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Antibiotic overuse is common in outpatient pediatrics and varies across clinical setting and clinician type. We sought to identify social, behavioral, and environmental drivers of outpatient antibiotic prescribing for pediatric patients.
We conducted semistructured interviews with physicians and advanced practice providers (APPs) across diverse outpatient settings including pediatric primary, urgent, and retail care. We used the grounded theory constant comparative method and a thematic approach to analysis. We developed a conceptual model, building on domains of continuity to map common themes and their relationships within the healthcare system.
We interviewed 55 physicians and APPs. Clinicians across all settings prioritized provision of guideline-concordant care but implemented these guidelines with varying degrees of success. The provision of guideline-concordant care was influenced by the patient–clinician relationship and patient or parent expectations (relational continuity); the clinician’s access to patient clinical history (informational continuity); and the consistency of care delivered (management continuity). No difference in described themes was determined by setting or clinician type; however, clinicians in primary care described having more reliable relational and informational continuity.
Clinicians described the absence of long-term relationships (relational continuity) and lack of availability of prior clinical history (informational continuity) as factors that may influence outpatient antibiotic prescribing. Guideline-concordant outpatient antibiotic prescribing was facilitated by consistent practice across settings (management continuity) and the presence of relational and informational continuity, which are common only in primary care. Management continuity may be more modifiable than informational and relational continuity and thus a focus for outpatient stewardship programs.
To improve appropriate antibiotic prescribing for children in Tennessee.
We performed a before-and-after intervention study with 3 comparison periods: period 1 (P1, baseline) May 2018–September 2019; period 2 (P2, intervention before the COVID-19 pandemic) November 11, 2019–March 20, 2020; and period 3 (P3, intervention during the coronavirus disease 2019 [COVID-19] pandemic) March 21, 2020–November 10, 2020. We additionally surveyed participating providers to assess acceptance of the intervention.
Community general pediatrics practices.
In total, 81 general pediatricians, family medicine physicians, and nurse practitioners in 5 general pediatrics practices participated in this study.
Each practice identified a practice and operations champion for the project. Practices chose 2–4 implementation strategies previously shown to be effective at reducing outpatient antibiotic use to implement in their practice throughout the study intervention period. Study personnel also held quarterly meetings with all providers to review deidentified peer comparison feedback both across practices enrolled in the study and at the provider level within each practice.
We detected improvements in guideline-concordant antibiotic use in the pre-COVID-19 intervention period, and they were sustained in the study period during the pandemic (P3): otitis media (P1 72.14% vs P2 81.42% vs P3 86.11%), group A streptococcal pharyngitis (P1 66.13% vs P2 81.56% vs P3 80.44%), pneumonia (P1 70.6% vs P2 76.2% vs P3 100%), sinusitis (P1 76.2% vs P2 83.78% vs P3 82.86%), skin and soft-tissue infections (P1 97.18% vs P2 100% vs P3 100%).
Bundled implementation strategies led to significant increases in guideline-concordant antibiotic prescribing for all diagnoses. Survey results demonstrate that the bundled implementation strategies were well-accepted by providers.
Antibiotics are widely used in neonatal intensive care units (NICUs). We conducted a cross-sectional analysis of antibiotic use across US NICUs to evaluate overall, broad-spectrum, and combination antibiotic use. Patterns of antibiotic use varied by medical versus surgical service line, hospital, and geographic location.
