by 75.8% for school-aged children. Macrolide monotherapy for atypical CAP was appropriately selected by 88.2% and was associated with obtaining a CXR (adjusted odds ratio, 3.9 [95% confidence interval, 1.4-11.1]). Guideline-adherent antibiotic use for all vignettes was independently associated with congruence between respondent's presumed diagnosis and the vignette's intended etiologic diagnosis. CONCLUSIONS Reported ED CXR use in the management of outpatient CAP was often nonadherent to the PIDS/IDSA guidelines. Most respondents were adherent to the guidelines in their use of antibiotics. Strategies to increase diagnostic test accuracy are needed to improve adherence and reduce variation in care.
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Affiliation(s)
- Son H McLaren
- From the Morgan Stanley Children's Hospital, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Rakesh D Mistry
- Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, CO
| | - Mark I Neuman
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Todd A Florin
- Ann and Robert H Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Peter S Dayan
- From the Morgan Stanley Children's Hospital, College of Physicians and Surgeons, Columbia University, New York, NY
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19
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Warris A. Macrolides (alone or in combination) should be used as first-line empirical therapy of community-acquired pneumonia in children: myth or maxim? Breathe (Sheff) 2021; 17:210056. [PMID: 35035545 PMCID: PMC8753631 DOI: 10.1183/20734735.0056-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/09/2021] [Indexed: 11/10/2022] Open
Abstract
Macrolides should not be used as first-line therapy for community-acquired pneumonia in children as no clinical benefit is shown and widespread use is associated with an emerging increase in macrolide resistance amongst S. pneumoniae and M. pneumoniae https://bit.ly/3yQuedF.
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Affiliation(s)
- Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, UK; Great Ormond Street Hospital, London, UK
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20
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Payton KSE, Brunetti MA. Antibiotic Stewardship in Pediatrics. Adv Pediatr 2021; 68:37-53. [PMID: 34243858 DOI: 10.1016/j.yapd.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kurlen S E Payton
- Department of Pediatrics, Division of Neonatology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, NT Suite 4221, Los Angeles, CA 90048, USA.
| | - Marissa A Brunetti
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard Suite 8NE51, Philadelphia, PA 19104, USA
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21
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Kamzan AD, Ng E. When Less is More: The Role of Overdiagnosis and Overtreatment in Patient Safety. Adv Pediatr 2021; 68:21-35. [PMID: 34243853 DOI: 10.1016/j.yapd.2021.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Audrey D Kamzan
- Division of Pediatric Hospital Medicine, Mattel Children's Hospital, 10833 LeConte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA; David Geffen School of Medicine at the University of California, Los Angeles, 10833 Le Conte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA.
| | - Elayna Ng
- Division of Pediatric Hospital Medicine, Mattel Children's Hospital, 10833 LeConte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA; David Geffen School of Medicine at the University of California, Los Angeles, 10833 Le Conte Avenue, A2-383 MDCC, Los Angeles, CA 90095, USA
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22
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Murphy ME, Powell E, Courter J, Mortensen JE. Predicting Oral Beta-lactam susceptibilities against Streptococcus pneumoniae. BMC Infect Dis 2021; 21:679. [PMID: 34256734 PMCID: PMC8278757 DOI: 10.1186/s12879-021-06341-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 06/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral beta-lactam antimicrobials are not routinely tested against Streptococcus pneumoniae due to presumed susceptibility based upon penicillin minimum inhibitory concentration (MIC) testing. Currently, Clinical and Laboratory Standards Institute provides comments to use penicillin MIC ≤0.06 to predict oral cephalosporin susceptibility. However, no guidance is provided when cefotaxime MIC is known, leading to uncertainty with interpretation. The purpose of this study was to evaluate cefotaxime and penicillin MICs and their respective correlation to oral beta-lactam categorical susceptibility patterns. METHODS 249 S. pneumoniae isolates were identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-ToF) and then tested by broth microdilution method to penicillin, cefotaxime, amoxicillin, cefdinir, cefpodoxime, and cefuroxime. RESULTS Using Clinical and Laboratory Standards Institute (CLSI) non-meningitis breakpoints for cefotaxime, 240/249 isolates were classified as susceptible. Of the cefotaxime susceptible isolates, 23% of the isolates are misrepresented as cefdinir susceptible. Amoxicillin correlated well with penicillin MIC breakpoints with only 1 discordant isolate out of 249. CONCLUSION The correlation between amoxicillin and penicillin creates a very reliable predictor to determine categorical susceptibility. However oral cephalosporins were not well predicted by either penicillin or cefotaxime leading to the possible risk of treatment failures. Caution should be used when transitioning to oral cephalosporins in cefotaxime susceptible isolates, especially with higher cefotaxime MICs.
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Affiliation(s)
- Mark E Murphy
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eleanor Powell
- Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Joshua Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joel E Mortensen
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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23
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Mustafa ZU, Salman M, Aslam N, Asif N, Hussain K, Shehzadi N, Hayat K. Antibiotic use among hospitalized children with lower respiratory tract infections: a multicenter, retrospective study from Punjab, Pakistan. Expert Rev Anti Infect Ther 2021; 20:131-136. [PMID: 34047247 DOI: 10.1080/14787210.2021.1935235] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Lower respiratory tract infection (LRTI) is one of the triggering factors toward death in children below the age of five years necessitating appropriate antibiotic selection. This study aimed to evaluate antibiotic use among hospitalized children (≤5 years age) with LRTIs. METHODS A retrospective study was conducted in seven health facilities of the central region of Punjab province of Pakistan. The medical records of hospitalized children ≤5 years diagnosed with LRTI were thoroughly evaluated to get information on demographics, clinical characteristics, and details of prescribed antibiotics. The appropriateness of antibiotics was assessed according to guidelines of the British National Formulary due to a lack of indigenous standard treatment guidelines. RESULTS The medical records of 5926 children were searched with the majority (70.9%) diagnosed with community-acquired pneumonia (CAP) followed by acute bronchitis (14.1%). Ceftriaxone plus ampicillin and ceftriaxone plus ampicillin plus amikacin were prescribed to 39% and 11.7% study population, respectively. One-fourth of children were prescribed the wrong dose, and more than half were encountered with the incorrect route of antibiotic administration. Alarmingly, 90.2% of antibiotic prescriptions were inappropriate in our findings. CONCLUSIONS Current surveillance study revealed a worrying degree of antibiotic misuse among hospitalized LRTI children aged ≤5 years.
