1
|
A multimodal intervention to decrease inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated healthcare system. Infect Control Hosp Epidemiol 2023; 44:392-399. [PMID: 35491941 DOI: 10.1017/ice.2022.83] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of Carolinas Healthcare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN), a multicomponent outpatient stewardship program to reduce inappropriate antibiotic prescribing for upper respiratory infections by 20% over 2 years. DESIGN Before-and-after interrupted time series of antibiotics prescribed between 2 periods: April 2016-October 2017 and May 2018-March 2020. SETTING The study included 162 primary-care practices within a large healthcare system in the greater Charlotte, North Carolina region. PARTICIPANTS Adult and pediatric patients with encounters for upper respiratory infections for which an antibiotic is inappropriate. METHODS Patient and provider educational materials, along with a web-based provider prescribing dashboard aimed at reducing inappropriate antibiotic prescribing were developed and distributed. Monthly antibiotic prescribing rates were calculated as the number of eligible encounters with an antibiotic prescribed divided by the total number of eligible encounters. A segmented regression analysis compared monthly antibiotic prescribing rates before versus after CHOSEN implementation, while also accounting for practice type and seasonal trends in prescribing. RESULTS Overall, 286,580 antibiotics were prescribed during 704,248 preintervention encounters and 277,177 during 832,200 intervention encounters. Significant reductions in inappropriate prescribing rates were observed in all outpatient specialties: family medicine (relative difference before and after the intervention, -20.4%), internal medicine (-19.5%), pediatric medicine (-17.2%), and urgent care (-16.6%). CONCLUSIONS A robust multimodal intervention that combined a provider prescribing dashboard with a targeted education campaign demonstrated significant decreases in inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated ambulatory network.
Collapse
|
2
|
Otake S, Kusama Y, Tsuzuki S, Myojin S, Kimura M, Kamiyoshi N, Takumi T, Ishida A, Kasai M. Comparing the effects of antimicrobial stewardship at primary emergency centers. Pediatr Int 2023; 65:e15614. [PMID: 37658628 DOI: 10.1111/ped.15614] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 06/24/2023] [Accepted: 06/30/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Antimicrobial prescription rates tend to be high in outpatient settings and Primary Emergency Medical Centers (PECs) in Japan encounter difficulties in implementing antimicrobial stewardship programs (ASPs). While a nudge-based ASP publishing monthly newsletters reduces inappropriate prescription of oral third-generation cephalosporins (3GCs), which requires considerable effort. Therefore, developing more preferable ASP models in PECs is essential. METHODS We conducted a three-center, retrospective observational study. Himeji City Emergency Medical Center (Site A) introduced a facility-specific guideline for antimicrobial stewardship with reference to national guidelines. The Kobe Children's Primary Emergency Medical Center (Site B) provided the results of monitoring antibiotics prescription in a monthly newsletter. The Hanshin-Kita Children's First-Aid Center (Site C) did not perform a specific ASP. Prescription rates for 3GCs were categorized into pre- and post-intervention and compared using Poisson regression analysis. The difference-in-difference method was used to assess the effect of these interventions. RESULTS The numbers of patients pre- and post- intervention were 177,126 and 91,251, respectively. The 3GCs prescription rate at Site A, Site B, and Site C decreased from 6.7%, 4.2%, and 6.1% in 2016 to 2.3%, 1.0%, and 2.0% in 2019, respectively. Site B had a greater reduction than Site A and Site C (relative risk [RR] 0.71 [95% confidence interval (CI): 0.62-0.82]; p < 0.001, RR 0.71, [95% CI: 0.62-0.81]; p < 0.001). There was no significant difference between Site A and Site C (RR 1.00 [95% CI 0.88-1.13]; p = 0.963). CONCLUSION A facility-specific guideline was less effective than a nudge-based ASP for decreasing oral 3GC prescriptions in PECs.
