Joshua C. Herigon

Impact of a Guideline on Management of Children Hospitalized With Community-Acquired Pneumonia

OBJECTIVES: We sought to describe the impact a clinical practice guideline (CPG) had on antibiotic management of children hospitalized with community-acquired pneumonia (CAP). PATIENTS AND METHODS: We conducted a retrospective study of discharged patients from a children’s hospital with an ICD-9-CM code for pneumonia (480–486). Eligible patients were admitted from July 8, 2007, through July 9, 2009, 12 months before and after the CAP CPG was introduced. Three-stage least squares regression analyses were performed to examine hypothesized simultaneous relationships, including the impact of our institution\x{2019}s antimicrobial stewardship program (ASP). RESULTS: The final analysis included 1033 patients: 530 (51%) before the CPG (pre-CPG) and 503 (49%) after the CPG (post-CPG). Pre-CPG, ceftriaxone (72%) was the most commonly prescribed antibiotic, followed by ampicillin (13%). Post-CPG, the most common antibiotic was ampicillin (63%). The effect of the CPG was associated with a 34% increase in ampicillin use (P < .001). Discharge antibiotics also changed post-CPG, showing a significant increase in amoxicillin use (P < .001) and a significant decrease in cefdinir and amoxicillin/clavulanate (P < .001), with the combined effect of the CPG and ASP leading to 12% (P < 0.001) and 16% (P < .001) reduction, respectively. Overall, treatment failure was infrequent (1.5% vs 1%). CONCLUSIONS: A CPG and ASP led to the increase in use of ampicillin for children hospitalized with CAP. In addition, less broad-spectrum discharge antibiotics were used. Patient adverse outcomes were low, indicating that ampicillin is appropriate first-line therapy for otherwise healthy children admitted with uncomplicated CAP.

Antibiotic Management of Staphylococcus aureus Infections in US Children's Hospitals, 1999–2008

OBJECTIVES: The objective of this study was to describe trends in antibiotic management for Staphylococcus aureus infections among hospitalized children from 1999 to 2008. METHODS: A retrospective study was conducted by using the Pediatric Health Information Systems database to describe antibiotic treatment of inpatients with S aureus infection at 25 childrens hospitals in the United States. Patients who were admitted from 1999 to 2008 with International Classification of Diseases, Ninth Revision, Clinical Modification codes for S aureus infection were included. Trends in the use of vancomycin, clindamycin, linezolid, trimethoprim-sulfamethoxazole, cefazolin, and oxacillin/nafcillin were examined for percentage use and days of therapy per 1000 patient-days. RESULTS: A total of 64813 patients had a discharge diagnosis for S aureus infection. The incidence of methicillin-resistant S aureus (MRSA) infections during this period increased 10-fold, from 2 to 21 cases per 1000 admissions, whereas the methicillin-susceptible S aureus infection rate remained stable. Among patients with S aureus infections, antibiotics that treat MRSA increased from 52% to 79% of cases, whereas those that treat only methicillin-susceptible S aureus declined from 66% to <30% of cases. Clindamycin showed the greatest increase, from 21% in 1999 to 63% in 2008. Similar trends were observed by using days of therapy per 1000 patient-days. CONCLUSIONS: Antibiotic prescribing patterns for the treatment of S aureus infections have changed significantly during the past decade, reflecting the emergence of community-associated MRSA. Clindamycin is now the most commonly prescribed antibiotic for S aureus infections among hospitalized children. The substantial use of clindamycin emphasizes the importance of continuous monitoring of local S aureus susceptibility patterns.

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.

A pilot program to improve vaccination status for hospitalized children.

OBJECTIVES Screening of immunization status at each health care encounter is recommended to improve immunization coverage rates but is often limited to primary care practices. A pilot intervention study was performed to ascertain the immunization status of hospitalized children and determine if development of an immunization plan before discharge would improve the vaccination status for such children. METHODS On the basis of power calculations estimated to detect an increase in immunization status from 60% to 70% with 80% power, 356 randomly selected children were enrolled between March 6, 2012 and June 14, 2012. Immunization records were obtained, immunization status determined, and parent/guardian informed if catch-up dose(s) were needed. If parent requested vaccine dose(s), they were administered before discharge. RESULTS Vaccination status was current per Advisory Committee on Immunization Practices guidelines in 73% of hospitalized children, and 27% children required catch-up dose(s) (200 doses for 95 children). Human papilloma virus vaccine (dose 1), varicella zoster vaccine (dose 2), and meningococcal conjugate vaccine were the most commonly identified dose(s) needed. Of those requiring catch-up dose(s), 25% were caught up, increasing vaccination status to 80% at 1-month post hospital discharge. CONCLUSIONS This is the first study to determine the immunization status of hospitalized pediatric patients of all ages, including adolescents, providing new data on the immunization status of the inpatient pediatric population. A pilot intervention consisting of obtaining immunization records, determining immunization status, and discussing catch-up dose(s) before discharge resulted in improvement of immunization status, suggesting that the inpatient setting may be used along with many other national strategies to help address missed vaccination opportunities.

