Antibiotic route and outcomes for children hospitalized with pneumonia

BACKGROUND

Emerging evidence suggests that initial oral and intravenous (IV) antibiotics have similar efficacy in pediatric community-acquired pneumonia (CAP), but further data are needed.

OBJECTIVE

We determined the association between hospital-level initial oral antibiotic rates and outcomes in pediatric CAP.

DESIGNS, SETTINGS AND PARTICIPANTS

This retrospective cohort study included children hospitalized with CAP at 43 hospitals in the Pediatric Health Information System (2016-2022). Hospitals were grouped by whether initial antibiotics were given orally in a high, moderate, or low proportion of patients.

MAIN OUTCOME AND MEASURES

Regression models examined associations between high versus low oral-utilizing hospitals and length of stay (LOS, primary outcome), intensive care unit (ICU) transfers, escalated respiratory care, complicated CAP, cost, readmissions, and emergency department (ED) revisits.

RESULTS

Initial oral antibiotics were used in 16% (interquartile range: 10%-20%) of 30,207 encounters, ranging from 1% to 68% across hospitals. Comparing high versus low oral-utilizing hospitals (oral rate: 32% [27%-47%] and 10% [9%-11%], respectively), there were no differences in LOS, intensive care unit, complicated CAP, cost, or ED revisits. Escalated respiratory care occurred in 1.3% and 0.5% of high and low oral-utilizing hospitals, respectively (relative ratio [RR]: 2.96 [1.12, 7.81]), and readmissions occurred in 1.5% and 0.8% (RR: 1.68 [1.31, 2.17]). Initial oral antibiotics varied across hospitals without a difference in LOS. While high oral-utilizing hospitals had higher escalated respiratory care and readmission rates, these were rare, the clinical significance of these small differences is uncertain, and there were no differences in other clinically relevant outcomes. This suggests some children may benefit from initial IV antibiotics, but most would probably do well with oral antibiotics.

Acute care utilization for ambulatory care-sensitive conditions among publicly insured children

BACKGROUND

Although characteristics of preventable hospitalizations for ambulatory care-sensitive conditions (ACSCs) have been described, less is known about patterns of emergency and other acute care utilization for ACSCs among children who are not hospitalized. We sought to describe patterns of utilization for ACSCs according to the initial site of care and to determine characteristics associated with seeking initial care in an acute care setting rather than in an office. A better understanding of the sequence of health care utilization for ACSCs may inform efforts to shift care for these common conditions to the medical home.

METHODS

We performed a retrospective analysis of pediatric encounters for ACSCs between 2017 and 2019 using data from the IBM Watson MarketScan Medicaid database. The database includes insurance claims for Medicaid-insured children in 10 anonymized states. We assessed the initial sites of care for ACSC encounters, which were defined as either acute care settings (emergency or urgent care) or office-based settings. We used generalized estimating equations clustered on patient to identify associations between encounter characteristics and the initial site of care.

RESULTS

Among 7,128,515 encounters for ACSCs, acute care settings were the initial site of care in 27.9%. Diagnoses with the greatest proportion of episodes presenting to acute care settings were urinary tract infection (52.0% of episodes) and pneumonia (44.6%). Encounters on the weekend (adjusted odds ratio [aOR] 6.30, 95% confidence interval [CI] 6.27-6.34 compared with weekday) and among children with capitated insurance (aOR 1.55, 95% CI 1.54-1.56 compared with fee for service) were associated with increased odds of seeking care first in an acute care setting.

CONCLUSIONS

Acute care settings are the initial sites of care for more than one in four encounters for ACSCs among publicly insured children. Expanded access to primary care on weekends may shift care for ACSCs to the medical home.

Harnessing the Power of Generative AI for Clinical Summaries: Perspectives From Emergency Physicians

STUDY OBJECTIVE

The workload of clinical documentation contributes to health care costs and professional burnout. The advent of generative artificial intelligence language models presents a promising solution. The perspective of clinicians may contribute to effective and responsible implementation of such tools. This study sought to evaluate 3 uses for generative artificial intelligence for clinical documentation in pediatric emergency medicine, measuring time savings, effort reduction, and physician attitudes and identifying potential risks and barriers.

METHODS

This mixed-methods study was performed with 10 pediatric emergency medicine attending physicians from a single pediatric emergency department. Participants were asked to write a supervisory note for 4 clinical scenarios, with varying levels of complexity, twice without any assistance and twice with the assistance of ChatGPT Version 4.0. Participants evaluated 2 additional ChatGPT-generated clinical summaries: a structured handoff and a visit summary for a family written at an 8th grade reading level. Finally, a semistructured interview was performed to assess physicians' perspective on the use of ChatGPT in pediatric emergency medicine. Main outcomes and measures included between subjects' comparisons of the effort and time taken to complete the supervisory note with and without ChatGPT assistance. Effort was measured using a self-reported Likert scale of 0 to 10. Physicians' scoring of and attitude toward the ChatGPT-generated summaries were measured using a 0 to 10 Likert scale and open-ended questions. Summaries were scored for completeness, accuracy, efficiency, readability, and overall satisfaction. A thematic analysis was performed to analyze the content of the open-ended questions and to identify key themes.

RESULTS

ChatGPT yielded a 40% reduction in time and a 33% decrease in effort for supervisory notes in intricate cases, with no discernible effect on simpler notes. ChatGPT-generated summaries for structured handoffs and family letters were highly rated, ranging from 7.0 to 9.0 out of 10, and most participants favored their inclusion in clinical practice. However, there were several critical reservations, out of which a set of general recommendations for applying ChatGPT to clinical summaries was formulated.

CONCLUSION

Pediatric emergency medicine attendings in our study perceived that ChatGPT can deliver high-quality summaries while saving time and effort in many scenarios, but not all.

Comparison of antibiotic prescribing between physicians and advanced practice clinicians

We compared antibiotic prescribing rates for respiratory conditions in a national sample of outpatient visits from 2010 to 2018 between physicians and advanced practice clinicians (APCs). APCs prescribed antibiotics more frequently than physicians (58% vs 52%), but there were no differences in selection of guideline recommended first-line agents between specialties.

Management of Pediatric Pneumonia: A Decade After the Pediatric Infectious Diseases Society and Infectious Diseases Society of America Guideline

BACKGROUND

Incomplete uptake of guidelines can lead to nonstandardized care, increased expenditures, and adverse clinical outcomes. The objective of this study was to evaluate the impact of the 2011 Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) pediatric community-acquired pneumonia (CAP) guideline that emphasized aminopenicillin use and de-emphasized the use of chest radiographs (CXRs) in certain populations.

METHODS

This quasi-experimental study queried a national administrative database of children's hospitals to identify children aged 3 months-18 years with CAP who visited 1 of 28 participating hospitals from 2009 to 2021. PIDS/IDSA pediatric CAP guideline recommendations regarding antibiotic therapy, diagnostic testing, and imaging were evaluated. Segmented regression interrupted time series was used to measure guideline-concordant practices with interruptions for guideline publication and the Coronavirus Disease 2019 (COVID-19) pandemic.

RESULTS

Of 315 384 children with CAP, 71 804 (22.8%) were hospitalized. Among hospitalized children, there was a decrease in blood culture performance (0.5% per quarter) and increase in aminopenicillin prescribing (1.1% per quarter). Among children discharged from the emergency department (ED), there was an increase in aminopenicillin prescription (0.45% per quarter), whereas the rate of obtaining CXRs declined (0.12% per quarter). However, use of CXRs rebounded during the COVID-19 pandemic (increase of 1.56% per quarter). Hospital length of stay, ED revisit rates, and hospital readmission rates remained stable.