Collapse
Affiliation(s)
- Shogo Otake
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Yoshiki Kusama
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan
| | - Shota Myojin
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Makoto Kimura
- Department of Pharmacy, Kobe Children's Primary Emergency Medical Center, Kobe, Hyogo, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Toru Takumi
- Hanshin-Kita Children's First-Aid Center, Itami, Hyogo, Japan
| | - Akihito Ishida
- Kobe Children's Primary Emergency Medical Center, Kobe, Hyogo, Japan
| | - Masashi Kasai
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, Kobe, Hyogo, Japan
| |
Collapse
|
3
|
Bregman S, Thau E, Pusic M, Perez M, Boutis K. A Performance-Based Competency Assessment of Pediatric Chest Radiograph Interpretation Among Practicing Physicians. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2022; 44:28-34. [PMID: 36728983 DOI: 10.1097/ceh.0000000000000481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/19/2022] [Indexed: 06/18/2023]
Abstract
INTRODUCTION There is limited knowledge on pediatric chest radiograph (pCXR) interpretation skill among practicing physicians. We systematically determined baseline interpretation skill, the number of pCXR cases physicians required complete to achieve a performance benchmark, and which diagnoses posed the greatest diagnostic challenge. METHODS Physicians interpreted 434 pCXR cases via a web-based platform until they achieved a performance benchmark of 85% accuracy, sensitivity, and specificity. Interpretation difficulty scores for each case were derived by applying one-parameter item response theory to participant data. We compared interpretation difficulty scores across diagnostic categories and described the diagnoses of the 30% most difficult-to-interpret cases. RESULTS 240 physicians who practice in one of three geographic areas interpreted cases, yielding 56,833 pCXR case interpretations. The initial diagnostic performance (first 50 cases) of our participants demonstrated an accuracy of 68.9%, sensitivity of 69.4%, and a specificity of 68.4%. The median number of cases completed to achieve the performance benchmark was 102 (interquartile range 69, 176; min, max, 54, 431). Among the 30% most difficult-to-interpret cases, 39.2% were normal pCXR and 32.3% were cases of lobar pneumonia. Cases with a single trauma-related imaging finding, cardiac, hilar, and diaphragmatic pathologies were also among the most challenging. DISCUSSION At baseline, practicing physicians misdiagnosed about one-third of pCXR and there was up to an eight-fold difference between participants in number of cases completed to achieve the standardized performance benchmark. We also identified the diagnoses with the greatest potential for educational intervention.
Collapse
Affiliation(s)
- Stacey Bregman
- Dr. Bregman: Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada. Dr. Thau: Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada. Dr. Pusic: Division of Pediatric Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard University; Boston, MA. Dr. Perez: Department of Diagnostic Imaging, University of Toronto, Ontario, Canada. Dr. Boutis: Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | |
Collapse
|
4
|
Ohler AM, Braddock A. Infections and antibiotic use in early life, and obesity in early childhood: a mediation analysis. Int J Obes (Lond) 2022; 46:1608-1614. [PMID: 35654887 DOI: 10.1038/s41366-022-01155-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 05/16/2022] [Accepted: 05/23/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVE Literature shows a positive association between antibiotics and obesity in childhood, but fails to account for confounding by indication. We evaluate the direct effect of infection on obesity and the indirect effect mediated by antibiotics by performing a mediation analysis of the infection-obesity association. METHODS A Medicaid cohort of children age 2-14 years old between 2015-2019 (n = 61,330) is used to perform mediation analysis of infections and antibiotic use in the first year of life, and obesity in childhood in Missouri, U.S.A. RESULTS An additional infection increases the risk of obesity in childhood (aIRR = 1.050, p < 0.001); however, mediation by antibiotic use is clinically and statistically insignificant. If the number of infections is not considered in the analysis, then antibiotic use as a risk factor for obesity is overstated (aIRR = 1.037 vs. 1.013 p < 0.001). CONCLUSIONS The number of infections exhibits a significant relationship with obesity and is a stronger risk factor for obesity than antibiotic use. In particular, a greater number of bronchitis, otitis media, and upper respiratory infections in the first year of life are associated with a significant increased risk of obesity in childhood. We find only weak evidence that an additional antibiotics claim increases the risk of obesity in childhood and this risk may not be clinically meaningful. Further research is needed to explore the association between early childhood infections, especially in the first 6 months of life, and obesity including the biological mechanism and environmental factor of early life infections associated with obesity.
