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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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Clark JA, Conway Morris A, Kanaris C, Inwald D, Butt W, Osowicki J, Schlapbach LJ, Curran MD, White D, Daubney E, Agrawal S, Navapurkar V, Török ME, Baker S, Pathan N. A qualitative investigation of paediatric intensive care staff attitudes towards the diagnosis of lower respiratory tract infection in the molecular diagnostics era. INTENSIVE CARE MEDICINE. PAEDIATRIC AND NEONATAL 2023; 1:10. [PMID: 37425493 PMCID: PMC10329081 DOI: 10.1007/s44253-023-00008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/09/2023] [Indexed: 07/11/2023]
Abstract
Background In the past decade, molecular diagnostic syndromic arrays incorporating a range of bacterial and viral pathogens have been described. It is unclear how paediatric intensive care unit (PICU) staff diagnose lower respiratory tract infection (LRTI) and integrate diagnostic array results into antimicrobial decision-making. Methods An online survey with eleven questions was distributed throughout paediatric intensive care societies in the UK, continental Europe and Australasia with a total of 755 members. Participants were asked to rate the clinical factors and investigations they used when prescribing for LRTI. Semi-structured interviews were undertaken with staff who participated in a single-centre observational study of a 52-pathogen diagnostic array. Results Seventy-two survey responses were received; most responses were from senior doctors. Whilst diagnostic arrays were used less frequently than routine investigations (i.e. microbiological culture), they were of comparable perceived utility when making antimicrobial decisions. Prescribers reported that for arrays to be clinically impactful, they would need to deliver results within 6 h for stable patients and within 1 h for unstable patients to inform their immediate decision to prescribe antimicrobials. From 16 staff interviews, we identified that arrays were helpful for the diagnosis and screening of bacterial LRTI. Staff reported it could be challenging to interpret results in some cases due to the high sensitivity of the test. Therefore, results were considered within the context of the patient and discussed within the multidisciplinary team. Conclusions Diagnostic arrays were considered of comparable value to microbiological investigations by PICU prescribers. Our findings support the need for further clinical and economic evaluation of diagnostic arrays in a randomised control trial. Trial registration Clinicaltrials.gov, NCT04233268. Registered on 18 January 2020. Supplementary Information The online version contains supplementary material available at 10.1007/s44253-023-00008-z.
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Affiliation(s)
- John A. Clark
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew Conway Morris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Immunology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Constantinos Kanaris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Blizard Institute, Queen Mary University of London, London, UK
| | - David Inwald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Warwick Butt
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Joshua Osowicki
- Infectious Diseases Unit, Department of General Medicine, Royal Children’s Hospital Melbourne, Parkville, Australia
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology and Children’s Research Center, University Children’s Hospital Zürich, Zurich, Switzerland
| | - Martin D. Curran
- United Kingdom Health Security Agency, Clinical Microbiology and Public Health Laboratory, Cambridge, UK
| | - Deborah White
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Esther Daubney
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Shruti Agrawal
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Vilas Navapurkar
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M. Estée Török
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Infectious Diseases, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Solomonian L, Blesoff J, Garofalo L, Lucas S, Picardo A, Garber A, Wilson M, Leach M. Naturopathic Management of Acute Pediatric Respiratory Infections: A Modified Delphi Study. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2023; 29:181-195. [PMID: 36827416 DOI: 10.1089/jicm.2022.0669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
Objective: Both the United Nations and the World Health Organization have identified antimicrobial resistance as a significant threat to global health. The Centers for Disease Control and Prevention identified five pediatric respiratory conditions as requiring particular scrutiny in terms of antibiotic stewardship. This study sought to identify strategies used by experienced naturopathic practitioners to treat acute respiratory infections in children. The authors theorize that naturopathic strategies safely fill the gap between watchful waiting and antibiotic prescription, thus reducing the use of antibiotics. Methods: Naturopathic practitioners in Canada, the United States, and Australia with a minimum of 5 years of experience in clinical naturopathic care of children were recruited for a modified Delphi study. A 14-person panel of practitioners was selected to complete a series of four iterative surveys assessing agreement to statements in five domains of knowledge/attitudes, assessment/diagnosis, management, monitoring, and education. Items were deemed to have reached consensus if they reached a predetermined threshold of 70% agreement, or failed to reach a threshold of 40% agreement. Items between these boundaries were modified and retested until either consensus was reached or the four surveys had been completed. Results: Results yielded a large degree of agreement on core naturopathic approaches to the management of acute pediatric respiratory infections, especially lifestyle strategies, including adequate rest and dietary recommendations. The use of vitamins C and D was strongly supported, as were herbs, particularly echinacea and elderberry. Some hydrotherapy and topical applications specific to the individual focus on infection also reached consensus. Results suggested that most respondents, even if they have the authority to prescribe antibiotics, rarely deem it necessary to do so. Conclusion: Findings of this study provide (1) clarity on the role of naturopathic doctors in the management of pediatric health concerns and the stewardship of antibiotics; and (2) initial guidance to less experienced naturopathic practitioners. The findings also identify key priorities for research into the safety and effectiveness of naturopathic interventions to reduce the unnecessary prescribing of antibiotics.