CONCLUSIONS

Guideline publication was associated with an increase of aminopenicillin prescribing. However, rates of diagnostic testing did not materially change, suggesting the need to consider implementation strategies to meaningfully change clinical practice for children with CAP.

National Patterns of Outpatient Follow-Up Visits After Emergency Care for Acute Bronchiolitis

This cohort study examines the frequency of postdischarge follow-up visits among US emergency department encounters for bronchiolitis and assesses whether follow-up was associated with decreased hospital reutilization or increased treatment with nonrecommended medications.

Association between clinician specialty and prescription of preventive medication for young adults with migraine: A retrospective cohort study

OBJECTIVE

We aimed to compare the prescribing patterns of preventive medications between pediatric and adult neurologists for young adults with migraine.

BACKGROUND

Although preventive medications are effective for adults with migraine, studies in children have failed to demonstrate similar efficacy. As a result, lifestyle modifications and non-pharmacological interventions are often emphasized in children. It is not known whether young adults are prescribed preventive medications at different rates according to whether they are cared for by an adult or pediatric neurologist.

METHODS

We performed a multicenter retrospective cohort analysis of patients with migraine aged 18-25 years who were seen by a pediatric or adult neurologist at Mass General Brigham Hospital between 2017 and 2021. The primary outcome was whether the patient received a prescription for any preventive medication during the study period.

RESULTS

Among the 767 included patients, 290 (37.8%) were seen by a pediatric neurologist. Preventive medications were prescribed for 131/290 (45.2%; 95% confidence interval [CI]: 39.5%, 51.0%) patients seen by a pediatric neurologist and 206/477 (43.2%; 95% CI: 39.0%, 47.7%) patients seen by an adult neurologist (p = 0.591). In the mixed effects logistic regression model, clinician specialty was not associated with preventive medication use (adjusted odds ratio [AOR] 1.20, 95% CI: 0.62, 2.31). Female sex (AOR 1.69, 95% CI: 1.07, 2.66) and number of visits during the study period (AOR 1.64, 95% CI: 1.49, 1.80) were associated with receiving preventive medication.

CONCLUSION

Approximately two fifths of young adults with migraine were prescribed preventive medications, and this proportion did not differ according to clinician specialty. Although these findings suggest that pediatric and adult neurologists provide comparable care, both specialties may be underusing preventive medications in this patient population.

Patterns of Outpatient Follow-up Visits After Hospitalizations for Acute Bronchiolitis

This cohort study examines the associations of posthospitalization follow-up with emergency department visits, readmissions, and use of nonrecommended medications among children with bronchiolitis.

Ambulatory follow-up among publicly insured children discharged from the emergency department

BACKGROUND

While children discharged from the emergency department (ED) are frequently advised to follow up with ambulatory care providers, the extent to which this occurs is unknown. We sought to characterize the proportion of publicly insured children who have an ambulatory visit following ED discharge, identify factors associated with ambulatory follow-up, and evaluate the association of ambulatory follow-up with subsequent hospital-based health care utilization.

METHODS

We performed a cross-sectional study of pediatric (<18 years) encounters during 2019 included in the IBM Watson Medicaid MarketScan claims database from seven U.S. states. Our primary outcome was an ambulatory follow-up visit within 7 days of ED discharge. Secondary outcomes were 7-day ED return visits and hospitalizations. Logistic regression and Cox proportional hazards were used for multivariable modeling.

RESULTS

We included 1,408,406 index ED encounters (median age 5 years, IQR 2-10 years), for which a 7-day ambulatory visit occurred in 280,602 (19.9%). Conditions with the highest proportion of 7-day ambulatory follow-up included seizures (36.4%); allergic, immunologic, and rheumatologic diseases (24.6%); other gastrointestinal diseases (24.5%); and fever (24.1%). Ambulatory follow-up was associated with younger age, Hispanic ethnicity, weekend ED discharge, ambulatory encounters prior to the ED visit, and diagnostic testing performed during the ED encounter. Ambulatory follow-up was inversely associated with Black race and ambulatory care-sensitive or complex chronic conditions. In Cox models, ambulatory follow-up was associated with a higher hazard ratio (HR) of subsequent ED return (HR range 1.32-1.65) visit and hospitalization (HR range 3.10-4.03).

CONCLUSIONS

One-fifth of children discharged from the ED have an ambulatory visit within 7 days, which varied by patient characteristics and diagnoses. Children with ambulatory follow-up have a greater subsequent health care utilization, including subsequent ED visit and/or hospitalization. These findings identify the need to further research the role and costs associated with routine post-ED visit follow-up.

Respiratory virus testing and clinical outcomes among children hospitalized with pneumonia

BACKGROUND

Despite the increased availability of diagnostic tests for respiratory viruses, their clinical utility for children with community-acquired pneumonia (CAP) remains uncertain.

OBJECTIVE

To identify patterns of respiratory virus testing across children's hospitals prior to the COVID-19 pandemic and to determine whether hospital-level rates of viral testing were associated with clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter retrospective cohort study of children hospitalized for CAP at 19 children's hospitals in the United States from 2010-2019.

MAIN OUTCOMES AND MEASURES

Using a novel method to identify the performance of viral testing, we assessed time trends in the use of viral tests, both overall and stratified by testing method. Adjusted proportions of encounters with viral testing were compared across hospitals and were correlated with length of stay, antibiotic and oseltamivir use, and performance of ancillary laboratory testing.

RESULTS

There were 46,038 hospitalizations for non-severe CAP among children without complex chronic conditions. The proportion with viral testing increased from 38.8% to 44.2% during the study period (p < .001). Molecular testing increased (27.2% to 40.0%, p < .001) and antigen testing decreased (33.2% to 7.8%, p < .001). Hospital-specific adjusted proportions of testing ranged from 10.0% to 83.5% and were not associated with length of stay, antibiotic use, or antiviral use. Hospitals that performed more viral testing did not have lower rates of ancillary laboratory testing.

CONCLUSIONS

Viral testing practices varied widely across children's hospitals and were not associated with clinically important process or outcome measures. Viral testing may not influence clinical management for many children hospitalized with CAP.

Antibiotics and outcomes of CF pulmonary exacerbations in children infected with MRSA and Pseudomonas aeruginosa

BACKGROUND

Limited data exist to inform antibiotic selection among people with cystic fibrosis (CF) with airway infection by multiple CF-related microorganisms. This study aimed to determine among children with CF co-infected with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (Pa) if the addition of anti-MRSA antibiotics to antipseudomonal antibiotic treatment for pulmonary exacerbations (PEx) would be associated with improved clinical outcomes compared with antipseudomonal antibiotics alone.

METHODS

Retrospective cohort study using data from the CF Foundation Patient Registry-Pediatric Health Information System linked dataset. The odds of returning to baseline lung function and having a subsequent PEx requiring intravenous antibiotics were compared between PEx treated with anti-MRSA and antipseudomonal antibiotics and those treated with antipseudomonal antibiotics alone, adjusting for confounding by indication using inverse probability of treatment weighting.

RESULTS

943 children with CF co-infected with MRSA and Pa contributed 2,989 PEx for analysis. Of these, 2,331 (78%) PEx were treated with both anti-MRSA and antipseudomonal antibiotics and 658 (22%) PEx were treated with antipseudomonal antibiotics alone. Compared with PEx treated with antipseudomonal antibiotics alone, the addition of anti-MRSA antibiotics to antipseudomonal antibiotic therapy was not associated with a higher odds of returning to ≥90% or ≥100% of baseline lung function or a lower odds of future PEx requiring intravenous antibiotics.