Collapse
Affiliation(s)
- Adrienne M Ohler
- Department of Child Health, Child Health Research Institute, University of Missouri, COLUMBIA, MO, USA.
| | - Amy Braddock
- Department of Family and Community Medicine, University of Missouri, Columbia, MO, USA.
| |
Collapse
|
5
|
Correlation Analysis of Chaige Qinlian Decoction and Acupuncture Combined Intervention on Prognosis of Children with Pneumonia. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:8229251. [PMID: 34956578 PMCID: PMC8695006 DOI: 10.1155/2021/8229251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/11/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022]
Abstract
Background Traditional Chinese medicine (TCM) treatment is of great importance to improve the clinical symptoms of children with pneumonia, and this study was conducted in this context. Methods The clinical data of 82 child patients with pneumonia admitted to our hospital from February 2019 to February 2020 were retrospectively analyzed, and the patients were divided into the conventional group and the combined group according to the parity of their admission numbers, with 41 cases each. Conventional Western medicine therapy was given to children in the conventional group, and on this basis, acupuncture combined with Chaige Qinlian decoction was performed on children in the combined group, so as to evaluate the clinical application value of combined treatment and analyze its relationship with prognosis by recording the recovery time of each symptom, serum indicators, and immune indicators. Results Children in the combined group had significantly shorter recovery time of each symptom and lower mean CPIS scores after treatment than the conventional group (P < 0.001); the TCM symptom scores at T1 (1 d after treatment), T2 (3 d after treatment), T3 (7 d after treatment), and T4 (10 d after treatment) of children in the combined group were significantly higher than those in the conventional group (P < 0.05); various immune indicators of the combined group before and after treatment were significantly different (P < 0.001), and after treatment, the combined group obtained significantly higher IgG levels and lower IgA, complement C3, and complement C4 levels than the conventional group (P < 0.001); and there was a positive correlation between the CPIS scores and serum IL-8, IL-6, and CRP levels at the first day (r = 0.706, 0.712, 0.734, P < 0.001). Conclusion Acupuncture combined with Chaige Qinlian decoction can effectively shorten the course of disease, reduce the levels of serum inflammatory factors, and improve the immune function of body for child patients with pneumonia. Serum IL-8, IL-6, and CRP levels in child patients can reflect the clinical prognosis, with higher levels indicating worse prognosis.
Collapse
|
6
|
Santos-Cortez RLP, Ehrlich GD, Ryan AF. Editorial: Otitis Media Genomics and the Middle Ear Microbiome. Front Genet 2021; 12:763688. [PMID: 34712274 PMCID: PMC8546293 DOI: 10.3389/fgene.2021.763688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Regie Lyn P Santos-Cortez
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Garth D Ehrlich
- Institute for Molecular Medicine and Infectious Disease, Drexel University College of Medicine, Philadelphia, PA, United States.,Departments of Otolaryngology-Head and Neck Surgery, and Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Allen F Ryan
- Division of Otolaryngology, Department of Surgery, University of California San Diego School of Medicine, La Jolla, CA, United States.,Veterans Affairs Medical Center, La Jolla, CA, United States
| |
Collapse
|
7
|
Bianco A, Licata F, Nobile CG, Napolitano F, Pavia M. Pattern and appropriateness of antibiotic prescriptions for upper respiratory tract infections in primary care paediatric patients. Int J Antimicrob Agents 2021; 59:106469. [PMID: 34757133 DOI: 10.1016/j.ijantimicag.2021.106469] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/12/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this cross-sectional study was to investigate the pattern of antibiotic prescriptions for upper respiratory tract infections (URTIs) in children seen by primary care paediatricians (PCPs). METHODS Data were collected from face-to-face interviews administered to a sample of parents of outpatient children aged 0-14 years in two regions in Southern Italy. To be eligible, children had to be diagnosed with sinusitis, pharyngotonsillitis, otitis media, bronchitis, influenza or a common cold. The presence of an indication of antibiotic therapy was evaluated according to national and international guidelines. RESULTS An antibiotic prescription was indicated in 57 (10.1%) of the sampled patients, of whom 33.3% did not receive an antibiotic prescription; among the 508 patients for whom an antibiotic prescription was not indicated, 27.4% received a prescription. Of all PCP consultations, 72% were appropriate (an antibiotic was prescribed when indicated and not prescribed when not indicated), whilst an antibiotic prescription not indicated by guidelines was given to 24.6% of the participants, and 3.4% of the sample did not receive an antibiotic prescription when indicated. The most frequently prescribed antibiotic was amoxicillin with clavulanic acid. A rapid microbiological examination was performed in two patients. CONCLUSIONS The study findings highlight a high rate of sub-optimal antibiotic therapeutic profile. Over-prescription of antibiotic therapy and the use of broad-spectrum molecules are widespread in children with URTIs. Antibiotic under-prescription, which may deprive paediatric patients of an effective treatment when indicated, also occurs.