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Affiliation(s)
| | - Jamine Blesoff
- National University of Health Sciences, Lombard, IL, USA
| | | | - Sandra Lucas
- School of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Andrea Picardo
- Canadian College of Naturopathic Medicine, Toronto, ON, Canada
| | - Anna Garber
- Canadian College of Naturopathic Medicine, Toronto, ON, Canada
| | - Mariah Wilson
- Canadian College of Naturopathic Medicine, Toronto, ON, Canada
| | - Matthew Leach
- National Centre for Naturopathic Medicine, Southern Cross University, Lismore, NSW, Australia
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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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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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Baumann P, Fuchs A, Gotta V, Ritz N, Baer G, Bonhoeffer JM, Buettcher M, Heininger U, Szinnai G, Bonhoeffer J. The kinetic profiles of copeptin and mid regional proadrenomedullin (MR-proADM) in pediatric lower respiratory tract infections. PLoS One 2022; 17:e0264305. [PMID: 35271609 PMCID: PMC8912143 DOI: 10.1371/journal.pone.0264305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 01/31/2022] [Indexed: 11/23/2022] Open
Abstract
Background Kinetics of copeptin and mid regional proadrenomedullin (MR-proADM) during febrile pediatric lower respiratory tract infections (LRTI) are unknown. We aimed to analyze kinetic profiles of copeptin and MR-proADM and the impact of clinical and laboratory factors on those biomarkers. Methods This is a retrospective post-hoc analysis of a randomized controlled trial, evaluating procalcitonin guidance for antibiotic treatment of LRTI (ProPAED-study). In 175 pediatric patients presenting to the emergency department plasma copeptin and MR-proADM concentrations were determined on day 1, 3, and 5. Their association with clinical characteristics and other inflammatory biomarkers were tested by non-linear mixed effect modelling. Results Median copeptin and MR-proADM values were elevated on day 1 and decreased during on day 3 and 5 (-26%; -34%, respectively). The initial concentrations of MR-proADM at inclusion were higher in patients receiving antibiotics intravenously compared to oral administration (difference 0.62 pmol/L, 95%CI 0.44;1.42, p<0.001). Intensive care unit (ICU) admission was associated with a daily increase of MR-proADM (increase/day 1.03 pmol/L, 95%CI 0.43;1.50, p<0.001). Positive blood culture in patients with antibiotic treatment and negative results on nasopharyngeal aspirates, or negative blood culture were associated with a decreasing MR-proADM (decrease/day -0.85 pmol/L, 95%CI -0.45;-1.44), p<0.001). Conclusion Elevated MR-proADM and increases thereof were associated with ICU admission suggesting the potential as a prognostic factor for severe pediatric LRTI. MR-proADM might only bear limited value for decision making on stopping antibiotics due to its slow decrease. Copeptin had no added value in our setting.
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Affiliation(s)
- Philipp Baumann
- Department of Paediatric Infectious Diseases and Vaccines, University of Basel Children’s Hospital, Basel, Switzerland
- * E-mail:
| | - Aline Fuchs
- Department of Paediatric Pharmacology and Pharmacometrics, University of Basel Children’s Hospital, Basel, Switzerland
| | - Verena Gotta
- Department of Paediatric Pharmacology and Pharmacometrics, University of Basel Children’s Hospital, Basel, Switzerland
| | - Nicole Ritz
- Department of Paediatric Infectious Diseases and Vaccines, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Paediatric Pharmacology and Pharmacometrics, University of Basel Children’s Hospital, Basel, Switzerland
| | - Gurli Baer
- Department of Paediatric Infectious Diseases and Vaccines, University of Basel Children’s Hospital, Basel, Switzerland
| | - Jessica M. Bonhoeffer
- Department of Paediatrics, University of Basel Children’s Hospital, Basel, Switzerland
| | | | - Ulrich Heininger
- Department of Paediatric Infectious Diseases and Vaccines, University of Basel Children’s Hospital, Basel, Switzerland
| | - Gabor Szinnai
- Department of Paediatric Endocrinology and Diabetology, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jan Bonhoeffer
- Department of Paediatric Infectious Diseases and Vaccines, University of Basel Children’s Hospital, Basel, Switzerland