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Affiliation(s)
- Zia Ul Mustafa
- Department of Pharmacy Services, District Head Quarter (DHQ) Hospital, Pakpattan, Pakistan
| | - Muhammad Salman
- Department of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Naeem Aslam
- Department of Surgery & Allied, District Head Quarter (DHQ) Hospital, Pakpattan, Pakistan
| | - Noman Asif
- Department of pharmaceutic, Gulab Devi institute of pharmacy, Lahore, Pakistan
| | - Khalid Hussain
- Punjab University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | - Naureen Shehzadi
- Punjab University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | - Khezar Hayat
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China.,Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
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24
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Antibiotic Prescribing Patterns for Hospitalized children with Community-Acquired Pneumonia in a Secondary Care Center. J Infect Public Health 2021; 14:1035-1041. [PMID: 34166877 DOI: 10.1016/j.jiph.2021.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 04/17/2021] [Accepted: 05/30/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Narrow-spectrum antibiotics are recommended as the first-line therapy for management of children hospitalized with community-acquired pneumonia (CAP). There are limited data evaluating the antibiotic prescription patterns for CAP in Saudi Arabia. The goal of this study to report on the antibiotic patterns in children hospitalized with CAP. METHODS A prospective cross-sectional study was conducted in children aged 1 month to 13 years who were hospitalized with a diagnosis of CAP at King Khalid Hospital in Majmaah, Saudi Arabia, between January 2019 and January 2020. RESULTS Data from 233 patients were collected. The majority of patients received amoxicillin clavulanate (57.9%), followed by ceftriaxone (30%), azithromycin (20.6%), cefuroxime (6%), ampicillin (2.1%), and piperacillin-tazobactam (2.1%). None of our patients were started on narrow-spectrum therapy. The younger age group (1-3 months) and patients with severe pneumonia were more likely to receive broad-spectrum cephalosporin and have a longer hospital stay (P = .000 and P = .002, respectively). However, the 4 months to 5 years age group was more likely to receive amoxicillin clavulanate (P = .001). Male gender was a significate risk factor for patients with severe pneumonia (P=.013) CONCLUSIONS: We demonstrated the inappropriate use of broad-spectrum therapy in children hospitalized with CAP. Further large multicenter studies are necessary to evaluate the patterns of antibiotic use and implement antimicrobial stewardship programs or quality-improvement projects to improve adherence to guidelines.
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25
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Rural-urban differences in antibiotic prescribing for uncomplicated urinary tract infection. Infect Control Hosp Epidemiol 2021; 42:1437-1444. [PMID: 33622432 DOI: 10.1017/ice.2021.21] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To examine rural-urban differences in temporal trends and risk of inappropriate antibiotic use by agent and duration among women with uncomplicated urinary tract infection (UTI). DESIGN Observational cohort study. METHODS Using the IBM MarketScan Commercial Database (2010-2015), we identified US commercially insured women aged 18-44 years coded for uncomplicated UTI and prescribed an oral antibiotic agent. We classified antibiotic agents and durations as appropriate versus inappropriate based on clinical guidelines. Rural-urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural-urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics. We used multivariable logistic regression to estimate trends in antibiotic use by rural-urban status. RESULTS Of 670,450 women with uncomplicated UTI, a large proportion received antibiotic prescriptions for inappropriate agents (46.7%) or durations (76.1%). Compared to urban women, rural women were more likely to receive prescriptions with inappropriately long durations (adjusted risk ratio 1.10, 95% CI, 1.10-1.10), which was consistent across subgroups. From 2011 to 2015, there was slight decline in the quarterly proportion of patients who received inappropriate agents (48.5% to 43.7%) and durations (78.3% to 73.4%). Rural-urban differences varied over time by agent (duration outcome only), geographic region, and provider specialty. CONCLUSIONS Inappropriate antibiotic prescribing is quite common for the treatment of uncomplicated UTI. Rural women are more likely to receive inappropriately long antibiotic durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and to reduce unnecessary exposure to antibiotics, particularly in rural settings.
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Costenaro P, Cantarutti A, Barbieri E, Scamarcia A, Oletto A, Sacerdoti P, Lundin R, Cantarutti L, Giaquinto C, Donà D. Antibiotic Prescriptions for Children With Community-acquired Pneumonia: Findings From Italy. Pediatr Infect Dis J 2021; 40:130-136. [PMID: 33055500 DOI: 10.1097/inf.0000000000002934] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION AND OBJECTIVE Community-acquired pneumonia (CAP) is one of the most common reasons of prescribing antibiotics for children, often with overuse of broad-spectrum antibiotics. The aim of this study is to describe the antibiotic prescriptions for Italian children with CAP, at the primary care level. STUDY DESIGN Retrospective cohort study conducted among children 3 months-14 years of age with CAP, enrolled in Pedianet (http://www.pedianet.it) from January 1, 2009 to December 31, 2018. Antibiotic treatment was defined as narrow-spectrum (NS-ABT) if amoxicillin and broad-spectrum (BS-ABT) if amoxicillin/clavulanic acid, cephalosporins or any combination. Crude and adjusted logistic regressions for the odds of receiving NS-ABT were conducted (all episodes of CAP and per patient). A P value <0.05 was considered statistically significant. RESULTS Among 9691 CAP, 7260 episodes from 6409 children followed by 147 pediatricians were analyzed. The 16.7% of CAP [1216/7260, 95% confidence interval (CI): 15.9%-17.6%] received an NS-ABT while 53.3% (3863/7260, 95% CI: 52%-54.4%) received BS-ABTs and 30% (2181/7260, 95% CI: 28.9%-31.1%) macrolides. Within 10 years, a slight but increasing trend of NS-ABT prescription was observed (P < 0.001). Factors independently associated with reduced odds of receiving an NS-ABT compared with BS-ABT including macrolides were being older than 5 years [odds ratio (OR) 0.45, 95% CI: 0.39-0.52], living in Central/Southern Italy (OR 0.13, 95% CI: 0.10-0.16) and being exposed to ABT 3 months before (OR 0.61, 95% CI: 0.53-0.70). These findings were confirmed comparing NS-ABT versus BS-ABT excluding macrolides (n = 5079) and when the analysis was limited to index CAP. CONCLUSION Our findings report a very limited prescription of narrow-spectrum antibiotics for Italian children with CAP.