Collapse
Affiliation(s)
- Aida Bianco
- Department of Health Sciences, School of Medicine, University of Catanzaro "Magna Græcia", Catanzaro, Italy
| | - Francesca Licata
- Department of Health Sciences, School of Medicine, University of Catanzaro "Magna Græcia", Catanzaro, Italy
| | - Carmelo Ga Nobile
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Cosenza, Italy
| | - Francesco Napolitano
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Pavia
- Department of Health Sciences, School of Medicine, University of Catanzaro "Magna Græcia", Catanzaro, Italy; Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| |
Collapse
|
8
|
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
| |
Collapse
|
9
|
Marom T, Shefer G, Tshori S, Mingelgrin S, Pitaro J. Antibiotic prescription policy for acute otitis media: do we follow the guidelines? J Antimicrob Chemother 2021; 76:2717-2724. [PMID: 34278423 DOI: 10.1093/jac/dkab250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/25/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Acute otitis media (AOM) is a common cause for antibiotic prescription. Most guidelines endorse abstaining from immediate antibiotic treatment ('watchful waiting', WW) in mild-moderate episodes. We studied adherence rates to the latest AOM guidelines (2013), in terms of antibiotic type and prescription options. METHODS In this population-based study, AOM episodes were identified in Clalit Health Services-insured children aged 0-10 years between 2011 and 2018, using a data-sharing platform. After identifying the index, prescription and issuing dates for antibiotics for each AOM episode, treatment was categorized as immediate (≤2 days after diagnosis) or WW (antibiotic not prescribed/issued; prescribed ≤2 days after diagnosis but issued on Days 2-7; or prescribed/issued on Days 2-7). Guideline adherence was measured according to age. RESULTS Of the 491 106 episodes, 361 518 (73.6%) were treated with antibiotics. Following the 2013 guidelines, the ratio of episodes in children aged ≤6 months that were adherent (immediate treatment) was higher (OR = 1.22; 95% CI 1.15-1.29; P < 0.001), whereas the adherent episode ratio for children aged 6-24 months and 2-10 years (WW) was lower (OR = 0.87; 95% CI 0.85-0.88 and OR = 0.94; 95% CI 0.92-0.96, respectively; P < 0.001). Antibiotic prescription rates after 2013 for children aged ≤6 months were not different (OR = 1.03; 95% CI 0.96-1.1; P = 0.4), but were higher in children aged 6-24 months and 2-10 years (OR = 1.07; 95% CI 1.05-1.09; P < 0.001 and OR = 1.02; 95% CI 1.01-1.04; P = 0.015, respectively). Amoxicillin was the most common antibiotic, administered in 75.6% of episodes. Azithromycin was most commonly associated with treatment failure (6.6%). CONCLUSIONS Improved adherence to the 2013 guidelines was observed only in children aged ≤6 months and over-treatment with antibiotics was still high.
