Improvements in appropriate ambulatory antibiotic prescribing using a bundled antibiotic stewardship intervention in general pediatrics practices

Bridging the continuity: Practice-enhancing publications about the ambulatory care medication-use process in 2022

PURPOSE

This article identifies, summarizes, and prioritizes literature on the ambulatory care medication-use process (ACMUP) published in 2022 that can describe ambulatory pharmacy practice. The medication-use process (MUP) is the foundational system that provides the framework for safe medication utilization within the healthcare environment and was reimagined to focus on new innovations and advancements in ambulatory pharmacy practice. The ACMUP is defined in this article as having the following components: transitions of care, prescribing, access, dispensing, adherence, and evaluating. Articles evaluating at least one step of the ACMUP were assessed for their usefulness toward practice improvement.

SUMMARY

A PubMed search for articles published in 2022 was conducted in January 2023 using targeted Medical Subject Headings (MeSH) keywords and the table of contents of selected pharmacy journals, providing a total of 4,125 articles. A thorough review identified 49 potentially practice-enhancing articles: 6 for transitions of care, 9 for prescribing, 5 for access, 2 for dispensing, 6 for adherence, and 21 articles for evaluating. Trends from the impact articles are described.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article continues a series of articles defining and evaluating the currently published literature around the ACMUP. As healthcare continues to advance and care shifts to ambulatory settings, the ACMUP will continue to be a crucial process to evaluate.

Development and maintenance of consensus recommendations on pediatric outpatient antibiotic therapy in Germany: a framework for rational use

In pediatric outpatient care, overuse and misuse of antibiotics is linked to a high risk of adverse events and increased antibiotic resistance. In 2019, building upon the work of the Antibiotic Therapy in Bielefeld (AnTiB) project (founded in 2016), a collaboration among the AnTiB, the German Society for Pediatric Infectious Diseases (DGPI), and the Professional Association of Outpatient Pediatricians and Adolescent Physicians (BVKJ) was established to develop consensus recommendations for antibiotic therapy in pediatric outpatient settings in Germany. This working group became the Antibiotic Stewardship in Outpatient Pediatrics (ABSaP). ABSaP institutes recommendations for antibiotic use in outpatient pediatric settings in Germany and updates them regularly. The ABSaP guidelines recommend restrictive, targeted, evidence-based prescription practices for antibiotics used to treat common infections among pediatric outpatients. This expert-driven, pragmatic, best-practice guidance is designed to be a living document. ABSaP's most recent update was published in March 2024. The recommendations aim to guide and standardize rational antibiotics use by emphasizing the importance of avoiding unnecessary prescriptions, while also promoting the application of narrow-spectrum antibiotics, short-duration therapy, and watchful waiting, when treating mild, self-limiting infections in children without significant risk factors.

CONCLUSIONS

ABSaP's guidelines may provide a model for others, as well as offer a basis for discussing practical, effective antibiotic stewardship (ABS) measures in pediatric primary care. An international, expert consensus on ABS for pediatric outpatients could help promote a culture of responsible antibiotic use, improve prescribing safety, and contribute to broader ABS efforts.

WHAT IS KNOWN

• Overuse and misuse of antibiotics are associated with adverse events and increased antibiotic resistance, prompting the need for effective antibiotic stewardship initiatives. • The Antibiotic Stewardship in Outpatient Pediatrics (ABSaP) working group was established to develop and regularly update evidence-based best practice recommendations for the targeted and restrictive use of antibiotics in pediatric outpatient settings in Germany.

WHAT IS NEW

• The most recent update of the ABSaP guidelines was published in March 2024, emphasizing the importance of narrow-spectrum antibiotics, short-duration therapy, and watchful waiting for mild infections, aiming to standardize rational antibiotic use in children. • The ABSaP guidelines have become widely accepted in Germany and are now being translated into English to foster international dialogue and collaboration on antibiotic stewardship in pediatric primary care, potentially serving as a model for similar initiatives in other countries.