Background:Pseudomonas aeruginosa uncommonly causes illness in neonatal intensive care units (NICU). A cluster of 4 infections was appreciated over 6 weeks in our inborn–delivery NICU, prompting an investigation. Methods: Upon recognition of a cluster of infections, we retrospectively audited all cultures positive for P. aeruginosa from all sites (sterile and nonsterile) over the prior year in the index NICU (NICU 1, inborn) and for comparison in the adjacent NICU (NICU 2, larger, outborn–surgical). We performed multilocus sequence testing (MLST) of available clinical isolates to identify clonality. We initiated quarterly prospective surveillance of P. aeruginosa colonization of infants through nares, perirectal swabs, and tracheal aspirates of intubated infants or oropharyngeal swabs of nonintubated infants. We also swabbed incubators, ventilatory equipment, and sinks for selective P. aeruginosa culturing. Results: We identified 7 invasive P. aeruginosa infections in the inborn NICU (5 bloodstream and 2 pneumonia) over an 11-month period (Figure 1). Over the same period, there were no P. aeruginosa bloodstream infections in the adjacent NICU. Affected neonates were high risk: gestational age ranged from 22 weeks and 4 days to 26 weeks and 3 days; day of life at infection ranged from 6 to 37; 6 infants were on a jet ventilator; and all infants were receiving enteral nutrition (6 of 7 with donor human milk and 7 of 7 with expressed mother’s milk). Two infants died from their infection, and 5 infants survived to hospital discharge. All 7 isolates were pansusceptible to routine antimicrobials. MLST of the first 4 available isolates demonstrated 4 different sequence types; however, the first 2 were from the same clonal complex, indicating relatedness (Figure 1). For environmental samples, 8 obtained 8 cultures (swabs) of incubators and ventilatory equipment, and 24 cultures of faucets and drains of all sinks. Only sink cultures were positive, yielding 3 isolates identified as P. aeruginosa and 4 isolates identified as P. aeruginosa–like. Whole-genome sequencing (WGS) is underway to identify relatedness to the clinical isolates. We initiated quarterly infant surveillance by swab culture for P. aeruginosa nasal colonization then escalated to perirectal and oropharyngeal swab or tracheal aspirate cultures (intubated infants) in subsequent quarters. We did not detect any infants colonized with P. aeruginosa. Conclusions: We identified a cluster of P. aeruginosa in high-risk neonates with no point source. Molecular typing indicated a multiclonal cluster. This finding poses a management dilemma. A colonized water system is suspected and WGS of environmental samples is underway.
We surveyed pediatric antimicrobial stewardship program (ASP) site leaders within the Sharing Antimicrobial Reports for Pediatric Stewardship collaborative regarding discharge stewardship practices. Among 67 sites, 13 (19%) reported ASP review of discharge antimicrobial prescriptions. These findings highlight discharge stewardship as a potential opportunity for improvement during the hospital-to-home transition.
To quantify the impact of clinical guidance and rapid respiratory and meningitis/encephalitis multiplex polymerase chain reaction (mPCR) testing on the management of infants.
Before-and-after intervention study.
Tertiary-care children’s hospital.
Infants ≤90 days old presenting with fever or hypothermia to the emergency department (ED).
The study spanned 3 periods: period 1, January 1, 2011, through December 31, 2014; period 2, January 1, 2015, through April 30, 2018; and period 3, May 1, 2018, through June 15, 2019. During period 1, no standardized clinical guideline had been established and no rapid pathogen testing was available. During period 2, a clinical guideline was implemented, but no rapid testing was available. During period 3, a guideline was in effect, plus mPCR testing using the BioFire FilmArray respiratory panel 2 (RP 2) and the meningitis encephalitis panel (MEP). Outcomes included antimicrobial and ancillary test utilization, length of stay (LOS), admission rate, 30-day mortality. Outcomes were compared across periods using Kruskal-Wallis and Pearson tests and interrupted time series analysis.
Overall 5,317 patients were included: 2,514 in period 1, 2,082 in period 2, and 721 in period 3. Over the entire study period, we detected reductions in the use of chest radiographs, lumbar punctures, LOS, and median antibiotic duration. After adjusting for temporal trends, we observed that the introduction of the guideline was associated with reductions in ancillary tests and lumbar punctures. Use of mPCR testing with the febrile infant clinical guideline was associated with additional reductions in ancillary testing for all patients and a higher proportion of infants 29–60 days old being managed without antibiotics.
Use of mPCR testing plus a guideline for young infant evaluation in the emergency department was associated with less antimicrobial and ancillary test utilization compared to the use of a guideline alone.
To characterize the prevalence of and seasonal and regional variation in inpatient antibiotic use among hospitalized US children in 2017–2018.
We conducted a cross-sectional examination of hospitalized children. The assessments were conducted on a single day in spring (May 3, 2017), summer (August 2, 2017), fall (October 25, 2017), and winter (January 31, 2018). The main outcome of interest was receipt of an antibiotic on the study day.