Collapse
Affiliation(s)
- Tal Marom
- Central District, Clalit Health Services, Tel Aviv-Yafo, Israel.,Department of Otolaryngology-Head and Neck Surgery, Samson Assuta Ashdod University Hospital, Ben Gurion University Faculty of Health Sciences, Ashdod, Israel
| | - Galit Shefer
- Research Authority, Kaplan Medical Center, Rehovot, Israel
| | - Sagi Tshori
- Research Authority, Kaplan Medical Center, Rehovot, Israel.,Department of Biochemistry and Molecular Biology, Institute for Medical Research Israel-Canada, The Hebrew University, Jerusalem, Israel
| | | | - Jacob Pitaro
- Central District, Clalit Health Services, Tel Aviv-Yafo, Israel.,Department of Otolaryngology-Head and Neck Surgery, Shamir (Assaf Harofeh) Medical Center, Tel Aviv University Sackler School of Medicine, Zerifin, Israel
| |
Collapse
|
10
|
Cheng J, Mackie A, Chang AB, Grimwood K, Scott M, King A, Goyal V, Marchant JM, O'Grady KAF. Medication and healthcare use, parent knowledge and cough in children: A cohort study. Pediatr Pulmonol 2021; 56:2345-2354. [PMID: 33902157 DOI: 10.1002/ppul.25424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/30/2021] [Accepted: 04/09/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Cough is an important contributor to the health burden of children and their families. There are limited data describing healthcare utilization and medication use over the course of a cough illness beyond the initial presentation. Our primary objective was to describe medication and healthcare use in children with a respiratory illness with cough as a symptom over the course of the illness. METHODS A cohort study of children aged less than 15-years presenting to three primary healthcare centers and three emergency departments with a cough illness between July 7, 2015 and October 6, 2018. Children with immunosuppression, known chronic lung diseases (except asthma) and those requiring hospitalization at screening were excluded. The primary outcomes were cough-related frequency and type of healthcare seeking and medication use up to 28 days following enrolment. RESULTS Data for 465 children were analyzed; median age 2.2-years (interquartile range = 1.1-5.3). Cough at Day 28 persisted in 117 children (25.2%). Overall, 436 (94%) children received medications in the week before and/or 4 weeks following enrolment. Half with upper respiratory tract infections were prescribed antibiotics. Among children with no diagnosis of asthma, reactive airways disease or croup (n = 404), 16.8% were given steroids. Fifty-eight percent of children sought healthcare at least once before their baseline presentation (median = 1, range = 0-20) and 49.7% had at least one further presentation in the following 28 days. CONCLUSIONS High healthcare utilization, inappropriate medication use, and suboptimal parent knowledge regarding cough suggests targeted education is needed to improve management and reduce cough burden.
Collapse
Affiliation(s)
- Joan Cheng
- Somerville House, South Brisbane, Queensland, Australia
| | - Amelia Mackie
- Somerville House, South Brisbane, Queensland, Australia
| | - Anne B Chang
- Australian Health Services Institute, Center for Healthcare Transformation, Queensland University of Technology, South Brisbane, Queensland, Australia.,Child Health Division, Menzies School of Health Research, Charles Darwin University, Tiwi, Australia.,Department of Respiratory Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Keith Grimwood
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia.,Department of Infectious Disease and Paediatrics, Gold Coast Health, Southport, Queensland, Australia
| | - Mark Scott
- Department of Emergency Medicine, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Alex King
- Department of Emergency Medicine, The Toowoomba Hospital, Toowoomba, Queensland, Australia
| | - Vikas Goyal
- Australian Health Services Institute, Center for Healthcare Transformation, Queensland University of Technology, South Brisbane, Queensland, Australia.,Department of Respiratory Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Julie M Marchant
- Australian Health Services Institute, Center for Healthcare Transformation, Queensland University of Technology, South Brisbane, Queensland, Australia.,Department of Respiratory Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Kerry-Ann F O'Grady
- Australian Health Services Institute, Center for Healthcare Transformation, Queensland University of Technology, South Brisbane, Queensland, Australia
| |
Collapse
|
11
|
Shishido A, Otake S, Kimura M, Tsuzuki S, Fukuda A, Ishida A, Kasai M, Kusama Y. Effects of a nudge-based antimicrobial stewardship program in a pediatric primary emergency medical center. Eur J Pediatr 2021; 180:1933-1940. [PMID: 33558964 DOI: 10.1007/s00431-021-03979-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
Outpatient medical facilities tend to have high antimicrobial prescription rates and are therefore major targets for antimicrobial stewardship programs (ASPs). Pediatric primary emergency medical centers in Japan have difficulties in implementing conventional ASPs due to the low continuity of stewardship. Accordingly, there is a need to develop effective ASP models for these facilities. We conducted a single-center, quasi-experimental study to evaluate the effects of a nudge-based ASP in reducing unnecessary third-generation cephalosporin (3GC) prescriptions in a pediatric primary emergency care center (PEC). The implemented ASP utilizes monthly newsletters that report current antimicrobial use patterns and prescribing targets. We compared the monthly 3GC prescription numbers and proportions of unnecessary prescriptions before and after the ASP was implemented. The trends in 3GC prescriptions were examined using an interrupted time-series analysis. The numbers of patients before and after ASP implementation were 129,156 and 28,834, respectively. The number of unnecessary 3GC prescriptions decreased by 67.2% in the year after ASP implementation. The interrupted time-series analysis showed that the ASP was significantly associated with a reduction in 3GC prescriptions (regression coefficient - 0.58, P < 0.001).Conclusion: The nudge-based ASP was effective in reducing 3GC use in a Japanese PEC. This simple and inexpensive approach may have applications in other outpatient facilities. What is Known: • Outpatient medical facilities tend to have high antimicrobial prescription rates. Despite the development of several strategies for outpatient antimicrobial stewardship programs, these approaches have not sufficiently reduced antimicrobial use. What is New • Our nudge-based antimicrobial stewardship program using newsletters was shown to be a simple, inexpensive, and feasible method for reducing unnecessary antimicrobial use in a pediatric primary emergency care center. This may represent an effective antimicrobial stewardship strategy in Japanese outpatient facilities.