Improving Antibiotic Prescribing for Children with Community-acquired Pneumonia in Outpatient Settings

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.

Parental Attitude, Knowledge, and Practices Regarding the Usage of Antibiotics for Upper Respiratory Tract Infections in Children During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has raised knowledge of the proper antibiotic dosage for treating childhood upper respiratory tract infections (URTIs). In order to ensure proper antibiotic usage and prevent the establishment of illnesses that is antibiotic-resistant during the COVID-19 pandemic, parental attitudes, knowledge, and behaviour surrounding antibiotic use for URTIs in children are essential. The goal of this study was to find out the parental attitude, knowledge, and practices regarding the usage of antibiotics for URTIs in children during the COVID-19 epidemic.

METHODOLOGY

This cross-sectional was conducted in the Department of Paediatric Medicine, Central Hospital, Ganesh Nagar, New Delhi, India from September 2022 to February 2023. The study analysed a total of 500. All the children had URTIs. A structured questionnaire was randomly distributed among parents. Socio-demographic information like gender, age, occupation, monthly family income, and age of the children were noted at the time of enrollment. Outcomes were recorded in terms of responses to questions regarding attitude, knowledge, and practices regarding the use of antibiotics for URTIs in children during the COVID-19 epidemic.  Results: Of a total of 500 parents, 380 (76.0%) were male. The mean age was 39.9±8.3 years while 280 (56.0%) participants were aged between 31 to 45 years. Relatively older age (p<0.0001) and occupational status as unemployed (p<0.0001) were found to have a significant association with response to "virus being the cause of COVID-19". Females (p=0.0004) and increasing age (p<0.0001) were found to have significant associations with incorrect responses to "antibiotics are essential for managing the symptoms in children with COVID-19". Incorrect responses to "without the use of antibiotics, children usually suffer from greater periods of sickness" were associated with females and increasing age (p<0.0001). Incorrect responses to "not using antibiotics will prove beneficial for the children suffering from COVID-19" were significantly associated with female gender (p=0.0016) and increasing age (p<0.0001). The incorrect responses to "how often are antibiotics being prescribed to the COVID-19 children" was significantly linked with females and relatively older age (p<0.0001).

CONCLUSIONS

Parental attitude, knowledge, and practices regarding the usage of antibiotics for URTIs in children during the COVID-19 epidemic showed variations. Parental attitude, knowledge, and practices were associated with gender, age, and socio-economic status.

Clostridioides difficile Infection in Hospitalized Pediatric Patients: Comparisons of Epidemiology, Testing, and Treatment from 2013 to 2019

OBJECTIVES

To compare the incidence, epidemiology, testing patterns, treatment, and outcomes of Clostridioides difficile infection (CDI) among hospitalized pediatric patients from 2013 to 2019.

STUDY DESIGN

The Pediatric Health Information System database was queried for patient admissions (age 0-17 years) with International Classification of Diseases, 9th and 10th edition, codes for diagnoses of CDI with a billing code for a CDI-related antibiotic treatment.

RESULTS

We identified 17 142 pediatric patients, representing 23 052 admissions, with CDI. The adjusted annual CDI incidence decreased over the study period from 7.09 cases per 10 000 patient-days (95% CI, 6.15-8.18) in 2013 to 4.89 cases per 10 000 patient-days (95% CI, 4.03-5.93) in 2019 (P < .001). C difficile-specific testing also decreased during the study period (P < .001). Chronic gastrointestinal conditions (36%) and malignancy (32%) were the most common comorbidities in CDI encounters. Oral metronidazole use decreased during the study period (P < .01) and oral vancomycin use increased (P < .001).

CONCLUSIONS

Our study demonstrates a decrease in CDI incidence in hospitalized pediatric patients, a notable change from prior studies, although this may have been influenced by altered testing patterns. We found a high incidence of CDI in patients with cancer and gastrointestinal conditions: groups that warrant targeted evaluation of CDI prevention and treatment.