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Affiliation(s)
- Paola Costenaro
- From the Division of Paediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua
| | - Anna Cantarutti
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca
- Department of Statistics and Quantitative Methods, Unit of Biostatistics Epidemiology and Public Health, University of Milano-Bicocca, Milan
| | - Elisa Barbieri
- From the Division of Paediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca
- Department of Statistics and Quantitative Methods, Unit of Biostatistics Epidemiology and Public Health, University of Milano-Bicocca, Milan
- Pedianet Project
- Paediatric Network for Treatment of AIDS or Penta Foundation, Padua, Italy
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | | | - Andrea Oletto
- Paediatric Network for Treatment of AIDS or Penta Foundation, Padua, Italy
| | - Paolo Sacerdoti
- Paediatric Network for Treatment of AIDS or Penta Foundation, Padua, Italy
| | - Rebecca Lundin
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | | | - Carlo Giaquinto
- From the Division of Paediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua
- Pedianet Project
- Paediatric Network for Treatment of AIDS or Penta Foundation, Padua, Italy
| | - Daniele Donà
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca
- Paediatric Network for Treatment of AIDS or Penta Foundation, Padua, Italy
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Gareca Perales J, Soleto Ortiz L, Loayza Mafayle R, Machuca Soto B, Hidalgo Flores L, López Montaño J, Zuna Calle N, Jarovsky D, Naaman Berezin E. Diagnosis of Community-acquired Pneumonia in Hospitalized Children: A Multicenter Experience in Bolivia. Pediatr Infect Dis J 2021; 40:32-38. [PMID: 33006878 DOI: 10.1097/inf.0000000000002909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) represents a major cause of hospitalization, especially among young children. In the third world countries, information about CAP etiology is scarce. Therefore, rapid and highly sensitive diagnostic methods are crucial to determine etiologic agents. METHODS Between March 2016 and March 2017, we have prospectively studied the clinical, radiologic, laboratory, and molecular aspects of patients with CAP at 2 tertiary-level hospitals in Santa Cruz de la Sierra, using a multiplex real-time polymerase chain reaction (RT-PCR). RESULTS A total of 274 children were evaluated, with a median age of 13 months. An etiologic agent was identified in 187 patients (68.2%): 54% (n = 148) were viruses and 14.2% (n = 39) were bacteria. CAP prevalence was highest among children under 2 years (71%; 195/274); respiratory syncytial virus (RSV) was the most frequent cause in 22% (60/274), especially among infants, followed by influenza (14.5%; 40/274). Streptococcus pneumoniae accounted for 7% of the total (19/274), followed by Staphylococcus aureus (3%;8/274) and Haemophilus influenzae (1.4%;4/274). Together, these cases accounted for 79.5% (31/39) of all bacterial CAP. Pleural effusion (PE) complicated CAP in 13.8% (38/274), of which 29 were of bacterial etiology. RT-PCR increased the detection rate of pneumococcus by 47%. Coinfection occurred in 28 patients (10%); 26 (9.5%) required intensive care and 9 patients (3%) died. CONCLUSIONS RT-PCR provided additional diagnostic value to conventional, clinical, and laboratory methods. The higher prevalence of RSV, influenza, and Streptococcus pneumoniae reveals the need for preventive measures with better vaccine uptake and future research for RSV vaccines.
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Affiliation(s)
- José Gareca Perales
- From the Centro de Pediatría Especializada "CRECER," Santa Cruz de la Sierra, Bolivia
| | - Lorena Soleto Ortiz
- Centro Nacional de Enfermedades Tropicales (CENETROP), Santa Cruz de la Sierra, Bolivia
| | - Roxana Loayza Mafayle
- Centro Nacional de Enfermedades Tropicales (CENETROP), Santa Cruz de la Sierra, Bolivia
| | - Blanca Machuca Soto
- Hospital Municipal de Niños "Dr. Mario Ortiz Suárez," Santa Cruz de la Sierra, Bolivia
| | - Lucia Hidalgo Flores
- Hospital Municipal de Niños "Dr. Mario Ortiz Suárez," Santa Cruz de la Sierra, Bolivia
| | - Javier López Montaño
- Hospital Municipal de Niños "Dr. Mario Ortiz Suárez," Santa Cruz de la Sierra, Bolivia
| | | | - Daniel Jarovsky
- Pediatric Infectious Disease Unit, Santa Casa de São Paulo, São Paulo, Brazil
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28
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Dantuluri KL, Bruce J, Edwards KM, Banerjee R, Griffith H, Howard LM, Grijalva CG. Rurality of Residence and Inappropriate Antibiotic Use for Acute Respiratory Infections Among Young Tennessee Children. Open Forum Infect Dis 2020; 8:ofaa587. [PMID: 33511228 PMCID: PMC7814393 DOI: 10.1093/ofid/ofaa587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background Antibiotic use is common for acute respiratory infections (ARIs) in children, but much of this use is inappropriate. Few studies have examined whether rurality of residence is associated with inappropriate antibiotic use. We examined whether rates of ARI-related inappropriate antibiotic use among children vary by rurality of residence. Methods We conducted a retrospective cohort study of children aged 2 months-5 years enrolled in Tennessee Medicaid between 2007 and 2017 and diagnosed with ARI in the outpatient setting. Study outcomes included ARI, ARI-related antibiotic use, and ARI-related inappropriate antibiotic use. Multivariable Poisson regression was used to measure associations between rurality of residence, defined by the US Census Bureau, and the rate of study outcomes, while accounting for other factors including demographics and underling comorbidities. Results A total of 805 332 children met selection criteria and contributed 1 840 048 person-years (p-y) of observation. Children residing in completely rural, mostly rural, and mostly urban counties contributed 70 369 (4%) p-y, 479 121 (26%) p-y, and 1 290 558 p-y (70%), respectively. Compared with children in mostly urban counties (238 per 1000 p-y), children in mostly rural (450 per 1000 p-y) and completely rural counties (468 per 1000 p-y) had higher rates of inappropriate antibiotic use (adjusted incidence rate ratio [aIRR] = 1.34, 95% confidence interval [CI] = 1.33-1.35 and aIRR = 1.33, 95% CI = 1.32-1.35, respectively). Conclusions Inappropriate antibiotic use is common among young children with ARI, with higher rates in rural compared with urban counties. These differences should inform targeted outpatient antibiotic stewardship efforts.
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Affiliation(s)
- Keerti L Dantuluri
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jean Bruce
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn M Edwards
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ritu Banerjee
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hannah Griffith
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leigh M Howard
- Department of Pediatrics (Infectious Diseases), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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29
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Diaz MCG, Handy LK, Crutchfield JH, Cadilla A, Hossain J, Werk LN. Impact of a Personalized Audit and Feedback Intervention on Antibiotic Prescribing Practices for Outpatient Pediatric Community-Acquired Pneumonia. Clin Pediatr (Phila) 2020; 59:988-994. [PMID: 32486840 DOI: 10.1177/0009922820928054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibiotic choice for pediatric community-acquired pneumonia (CAP) varies widely. We aimed to determine the impact of a 6-month personalized audit and feedback program on primary care providers' antibiotic prescribing practices for CAP. Participants in the intervention group received monthly personalized feedback. We then analyzed enrolled providers' CAP antibiotic prescribing practices. Participants diagnosed 316 distinct cases of CAP (214 control, 102 intervention); among these 316 participants, 301 received antibiotics (207 control, 94 intervention). In patients ≥5 years, the intervention group had fewer non-guideline-concordant antibiotics prescribed (22/103 [21.4%] control; 3/51 [5.9%] intervention, P < .05) and received more of the guideline-concordant antibiotics (amoxicillin and azithromycin). Personalized, scheduled audit and feedback in the outpatient setting was feasible and had a positive impact on clinician's selection of guideline-recommended antibiotics. Audit and feedback should be combined with other antimicrobial stewardship interventions to improve guideline adherence in the management of outpatient CAP.