The study included 51 freestanding US children’s hospitals that participate in the Pediatric Health Information System (PHIS).
This study included all patients <18 years old who were admitted to a participating PHIS hospital, excluding patients who were admitted solely for research purposes.
Of 52,769 total hospitalized children, 19,174 (36.3%) received antibiotics on the study day and 6,575 of these (12.5%) received broad-spectrum antibiotics. The overall prevalence of antibiotic use varied across hospitals from 22.3% to 51.9%. Antibiotic use prevalence was 29.2% among medical patients and 47.7% among surgical patients. Although there was no significant seasonal variation in antibiotic use prevalence, regional prevalence varied, ranging from 32.7% in the Midwest to 40.2% in the West (P < .001). Among units, pediatric intensive care unit patients had the highest prevalence of both overall and broad-spectrum antibiotic use at 58.3% and 26.6%, respectively (P < .001).
On any given day in a national network of children’s hospitals, more than one-third of hospitalized children received an antibiotic, and 1 in 8 received a broad-spectrum antibiotic. Variation across hospitals, setting and regions identifies potential opportunities for enhanced antibiotic stewardship activities.
To identify patient and provider characteristics associated with high-volume antibiotic prescribing for children in Tennessee, a state with high antibiotic utilization.
Cross-sectional, retrospective analysis of pediatric (aged <20 years) outpatient antibiotic prescriptions in Tennessee using the 2016 IQVIA Xponent (formerly QuintilesIMS) database.
Patient and provider characteristics, including county of prescription fill, rural versus urban county classification, patient age group, provider type (nurse practitioner, physician assistant, physician, or dentist), physician specialty, and physician years of practice were analyzed.
Tennessee providers wrote 1,940,011 pediatric outpatient antibiotic prescriptions yielding an antibiotic prescribing rate of 1,165 per 1,000 population, 50% higher than the national pediatric antibiotic prescribing rate. Mean antibiotic prescribing rates varied greatly by county (range, 39–2,482 prescriptions per 1,000 population). Physicians wrote the greatest number of antibiotic prescriptions (1,043,030 prescriptions, 54%) of which 56% were written by general pediatricians. Pediatricians graduating from medical school prior to 2000 were significantly more likely than those graduating after 2000 to be high antibiotic prescribers. Overall, 360 providers (1.7% of the 21,798 total providers in this dataset) were responsible for nearly 25% of both overall and broad-spectrum antibiotic prescriptions; 20% of these providers practiced in a single county.
Fewer than 2% of providers account for 25% of pediatric antibiotic prescriptions. High antibiotic prescribing for children in Tennessee is associated with specific patient and provider characteristics that can be used to design stewardship interventions targeted to the highest prescribing providers in specific counties and specialties.
We observed pediatric S. aureus hospitalizations decreased 36% from 26.3 to 16.8 infections per 1,000 admissions from 2009 to 2016, with methicillin-resistant S. aureus (MRSA) decreasing by 52% and methicillin-susceptible S. aureus decreasing by 17%, among 39 pediatric hospitals. Similar decreases were observed for days of therapy of anti-MRSA antibiotics.
To identify current outpatient parenteral antibiotic therapy practice patterns and complications.
We administered an 11-question survey to adult infectious disease physicians participating in the Emerging Infections Network (EIN), a Centers for Disease Control and Prevention–sponsored sentinel event surveillance network in North America. The survey was distributed electronically or via facsimile in November and December 2012. Respondent demographic characteristics were obtained from EIN enrollment data.
Overall, 555 (44.6%) of EIN members responded to the survey, with 450 (81%) indicating that they treated 1 or more patients with outpatient parenteral antimicrobial therapy (OPAT) during an average month. Infectious diseases consultation was reported to be required for a patient to be discharged with OPAT by 99 respondents (22%). Inpatient (282 [63%] of 449) and outpatient (232 [52%] of 449) infectious diseases physicians were frequently identified as being responsible for monitoring laboratory results. Only 26% (118 of 448) had dedicated OPAT teams at their clinical site. Few infectious diseases physicians have systems to track errors, adverse events, or “near misses” associated with OPAT (97 [22%] of 449). OPAT-associated complications were perceived to be rare. Among respondents, 80% reported line occlusion or clotting as the most common complication (occurring in 6% of patients or more), followed by nephrotoxicity and rash (each reported by 61%). Weekly laboratory monitoring of patients who received vancomycin was reported by 77% of respondents (343 of 445), whereas 19% of respondents (84 of 445) reported twice weekly laboratory monitoring for these patients.