Collapse
Affiliation(s)
- Ayumi Shishido
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, 7-6-1, Minami-machi, Minatojima, Tyuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Shogo Otake
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, 7-6-1, Minami-machi, Minatojima, Tyuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Makoto Kimura
- Department of Pharmacy, Kobe Children's Primary Emergency Medical Center, 1-4-1, Wakinohama-Kaigandori, Tyuo-ku, Kobe, Hyogo, 651-0073, Japan
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, 1-21-1 Toyama Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Akiko Fukuda
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, 7-6-1, Minami-machi, Minatojima, Tyuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Akihito Ishida
- Kobe Children's Primary Emergency Medical Center, 1-4-1, Wakinohama-Kaigandori, Tyuo-ku, Kobe, Hyogo, 651-0073, Japan
| | - Masashi Kasai
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, 7-6-1, Minami-machi, Minatojima, Tyuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Yoshiki Kusama
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, 1-21-1 Toyama Shinjuku-ku, Tokyo, 162-8655, Japan.
| |
Collapse
|
12
|
Norlin C, Fleming-Dutra K, Mapp J, Monti J, Shaw A, Bartoces M, Barger K, Emmer S, Dolins JC. A Learning Collaborative to Improve Antibiotic Prescribing in Primary Care Pediatric Practices. Clin Pediatr (Phila) 2021; 60:230-240. [PMID: 33764189 PMCID: PMC9357460 DOI: 10.1177/00099228211001623] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An American Academy of Pediatrics State Chapter organized a 6-month, mostly online quality improvement learning collaborative to improve antibiotic prescribing and patient education for upper respiratory infection (URI) and acute otitis media (AOM). Practices submitted data on quality measures at baseline, monthly, and 4 months post-project. Fifty-three clinicians from 6 independent, private primary care pediatric practices participated. Use of first-line antibiotics for AOM increased from 63.5% at baseline to 80.4% 4 months post-project. Use of safety-net antibiotic prescriptions (SNAP) for AOM increased from 4.5% to 16.9%. Educating patients about management for URI increased from 66.1% to 88.0% and for AOM from 20.4% to 85.6%. Practices maintained high performance for not prescribing antibiotics for URI (94.4% to 96.2%). Leveraging local relationships and national resources, this replicable antibiotic stewardship project engaged independent private practices to improve patient education for URI and AOM and prescribing and use of SNAP for AOM.