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Affiliation(s)
| | - Lori K Handy
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Jobayer Hossain
- Nemours/Alfred I. du Pont Hospital for Children, Wilmington, DE, USA
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30
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Gill M, Blacketer C, Chitti F, Telfer K, Papanicolas L, Dann LM, Tucker EC, Bryant RV, Costello SP. Physician and patient perceptions of fecal microbiota transplant for recurrent or refractory Clostridioides difficile in the first 6 years of a central stool bank. JGH OPEN 2020; 4:950-957. [PMID: 33102769 PMCID: PMC7578309 DOI: 10.1002/jgh3.12396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/14/2020] [Indexed: 11/08/2022]
Abstract
Background and Aim Fecal microbiota transplantation (FMT) is a highly effective therapy for recurrent or refractory Clostridioides difficile infection (rCDI). Despite inclusion in society guidelines, the uptake of FMT therapy has been variable. Physician and patient attitudes may be a barrier to evidence‐based uptake of therapies; however, data assessing attitudes regarding FMT for rCDI are limited. Methods The South Australian FMT for CDI database prospectively recorded patient outcomes of FMT for CDI from August 2013 to January 2019. A total of 93 consecutive patients who underwent FMT for rCDI in South Australia were invited to participate in a 20‐question survey regarding the patient experience of FMT. All gastroenterologists and infectious disease physicians practicing in South Australia were invited to participate in an online survey comprised of 22 questions that addressed referral experience, indications for referral, perceived risks, and regulation and funding. Results Fifty‐four patients (54/93, 58%) returned the survey, of whom 52 (96%) would recommend FMT to others, and 51 (94%) were satisfied with treatment outcome. Fifty physicians returned the online survey (50/100, 50%), of whom 23 (46%) were concerned about disease transmission risk, and 15 (30%) believed that the risk of FMT would outweigh the benefit. Infectious diseases physicians and advanced trainees had significantly greater concern regarding the potential alteration of the microbiome than gastroenterology physicians and advanced trainees (8/17 (47%) vs 6/33 (18%); P = 0.047). Conclusion Despite high levels of patient‐reported satisfaction following FMT, physician‐reported reservations exist and may present a barrier to uptake of this therapy.
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Affiliation(s)
- Madeleine Gill
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia
| | - Charlotte Blacketer
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia
| | - Franco Chitti
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia
| | - Karmen Telfer
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia.,School of Medicine University of Adelaide Adelaide South Australia Australia
| | - Lito Papanicolas
- School of Medicine Flinders University Adelaide South Australia Australia.,Department of Infectious Diseases Royal Adelaide Hospital Adelaide South Australia Australia
| | - Lisa M Dann
- BiomeBank Adelaide South Australia Australia
| | - Emily C Tucker
- BiomeBank Adelaide South Australia Australia.,Department of Infectious Diseases Flinders Medical Centre Adelaide South Australia Australia
| | - Robert V Bryant
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia.,School of Medicine University of Adelaide Adelaide South Australia Australia.,BiomeBank Adelaide South Australia Australia
| | - Samuel P Costello
- Department of Gastroenterology The Queen Elizabeth Hospital Adelaide South Australia Australia.,School of Medicine University of Adelaide Adelaide South Australia Australia.,BiomeBank Adelaide South Australia Australia
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31
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Klatte JM. Pediatric Antimicrobial Stewardship Programs: Current Perspectives. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2020; 11:245-255. [PMID: 32801990 PMCID: PMC7383043 DOI: 10.2147/phmt.s224774] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/17/2020] [Indexed: 11/23/2022]
Abstract
With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.
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Affiliation(s)
- J Michael Klatte
- Division of Infectious Disease, Dayton Children's Hospital, Dayton, OH, USA
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32
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Le Saux NMA, Bowes J, Viel-Thériault I, Thampi N, Blackburn J, Buba M, Harrison MA, Barrowman N. Combined influence of practice guidelines and prospective audit and feedback stewardship on antimicrobial treatment of community-acquired pneumonia and empyema in children: 2012 to 2016. Paediatr Child Health 2020; 26:234-241. [PMID: 34136053 DOI: 10.1093/pch/pxaa066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/20/2020] [Indexed: 01/15/2023] Open
Abstract
Background Aminopenicillins are recommended empiric therapy for community-acquired pneumonia (CAP). The aim of the study was to assess treatment over a 5-year period after CAP guideline publication and introduction of an antimicrobial stewardship program (ASP). Methods Using ICD-10 discharge codes for pneumonia, children less than 18 years admitted to the Children's Hospital of Eastern Ontario January 1, 2012 and December 31, 2016 were identified. Children ≥ 2 months with consolidation were included. One day of therapy (DOT) was one or more doses of an antimicrobial given for 1 day. Results Of 1,707 patients identified, 713 met inclusion criteria. Eighteen (2.5%) had bacteria identified by culture and 79 of 265 (29.8%) had Mycoplasma pneumoniae detected. Mean DOT/1,000 patient days of aminopenicillins/penicillin (AAP) increased by 18.1% per year (95% confidence interval [CI] -0.2, 39.9%) and decreased by 37.6% per year (95% CI -56.1, -11.3%) for second- and third-generation cephalosporins in the post-ASP period. The duration of discharge antimicrobials decreased. Of 74 (10.4%) patients who had pleural fluid drained, 35 (47.3%) received more than 5 days of AAP and ≤ 5 days of second-/third-generation cephalosporins with no difference in median length of stay nor mean duration of antimicrobials. Conclusions Implementation of CAP management guidelines followed by prospective audit and feedback stewardship was associated with a sustained decrease in the use of broad-spectrum antibiotics in childhood CAP. Use of AAP should also be strongly considered in patients with effusions (even if no pathogen is identified), as clinical outcome appears similar to patients treated with broad-spectrum antimicrobials.