Although use of OPAT is common, there is significant variation in practice patterns. More uniform OPAT practices may enhance patient safety.
Rectal colonization with multidrug-resistant Enterobacteriaceae was found in 23 of 94 consecutively enrolled international patients hospitalized at Mayo Clinic, Rochester, Minnesota. No carbapenemase producers were detected. Twenty-one isolates were extended-spectrum β-lactamase-producing Escherichia coli. Colonization was associated with gastrointestinal disease and central venous catheter placement within the antecedent year.
To identify predictors of community-onset extended-spectrum β-lactamase (ESBL)-producing Escherichia coli infection.
Prospective case-control study.
Acute care hospitals and ambulatory clinics in the Chicago, Illinois, region.
Adults with E. coli clinical isolates cultured in ambulatory settings or within 48 hours of hospital admission.
Cases were patients with ESBL-producing E. coli clinical isolates cultured in ambulatory settings or within 48 hours of admission, and controls were patients with non-ESBL-producing E. coli isolates, matched to cases by specimen, location, and date. Clinical variables were ascertained through interviews and medical record review. Molecular methods were used to identify ESBL types, sequence type ST131, and aac(6′)-Ib-cr.
We enrolled 94 cases and 158 controls. Multivariate risk factors for ESBL-producing E. coli infection included travel to India in the past year (odds ratio [OR], 14.40 [95% confidence interval (CI), 2.92-70.95]), ciprofloxacin use (OR, 3.92 [95% CI, 1.90-8.1]), and age (OR, 1.04 [95% CI, 1.02-1.06]). Case isolates exhibited high prevalence of CTX-M-15 (78%), ST131 (50%), and aac(6′)-Ib-cr (66% of isolates with CTX-M-15).
Providers should be aware of the increased risk of ESBL-producing E. coli infection among returned travelers, especially those from India.
To determine prevalence, predictors, and outcomes of infection due to Escherichia coli sequence type ST131.
All healthcare settings in Olmsted County, Minnesota (eg, community hospital, tertiary care center, long-term care facilities, and ambulatory clinics).
Ambulatory and hospitalized children and adults with extraintestinal E. coli isolates.
We analyzed 299 consecutive, nonduplicate extraintestinal E. coli isolates submitted to Olmsted County laboratories in February and March 2011. ST131 was identified using single-nucleotide polymorphism polymerase chain reaction and further evaluated through pulsed-field gel electrophoresis. Associated clinical data were abstracted through medical record review.
Most isolates were from urine specimens (90%), outpatients (68%), and community-associated infections (61%). ST131 accounted for 27% of isolates overall and for a larger proportion of those isolates resistant to fluoroquinolones (81%), trimethoprim-sulfamethoxazole (42%), gentamicin (79%), and ceftriaxone (50%). The prevalence of ST131 increased with age (accounting for 5% of isolates from those 11–20 years of age, 26% of isolates from those 51–60 years of age, and 50% of isolates from those 91–100 years of age). ST131 accounted for a greater proportion of healthcare-associated isolates (49%) than community-associated isolates (15%) and for fully 76% of E. coli isolates from long-term care facility (LTCF) residents. Multivariable predictors of ST131 carriage included older age, LTCF residence, previous urinary tract infection, high-complexity infection, and previous use of fluoroquinolones, macrolides, and extended-spectrum cephalosporins. With multivariable adjustment, ST131-associated infection outcomes included receipt of more than 1 antibiotic (odds ratio [OR], 2.54 [95% confidence interval (CI), 1.25–5.17]) and persistent or recurrent symptoms (OR, 2.53 [95% CI, 1.08–5.96]). Two globally predominant ST131 pulsotypes accounted for 45% of STB 1 isolates.
ST131isa dominant, antimicrobial-resistant clonal group associated with healthcare settings, elderly hosts, and persistent or recurrent symptoms.
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