Collapse
Affiliation(s)
- Chuck Norlin
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Katherine Fleming-Dutra
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jeff Mapp
- Pediatric Associates of Richmond, Richmond, VA
| | - Jennifer Monti
- Division of Chapter Quality Improvement Initiatives, American Academy of Pediatrics, Itasca, IL
| | - Allison Shaw
- Ann & Robert H. Lurie Children’s Hospital, Chicago, IL
| | - Monina Bartoces
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Suzanne Emmer
- Division of Chapter Quality Improvement Initiatives, American Academy of Pediatrics, Itasca, IL
| | - Judith C. Dolins
- Community & Chapter Affairs and Quality Improvement, American Academy of Pediatrics
| |
Collapse
|
13
|
Haase R, Baier J, Cristofolini M, Scheller K, Moritz S. [Effects of an In-House Antibiotic Stewardship Initiative on Diagnosis and Management of Community-Acquired Pneumonia in Childhood and Adolescence]. Pneumologie 2021; 75:507-515. [PMID: 33556975 DOI: 10.1055/a-1346-4444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pediatric community-acquired pneumonia (pCAP) often leads to prescription of antibiotics and hospital admission of children. Unfortunately, adherence to diagnosis and treatment guidelines is inconsistent, and misuse of antibiotics may occur. Antimicrobial stewardship interventions, which were started in many hospitals during the last decade, can optimize management of pCAP without negative patient outcomes. OBJECTIVES The objective of this retrospective analysis was to assess the influence of a newly implemented in-house pediatric antibiotic stewardship (ABS) initiative on guideline adherence and treatment quality. MATERIALS AND METHODS Retrospective, patients' file-based analysis of the effects of an ABS initiative in a pediatric university hospital from January 2017 until March 2020. ABS initiative included creation of a local pCAP guideline for hospitalized children aged 90 days - 18 years, periodic training and continuous ABS support. RESULTS A total of 230 patients with pCAP were included (145 before and 85 after intervention). Implementation of the ABS program led to reduction of antibiotics prescription without clear indication from 26 % to 10 % (p < 0.05). The inappropriate use of antibiotics decreased from 64 % to 27 % (p < 0.05), the rate of incorrect doses declined from 17 % to 10 % (p < 0.05) and the mean duration of antibiotic treatment declined from 10 to 7 days (p < 0.05). There were no differences between the two groups regarding length of stay, treatment failure or readmissions for respiratory infection. CONCLUSIONS Pediatric antibiotic stewardship is an appropriate and safe method, and is beneficial to hospitalized patients with pCAP. Application of ABS programs may increase adherence to clinical guidelines and improve appropriate antimicrobial use without negative impact on patient outcomes. Multicenter follow-up studies are needed to clarify long-term effects of ABS programs.
Collapse
Affiliation(s)
- R Haase
- Abteilung für Neonatologie und Pädiatrische Intensivmedizin, Universitätsklinikum Halle, Halle.,Klinik für Neonatologie und Kinderintensivmedizin, Krankenhaus St. Elisabeth und St. Barbara, Halle
| | - J Baier
- Abteilung für Neonatologie und Pädiatrische Intensivmedizin, Universitätsklinikum Halle, Halle
| | - M Cristofolini
- Landesamt für Verbraucherschutz Sachsen-Anhalt, Magdeburg
| | - K Scheller
- Universitätsklinik und Poliklinik für Mund-, Kiefer- und Plastische Gesichtschirurgie, Universitätsklinikum Halle, Halle
| | - S Moritz
- Klinische Infektiologie, Universitätsklinikum Halle, Halle
| |
Collapse
|
14
|
Abstract
BACKGROUND The human microbiome evolves rapidly in early life with contributions from various factors such as diet, delivery mode, medical history, antibiotics exposure, genetics, immunomodulators and the environment. A high use of antibiotics in pediatric outpatient settings has been well documented, and improvement in antibiotic selection is required to reduce the risks of antibiotic resistance and disruption of the microbiome. METHODS We performed an exploratory study using 16S rRNA gene-based sequencing to characterize the gut and nasopharyngeal microbiome of children (n = 50) age 1-6 years of age in a pediatric otolaryngology practice. RESULTS Relative abundance of Haemophilus and Moraxella were higher in nasopharyngeal swabs, while Prevotella, Bacteroides, Porphyromonas and Faecalibacterium were highly abundant in rectal swabs. The gut microbiome composition in children <2 years old was different compared with children ≥2 years age. Gut bacterial diversity increased with an increase in age of the children. Children taking probiotics had a notable increase in abundance of potentially beneficial gut bacteria such as Bacteroides and Akkermansia. The nasopharyngeal microbiome differed between children who received antibiotics in the 3 months before sample collection compared with those that did not. Haemophilus spp. was highly abundant in children who received antibiotics 3 months before sampling. CONCLUSIONS The pediatric nasopharyngeal and rectal microbiomes differ in bacterial composition and diversity. The increased abundance of Haemophilus spp. in the nasopharyngeal microbiome of children who received antibiotics during the 3 months before sampling suggests a potential impact of antibiotics in colonization with the otopathogen and may be relevant to clinical practice.
Collapse
|