CONCLUSIONS

Children with CF co-infected with MRSA and Pa may not benefit from the addition of anti-MRSA antibiotics for PEx treatment. Prospective studies evaluating optimal antibiotic selection strategies for PEx treatment are needed to optimize clinical outcomes following PEx treatment.

Factors Associated With Corticosteroid Treatment for Pediatric Acute Respiratory Tract Infections

Systemic corticosteroids are not recommended to treat children with acute respiratory tract infections (ARTIs). Using data from a national commercial health care company, we found that corticosteroid treatment occurred in 3.2% of ARTI encounters. The adjusted odds of corticosteroid treatment were highest for bronchitis/bronchiolitis, in emergency departments, and in the South.

Patient Ethnicity and Pediatric Visits to the Emergency Department for Fever

OBJECTIVES

Previous research has identified ethnic differences in parents' beliefs about fever, but whether patient ethnicity is associated with health care use for fever is uncertain. Our objectives were to describe the national rate of pediatric visits to the emergency department (ED) for fever and to determine whether there is variation in this rate by patient ethnicity.

METHODS

Using the National Hospital Ambulatory Medical Care Survey between 2012 and 2015, we estimated the proportion of ED visits with a complaint of fever by patients 0 to 18 years old and compared this proportion across patient ethnicity. We performed multivariable logistic regression controlling for sociodemographic characteristics and visit acuity to determine whether patient ethnicity was independently associated with visits for fever.

RESULTS

Fever was the reason for 19% [95% confidence interval (CI), 18%-20%] of pediatric visits to the ED, and the proportion of visits for fever was highest among Hispanic patients (25%; 95% CI, 23%-27%) and lowest among non-Hispanic white patients (15%; 95% CI, 14%-17%). In multivariable analysis, the adjusted odds of visits for fever were greater for Hispanic patients (odds ratio, 1.56; 95% CI, 1.38-1.83) and non-Hispanic non-black patients of other races (1.34; 95% CI, 1.02-1.77) compared with non-Hispanic white patients.

CONCLUSIONS

There is significant ethnic variation in the use of emergency medical services for fever in the United States, and these disparities are not fully explained by differences in the acuity of illness or differences in socioeconomic status. Interventions to empower parents to manage nonurgent pediatric fever should incorporate ethnocultural differences in parents' understanding of fever.

Short- Versus Prolonged-Duration Antibiotics for Outpatient Pneumonia in Children

OBJECTIVE

To identify practice patterns in the duration of prescribed antibiotics for the treatment of ambulatory children with community-acquired pneumonia (CAP) and to compare the frequency of adverse clinical outcomes between children prescribed short-vs prolonged-duration antibiotics.

STUDY DESIGN

We performed a retrospective cohort study from 2010-2016 using the IBM Watson MarketScan Medicaid Database, a claims database of publicly insured patients from 11 states. We included children 1-18 years old with outpatient CAP who filled a prescription for oral antibiotics (n = 121 846 encounters). We used multivariable logistic regression to determine associations between the duration of prescribed antibiotics (5-9 days vs 10-14 days) and subsequent hospitalizations, new antibiotic prescriptions, and acute care visits. Outcomes were measured during the 14 days following the end of the dispensed antibiotic course.

RESULTS

The most commonly prescribed duration of antibiotics was 10 days (82.8% of prescriptions), and 10.5% of patients received short-duration therapy. During the follow-up period, 0.2% of patients were hospitalized, 6.2% filled a new antibiotic prescription, and 5.1% had an acute care visit. Compared with the prolonged-duration group, the aORs for hospitalization, new antibiotic prescriptions, and acute care visits in the short-duration group were 1.16 (95% CI 0.80-1.66), 0.93 (95% CI 0.85-1.01), and 1.06 (95% CI 0.98-1.15), respectively.

CONCLUSIONS

Most children treated for CAP as outpatients are prescribed at least 10 days of antibiotic therapy. Among pediatric outpatients with CAP, no significant differences were found in rates of adverse clinical outcomes between patients prescribed short-vs prolonged-duration antibiotics.

Unnecessary Antibiotic Prescribing in US Ambulatory Care Settings, 2010-2015

The proportion of antibiotic prescriptions prescribed in US physician offices and emergency departments that were unnecessary decreased slightly, from 30% in 2010-2011 to 28% in 2014-2015. However, a greater decrease occurred in children: 32% in 2010-2011 to 19% in 2014-2015. Unnecessary prescribing in adults did not change during this period.

A Young Boy with Fever and Grunting

CASE PRESENTATION

A 16-month-old boy presented with a temperature of 99°Fahrenheit (F) (down from 102°F at home after antipyretics), grunting, and tachypnea. On examination, he was tachycardic, tachypneic, and ill-appearing with abdominal distention and diffuse tenderness. A plain film abdominal radiograph showed moderate free air, and emergent laparoscopy revealed perforated Meckel's diverticulitis with peritonitis.

DISCUSSION

Although tachypnea and grunting in preverbal or nonverbal patients are often considered to be signs of respiratory illness, these findings may reflect intra-abdominal emergencies. Perforated Meckel's diverticulitis is an important differential consideration in patients with pneumoperitoneum.

National Trends in Incidence of Purulent Skin and Soft Tissue Infections in Patients Presenting to Ambulatory and Emergency Department Settings, 2000-2015

Nationally representative data from 2000-2015 demonstrated a rise in the incidence of outpatient visits for skin infections, peaking in 2010-2013, followed by a plateau. While cephalexin was the most frequently prescribed antibiotic at the beginning, trimethoprim-sulfamethoxazole was most frequently prescribed by the end of the study period.

Contribution of Penicillin Allergy Labels to Second-Line Broad-Spectrum Antibiotic Prescribing for Pediatric Respiratory Tract Infections

Introduction

Antibiotic allergies are overdiagnosed. This may lead to unnecessary use of second-line broader-spectrum agents in place of narrower-spectrum guideline-recommended first-line therapies especially for uncomplicated respiratory tract infections. The extent to which this occurs for children with respiratory tract infections is unknown.

Methods

We included outpatient encounters for patients < 18 years with acute respiratory tract infections (sinusitis, bronchitis, bronchiolitis, upper respiratory tract infection, pharyngitis, otitis media). Patients were classified as penicillin allergic based on the presence of an allergy label in the electronic medical record. First-line guideline-recommended antibiotics included penicillin, amoxicillin or amoxicillin-clavulanate; all others were considered second line. The percentage of patients treated with first-line versus second-line antibiotics was compared between those with and without penicillin allergy. Additionally, we calculated the contribution of penicillin allergy to overall use of second-line antibiotics.

Results

Among 17,578 eligible encounters for respiratory tract infections, 1332 (8%) included patients with a penicillin allergy label. Overall, second-line antibiotics were prescribed in 15% of encounters. Second-line antibiotics were prescribed in 91% of encounters for penicillin-allergic patients, compared with 8% of encounters for non-allergic patients (P < 0.001). Patients with penicillin allergy labels accounted for 47% of all second-line antibiotic prescriptions.

Conclusion

In a large population of pediatric outpatient encounters for acute respiratory tract infections, patients labeled with a penicillin allergy accounted for nearly half of second-line antibiotics, which are often broader spectrum. Efforts to de-label children with penicillin allergies have the potential to reduce broader-spectrum antibiotic use.

Identifying Patients at Lowest Risk for Streptococcal Pharyngitis: A National Validation Study

OBJECTIVES

To determine the prevalence of features of viral illness in a national sample of visits involving children tested for group A Streptococcus pharyngitis. Additionally, we sought to derive a decision rule to identify patients with features of viral illness who were at low risk of having group A Streptococcus and for whom laboratory testing might be avoided.

