Study: Inappropriate presurgical antibiotic use common in children
A point-prevalence study of 32 US children's hospitals found that prophylactic (preventive) antibiotics were inappropriately given in 33.0% of pediatric surgical patients. The study, published today in Infection Control & Hospital Epidemiology, was led by members of the SHARPS Collaborative based at Washington University in St. Louis.
The researchers collected chart data from the hospitals' electronic medical records from September 2016 to December 2017, identifying 1,324 children receiving antibiotics (cefazolin, clindamycin, vancomycin, cefoxitin, and piperacillin/tazobactam) for surgical prophylaxis.
Overall, 485 prophylactic antibiotics were classified as inappropriate because of administration longer than 24 hours (n = 387, 79.8%), no indication for prophylaxis (32, 6.6%), and the use of antibiotics that were too broad spectrum (29, 6.0%).
National guidelines give procedure-specific recommendations for antibiotic prophylaxis, including drug and dosing, to prevent surgical-site infections. "The 2017 Centers for Disease Control and Prevention (CDC) guideline recommends only a single dose of perioperative prophylaxis for clean and clean-contaminated cases," the authors wrote. "Despite these guidelines, inappropriate surgical prophylaxis use continues to be common."
Inappropriate surgical prophylaxis was highest in otolaryngologic patients (62.7%; 95% confidence interval [CI], 52.6% to 72.1%), cosmetic or reconstructive surgery patients (40.7%; 95% CI, 30.0–52.2), and neurosurgery patients (40.3%; 95% CI, 34.2% to 46.6%).
Of the 485 prescriptions deemed inappropriate, 258 (53.2%) would not have been routinely reviewed by the hospitals' antimicrobial surgical programs, according to the authors. The hospitals' use of inappropriate prophylaxis varied significantly, from 0.0% to 62.8%.
The study likely underestimated the percentages of inappropriate use, considering the new CDC recommendation of no antibiotics for low-risk procedures, the investigators said. They called for more studies to better estimate the inappropriate prophylaxis rate, identify contributing factors, and determine the best ways to optimize prophylactic use of antibiotics.
Mar 4 Infect Control Hosp Epidemiol study
Study: De-escalation rates low in hospitalized pneumonia patients
An analysis of adults with pneumonia at 164 US hospitals has found that less than 15% of those treated with broad-spectrum antibiotics had their coverage de-escalated by day 4, researchers reported today in Clinical Infectious Diseases.
The study, conducted by researchers with Cleveland Clinic and the University of Massachusetts Medical School, aimed to assess de-escalation practices in a cohort of hospitalized pneumonia patients after negative cultures for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa.
New guidelines from the American Thoracic Society and the Infectious Disease Society of America recommend switching from broad-spectrum to narrower-spectrum antibiotics at 48 hours if microbial cultures do not reveal these multidrug-resistant pathogens and the patient is improving. The researchers wanted to know to what degree hospitals will have to change their practices to adhere to this recommendation.
The study’s primary outcome was de-escalation on hospital day 4. The researchers also looked at the association of de-escalation with all-cause mortality, transfer to an intensive care unit (ICU), length of hospital stay, and costs.
Of the 14,170 pneumonia patients treated with one anti-MRSA and at least one anti-pseudomonal antibiotic from 2010 through 2015, both antibiotics were de-escalated in 1,924 patients (13%) by day 4. Hospital de-escalation rates ranged from 2% to 35% and varied across regions, but de-escalation was more common in large teaching hospitals.
At hospitals in the top quartile of de-escalation, rates of de-escalation were less than 50%—even in patients at lowest risk for death. In propensity-adjusted analysis, patients with de-escalation had lower odds of subsequent transfer to the ICU (adjusted odds ratio, 0.38; 95% CI, 0.18 to 0.79), shorter hospital stays (adjusted ratio of means, 0.76; 95% CI, 0.75 to 0.78), and costs (adjusted ratio of means, 0.74; 95% CI, 0.72 to 0.76).
The authors of the study concluded that, in order to adhere to the new guidelines, physicians will need to substantially change their response to negative cultures for most non-critically ill patients. "Since antibiotics are not benign, and antimicrobial stewardship is an important priority, hospital antibiotic stewardship programs should emphasize de-escalation following negative cultures as an opportunity to reduce exposure to broad-spectrum antibiotics, improving both antimicrobial stewardship and medication safety by substitution of lower-toxicity agents," they wrote.
Mar 4 Clin Infect Dis abstract