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Moorthy GS, Young RR, Raman SR, Smith MJ. Variations in antibiotic prescribing among children enrolled in North Carolina Medicaid, 2013-2019. J Rural Health 2024. [PMID: 38287204 DOI: 10.1111/jrh.12825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 01/31/2024]
Abstract
PURPOSE The majority of pediatric antibiotic prescribing occurs in the outpatient setting and inappropriate use contributes to antimicrobial resistance. There are regional variations in outpatient antibiotic use with the highest rates occurring in the Southern states, including in Appalachia. The purpose of this study was to describe the rates and risk factors for inappropriate antibiotic prescription among pediatric patients enrolled in North Carolina (NC) Medicaid. METHODS We used Medicaid prescription claims data from 2013 to 2019 to describe patterns of pediatric antibiotic prescription in NC. We assessed patient and provider factors to identify variations in prescribing. FINDINGS Children who were less than 2 years of age, non-Hispanic White, and living in a rural area had the highest overall rates of antibiotic prescription. Compared to pediatricians, the risk of inappropriate antibiotic prescription was highest among other specialists and general practioners and lowest among nurse practitioners. Rural areas of NC had the highest rates of inappropriate antibiotic prescribing, and the risk for non-Hispanic Black children compared to children of other races/ethnicities was compounded by rurality. CONCLUSIONS Prescribing practices in NC differ compared to neighboring states with a lower overall risk of inappropriate prescription in Appalachian regions; however, disparities by race and rurality exist. Outpatient stewardship efforts in NC should focus on ensuring health equity by appreciating racial and geographic variations in prescribing patterns and providing education to all health care providers.
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Affiliation(s)
- Ganga S Moorthy
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University Medical Center, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Rebecca R Young
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Sudha R Raman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael J Smith
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University Medical Center, Durham, North Carolina, USA
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Whittington KJ, Malone SM, Hogan PG, Ahmed F, Flowers J, Milburn G, Morelli JJ, Newland JG, Fritz SA. Staphylococcus aureus Bacteremia in Pediatric Patients: Uncovering a Rural Health Challenge. Open Forum Infect Dis 2023; 10:ofad296. [PMID: 37469617 PMCID: PMC10352649 DOI: 10.1093/ofid/ofad296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/30/2023] [Indexed: 07/21/2023] Open
Abstract
Background Staphylococcus aureus bacteremia poses significant risk for morbidity and mortality. This may be exacerbated in rural populations facing unique health challenges. Methods To investigate factors influencing S. aureus bacteremia outcomes, we conducted a retrospective cohort study of children admitted to St. Louis Children's Hospital (SLCH) from 2011 to 2019. Exposures included rurality (defined by the Rural-Urban Continuum Code), Area Deprivation Index, and outside hospital (OSH) admission before SLCH admission. The primary outcome was treatment failure, a composite of 90-day all-cause mortality and hospital readmission. Results Of 251 patients, 69 (27%) were from rural areas; 28 (11%) were initially admitted to an OSH. Treatment failure occurred in 39 (16%) patients. Patients from rural areas were more likely to be infected with methicillin-resistant S. aureus (45%) vs urban children (29%; P = .02). Children initially admitted to an OSH, vs those presenting directly to SLCH, were more likely to require intensive care unit-level (ICU) care (57% vs 29%; P = .002), have an endovascular source of infection (32% vs 12%; P = .004), have a longer duration of illness before hospital presentation (4.1 vs 3.0 days; P = .04), and have delayed initiation of targeted antibiotic therapy (3.9 vs 2.6 days; P = .01). Multivariable analysis revealed rural residence (adjusted odds ratio [aOR], 2.3; 95% CI, 1.1-5.0), comorbidities (aOR, 2.9; 95% CI, 1.3-6.2), and ICU admission (aOR, 3.9; 95% CI, 1.9-8.3) as predictors of treatment failure. Conclusions Children from rural areas face barriers to specialized health care. These challenges may contribute to severe illness and worse outcomes among children with S. aureus bacteremia.
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Affiliation(s)
- Kyle J Whittington
- Correspondence: Stephanie A. Fritz, MD, MSCI, 660 S. Euclid Avenue, MSC 8116-43-10, St Louis, MO 63110-9872 (); or Kyle Whittington, MD, 660 S. Euclid Avenue, MSC 8116-43-10, St Louis, MO 63110-9872 ()
| | - Sara M Malone
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Patrick G Hogan
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Faria Ahmed
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - JessieAnn Flowers
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Grace Milburn
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John J Morelli
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephanie A Fritz
- Correspondence: Stephanie A. Fritz, MD, MSCI, 660 S. Euclid Avenue, MSC 8116-43-10, St Louis, MO 63110-9872 (); or Kyle Whittington, MD, 660 S. Euclid Avenue, MSC 8116-43-10, St Louis, MO 63110-9872 ()
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Wattles BA, Smith MJ, Feygin Y, Jawad KS, Bhadury S, Sun J, Kong M, Woods CR. Recurrent Antibiotic Use in Kentucky Children With 6 Years of Continuous Medicaid Enrollment. J Pediatric Infect Dis Soc 2022; 11:492-497. [PMID: 35964236 DOI: 10.1093/jpids/piac079] [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: 11/03/2021] [Accepted: 07/22/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Little is known about the distribution of antibiotic use in individual children over time. The amoxicillin index is a recently proposed metric to assess first-line antibiotic prescribing to children. METHODS We constructed a cohort of continuously enrolled Medicaid children using enrollment claims from 2012 to 2017. Pharmacy claims were used to identify antibiotic prescription data. RESULTS Among 169 724 children with 6 years of Medicaid enrollment, 10 804 (6.4%) had no antibiotic prescription claims during the study period; 43 473 (25.6%) had 1-3 antibiotics; 34 318 (20.2%) had 4-6 antibiotics; 30 994 (18.3%) had 7-10; 35 018 (20.6%) had 11-20; and 15 117 (8.9%) children had more than 20 antibiotic prescriptions. Overall, the population had a median total of 6 antibiotic prescriptions during the study period, but use was higher in certain patient groups: younger age (8 antibiotic fills over the 6-year period, [IQR 4-14]), White children (7 [IQR 3-13], compared to 3 [IQR 1-6] in Black children), rural settings (9 [IQR 4-15]) and chronic conditions (8 [IQR 4-15]). Higher-use groups also had lower rates of amoxicillin fills, reported as amoxicillin indices. CONCLUSIONS Antibiotic use is common among most children insured by Kentucky Medicaid. A number of fills over time were higher in younger children, and in White children, children living in rural settings and children with chronic conditions. Patients with higher recurrent antibiotic use are important targets for designing high-impact antibiotic stewardship efforts.
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Affiliation(s)
- Bethany A Wattles
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Michael J Smith
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Yana Feygin
- Norton Children's Research Institute Affiliated with University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Kahir S Jawad
- Norton Children's Research Institute Affiliated with University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Sagnik Bhadury
- School of Public Health and Information Sciences, Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky, USA
| | - Jingchao Sun
- School of Public Health and Information Sciences, Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky, USA
| | - Maiying Kong
- School of Public Health and Information Sciences, Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky, USA
| | - Charles R Woods
- Department of Pediatrics, University of Tennessee College of Medicine-Chattanooga, Children's Hospital at Erlanger, Chattanooga, Tennessee, USA
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