STUDY DESIGN

Retrospective validation study using data from electronic health records of patients 3-21 years old evaluated for sore throat in a national network of retail health clinics (n = 67 127). We determined the prevalence of features of viral illness in patients tested for group A Streptococcus and developed a decision tree algorithm to identify patients with features of viral illness at low risk (<15%) of having group A Streptococcus.

RESULTS

Overall, 54% of patients had features of viral illness. Among patients with features of viral illness, those without tonsillar exudates who were 11 years or older and either lacked cervical adenopathy or had cervical adenopathy and lacked fever were identified as at low risk for group A Streptococcus according to the decision rule. This group comprised 34% of patients with features of viral illness, or 19% of all patients tested for group A Streptococcus infection.

CONCLUSIONS

Our findings provide an objective way to identify patients with features of viral illness who are at low risk of having group A Streptococcus. Improved identification such patients at low risk of group A Streptococcus could improve appropriate testing and antibiotic prescribing for pharyngitis.

Ambulatory Antibiotic Prescribing for Children with Pneumonia After Publication of National Guidelines: A Cross-Sectional Retrospective Study

INTRODUCTION

National guidelines published in 2011 recommend amoxicillin as first-line treatment for non-hospitalized children with community-acquired pneumonia (CAP). We aimed to understand visit rates, antibiotic selection, and factors associated with amoxicillin prescribing for children with CAP since guideline publication.

METHODS

We performed a cross-sectional retrospective study of patients aged 90 days-18 years with an outpatient clinic or emergency department (ED) visit from 2008 to 2015 using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey ED data files, respectively. We estimated the incidence rates of ambulatory CAP visits, examined time trends in antibiotics prescribed at CAP visits, and determined factors independently associated with first-line guideline-recommended antibiotic prescribing using multivariable logistic regression, including patient age, setting, and US census region.

RESULTS

From 2008 to 2015, there were an estimated 1.5 million [95% confidence interval (CI) 1.3-1.7 million] pediatric CAP visits annually. Amoxicillin was prescribed in 23% (95% CI 18-30%), azithromycin was prescribed in 47% (95% CI 41-54%), and cephalosporins were prescribed in 26% (95% CI 21-31%) of antibiotic visits for CAP. There were no significant differences in annual CAP visits or prescribing by antibiotic class since guideline publication. Amoxicillin prescribing was significantly less likely in visits by older children, aged 5-18 years, [adjusted odds ratio (aOR) 0.22, 95% CI 0.10-0.49] compared to visits by younger children aged 90 days-4 years with CAP. Compared with the Northeast, amoxicillin prescribing was significantly lower in the Midwest (aOR 0.35, 95% CI 0.13-0.98) and South (aOR 0.23, 95% CI 0.08-0.63). Azithromycin prescribing was significantly more likely in visits to EDs (aOR 1.46, 95% CI 1.07-1.98) compared to physician offices.

CONCLUSION

Despite national guideline recommendations, amoxicillin prescribing for CAP in outpatient settings is low and azithromycin remains the predominant antibiotic prescribed, highlighting the need for dedicated antibiotic stewardship efforts in ambulatory settings.

Antibiotic Prescribing for Children in United States Emergency Departments: 2009-2014

: media-1vid110.1542/5972296744001PEDS-VA_2018-1056Video Abstract OBJECTIVES: To characterize and compare ambulatory antibiotic prescribing for children in US pediatric and nonpediatric emergency departments (EDs).

METHODS

A cross-sectional retrospective study of patients aged 0 to 17 years discharged from EDs in the United States was conducted by using the 2009-2014 National Hospital Ambulatory Medical Care Survey ED data. We estimated the proportion of ED visits resulting in antibiotic prescriptions, stratified by antibiotic spectrum, class, diagnosis, and ED type ("pediatric" defined as >75% of visits by patients aged 0-17 years, versus "nonpediatric"). Multivariable logistic regression was used to determine factors independently associated with first-line, guideline-concordant prescribing for acute otitis media, pharyngitis, and sinusitis.

RESULTS

In 2009-2014, of the 29 million mean annual ED visits by children, 14% (95% confidence interval [CI]: 10%-20%) occurred at pediatric EDs. Antibiotics overall were prescribed more frequently in nonpediatric than pediatric ED visits (24% vs 20%, P < .01). Antibiotic prescribing frequencies were stable over time. Of all antibiotics prescribed, 44% (95% CI: 42%-45%) were broad spectrum, and 32% (95% CI: 30%-34%, 2.1 million per year) were generally not indicated. Compared with pediatric EDs, nonpediatric EDs had a higher frequency of prescribing macrolides (18% vs 8%, P < .0001) and a lower frequency of first-line, guideline-concordant prescribing for the respiratory conditions studied (77% vs 87%, P < .001).

CONCLUSIONS

Children are prescribed almost 7 million antibiotic prescriptions in EDs annually, primarily in nonpediatric EDs. Pediatric antibiotic stewardship efforts should expand to nonpediatric EDs nationwide, particularly regarding avoidance of antibiotic prescribing for conditions for which antibiotics are not indicated, reducing macrolide prescriptions, and increasing first-line, guideline-concordant prescribing.

Antibiotic Prescriptions Associated With Dental-Related Emergency Department Visits

STUDY OBJECTIVE

The frequency of antibiotic prescribing and types of antibiotics prescribed for dental conditions presenting to the emergency department (ED) is not well known. The objective of this study is to quantify how often and which dental diagnoses made in the ED resulted in an antibiotic prescription.

METHODS

From 2011 to 2015, there were an estimated 2.2 million (95% confidence interval [CI] 1.9 to 2.5 million) ED visits per year for dental-related conditions, which accounted for 1.6% (95% CI 1.5% to 1.7%) of ED visits. This is based on an unweighted 2,125 observations from the National Hospital Ambulatory Medical Care Survey in which a dental-related diagnosis was made.

RESULTS

An antibiotic, most often a narrow-spectrum penicillin or clindamycin, was prescribed in 65% (95% CI 61% to 68%) of ED visits with any dental diagnosis. The most common dental diagnoses for all ages were unspecified disorder of the teeth and supporting structures (44%; 95% CI 41% to 48%; International Classification of Diseases, Ninth Revision, Clinical Modification[ICD-9-CM] code 525.9), periapical abscess without sinus (21%; 95% CI 18% to 25%; ICD-9-CM code 522.5), and dental caries (18%; 95% CI 15% to 22%; ICD-9-CM code 521.0). Recommended treatments for these conditions are usually dental procedures rather than antibiotics.

CONCLUSION

The common use of antibiotics for dental conditions in the ED may indicate the need for greater access to both preventive and urgent care from dentists and other related specialists as well as the need for clearer clinical guidance and provider education related to oral infections.

Uropathogen Resistance and Antibiotic Prophylaxis: A Meta-analysis

CONTEXT

Limited data exist regarding uropathogen resistance in randomized controlled trials of urinary tract infection (UTI) prevention and antibiotic prophylaxis.

OBJECTIVE

To assess the effect of prophylaxis on developing a multidrug-resistant first recurrent UTI among children with vesicoureteral reflux.

DATA SOURCES

Cochrane Kidney and Transplant Specialized Register through May 25, 2017.

STUDY SELECTION

Randomized controlled trials of patients ≤18 years of age with a history of vesicoureteral reflux being treated with continuous antibiotic prophylaxis compared with no treatment or placebo with available antibiotic sensitivity profiles.