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Affiliation(s)
- Nicole M A Le Saux
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Jennifer Bowes
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Service d'Infectiologie, Département de Pédiatrie, Centre hospitalier université Laval et Centre mère-enfant Soleil, Québec, Québec
| | - Nisha Thampi
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Julie Blackburn
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Services de microbiologie et de maladies infectieuses, CHU Sainte-Justine, Montréal, Québec
| | - Melanie Buba
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Mary-Ann Harrison
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
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33
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Lipshaw MJ, Eckerle M, Florin TA, Crotty EJ, Lipscomb J, Jacobs J, Rattan MS, Ruddy RM, Shah SS, Ambroggio L. Antibiotic Use and Outcomes in Children in the Emergency Department With Suspected Pneumonia. Pediatrics 2020; 145:peds.2019-3138. [PMID: 32179662 PMCID: PMC7111492 DOI: 10.1542/peds.2019-3138] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Antibiotic therapy is often prescribed for suspected community-acquired pneumonia (CAP) in children despite a lack of knowledge of causative pathogen. Our objective in this study was to investigate the association between antibiotic prescription and treatment failure in children with suspected CAP who are discharged from the hospital emergency department (ED). METHODS We performed a prospective cohort study of children (ages 3 months-18 years) who were discharged from the ED with suspected CAP. The primary exposure was antibiotic receipt or prescription. The primary outcome was treatment failure (ie, hospitalization after being discharged from the ED, return visit with antibiotic initiation or change, or antibiotic change within 7-15 days from the ED visit). The secondary outcomes included parent-reported quality-of-life measures. Propensity score matching was used to limit potential bias attributable to treatment selection between children who did and did not receive an antibiotic prescription. RESULTS Of 337 eligible children, 294 were matched on the basis of propensity score. There was no statistical difference in treatment failure between children who received antibiotics and those who did not (odds ratio 1.0; 95% confidence interval 0.45-2.2). There was no difference in the proportion of children with return visits with hospitalization (3.4% with antibiotics versus 3.4% without), initiation and/or change of antibiotics (4.8% vs 6.1%), or parent-reported quality-of-life measures. CONCLUSIONS Among children with suspected CAP, the outcomes were not statistically different between those who did and did not receive an antibiotic prescription.
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Affiliation(s)
| | - Michelle Eckerle
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Todd A. Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois; and
| | - Eric J. Crotty
- Radiology,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Mantosh S. Rattan
- Radiology,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Richard M. Ruddy
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Samir S. Shah
- Hospital Medicine, and,Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado Denver and Sections of Emergency Medicine and Hospital Medicine, Children’s Hospital Colorado, Denver, Colorado
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34
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Broom A, Kenny K, Prainsack B, Broom J. Antimicrobial resistance as a problem of values? Views from three continents. CRITICAL PUBLIC HEALTH 2020. [DOI: 10.1080/09581596.2020.1725444] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Alex Broom
- Department of Sociology and Social Policy, School of Social and Political Sciences, The University of Sydney, Sydney, Australia
| | - Katherine Kenny
- Department of Sociology and Social Policy, School of Social and Political Sciences, The University of Sydney, Sydney, Australia
| | - Barbara Prainsack
- Department of Political Science, University of Vienna, Vienna, Austria
| | - Jennifer Broom
- Sunshine Coast, Sunshine Coast University Hospital, Queensland, Australia
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35
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Vagedes J, Martin D, Müller V, Helmert E, Huber BM, Andrasik F, von Schoen-Angerer T. Restrictive antibiotic use in children hospitalized for pneumonia: A retrospective inpatient study. Eur J Integr Med 2020. [DOI: 10.1016/j.eujim.2020.101068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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36
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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.
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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
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37
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Krishnakumar J, Tsopra R. What rationale do GPs use to choose a particular antibiotic for a specific clinical situation? BMC FAMILY PRACTICE 2019; 20:178. [PMID: 31862003 PMCID: PMC6925435 DOI: 10.1186/s12875-019-1068-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 12/11/2019] [Indexed: 11/16/2022]
Abstract
Background Many studies have investigated the ways in which physicians decide whether to prescribe antibiotics, but very few studies have focused on the reasons for which general practitioners (GPs) choose to prescribe a particular antibiotic in a specific clinical situation. Improvements in our understanding of the rationale behind GPs’ decisions would provide insight into the reasons for which GPs do not always prescribe the antibiotic recommended in clinical practice guidelines and facilitate the development of appropriate interventions to improve antibiotic prescription. The objective of the study was to understand the rationale used by GPs to decide which antibiotic to prescribe in a specific clinical situation, and to propose a model representing this rationale. Methods We used a three-step process. First, data were collected from interviews with 20 GPs, and analysed according to the grounded theory approach. Second, data were collected from publications exploring the factors used by GPs to choose an antibiotic. Third, data were used to develop a comprehensive model of the rationale used by GPs to decide which antibiotic to prescribe. Results The GPs considered various factors when choosing antibiotics: factors relating to microbiology (bacterial resistance), pharmacology (adverse effects, efficacy, practicality of the administration protocol, antibiotic class, drug cost), clinical conditions (patient profile and comorbid conditions, symptoms, progression of infection, history of antibiotic treatment, preference), and personal factors (GP’s experience, knowledge, emotion, preference). Conclusions Various interventions, targeting all the factors underlying antibiotic choice, are required to improve antibiotic prescription. GP-related factors could be improved through interventions aiming to improve the GPs’ knowledge of antibiotics (e.g. continuing medical education). Factors relating to microbiology, pharmacology and clinical conditions could be targeted through the use of clinical decision support systems in everyday clinical practice.
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Affiliation(s)
| | - Rosy Tsopra
- Université Paris 13, 74 rue Marcel Cachin, Bobigny, France. .,Leeds Centre for Respiratory Medicine, St James's University Hospital, Leeds, UK.
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Pediatric Inpatient Antimicrobial Stewardship Program Safely Reduces Antibiotic Use in Patients with Bronchiolitis Caused by Respiratory Syncytial Virus: A Retrospective Chart Review. Pediatr Qual Saf 2019; 4:e211. [PMID: 31745514 PMCID: PMC6831042 DOI: 10.1097/pq9.0000000000000211] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 08/06/2019] [Indexed: 12/31/2022] Open
Abstract
Bronchiolitis is a common lower respiratory tract illness in young children often caused by the respiratory syncytial virus (RSV). Antimicrobials are not recommended in infants with bronchiolitis unless there is strong evidence that a bacterial coinfection exists.
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Florin TA, Byczkowski T, Gerber JS, Ruddy R, Kuppermann N. Diagnostic Testing and Antibiotic Use in Young Children With Community-Acquired Pneumonia in the United States, 2008-2015. J Pediatric Infect Dis Soc 2019; 9:248-252. [PMID: 31107533 PMCID: PMC7192397 DOI: 10.1093/jpids/piz026] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/12/2019] [Indexed: 11/14/2022]
Abstract
Diagnostic testing and antibiotics are not routinely recommended for young children with community-acquired pneumonia. In a national sample of >6 million outpatient 1- to 6-year-olds with community-acquired pneumonia between 2008 and 2015, a complete blood count was obtained for 8.6% (95% confidence interval [CI], 6.1%-11.1%), radiography was performed for 43% (95% CI, 36%-50%), and antibiotics were given for 73.9% (95% CI, 67.1%-80.7%). There were no changes in testing or antibiotic use over time.
