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Otake S, Shoji T, Yamada K, Kimura M, Myojin S, Kamiyoshi N, Ochi F, Nezu M, Ishida A, Miyairi I, Kasai M. Trend in antibiotic prescription at pediatric primary emergency medical centers in Japan: A multi-center, cross-sectional study. J Infect Chemother 2024; 30:616-620. [PMID: 38237860 DOI: 10.1016/j.jiac.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024]
Abstract
INTRODUCTION Antimicrobial resistance is a global issue, and implementation of antimicrobial stewardship programs in outpatient settings is crucial. Japan has also focused on outpatient oral antimicrobial stewardship programs and difficulties in standardizing prescriptions have led to overprescription in primary emergency medical centers. There is a lack of research investigating the antibiotic prescription status of pediatric primary emergency medical centers and the benchmark prescription rates in pediatric outpatient settings. METHODS We conducted a multi-center, cross-sectional study of seven pediatric primary emergency medical centers located in five prefectures of Japan. We retrospectively extracted data from health claims or directly obtained them from charts at each institution and evaluated trends in the antibiotic prescription rate based on the AWaRe classification between April 2016 and December 2019. RESULTS Our study included 383,525 encounters, with the most common infectious disease diagnosis being acute upper respiratory tract infection in 93,449 cases (24.4 %). The antibiotic prescription rate during the study period was 7.4 %, representing a decrease of 46 %, from 10.2 % in 2016 to 5.5 % in 2019. The percentage of prescriptions in the Access group increased at all institutions; however, it exceeded 60 % in only three facilities in 2019. The percentage of third-generation cephalosporins varied among facilities, ranging from 1.7 % to 59.4 %, as of 2019. CONCLUSIONS For pediatric primary emergency medical centers where antimicrobial stewardship programs are implemented, we suggest 5 % as a reasonable benchmark level for the antibiotic prescription rate. Prescribing the antibiotics in the Access groups less frequently remains a domestic challenge in Japan.
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Affiliation(s)
- Shogo Otake
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan; Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, Hyogo, Japan.
| | - Takayo Shoji
- Department of Infectious Diseases, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Kenta Yamada
- Department of Pediatrics, University of Fukui Hospital, Fukui, Japan
| | - Makoto Kimura
- Kobe Children's Primary Emergency Medical Center, Hyogo, Japan
| | - Shota Myojin
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Japanese Red Cross Society Himeji Hospital, Hyogo, Japan
| | - Fumihiro Ochi
- Department of Pediatrics, Ehime Prefectural Niihama Hospital, Ehime, Japan
| | - Mari Nezu
- Department of Clinical Epidemiology, Hyogo Medical University, Hyogo, Japan
| | - Akihito Ishida
- Kobe Children's Primary Emergency Medical Center, Hyogo, Japan
| | - Isao Miyairi
- Department of Pediatrics, Hamamatsu University School of Medicine, Shizuoka, Japan; Department of Microbiology, Immunology, and Biochemistry, University of Tennessee Health Science Center, TN, USA
| | - Masashi Kasai
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, Hyogo, Japan
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Nedved A, Bizune D, Fung M, Liu CM, Tsay S, Hamdy RF, Montalbano A. Communication Strategies to Improve Antibiotic Prescribing in Pediatric Urgent Care Centers. Pediatr Emerg Care 2024; 40:265-269. [PMID: 37195689 PMCID: PMC10906363 DOI: 10.1097/pec.0000000000002977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Urgent care (UC) clinicians frequently prescribe inappropriate antibiotics for upper respiratory illnesses. In a national survey, pediatric UC clinicians reported family expectations as a primary driver for prescribing inappropriate antibiotics. Communication strategies effectively reduce unnecessary antibiotics while increasing family satisfaction. We aimed to reduce inappropriate prescribing practices in otitis media with effusion (OME), acute otitis media (AOM), and pharyngitis in pediatric UC clinics by a relative 20% within 6 months using evidence-based communication strategies. METHODS We recruited participants via e-mails, newsletters, and Webinars from pediatric and UC national societies. We defined antibiotic-prescribing appropriateness based on consensus guidelines. Family advisors and UC pediatricians developed script templates based on an evidence-based strategy. Participants submitted data electronically. We reported data using line graphs and shared deidentified data during monthly Webinars. We used χ 2 tests to evaluate change in appropriateness at the beginning and end of the study period. RESULTS The 104 participants from 14 institutions submitted 1183 encounters for analysis in the intervention cycles. Using a strict definition of inappropriateness, overall inappropriate antibiotic prescriptions for all diagnoses trended downward from 26.4% to 16.6% ( P = 0.13). Inappropriate prescriptions trended upward in OME from 30.8% to 46.7% ( P = 0.34) with clinicians' increased use of "watch and wait" for this diagnosis. Inappropriate prescribing for AOM and pharyngitis improved from 38.6% to 26.5% ( P = 0.03) and 14.5% to 8.8% ( P = 0.44), respectively. CONCLUSIONS Using templates to standardize communication with caregivers, a national collaborative decreased inappropriate antibiotic prescriptions for AOM and had downward trend in inappropriate antibiotic prescriptions for pharyngitis. Clinicians increased the inappropriate use of "watch and wait" antibiotics for OME. Future studies should evaluate barriers to the appropriate use of delayed antibiotic prescriptions.