DATA EXTRACTION

Two independent observers abstracted data and assessed quality and validity per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Adjusted meta-analyses were performed by using a mixed-effects logistic regression model.

RESULTS

One thousand two hundred and ninety-nine patients contributed 224 UTIs. Patients treated with prophylaxis were more likely to have a multidrug-resistant infection (33% vs 6%, P < .001) and were more likely to receive broad-spectrum antibiotics (68% vs 49%, P = .004). Those receiving prophylaxis had 6.4 times the odds (95% confidence interval: 2.7-15.6) of developing a multidrug-resistant infection. One multidrug-resistant infection would develop for every 21 reflux patients treated with prophylaxis.

LIMITATIONS

Variables that may contribute to resistance such as medication adherence and antibiotic exposure for other illnesses could not be evaluated.

CONCLUSIONS

Prophylaxis increases the risk of multidrug resistance among recurrent infections. This has important implications in the risk-benefit assessment of prophylaxis as a management strategy and in the selection of empirical treatment of breakthrough infections in prophylaxis patients.

Opportunities to Improve Fluoroquinolone Prescribing in the United States for Adult Ambulatory Care Visits

The Food and Drug Administration warned against fluoroquinolone use for conditions with effective alternative agents. An estimated 5.1% of adult ambulatory fluoroquinolone prescriptions were for conditions that did not require antibiotics, and 19.9% were for conditions where fluoroquinolones are not recommended first-line therapy. Unnecessary fluoroquinolone use should be reduced.

Outpatient Macrolide Antibiotic Prescribing in the United States, 2008-2011

National Ambulatory Medical Care Survey data were used to assess outpatient macrolide prescribing and selection. Conditions for which macrolides are firstline therapy represented 5% of macrolide prescribing. Family practitioners selected macrolides for children more frequently than pediatricians. Macrolides are an important antibiotic stewardship target.

Viral Features and Testing for Streptococcal Pharyngitis

BACKGROUND AND OBJECTIVES

The Infectious Diseases Society of America recommends that clinicians forego testing for group A Streptococcal (GAS) pharyngitis in patients with clinical features of viral illness. The prevalence of viral features in patients tested for GAS pharyngitis is not known. The objectives of this study were as follows: to describe the prevalence of viral features in pediatric patients for whom rapid antigen detection tests (RADTs) for GAS pharyngitis are performed; and to compare the prevalence of GAS and the sensitivity of the RADT in patients with and without viral features.

METHODS

This secondary analysis of data from a prospective cohort study included children aged 3 to 21 years for whom RADTs were performed for sore throat in an urban tertiary care emergency department. The primary outcome was the prevalence of viral features, defined as cough, rhinorrhea, oral ulcers/vesicles, and/or conjunctival injection. Secondary outcomes were the prevalence of GAS and sensitivity of the RADT; these outcomes were compared between patients with and without viral features.

RESULTS

Overall, 63% (95% confidence interval [CI]: 57%-68%) of patients had at least 1 viral feature. The prevalence of GAS pharyngitis was higher in patients without viral features (42% [95% CI: 33%-51%]) than in patients with viral features (29% [95% CI: 23%-35%]) (P = .01). The sensitivity of the RADT was 84% (95% CI: 77%-91%) and was not significantly different in patients with and without viral features.

CONCLUSIONS

Because many asymptomatic children are carriers of GAS, judicious use of laboratory testing for GAS pharyngitis remains an important target for antimicrobial stewardship.

Abstract BS3-2: The unfolded protein response: A protective pathway and therapeutic target in breast cancer

We identified BHPI, a potent first-in-class non-competitive estrogen receptor α (ERα) biomodulator that kills therapy-resistant ER positive cancer cells. In mouse xenografts, BHPI induced rapid and dramatic regression of breast cancers. We also demonstrated BHPI's effectiveness in cancer cells containing ER mutations Y537S and D538G that are common in metastatic breast cancer. We used the CRISPR-Cas9 genome editing system to isolate T47D breast cancer cell lines in which both copies of wild type ER are replaced with ERY537S or ERD538G. In anchorage independent 3-dimensional culture, the ERY537S and ERD538G cells exhibit robust proliferation in micromolar 4-hydroxytamoxifen and fulvestrant/Faslodex/ICI 182,780, but are killed by nanomolar BHPI. BHPI is so effective because it works by distorting a newly identified normal pathway of estrogen-ER action. BHPI hyperactivates the endoplasmic reticulum stress sensor, the unfolded protein response (UPR). Estrogen-ER rapidly elicits moderate and transient anticipatory activation of the UPR. Activation of this conserved pathway is critical for estrogen and epidermal growth factor (EGF) induced gene expression and cell proliferation and for VEGF regulated angiogenesis and cell survival. Moreover, in analysis of data from approximately 1,000 ER positive breast cancer patients, activation of a UPR gene signature at diagnosis was tightly correlated with subsequent tumor recurrence, tamoxifen resistance and a poor prognosis.

A major mechanism by which tumors develop resistance to therapy is overexpression of pumps, such as multidrug resistance protein 1 (MDR1)/p-glycoprotein, that carry out ATP-dependent pumping of anticancer drugs out of tumor cells. Nontoxic small molecule inhibitors targeting MDR1 remain elusive. Instead, we used BHPI's novel action in cancer cells to target MDR1's substrate, ATP. Acting via ER, BHPI hyperactivates the anticipatory UPR pathway leading to an ATP-depleting futile cycle in which there is ATP-dependent pumping of calcium into the endoplasmic reticulum (EnR), but the EnR calcium channels opened by BHPI-ER action allow the calcium to leak back out. This futile cycle rapidly depletes intracellular ATP, inactivating MDR1 in multidrug resistant breast and ovarian cancer cells. BHPI restored sensitivity of multidrug resistant breast and ovarian cancer cells to killing by therapeutically relevant concentrations of several anticancer drugs. In an orthotopic ovarian cancer xenograft model using OVCAR-3 cells, that are highly resistant to diverse anticancer drugs, the taxane paclitaxel was ineffective and the paclitaxel-treated tumors were uniquely prone to metastasize to adjacent tissue. BHPI alone strongly reduced tumor growth. Notably, tumors were undetectable in mice treated with BHPI plus paclitaxel. Compared to control ovarian tumors, after the combination therapy, plasma levels of the cancer biomarker, CA125, were at least several hundred fold lower; moreover, CA125 levels progressively declined to undetectable.

Targeting drug resistance in ER positive tumors through BHPI-mediated, UPR-dependent, ATP depletion represents a promising new therapeutic strategy. (Support: NIH RO1 DK 071909, DOD BCRP W81XWH-13)

Citation Format: Shapiro DJ. The unfolded protein response: A protective pathway and therapeutic target in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr BS3-2.

Outpatient Antibiotic Prescribing Among United States Nurse Practitioners and Physician Assistants

We examined US nurse practitioner (NP) and physician assistant (PA) outpatient antibiotic prescribing. Antibiotics were more frequently prescribed during visits involving NP/PA visits compared with physician-only visits, including overall visits (17% vs 12%, P < .0001) and acute respiratory infection visits (61% vs 54%, P < .001). Antibiotic stewardship interventions should target NPs and PAs.

Outpatient Antibiotic Prescribing Practices for Uncomplicated Urinary Tract Infection in Women in the United States, 2002-2011

During 2002–2011, fluoroquinolones were the most frequently prescribed antibiotic class for women aged ≥18 years with a diagnosis of uncomplicated urinary tract infection. Outpatient antibiotic stewardship initiatives should include efforts to reduce overuse of fluoroquinolones for uncomplicated UTI.