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Affiliation(s)
- Todd A Florin
- Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Illinois,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Correspondence: T. A. Florin, MD, MSCE, Ann and Robert H. Lurie Children’s Hospital of Chicago, Division of Emergency Medicine, 225 E Chicago Ave, Box 62, Chicago, IL 60611 ()
| | - Terri Byczkowski
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Ohio
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Richard Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Ohio
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California School of Medicine and University of California Davis Health
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Abstract
PURPOSE OF REVIEW The majority of pediatric antibiotic use occurs in outpatients. However, the optimal strategies for antimicrobial stewardship in this setting are unknown. We sought to identify studies relevant to pediatric outpatient stewardship that have been published in the past decade. The details of this systemic review are presented along with targets for future stewardship efforts and discussion regarding effective outpatient stewardship strategies. RECENT FINDINGS In 2016, the CDC released the "Core Elements of Outpatient Antibiotic Stewardship" that serve as practical guidelines to develop impactful and sustainable ASP interventions: commitment, action for policy and practice, tracking and reporting, and education and expertise. However, there has not been a recent review of the primary medical literature on pediatric outpatient stewardship. A systematic review of pediatric antibiotic control strategies published in 2007 identified 28 studies overall, 8 of which focused on outpatients. Two subsequent systematic reviews published in 2015 and 2018 intentionally excluded outpatients. Outpatient settings are a crucial component of pediatric antimicrobial stewardship in the USA. Establishing effective stewardship interventions can protect children and optimize clinical outcomes in outpatient healthcare settings. Based on our review of the literature, it is clear that the optimal outpatient stewardship strategies remain to be elucidated. However, there is robust literature describing variability in outpatient antibiotic prescribing that can be used to target interventions.
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van de Maat J, van de Voort E, Mintegi S, Gervaix A, Nieboer D, Moll H, Oostenbrink R. Antibiotic prescription for febrile children in European emergency departments: a cross-sectional, observational study. THE LANCET. INFECTIOUS DISEASES 2019; 19:382-391. [PMID: 30827808 DOI: 10.1016/s1473-3099(18)30672-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/21/2018] [Accepted: 10/30/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Prevalence of serious bacterial infections in children in countries in western Europe and the USA is low. Antibiotic stewardship aims at a more rational use of antibiotics but information on the frequency of antibiotic prescription to children in emergency departments is scarce. We aimed to quantify and explain variability in antibiotic prescription in children attending European paediatric emergency departments. METHODS We did a cross-sectional, observational study of children aged between 1 month and 16 years who presented with fever to one of 28 European emergency departments on one random sampling day per month between Nov 1, 2014, and Feb 28, 2016. The surveyed sites were spread across 11 countries and included 17 academic hospitals with 3000 to up to 80 000 annual visits to their paediatric emergency departments. We determined the proportion of children without comorbidities who received antibiotic prescriptions by country, focus of infection, and type of antibiotic. We then did a detailed analysis of the same population, using a multilevel logistic regression analysis, into the variability in prescriptions across hospitals, focusing particularly on respiratory tract infections and correcting for a combination of result-dependent factors. Random group assignment was done by computer randomisation. FINDINGS Of 5177 children in total, 617 children had comorbidities. Of the 4560 children without comorbidities, 1454 (32%) received antibiotics. This percentage varied from 19% to 64% across countries. Of these 1454 prescriptions issued, 893 (61%) were second-line antibiotics. Antibiotic prescription for respiratory tract infections, the most common infection type, in children without comorbidities was most variable across countries (15-67% for upper respiratory tract infections and 24-87% for lower respiratory tract infections) and was associated with age (odds ratio [OR] 1·51, 95% CI 1·08-2·13), fever duration (OR 1·45, 1·01-2·07), blood concentrations of C-reactive protein (OR 2·31, 1·67-3·19), and chest x-ray results (OR 10·62, 5·65-19·94, for focal abnormalities; OR 3·49, 1·59-7·64, for diffuse abnormalities). After correcting for patient characteristics, diagnostic assessment, and hospital characteristics, antibiotic prescription for respiratory tract infections remained highly variable across emergency departments (standardised antibiotic prescription ratio 0·49-2·04). INTERPRETATION Antibiotic prescription in European emergency departments is highly variable, with frequent use of second-line antibiotics. To ensure successful antibiotic stewardship initiatives in Europe aimed at reducing unnecessary prescription of antibiotics, variability of prescription across hospitals should be considered, drivers of suboptimal antibiotic prescription at the local level need to be identified, and European guidelines need to be devised. FUNDING None.
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Affiliation(s)
- Josephine van de Maat
- Department of General Paediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands.
| | - Elles van de Voort
- Department of General Paediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Santiago Mintegi
- Cruces University Hospital, Paediatric Emergency Department, Bilbao, Spain
| | - Alain Gervaix
- University Hospital of Geneva, Department of Paediatrics, Geneva, Switzerland
| | - Daan Nieboer
- Erasmus Medical Center, Department of Public Health, Rotterdam, Netherlands
| | - Henriette Moll
- Department of General Paediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
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Gold J, Hametz P, Sen AI, Maykowski P, Leone N, Lee DS, Gagliardo C, Hymes S, Biller R, Saiman L. Provider Knowledge, Attitudes, and Practices Regarding Bronchiolitis and Pneumonia Guidelines. Hosp Pediatr 2019; 9:87-91. [PMID: 30610012 DOI: 10.1542/hpeds.2018-0211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Practice guidelines have been published for bronchiolitis and community-acquired pneumonia (CAP), but little is known about pediatricians' knowledge of and attitudes toward these guidelines since their publication. METHODS We surveyed pediatric providers at 6 children's hospitals in the New York City area. Two vignettes, an infant with bronchiolitis and a child with CAP, were provided, and respondents were asked about management. Associations between respondent characteristics and their reported practices were examined using χ2 and Fisher's exact tests. Associations between questions probing knowledge and attitude barriers relevant to guideline adherence and reported practices were examined using Cochran-Mantel-Haenszel relative risk estimates. RESULTS Of 283 respondents, 58% were trainees; 57% of attending physician respondents had finished training within 10 years. Overall, 76% and 45% of respondents reported they had read the bronchiolitis and CAP guidelines, respectively. For the bronchiolitis vignette, 40% reported ordering a chest radiograph (CXR), and 38% prescribed bronchodilators (neither recommended). For the CAP vignette, 38% prescribed ceftriaxone (not recommended). Study site, level of training, and practice locations were associated with nonrecommended practices. Site-adjusted knowledge and attitude barriers were used to identify that those who agreed CXRs were useful in managing bronchiolitis were more likely to order CXRs, and those who felt bronchodilators shortened length of stay were more likely to prescribe them. Concerns about ampicillin resistance and lack of confidence using local susceptibility patterns to guide prescribing were associated with ordering ceftriaxone. CONCLUSIONS Provider-level factors and knowledge gaps were associated with ordering nonrecommended treatments for bronchiolitis and CAP.