Antibiotics provide no additional short-term benefit to surgical management of paediatric skin abscesses

Commentary on: DuongMMarkwellSPeterJ. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med 2010;55:401–7.

Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project

Abstract Objective Implementing evidence-based practices requires a multi-faceted approach. Electronic clinical decision support (ECDS) tools may encourage evidence-based practice adoption. However, data regarding the role of mobile ECDS tools in pediatrics is scant. Our objective is to describe the development, distribution, and usage patterns of a smartphone-based ECDS tool within a national practice standardization project. Materials and Methods We developed a smartphone-based ECDS tool for use in the American Academy of Pediatrics, Value in Inpatient Pediatrics Network project entitled “Reducing Excessive Variation in the Infant Sepsis Evaluation (REVISE).” The mobile application (app), PedsGuide, was developed using evidence-based recommendations created by an interdisciplinary panel. App workflow and content were aligned with clinical benchmarks; app interface was adjusted after usability heuristic review. Usage patterns were measured using Google Analytics. Results Overall, 3805 users across the United States downloaded PedsGuide from December 1, 2016, to July 31, 2017, leading to 14 256 use sessions (average 3.75 sessions per user). Users engaged in 60 442 screen views, including 37 424 (61.8%) screen views that displayed content related to the REVISE clinical practice benchmarks, including hospital admission appropriateness (26.8%), length of hospitalization (14.6%), and diagnostic testing recommendations (17.0%). Median user touch depth was 5 [IQR 5]. Discussion We observed rapid dissemination and in-depth engagement with PedsGuide, demonstrating feasibility for using smartphone-based ECDS tools within national practice improvement projects. Conclusions ECDS tools may prove valuable in future national practice standardization initiatives. Work should next focus on developing robust analytics to determine ECDS tools’ impact on medical decision making, clinical practice, and health outcomes.

Characteristics of primary medical team disagreements with antimicrobial stewardship program interventions

Background. Antimicrobial stewardship programs (ASP) have been shown to reduce antibiotic use, development of antibiotic-resistant bacteria, and hospital costs. Previous research on prospective-audit-with-feedback (PAF) ASPs has characterized which antibiotics trigger recommendations, what type of recommendations are made, and how often primary medical teams agree with recommendations. However, factors involved with disagreements are poorly understood. Our objective was to identify characteristics when PAF ASP interventions are not agreed upon by the primary medical care team. Methods. Using the ASP data repository at Children’s Mercy Hospital-Kansas City, data was extracted on ASP interventions in which disagreement occurred from 3 March 2008 to 2 March 2015. Demographic information, medical specialty team, area of the hospital, presence of complex medical conditions, antimicrobial triggering review, and length of stay were examined. Percent disagreement was compared using Pearson’s chi-square and the Mann-Whitney U test was used to compare length of stay. Results. Over the study period, a total of 16,347 patients were reviewed by the ASP; 3144 (19.2%) had recommendations made; 761 (24%) interventions were not agreed upon. Patients with interventions not agreed upon had a significantly longer length of stay (14 versus 9 days; P < 0.001) and a higher prevalence of complex chronic conditions (27% versus 18%; P < 0.001). Disagreement was higher for patients seen in the NICU (32%; P < 0.001), PICU (27%; P < 0.001) and Heme/Onc (26%; P < 0.001) floors when compared with General Pediatrics (17%). Disagreement was also higher among patients receiving amoxicillin/clavulanate (40%; P < 0.001) and meropenem (31%; P < 0.001) compared to cefotaxime (20%). An intervention to stop therapy had the highest level of disagreement, specifically when a viral infection had been identified (45%; P < 0.001) or when no indication for antibiotics had been identified (40%; P < 0.001), compared to broadening coverage (14%). Conclusion. Complex medical care represents an area of significant disagreement with ASP recommendations. Subspecialty involvement in stewardship activities, tailoring interventions specifically for complex patients, and more research on appropriate antibiotic use in these settings could produce more effective stewardship strategies. Disclosures. All authors: No reported disclosures.

Antibiotic Management of Animal Bites in Children During the Methicillin-Resistant Staphylococcus aureus Era

Children presenting to an emergency department following an animal bite were found to be at risk for infection if they had puncture wounds, crush wounds, or were bitten by a cat. Of the infected wounds that were cultured, methicillin-resistant Staphylococcus aureus was not isolated as a pathogen.