Background. Urinary tract infection (UTI) is one of the most common diagnoses leading to an antibiotic prescription for women seeking ambulatory care. Understanding current national outpatient antibiotic prescribing practices will help ongoing stewardship efforts to optimize antibiotic use; however, information on recent national outpatient antibiotic prescribing trends for UTI is limited.

Methods. We analyzed the National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Survey datasets from 2002 to 2011. Outpatient visits of women aged ≥18 years with a diagnosis of uncomplicated UTI were included for analysis. We conducted weighted descriptive analyses, examined time trends in antibiotic prescribing, and used multivariable logistic regression to identify patient and provider factors associated with fluoroquinolone prescribing.

Results. A total of 7111 visits were identified. Eighty percent of visits resulted in an antibiotic prescription; fluoroquinolones were the most frequently prescribed antibiotics throughout the study period (49% overall). Older patients (adjusted odds ratio [AOR] for adults aged ≥70 years = 2.5; 95% confidence interval [CI], 1.6–3.8) and patients treated by internists (AOR = 2.0; 95% CI, 1.1–3.3) were more likely than younger patients and those treated by family practitioners to receive fluoroquinolones. Outpatient visits in the West US Census region were less likely to be associated with fluoroquinolone prescribing (AOR = 0.6; 95% CI, .4–1.0) compared with visits in the Northeast.

Conclusions. Fluoroquinolones were the most frequently selected antibiotic treatment for uncomplicated UTI in women during the study period. Outpatient antibiotic stewardship initiatives should include efforts to reduce overuse of fluoroquinolones for uncomplicated UTI.

Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011

IMPORTANCE

The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown.

OBJECTIVE

To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated.

EXPOSURES

Ambulatory care visits.

MAIN OUTCOMES AND MEASURES

Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population.

RESULTS

Of the 184,032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions.

CONCLUSIONS AND RELEVANCE

In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.

Clinical management of skin and soft tissue infections in the U.S. Emergency Departments

Introduction

Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) has emerged as the most common cause of skin and soft-tissue infections (SSTI) in the United States. A nearly three-fold increase in SSTI visit rates had been documented in the nation’s emergency departments (ED). The objective of this study was to determine characteristics associated with ED performance of incision and drainage (I+D) and use of adjuvant antibiotics in the management of skin and soft tissue infections (SSTI).

Methods

Cross-sectional study of the National Hospital Ambulatory Medical Care Survey, a nationally representative database of ED visits from 2007–09. Demographics, rates of I+D, and adjuvant antibiotic therapy were described. We used multivariable regression to identify factors independently associated with use of I+D and adjuvant antibiotics.

Results

An estimated 6.8 million (95% CI: 5.9–7.8) ED visits for SSTI were derived from 1,806 sampled visits; 17% were for children <18 years of age and most visits were in the South (49%). I+D was performed in 27% (95% CI 24–31) of visits, and was less common in subjects <18 years compared to adults 19–49 years (p<0.001), and more common in the South. Antibiotics were prescribed for 85% of SSTI; there was no relationship to performance of I+D (p=0.72). MRSA-active agents were more frequently prescribed after I+D compared to non-drained lesions (70% versus 56%, p<0.001). After multivariable adjustment, I+D was associated with presentation in the South (OR 2.36; 95% CI 1.52–3.65 compared with Northeast), followed by West (OR 2.13; 1.31–3.45), and Midwest (OR 1.96; 1.96–3.22).

Conclusion

Clinical management of most SSTIs in the U.S. involves adjuvant antibiotics, regardless of I+D. Although not necessarily indicated, CA-MRSA effective therapy is being used for drained SSTI.

Race, otitis media, and antibiotic selection

BACKGROUND AND OBJECTIVE

Previous research suggests that physicians may be less likely to diagnose otitis media (OM) and to prescribe broad-spectrum antibiotics for black versus nonblack children. Our objective was to determine whether race is associated with differences in OM diagnosis and antibiotic prescribing nationally.

METHODS

We examined OM visit rates during 2008 to 2010 for children ≤14 years old using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. We compared OM visits between black and nonblack children, as percentages of all outpatient visits and visit rates per 1000. We compared antibiotic prescribing by race as the percentage of OM visits receiving narrow-spectrum (eg, amoxicillin) versus broader-spectrum antibiotics. We used multivariable logistic regression to examine whether race was independently associated with antibiotic selection for OM.

RESULTS

The percentage of all visits resulting in OM diagnosis was 30% lower in black children compared with others (7% vs 10%, P = .004). However, OM visits per 1000 population were not different between black and nonblack children (253 vs 321, P = .12). When diagnosed with OM during visits in which antibiotics were prescribed, black children were less likely to receive broad-spectrum antibiotics than nonblack children (42% vs 52%, P = .01). In multivariable analysis, black race was negatively associated with broad-spectrum antibiotic prescribing (adjusted odds ratio 0.59; 95% confidence interval, 0.40-0.86).

CONCLUSIONS

Differences in treatment choice for black children with OM may indicate race-based differences in physician practice patterns and parental preferences for children with OM.

Anticipatory estrogen activation of the unfolded protein response is linked to cell proliferation and poor survival in estrogen receptor α-positive breast cancer

In response to cell stress, cancer cells often activate the endoplasmic reticulum (EnR) stress sensor, the unfolded protein response (UPR). Little was known about the potential role in cancer of a different mode of UPR activation; anticipatory activation of the UPR prior to accumulation of unfolded protein or cell stress. We show that estrogen, acting via estrogen receptor α (ERα), induces rapid anticipatory activation of the UPR, resulting in increased production of the antiapoptotic chaperone BiP/GRP78, preparing cancer cells for the increased protein production required for subsequent estrogen-ERα induced cell proliferation. In ERα containing cancer cells, the estrogen, 17β-estradiol (E₂) activates the UPR through a phospholipase C γ (PLCγ)-mediated opening of EnR IP₃R calcium channels, enabling passage of calcium from the lumen of the EnR into the cytosol. siRNA knockdown of ERα blocked the estrogen-mediated increase in cytosol calcium and UPR activation. Knockdown or inhibition of PLCγ, or of IP₃R, strongly inhibited the estrogen-mediated increases in cytosol calcium, UPR activation and cell proliferation. E₂-ERα activates all three arms of the UPR in breast and ovarian cancer cells in culture and in a mouse xenograft. Knockdown of ATF6α, which regulates UPR chaperones, blocked estrogen induction of BiP and strongly inhibited E₂-ERα stimulated cell proliferation. Mild and transient UPR activation by estrogen promotes an adaptive UPR response that protects cells against subsequent UPR-mediated apoptosis. Analysis of data from ERα positive breast cancers demonstrates elevated expression of a UPR gene signature that is a powerful new prognostic marker tightly correlated with subsequent resistance to tamoxifen therapy, reduced time to recurrence and poor survival. Thus, as an early component of the E₂-ERα proliferation program, the mitogen estrogen, drives rapid anticipatory activation of the UPR. Anticipatory activation of the UPR is a new role for estrogens in cancer cell proliferation and resistance to therapy.

A National Study of the Impact of Rapid Influenza Testing on Clinical Care in the Emergency Department

BACKGROUND

Rapid influenza diagnostic tests (RIDT) may influence physician decision-making. Single-center studies suggest that influenza diagnosed in association with RIDT reduces ancillary testing and antibiotic prescribing. The extent of RIDT use in US emergency departments (EDs) and their impact on patient management are unknown. We examined the use of RIDT and its effect on influenza management, using a national sample of ED visits.