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Affiliation(s)
- Jessica Gold
- Morgan Stanley Children's Hospital, Columbia University Medical Center and
| | - Patricia Hametz
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York
| | - Anita I Sen
- Morgan Stanley Children's Hospital, Columbia University Medical Center and
| | - Philip Maykowski
- College of Medicine-Phoenix, University of Arizona, Phoenix, Arizona
| | - Nicole Leone
- Cohen Children's Medical Center, Northwell Health, Queens, New York
| | - Diana S Lee
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York
| | - Christina Gagliardo
- Goryeb Children's Hospital, Morristown Medical Center, Morristown, New Jersey
| | - Saul Hymes
- Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, New York; and
| | - Rachel Biller
- Department of Pediatrics, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, New York
| | - Lisa Saiman
- Morgan Stanley Children's Hospital, Columbia University Medical Center and.,Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York City, New York
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Finkelstein JA, Raebel MA, Nordin JD, Lakoma M, Young JG. Trends in Outpatient Antibiotic Use in 3 Health Plans. Pediatrics 2019; 143:e20181259. [PMID: 30559122 PMCID: PMC6317571 DOI: 10.1542/peds.2018-1259] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Previous analyses of data from 3 large health plans suggested that the substantial downward trend in antibiotic use among children appeared to have attenuated by 2010. Now, data through 2014 from these same plans allow us to assess whether antibiotic use has declined further or remained stable. METHODS Population-based antibiotic-dispensing rates were calculated from the same health plans for each study year between 2000 and 2014. For each health plan and age group, we fit Poisson regression models allowing 2 inflection points. We calculated the change in dispensing rates (and 95% confidence intervals) in the periods before the first inflection point, between the first and second inflection points, and after the second inflection point. We also examined whether the relative contribution to overall dispensing rates of common diagnoses for which antibiotics were prescribed changed over the study period. RESULTS We observed dramatic decreases in antibiotic dispensing over the 14 study years. Despite previous evidence of a plateau in rates, there were substantial additional decreases between 2010 and 2014. Whereas antibiotic use rates decreased overall, the fraction of prescribing associated with individual diagnoses was relatively stable. Prescribing for diagnoses for which antibiotics are clearly not indicated appears to have decreased. CONCLUSIONS These data revealed another period of marked decline from 2010 to 2014 after a relative plateau for several years for most age groups. Efforts to decrease unnecessary prescribing continue to have an impact on antibiotic use in ambulatory practice.
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Affiliation(s)
- Jonathan A Finkelstein
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts;
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Marsha A Raebel
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado; and
| | | | - Matthew Lakoma
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jessica G Young
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Frost HM, McLean HQ, Chow BDW. Variability in Antibiotic Prescribing for Upper Respiratory Illnesses by Provider Specialty. J Pediatr 2018; 203:76-85.e8. [PMID: 30195553 DOI: 10.1016/j.jpeds.2018.07.044] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/11/2018] [Accepted: 07/11/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate variation in antibiotic prescribing between pediatric and nonpediatric providers for common upper respiratory illnesses. STUDY DESIGN Patient encounters for children aged <18 years from a regional health care system were identified. Electronic medical records from 2011 to 2016 were extracted for diagnoses of upper respiratory infection, pharyngitis, acute otitis media, and sinusitis. Encounters with competing medical diagnoses, recent hospitalization, and antibiotic prescriptions within 30 days were excluded. Adherence to antibiotic guidelines was assessed by provider training (pediatric, nonpediatric physicians, and advance practice providers). Additional factors assessed were calendar year, and patient's age, sex, insurance status, and number of sick visits in the prior year. RESULTS Across 6 years, 141 361 visits were examined: 43 914 for upper respiratory infection, 43 701 for pharyngitis, 43 925 for acute otitis media, and 9821 for sinusitis. Pediatricians were more likely than Advanced practice providers (APP) and nonpediatric providers to have guideline-concordant prescribing for pharyngitis (pediatricians, 66.7% [95% CI, 54.5-77.0]; nonpediatricians, 49.1% [95% CI, 36.3-62.0], APPs, 52.2% [95% CI, 39.4-64.7]; P < .0001) and sinusitis (pediatricians, 70.8% [95% CI, 53.8-83.4], nonpediatricians, 63.3% [95% CI, 46.8-77.2], APPs, 62.1% [95% CI, 45.1-76.5]; P = .48) and to withhold antibiotics for upper respiratory infection than APPs and nonpediatric providers (pediatricians, 86.6% [95% CI, 81.2-90.6], nonpediatricians, 80.8% [95% CI, 73.0-86.8], APPs, 76.8% [95% CI, 68.4-83.5]; P < .0001). Pediatricians were less likely to prescribe antibiotics for pharyngitis without a positive test for group A Streptococcus than APPs and nonpediatric providers (pediatricians, 15.1% [95% CI, 10.4-21.6], nonpediatricians, 29.4% [95% CI, 20.8-39.6], APPs, 27.2% [95% CI, 19.3-36.9]; P < .0001). First-line antibiotic prescribing for acute otitis media did not differ between provider specialties. A trend toward more guideline-concordant prescribing was seen for pharyngitis and sinusitis over the study period. CONCLUSIONS Pediatricians were more likely to adhere to guidelines for management of pediatric acute respiratory infections. Pediatric antibiotic stewardship efforts should also target nonpediatricians.
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Affiliation(s)
- Holly M Frost
- University of Colorado, Department of Pediatrics, Aurora, CO; Denver Health and Hospital Authority, Department of Pediatrics, Denver, CO; Marshfield Clinic Research Institute, Marshfield, WI.
| | | | - Brian D W Chow
- Tufts Medical Center, Division of Geographic Medicine and Infectious Diseases, Boston, MA; Tufts University School of Medicine, Boston, MA
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Dean P, Florin TA. Factors Associated With Pneumonia Severity in Children: A Systematic Review. J Pediatric Infect Dis Soc 2018; 7:323-334. [PMID: 29850828 PMCID: PMC6454831 DOI: 10.1093/jpids/piy046] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 05/02/2018] [Indexed: 12/25/2022]
Abstract
Community-acquired pneumonia in children is associated with significant morbidity and mortality; however, data are limited in predicting which children will have negative outcomes, including clinical deterioration, severe disease, or development of complications. The Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) pediatric pneumonia guideline includes criteria that were modified from adult criteria and define pneumonia severity to assist with resource allocation and site-of-care decision-making. However, the PIDS/IDSA criteria have not been formally developed or validated in children. Definitions for mild, moderate, and severe pneumonia also vary across the literature, further complicating the development of standardized severity criteria. This systematic review summarizes (1) the current state of the evidence for defining and predicting pneumonia severity in children as well as (2) emerging evidence focused on risk stratification of children with pneumonia.