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Multistep antimicrobial stewardship intervention on antibiotic prescriptions and treatment duration in children with pneumonia. PLoS One 2021; 16:e0257993. [PMID: 34705849 PMCID: PMC8550372 DOI: 10.1371/journal.pone.0257993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The Italian antimicrobial prescription rate is one of the highest in Europe, and antibiotic resistance has become a serious problem with high costs and severe consequences, including prolonged illnesses, the increased period of hospitalization and mortality. Inadequate antibiotic prescriptions have been frequently reported, especially for lower respiratory tract infections (LRTI); many patients receive antibiotics for viral pneumonia or bronchiolitis or broad-spectrum antibiotics for not complicated community-acquired pneumonia. For this reason, healthcare organizations need to implement strategies to raise physicians' awareness about this kind of drug and their overall effect on the population. The implementation of antibiotic stewardship programs and the use of Clinical Pathways (CPs) are excellent solutions because they have proven to be effective tools at diagnostic and therapeutic levels. AIMS This study evaluates the impact of CPs implementation in a Pediatric Emergency Department (PED), analyzing antibiotic prescriptions before and after the publication in 2015 and 2019. The CP developed in 2019 represents an update of the previous one with the introduction of serum procalcitonin. The study aims to evaluate the antibiotic prescriptions in patients with community-acquired pneumonia (CAP) before and after both CPs (2015 and 2019). METHODS The periods analyzed are seven semesters (one before CP-2015 called PRE period, five post CP-2015 called POST 1-5 and 1 post CP-2019 called POST6). The patients have been split into two groups: (i) children admitted to the Pediatric Acute Care Unit (INPATIENTS), and (ii) patients evaluated in the PED and sent back home (OUTPATIENTS). We have analyzed all descriptive diagnosis of CAP (the assessment of episodes with a descriptive diagnosis were conducted independently by two pediatricians) and CAP with ICD9 classification. All antibiotic prescriptions for pediatric patients with CAP were analyzed. RESULTS A drastic reduction of broad-spectrum antibiotics prescription for inpatients has been noticed; from 100.0% in the PRE-period to 66.7% in POST1, and up to 38.5% in POST6. Simultaneously, an increase in amoxicillin use from 33.3% in the PRE-period to 76.1% in POST1 (p-value 0.078 and 0.018) has been seen. The outpatients' group's broad-spectrum antibiotics prescriptions decreased from 54.6% PRE to 17.4% in POST6. Both for outpatients and inpatients, there was a decrease of macrolides. The inpatient group's antibiotic therapy duration decreased from 13.5 days (PRE-period) to 7.0 days in the POST6. Antibiotic therapy duration in the outpatient group decreased from 9.0 days (PRE) to 7.0 days (POST1), maintaining the same value in subsequent periods. Overlapping results were seen in the ICD9 group for both inpatients and outpatients. CONCLUSIONS This study shows that CPs are effective tools for an antibiotic stewardship program. Indeed, broad-spectrum antibiotics usage has dropped and amoxicillin prescriptions have increased after implementing the CAP CP-2015 and the 2019 update.
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Edwards G, Newbould L, Nesbitt C, Rogers M, Morris RL, Hay AD, Campbell SM, Hayward G. Predicting poor outcomes in children aged 1-12 with respiratory tract infections: A systematic review. PLoS One 2021; 16:e0249533. [PMID: 33872323 PMCID: PMC8055026 DOI: 10.1371/journal.pone.0249533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background Demand for NHS services is high and rising. In children respiratory tract infections (RTI) are the most common reason for consultation with primary care. Understanding which features are associated with good and poor prognosis with RTI will help develop interventions to support parents manage illness. Aim To identify symptoms, signs, and investigation results associated with good and poor prognosis, and clinical decision making in children aged 1–12 years with RTI symptoms, at home and presenting to ambulatory care. Design and setting Systematic literature review. Methods We searched MEDLINE, EMBASE, Cinahl, Web of Science and the Cochrane database of systematic reviews for studies of children aged 1 to 12 years with a RTI or related condition reporting symptoms, signs and investigation results associated with prognostic outcomes. Quality was assessed using the QUIPS tool. Results We included 27 studies which included 34802 children and measured 192 factors. Nine studies explored future outcomes and the remainder explored clinical management from the initial consultation with the health services. None were conducted in a home setting. Respiratory signs, vomiting, fever, dehydration and tachycardia at the initial contact were associated with future hospitalisation. Little evidence was available for other outcomes. Conclusion Some evidence is available to clinicians to stratify risk of, future hospitalisation, but not of other prognostic outcomes. There is little evidence available to parents to identify children at risk of poor prognosis. Research is needed into whether poor prognosis can be predicted by parents in the home.