METHODS

We performed a retrospective study using data from the National Hospital Ambulatory Medical Care Survey, an annually administered survey capturing a nationally representative sample of visits to US EDs. We identified patient visits in which RIDT was performed and/or influenza was diagnosed across 3 influenza seasons (2007-2009). Ancillary testing and antibiotic and antiviral prescribing were evaluated for 2 groups of patients in whom RIDT was performed (those given or not given a diagnosis of influenza) and a third group in whom influenza was diagnosed but RIDT was not performed.

RESULTS

Rapid influenza diagnostic tests were performed during 4.2 million visits. Forty-two percent of influenza diagnoses were made in association with RIDT. For patients diagnosed with influenza, ancillary test ordering was lower (45% vs 53% of visits) and there were fewer antibiotic prescriptions (11% vs 23%), and antiviral use was higher (56% vs 19%) when the diagnosis was made in association with RIDT.

CONCLUSIONS

Influenza diagnoses made in association with RIDT resulted in fewer tests and antibiotic prescriptions and more frequent use of antivirals. This finding suggests that test results influence physician behavior.

A comparison of inpatient versus outpatient resistance patterns of pediatric urinary tract infection

PURPOSE

Prior single center studies showed that antibiotic resistance patterns differ between outpatients and inpatients. We compared antibiotic resistance patterns for urinary tract infection between outpatients and inpatients on a national level.

MATERIALS AND METHODS

We examined outpatient and inpatient urinary isolates from children younger than 18 years using The Surveillance Network (Eurofins Scientific, Luxembourg, Luxembourg), a database of antibiotic susceptibility results, as well as patient demographic data from 195 American hospitals. We determined the prevalence and antibiotic resistance patterns of the 6 most common uropathogens, including Escherichia coli, Proteus mirabilis, Klebsiella, Enterobacter, Pseudomonas aeruginosa and Enterococcus. We compared differences in uropathogen prevalence and resistance patterns for outpatient and inpatient isolates using chi-square analysis.

RESULTS

We identified 25,418 outpatient (86% female) and 5,560 inpatient (63% female) urinary isolates. Escherichia coli was the most common uropathogen overall but its prevalence varied by gender and visit setting, that is 79% of uropathogens overall for outpatient isolates, including 83% of females and 50% of males, compared to 54% for overall inpatient isolates, including 64% of females and 37% of males (p <0.001). Uropathogen resistance to many antibiotics was lower in the outpatient vs inpatient setting, including trimethoprim/sulfamethoxazole 24% vs 30% and cephalothin 16% vs 22% for E. coli (each p <0.001), cephalothin 7% vs 14% for Klebsiella (p = 0.03), ceftriaxone 12% vs 24% and ceftazidime 15% vs 33% for Enterobacter (each p <0.001), and ampicillin 3% vs 13% and ciprofloxacin 5% vs 12% for Enterococcus (each p <0.001).

CONCLUSIONS

Uropathogen resistance rates of several antibiotics are higher for urinary specimens obtained from inpatients vs outpatients. Separate outpatient vs inpatient based antibiograms can aid in empirical prescribing for pediatric urinary tract infections.

Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09

OBJECTIVES

To determine patterns of ambulatory antibiotic prescribing in US adults, including the use of broad-spectrum versus narrow-spectrum agents, to provide a description of the diagnoses for which antibiotics are prescribed and to identify patient and physician factors associated with broad-spectrum antibiotic prescribing.

METHODS

We used data for patients aged ≥ 18 years from the National Ambulatory and National Hospital Ambulatory Medical Care Surveys (2007-09). These are nationally representative surveys of patient visits to offices, hospital outpatient departments and emergency departments (EDs) in the USA, collectively referred to as ambulatory visits. We determined the types of antibiotics prescribed, including the use of broad-spectrum versus narrow-spectrum antibiotics, and examined prescribing patterns by diagnoses. We used multivariable logistic regression to identify factors associated with broad-spectrum antibiotic prescribing.

RESULTS

Antibiotics were prescribed during 101 million (95% CI: 91-111 million) ambulatory visits annually, representing 10% of all visits. Broad-spectrum agents were prescribed during 61% of visits in which antibiotics were prescribed. The most commonly prescribed antibiotics were quinolones (25% of antibiotics), macrolides (20%) and aminopenicillins (12%). Antibiotics were most commonly prescribed for respiratory conditions (41% of antibiotics), skin/mucosal conditions (18%) and urinary tract infections (9%). In multivariable analysis, among patients prescribed antibiotics, broad-spectrum agents were more likely to be prescribed than narrow-spectrum antibiotics for respiratory infections for which antibiotics are rarely indicated (e.g. bronchitis), during visits to EDs and for patients ≥ 60 years.

CONCLUSIONS

Broad-spectrum agents constitute the majority of antibiotics in ambulatory care. More than 25% of prescriptions are for conditions for which antibiotics are rarely indicated. Antibiotic stewardship interventions targeting respiratory and non-respiratory conditions are needed in ambulatory care.

Sociodemographic characteristics and beverage intake of children who drink tap water

BACKGROUND

Tap water provides a calorie-free, no-cost, environmentally friendly beverage option, yet only some youth drink it.

PURPOSE

To examine sociodemographic characteristics, weight status, and beverage intake of those aged 1-19 years who drink tap water.

METHODS

National Health and Nutrition Examination Survey data (2005-2010) were used to examine factors associated with tap water consumption. A comparison was made of beverage intake among tap water consumers and nonconsumers, by age, race/ethnicity, and income.

RESULTS

Tap water consumption was more prevalent among school-aged children (OR=1.85, 95% CI=1.47, 2.33, for those aged 6-11 years; OR=1.85, 95% CI=1.32, 2.59, for those aged 12-19 years) as compared to those aged 1-2 years. Tap water intake was less prevalent among girls/women (OR=0.76, 95% CI=0.64, 0.89); Mexican Americans (OR=0.32, 95% CI=0.23, 0.45); non-Hispanic blacks (OR=0.48, 95% CI=0.34, 0.67); and others (OR=0.50, 95% CI=0.36, 0.68) as compared to whites; Spanish speakers (OR=0.72, 95% CI=0.55, 0.95); and among referents with a lower than Grade-9 education (OR=0.52, 95% CI=0.31, 0.88); Grade 9-11 education (OR=0.50, 95% CI=0.32, 0.77); and high school/General Educational Development test completion (OR=0.50, 95% CI=0.33, 0.76), as compared to college graduates. Tap water consumers drank more fluid (52.5 vs 48.0 ounces, p<0.01); more plain water (20.1 vs 15.2 ounces, p<0.01); and less juice (3.6 vs 5.2 ounces, p<0.01) than nonconsumers.

CONCLUSIONS

One in six children/adolescents does not drink tap water, and this finding is more pronounced among minorities. Sociodemographic disparities in tap water consumption may contribute to disparities in health outcomes. Improvements in drinking water infrastructure and culturally relevant promotion may help to address these issues.

Emergency department management of childhood pneumonia in the United States prior to publication of national guidelines

BACKGROUND

Recent publication of national guidelines by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) provide recommendations around diagnostic testing and antibiotic treatment for children with community-acquired pneumonia (CAP). These guidelines emphasize limited use of chest radiograph (CXR) and complete blood count (CBC) and routinely performing viral testing and use of narrow-spectrum antibiotics.

OBJECTIVES

The objective was to estimate the rate of emergency department (ED) visits for pediatric CAP in the United States and to describe management of patients prior to publication of consensus national guidelines.

METHODS

Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for ED visits from 2001 through 2009 for children with CAP.