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Affiliation(s)
- Preston Dean
- Cincinnati Children’s Hospital Medical Center Residency Training Program, Cincinnati Children’s Hospital Medical Center, Ohio,Corresponding Author: Preston Dean, MD, 3333 Burnet Ave, MLC 5018, Cincinnati, OH 45229. E-mail:
| | - Todd A Florin
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Ohio
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Yonts AB, Kronman MP, Hamdy RF. The Burden and Impact of Antibiotic Prescribing in Ambulatory Pediatrics. Curr Probl Pediatr Adolesc Health Care 2018; 48:272-288. [PMID: 30337150 DOI: 10.1016/j.cppeds.2018.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Antibiotics are one of the most commonly prescribed classes of medication for children and adolescents. While they are arguably the most powerful tool we possess against bacterial infections, they are frequently given to children whose illnesses are due to viruses or other non-infectious etiologies. When antibiotics are not used judiciously, the consequences can be serious and accumulate over time. This review article quantifies the burden of antimicrobial use in the pediatric outpatient setting in the United States, reviews recommended first line antibiotic regimens for common outpatient pediatric and adolescent conditions, investigates the reasons for inappropriate prescribing of antibiotics in outpatient healthcare settings, and explores the range of consequences of overuse and inappropriate use of antibiotics, from adverse drug reactions to impact on the microbiome to rising rates of antimicrobial resistance in common ambulatory conditions.
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Affiliation(s)
- Alexandra B Yonts
- Division of Infectious Diseases, Children's National Medical Center, Washington, D.C., United States
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle, WA, United States
| | - Rana F Hamdy
- Division of Infectious Diseases, Children's National Medical Center, Washington, D.C., United States; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, D.C., United States.
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47
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Duz M, Marshall JF, Parkin TD. Proportion of nonsteroidal anti-inflammatory drug prescription in equine practice. Equine Vet J 2018; 51:147-153. [PMID: 30048005 DOI: 10.1111/evj.12997] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 07/13/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is little knowledge of the prescription of nonsteroidal anti-inflammatory drugs (NSAIDs) and whether their prescription varies between countries. OBJECTIVE To describe prescription practices of NSAIDs in equids in the United Kingdom (UK), United States of America (USA) and Canada. STUDY DESIGN Descriptive observational study. METHODS Free-text electronic medical records from 141,543 equids from 10 equine practices in the UK, 255,777 equids from 7 equine practices with 20 branches from the USA and 2 practices with 7 branches from Canada were evaluated. A validated text-mining technique was used to describe the proportion of equids prescribed NSAIDs at least once in these countries. The choice of NSAIDs in orthopaedic and colic cases was evaluated. RESULTS The prescription of NSAIDs is more common in the USA (42.4%) and Canada (34.2%) than in the UK (28.6%). Phenylbutazone and flunixin meglumine were the drugs mostly prescribed in all countries. While flunixin meglumine was most prescribed with colic cases in all countries, a proportion received phenylbutazone despite this drug being licensed for use only with musculoskeletal disease. Phenylbutazone was the most commonly prescribed drug in cases with orthopaedic disease followed by flunixin meglumine in all countries. Only a small proportion of cases received meloxicam, ketoprofen or firocoxib. MAIN LIMITATIONS The retrospective design might have resulted in an unknown number of incomplete records, particularly in the reporting of colic and orthopaedic disease. Although the data set is large, the relatively small number of practices recruited from each country may introduce bias. CONCLUSIONS Clinical practice can differ between countries although the influence of individual practitioners and practice-specific policy on apparent intercountry differences requires further research. Despite several other NSAIDs being available and a substantial effort being made to evaluate their efficacy, the prescription of NSAIDs other than phenylbutazone and flunixin meglumine remains rather limited.
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Affiliation(s)
- M Duz
- Weipers Centre Equine Hospital, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - J F Marshall
- Weipers Centre Equine Hospital, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - T D Parkin
- Weipers Centre Equine Hospital, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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48
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Abstract
PURPOSE OF REVIEW We aim to systematically review the literature on the effectiveness of pediatric antimicrobial stewardship programs (ASPs) and antimicrobial stewardship (AS) strategies in the United States (US) inpatient setting. Furthermore, we review current gaps and challenges for unique pediatric populations and those in ambulatory settings. RECENT FINDINGS Misuse and overuse of antimicrobials have been identified as key factors for antimicrobial resistance (AR). Multiple professional organizations support the implementation of hospital-based ASPs to decrease antimicrobial consumption, improve patient outcomes, and reduce healthcare costs. There is limited data on the effectiveness of inpatient pediatric ASPs and AS strategies in unique populations. Furthermore, there is a paucity of evidence on ASPs in ambulatory settings. This review contributes to the growing body of evidence that supports the use of pediatric ASPs to optimize antimicrobial therapy in the inpatient setting as well as in unique patient populations and ambulatory settings. Active stewardship is critical and antimicrobial consumption is a key outcome metric for programs.
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Principi N, Esposito S. Emerging problems in the treatment of pediatric community-acquired pneumonia. Expert Rev Respir Med 2018; 12:595-603. [PMID: 29883232 DOI: 10.1080/17476348.2018.1486710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) remains one of the most common reasons for paediatric morbidity and accounts for about 16% of all the deaths occurring in children less than 5 years of age. Areas covered: The main aim of this paper is to discuss the emerging problems for CAP treatment in paediatric age. Expert commentary: Official recommendations for therapeutic approaches to paediatric CAP, despite being not very recent, seem still to be the best solution to assure the highest probabilities of cure for children with this disease living in industrialized countries. Amoxicillin remains the drug of choice and use of macrolides alone or in combination does not seem supported by solid evidence. Corticosteroids can be useful in CAP associated with bronco-obstruction, whereas their effectiveness in cases with a severe inflammatory response, although plausible, is not supported by data collected through randomized, placebo-controlled trials. Finally, for the administration of vitamin C and vitamin D, the available data are not adequate to draw firm conclusions regarding the real importance of supplementation. Further studies are needed to evaluate which modifications of presently available recommendations for paediatric CAP treatment can improve final prognosis of this still common disease.
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Affiliation(s)
| | - Susanna Esposito
- b Pediatric Clinic, Department of Surgical and Biomedical Sciences , Università degli Studi di Perugia , Perugia , Italy
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50
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Zetts RM, Stoesz A, Smith BA, Hyun DY. Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts. Pediatrics 2018; 141:peds.2017-4124. [PMID: 29793986 DOI: 10.1542/peds.2017-4124] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2018] [Indexed: 11/24/2022] Open
Abstract
Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician's prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.
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Affiliation(s)
- Rachel M Zetts
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - Andrea Stoesz
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - Brian A Smith
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - David Y Hyun
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
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