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Affiliation(s)
- George Edwards
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Louise Newbould
- Social Policy Research Unit, University of York, York, United Kingdom
| | - Charlotte Nesbitt
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Miranda Rogers
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rebecca L. Morris
- Division of Population Health, NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Alastair D. Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Stephen M. Campbell
- Division of Population Health, NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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van Aerde KJ, de Haan L, van Leur M, Gerrits GP, Schers H, Moll HA, Hagedoorn NN, Herberg JA, Levin M, Rivero-Calle I, de Jonge MI, de Groot R, van der Flier M. Respiratory Tract Infection Management and Antibiotic Prescription in Children: A Unique Study Comparing Three Levels of Healthcare in The Netherlands. Pediatr Infect Dis J 2021; 40:e100-e105. [PMID: 33395212 DOI: 10.1097/inf.0000000000003019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Respiratory tract infections (RTIs) are common in children with febrile illness visiting the general practitioner (GP) or emergency department. We studied the management of children with fever and RTI at 3 different levels of healthcare in The Netherlands, focusing on antibiotic prescription. METHODS This prospective observational study is part of the Management and Outcome of Febrile children in Europe study. Data were used from face-to-face patient contacts of children with febrile illness in three healthcare settings in Nijmegen, The Netherlands during 2017. These settings were primary (GP), secondary (general hospital) and tertiary care (university hospital). RESULTS Of 892 cases with RTI without complex comorbidities, overall antibiotic prescription rates were 29% with no differences between the 3 levels of healthcare, leading to an absolute number of 5031 prescriptions per 100,000 children per year in primary care compared with 146 in secondary and tertiary care combined. The prescription rate in otitis media was similar in all levels: 60%. In cases with lower RTI who received nebulizations prescription rates varied between 19% and 55%. CONCLUSIONS Antibiotic prescription rates for RTIs in children were comparable between the 3 levels of healthcare, thus leading to a majority of antibiotics being prescribed in primary care. Relatively high prescription rates for all foci of RTIs were found, which was not in agreement with the national guidelines. Antibiotic stewardship needs improvement at all 3 levels of healthcare. Guidelines to prescribe small spectrum antibiotics for RTIs need to be better implemented in hospital care settings.
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Affiliation(s)
- Koen J van Aerde
- From the Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences
- Radboud Center for Infectious Diseases, Radboud University Medical Center
| | - Liza de Haan
- Department of Pediatrics, Canisius Wilhelmina Hospital
| | | | | | - Henk Schers
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, FaME-Net, Nijmegen
| | - Henriette A Moll
- Department of General Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nienke N Hagedoorn
- Department of General Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jethro A Herberg
- Section of Pediatrics, Imperial College
- Pediatric Emergency Department, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael Levin
- Section of Pediatrics, Imperial College
- Pediatric Emergency Department, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Irene Rivero-Calle
- Genetics, Vaccines, Infections and Pediatrics Research group (GENVIP), Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Marien I de Jonge
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences
- Radboud Center for Infectious Diseases, Radboud University Medical Center
| | - Ronald de Groot
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences
- Radboud Center for Infectious Diseases, Radboud University Medical Center
| | - Michiel van der Flier
- Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences
- Genetics, Vaccines, Infections and Pediatrics Research group (GENVIP), Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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Antibiotic Prescribing for Viral Respiratory Infections in the Pediatric Emergency Department and Urgent Care. Pediatr Infect Dis J 2020; 39:406-410. [PMID: 32176186 DOI: 10.1097/inf.0000000000002586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Viral acute respiratory tract infections (vARTI) are a frequent source of inappropriate antibiotic prescribing. We describe the prevalence of antibiotic prescribing for vARTI in the pediatric emergency department (ED) and urgent care (UC) within a health system, and identify factors associated with overall and broad-spectrum antibiotic prescribing. METHODS Retrospective chart review within a single pediatric referral health system. Visits of patients, 3 months- 17 years old, with a discharge diagnosis of a vARTI from 2010 to 2015. Data collected included specific vARTI diagnosis, site type (ED or UC), provider type [pediatric emergency medicine subspecialist or physicians, nurse practitioners, physician assistants (non-PEM)] and discharge antibiotics. Odds ratios and 95% confidence intervals (CI) were calculated where appropriate. RESULTS There were 132,458 eligible visits, mean age 4.1 ± 4.3 years. Fifty-three percent were treated in an ED. Advanced practice providers, a term encompassing nurse practitioners and physician assistants, were the most common provider type (47.7%); 16.5% of patients were treated by a pediatric emergency medicine subspecialist. Antibiotics were prescribed for 3.8% (95% CI: 3.72-3.92) of children with vARTI; 25.4% (95% CI: 24.2-26.6) of these were broad-spectrum, most commonly first-generation cephalosporins (11%; 95% CI 10.2-11.9). Patients treated in an ED or by a non-PEM and those receiving chest radiograph (CXR) received antibiotics most frequently. Prescribing rates varied by specific vARTI diagnosis. CONCLUSIONS Patients discharged from the pediatric ED or UC with vARTI receive inappropriate antibiotics at a lower rate than reported in other community settings; however, they frequently receive broad-spectrum agents.
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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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