RESULTS

During the study period there were an estimated 375,000 ED visits for CAP annually; 85% occurred within a general, rather than pediatric, ED. Overall, 20% of children with CAP were hospitalized. Among children discharged from EDs with CAP, CBC was performed during 30% of visits, CXR during 83%, and viral testing in only 13%. Twelve percent of children discharged from EDs with CAP had blood cultures obtained. No major differences were observed in the rates of laboratory testing or antibiotic administration between children treated in general versus pediatric EDs. During the study period, only 21% of children discharged from EDs with CAP received amoxicillin, the guideline-recommended antibiotic.

CONCLUSIONS

Most ED visits for CAP in the United States occur in general EDs. To encourage care that is consistent with national guidelines, efforts should be made to reduce the performance of certain diagnostic testing, such as CBC and CXR, among children discharged from EDs with CAP. Additionally, the use of narrow-spectrum antibiotics should be encouraged.

Antibiotic resistance patterns of outpatient pediatric urinary tract infections

PURPOSE

We characterize the current national patterns of antibiotic resistance of outpatient pediatric urinary tract infection.

MATERIALS AND METHODS

We examined outpatient urinary isolates from patients younger than 18 years in 2009 using The Surveillance Network®, a database with antibiotic susceptibility results and patient demographic data from 195 United States hospitals. We determined the prevalence and antibiotic resistance patterns for the 6 most common uropathogens, ie Escherichia coli, Proteus mirabilis, Klebsiella, Enterobacter, Pseudomonas aeruginosa and Enterococcus. We compared differences in uropathogen prevalence between males and females using chi-square analysis.

RESULTS

We identified 25,418 outpatient urinary isolates. E. coli was the most common uropathogen overall but the prevalence of E. coli was higher among females (83%) than males (50%, p <0.001). Other common species among males were Enterococcus (17%), P. mirabilis (11%) and Klebsiella (10%). However, these uropathogens each accounted for 5% or less of female isolates (p <0.001). Resistance among E. coli was highest for trimethoprim-sulfamethoxazole (24%) but lower for nitrofurantoin (less than 1%) and cephalothin (15%). Compared to 2002 Surveillance Network data, E. coli resistance rates increased for trimethoprim-sulfamethoxazole (from 23% to 31% in males and from 20% to 23% in females) and ciprofloxacin (from 1% to 10% and from 0.6% to 4%, respectively).

CONCLUSIONS

E. coli remains the most common pediatric uropathogen. Although widely used, trimethoprim-sulfamethoxazole is a poor empirical choice for pediatric urinary tract infections in many areas due to high resistance rates. First-generation cephalosporins and nitrofurantoin are appropriate narrow-spectrum alternatives given their low resistance rates. Local antibiograms should be used to assist with empirical urinary tract infection treatment.

Trends in adverse reactions to trimethoprim-sulfamethoxazole

OBJECTIVE

To examine temporal trends of adverse drug reactions (ADRs) associated with trimethoprim-sulfamethoxazole (TMP-SMX) use in children.

METHODS

We performed a retrospective observational study to characterize TMP-SMX ADRs in children between 2000 and 2009. We completed a chart review at our institution by identifying children diagnosed with TMP-SMX ADRs. To compare local trends to comparable institutions, we estimated the frequency of hospitalizations for TMP-SMX ADRs at 25 tertiary pediatric hospitals utilizing the Pediatric Health Information System database. To determine whether changes in outpatient prescribing rates occurred, we used the National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey.

RESULTS

At our institution, 109 children were diagnosed with a TMP-SMX ADR (5 cases from 2000 to 2004 as compared with 104 cases from 2005 to 2009). Fifty-eight percent had been treated for a skin and soft tissue infection (SSTI). A similar trend was observed nationally, where the incidence of TMP-SMX ADRs more than doubled from 2004 to 2009 at comparable pediatric hospitals (P < .001). Although national outpatient data revealed no change in overall TMP-SMX prescribing, the percentage of children prescribed TMP-SMX for SSTI sharply increased during the study period (0%-2% [2000-2004]; 9%-17% [2005-2009]).

CONCLUSIONS

The majority of TMP-SMX ADRs at our institution occurred in conjunction with SSTI treatment. TMP-SMX ADRs have occurred more frequently coincident with increased prescribing for SSTI. Increased usage alone may explain the increasing trend of TMP-SMX ADRs in children; however drug-disease interaction may play a role and requires further investigation.

Hypertension screening during ambulatory pediatric visits in the United States, 2000-2009

BACKGROUND AND OBJECTIVE

Hypertension occurs in 2% to 5% of children in the United States, and its prevalence has increased during the obesity epidemic. There is no consensus among professional organizations about how frequently blood pressure should be measured in children >3 years old. The purpose of this study was to estimate the frequency of hypertension screening during ambulatory pediatric visits in the United States and to determine patient- and provider-level factors associated with screening during visits specifically for preventive care.

METHODS

We analyzed data from a nationally representative sample of ambulatory visits by using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from 2000 through 2009. In the subset of visits involving patients aged 3 to 18 years, we estimated the frequency of screening during all visits, preventive visits, and preventive visits in which overweight/obesity was diagnosed. We used multivariable logistic regression to identify patient- and provider-level factors associated with screening.

RESULTS

Hypertension screening occurred during 35% of ambulatory pediatric visits, 67% of preventive visits, and 84% of preventive visits in which overweight/obesity was diagnosed. Between 2000 and 2009, the frequency of screening increased in all visits and in preventive visits. Factors independently associated with screening included older age and overweight/obesity diagnosis.

CONCLUSIONS

Providers do not measure blood pressure in two-thirds of pediatric visits and one-third of pediatric preventive visits. Providers may understand the importance of screening among overweight/obese children; however, efforts to encourage routine screening, particularly in young children, may be needed.

Antibiotic prescribing in ambulatory pediatrics in the United States

BACKGROUND

Antibiotics are commonly prescribed for children with conditions for which they provide no benefit, including viral respiratory infections. Broad-spectrum antibiotic use is increasing, which adds unnecessary cost and promotes the development of antibiotic resistance.

OBJECTIVE

To provide a nationally representative analysis of antibiotic prescribing in ambulatory pediatrics according to antibiotic classes and diagnostic categories and identify factors associated with broad-spectrum antibiotic prescribing.

PATIENTS AND METHODS

We used the National Ambulatory and National Hospital Ambulatory Medical Care surveys from 2006 to 2008, which are nationally representative samples of ambulatory care visits in the United States. We estimated the percentage of visits for patients younger than 18 years for whom antibiotics were prescribed according to antibiotic classes, those considered broad-spectrum, and diagnostic categories. We used multivariable logistic regression to identify demographic and clinical factors that were independently associated with broad-spectrum antibiotic prescribing.

RESULTS

Antibiotics were prescribed during 21% of pediatric ambulatory visits; 50% were broad-spectrum, most commonly macrolides. Respiratory conditions accounted for >70% of visits in which both antibiotics and broad-spectrum antibiotics were prescribed. Twenty-three percent of the visits in which antibiotics were prescribed were for respiratory conditions for which antibiotics are not clearly indicated, which accounts for >10 million visits annually. Factors independently associated with broad-spectrum antibiotic prescribing included respiratory conditions for which antibiotics are not indicated, younger patients, visits in the South, and private insurance.

CONCLUSIONS

Broad-spectrum antibiotic prescribing in ambulatory pediatrics is extremely common and frequently inappropriate. These findings can inform the development and implementation of antibiotic stewardship efforts in ambulatory care toward the most important geographic regions, diagnostic conditions, and patient populations.