Stewardship / Resistance Scan for Mar 08, 2017

Antibiotics for kids' pneumonia
Post-discharge antibiotics

Study: Most kids not getting first-line antibiotics for pneumonia

Despite guidelines that recommend amoxicillin as a first-line therapy for children with community-acquired pneumonia (CAP), most kids diagnosed with CAP are receiving macrolides and broad-spectrum antibiotics, according to a study yesterday in Pediatrics.

The retrospective cohort study included patients between the ages of 3 months and 18 years who received a diagnosis of CAP from July 2009 through June 2013 at 31 primary care pediatric practices. The investigators were looking at what types of antibiotics the patients received, and the factors associated with the choice of antibiotics.

Of the 10,414 children who met the inclusion/exclusion criteria, 40.1% received amoxicillin, 42.5% received macrolides, and 16.8% received broad-spectrum antibiotics (mainly amoxicillin-clavulanic acid). In the multivariate logistic regression model for prescription of macrolides versus amoxicillin, the factors associated with increased odds of prescription of macrolides included age ≥5 years (adjusted odds ratio [aOR]: 6.18), private insurance (aOR: 1.47), history of asthma (aOR: 1.15), and previous antibiotic exposure (aOR: 1.79). The predicted probability of a macrolide being prescribed ranged from 0.22 to 0.83 across the clinical sites.

The factors most associated with increased odds of being prescribed a broad-spectrum antibiotic versus amoxicillin included suburban practice (aOR: 7.50) and previous antibiotic exposure (aOR: 3.31). The predicted probability of a broad-spectrum antibiotic being prescribed ranged from 0.02 to 0.81 across the clinical sites.

The authors note that while age and previous antibiotic use are appropriate drivers of antibiotic use, "sociodemographic factors, including insurance status and practice location, that should not be correlated with bacterial etiology were also associated with antibiotic choice."

"Efforts to increase guideline-adherent prescribing, such as provider education and decision-support tools, should address these nonclinical drivers of prescribing patterns, including physician preferences, prescribing norms within a practice, and parental drivers of prescribing practices," the authors write.
Mar 7 Pediatrics study


Study looks at intervention to improve antibiotic prescribing at discharge

A new study in Infection Control and Hospital Epidemiology has found that an intervention to optimize antibiotic prescribing at hospital discharge was associated with less frequent use of broad-spectrum antibiotics and shorter post-discharge treatment durations.

In the single-center, quasi-experimental retrospective cohort study, researchers evaluated the impact of a two-step intervention at an integrated healthcare system in Denver, Colorado. The intervention consisted of (1) institutional guidance for oral step-down antibiotic selection and duration of therapy and (2) pharmacy audit of discharge prescriptions with real-time prescribing recommendations to providers. The researchers were looking at changes in the total prescribed duration of therapy and the proportion of patients prescribed broad-spectrum antibiotics (fluoroquinolones or amoxicillin-clavulanate) before the intervention (July 2012-June 2013) and during the intervention (October 2014-February 2015).

Overall, the researchers identified 300 patients from the pre-intervention period and 200 patients from the intervention period. Compared with the pre-intervention period, the proportion of patients discharged with broad-spectrum antibiotics declined during the intervention (51% pre-intervention vs. 40% during the intervention). The total prescribed duration of therapy declined from a median of 10 days pre-intervention to 9 days during the intervention, but the decline was not considered statistically significant. The reduction in duration prescribed at hospital discharge (from a median of 6 days to 5 days), however, was considered statistically significant.

In a sub-group analysis of CAP, urinary tract infection, or skin infection, discharge prescriptions for broad-spectrum antibiotics dropped even more significantly, declining from 50% to 35%. The duration prescribed at discharge dropped from a median of 6 days to 4 days.

During the intervention, there was also a nonsignificant increase in the overall appropriateness of discharge prescriptions from 52% to 66%.

The authors note that the findings are significant because previous studies have shown that infections commonly managed in the hospital, 60% to 70% of the total antibiotic course is completed after discharge. "Thus, ensuring appropriate antibiotic selection at discharge represents an important opportunity to reduce use of antibiotics with overly broad-spectrum activity," they write.
Mar 6 Infect Control Hosp Epidemiol abstract

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