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Affiliation(s)
- Amanda Nedved
- Division of Urgent Care, Children’s Mercy Kansas City; University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Destani Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Melody Fung
- Antibiotic Resistance Action Center, Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Cindy M. Liu
- Antibiotic Resistance Action Center, Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Sharon Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Rana F. Hamdy
- Division of Infectious Diseases, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Amanda Montalbano
- Division of Urgent Care, Children’s Mercy Kansas City; University of Missouri-Kansas City School of Medicine, Kansas City, MO
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Seibert AM, Schenk C, Buckel WR, Patel PK, Fino N, Stanfield V, Hersh AL, Stenehjem E. Beyond antibiotic prescribing rates: first-line antibiotic selection, prescription duration, and associated factors for respiratory encounters in urgent care. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e146. [PMID: 37771738 PMCID: PMC10523551 DOI: 10.1017/ash.2023.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/03/2023] [Accepted: 07/09/2023] [Indexed: 09/30/2023]
Abstract
Objective Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis. Design Retrospective cohort study. Participants All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019-June 30th, 2020. Methods Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5-10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration. Results Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non-first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]). Conclusions First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts.
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Affiliation(s)
- Allan M. Seibert
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
| | | | | | - Payal K. Patel
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Valoree Stanfield
- Office of Patient Experience, Intermountain Health, Salt Lake City, UT, USA
| | - Adam L. Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Eddie Stenehjem
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
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El Feghaly RE, Nedved A, Katz SE, Frost HM. New insights into the treatment of acute otitis media. Expert Rev Anti Infect Ther 2023; 21:523-534. [PMID: 37097281 PMCID: PMC10231305 DOI: 10.1080/14787210.2023.2206565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/20/2023] [Indexed: 04/26/2023]
Abstract
INTRODUCTION Acute otitis media (AOM) affects most (80%) children by 5 years of age and is the most common reason children are prescribed antibiotics. The epidemiology of AOM has changed considerably since the widespread use of pneumococcal conjugate vaccines, which has broad-reaching implications for management. AREAS COVERED In this narrative review, we cover the epidemiology of AOM, best practices for diagnosis and management, new diagnostic technology, effective stewardship interventions, and future directions of the field. Literature review was performed using PubMed and ClinicalTrials.gov. EXPERT OPINION Inaccurate diagnoses, unnecessary antibiotic use, and increasing antimicrobial resistance remain major challenges in AOM management. Fortunately, effective tools and interventions to improve diagnostic accuracy, de-implement unnecessary antibiotic use, and individualize care are on the horizon. Successful scaling of these tools and interventions will be critical to improving overall care for children.
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Affiliation(s)
- Rana E. El Feghaly
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Amanda Nedved
- Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Sophie E. Katz
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Holly M. Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Blanco MV, Hamdy RF, Liu CM, Jones H, Montalbano A, Nedved A. Antibiotic Prescribing Patterns for Pediatric Urgent Care Clinicians. Pediatr Emerg Care 2022; 38:e1538-e1540. [PMID: 35947062 DOI: 10.1097/pec.0000000000002809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Previous studies have reported high rates of inappropriate antibiotic prescriptions in urgent care (UC). Specific prescribing patterns for the most common diagnoses are not known. The aim of the study is to determine the diagnoses for which antibiotics are prescribed in pediatric UC settings. METHODS We recruited pediatric UC providers via email to participate in a national multisite quality improvement study. Participants completed a survey on 10 consecutive encounters in which an antibiotic was given between March and May 2018. Encounters in which only topical antibiotics were prescribed were excluded. We categorized the encounters into 3 previously established tiers to determine appropriateness of antibiotic use. The tiers represent a descending order for antibiotic need based on diagnoses, with the first tier representing diagnoses almost always requiring antibiotics and the third tier representing diagnoses when an antibiotic is almost never required. We reported the diagnoses and frequency of antibiotic prescription within each tier. RESULTS The 157 providers from 20 institutions submitted a total of 2809 encounters. We excluded 339 encounters in which only topical antibiotics were prescribed. Most diagnoses fell into the tier 2 category (85.81%), with only 9.12% in tier 1 and 5.06% in tier 3. The most common diagnoses reported were acute otitis media (48.96%), pharyngitis (25.09%), and skin and soft tissue infections (7.29%). CONCLUSIONS In this sample of pediatric UC encounters, only 5% of diagnoses receiving antibiotic prescriptions were made up of tier 3 diagnoses, determined to almost never require antibiotics. While viral respiratory infections have been reported to frequently be treated with antibiotics in general UC centers, our study of pediatric UC centers showed that this was infrequent. However, otitis media with effusion and otalgia should be further investigated. With most antibiotic prescriptions being tier 2 diagnoses, pediatric UC providers can use evidence-based prescribing practices, shared decision making, and contingency plans to reduce unnecessary antibiotic exposure.
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Affiliation(s)
| | | | - Cindy M Liu
- Antibiotic Resistance Action Center, Department of Environmental and Occupational Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Heather Jones
- From the Department of Pediatrics, Children's Mercy Kansas City
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