Lori Handy

Variability in Antibiotic Prescribing for Community-Acquired Pneumonia

This study explores clinical and sociodemographic factors associated with variability in prescribing practices for antibiotics for CAP in a retrospective cohort. BACKGROUND AND OBJECTIVES: Published guidelines recommend amoxicillin for most children with community-acquired pneumonia (CAP), yet macrolides and broad-spectrum antibiotics are more commonly prescribed. We aimed to determine the patient and clinician characteristics associated with the prescription of amoxicillin versus macrolide or broad-spectrum antibiotics for CAP. METHODS: Retrospective cohort study in an outpatient pediatric primary care network from July 1, 2009 to June 30, 2013. Patients prescribed amoxicillin, macrolides, or a broad-spectrum antibiotic (amoxicillin–clavulanic acid, cephalosporin, or fluoroquinolone) for CAP were included. Multivariable logistic regression models were implemented to identify predictors of antibiotic choice for CAP based on patient- and clinician-level characteristics, controlling for practice. RESULTS: Of 10 414 children, 4239 (40.7%) received amoxicillin, 4430 (42.5%) received macrolides and 1745 (16.8%) received broad-spectrum antibiotics. The factors associated with an increased odds of receipt of macrolides compared with amoxicillin included patient age ≥5 years (adjusted odds ratio [aOR]: 6.18; 95% confidence interval [CI]: 5.53–6.91), previous antibiotic receipt (aOR: 1.79; 95% CI: 1.56–2.04), and private insurance (aOR: 1.47; 95% CI: 1.28–1.70). The predicted probability of a child being prescribed a macrolide ranged significantly between 0.22 and 0.83 across clinics. The nonclinical characteristics associated with an increased odds of receipt of broad-spectrum antibiotics compared with amoxicillin included suburban practice (aOR: 7.50; 95% CI: 4.16–13.55) and private insurance (aOR: 1.42; 95% CI: 1.18–1.71). CONCLUSIONS: Antibiotic choice for CAP varied widely across practices. Factors unlikely related to the microbiologic etiology of CAP were significant drivers of antibiotic choice. Understanding drivers of off-guideline prescribing can inform targeted antimicrobial stewardship initiatives.

What Is Wrong with Pertussis Vaccine Immunity? The Problem of Waning Effectiveness of Pertussis Vaccines

Pertussis is resurgent in some countries, particularly those in which children receive acellular pertussis (aP) vaccines in early infancy and boosters later in life. Immunologic studies show that, whereas whole-cell pertussis (wP) vaccines orient the immune system toward Th1/Th17 responses, acellular pertussis vaccines orient toward Th1/Th2 responses. Although aP vaccines do provide protection during the first years of life, the change in T-cell priming results in waning effectiveness of aP as early as 2-3 years post-boosters. Although other factors, such as increased virulence of pertussis strains, better diagnosis, and better surveillance may play a role, the increase in pertussis appears to be the result of waning immunity. In addition, studies in baboon models, requiring confirmation in humans, show that aP is less able to prevent nasopharyngeal colonization of Bordetella pertussis than wP or natural infection.

The impact of access to immunization information on vaccine acceptance in three countries

Introduction Vaccine acceptance is a critical component of sustainable immunization programs, yet rates of vaccine hesitancy are rising. Increased access to misinformation through media and anti-vaccine advocacy is an important contributor to hesitancy in the United States and other high-income nations with robust immunization programs. Little is known about the content and effect of information sources on attitudes toward vaccination in settings with rapidly changing or unstable immunization programs. Objective The objective of this study was to explore knowledge and attitudes regarding vaccines and vaccine-preventable diseases among caregivers and immunization providers in Botswana, the Dominican Republic, and Greece and examine how access to information impacts reported vaccine acceptance. Methods We conducted 37 focus groups and 14 semi-structured interviews with 96 providers and 153 caregivers in Botswana, the Dominican Republic, and Greece. Focus groups were conducted in Setswana, English, Spanish, or Greek; digitally recorded; and transcribed. Transcripts were translated into English, coded in qualitative data analysis software (NVivo 10, QSR International, Melbourne, Australia), and analyzed for common themes. Results Dominant themes in all three countries included identification of health care providers or medical literature as the primary source of vaccine information, yet participants reported insufficient communication about vaccines was available. Comments about level of trust in the health care system and government contrasted between sites, with the highest level of trust reported in Botswana but lower levels of trust in Greece. Conclusions In Botswana, the Dominican Republic, and Greece, participants expressed reliance on health care providers for information and demonstrated a need for more communication about vaccines. Trust in the government and health care system influenced vaccine acceptance differently in each country, demonstrating the need for country-specific data that focus on vaccine acceptance to fully understand which drivers can be leveraged to improve implementation of immunization programs.

Comparative Effectiveness of Beta-lactams Versus Azithromycin for Treatment of Outpatient Pediatric Community-Acquired Pneumonia

Abstract Background Guidelines recommend amoxicillin as first-line therapy for mild, community-acquired pneumonia (CAP) in healthy, immunized children because of its effectiveness against S. pneumoniae. However, macrolides, which have inferior anti-pneumococcal activity, are the most commonly prescribed class of antibiotics for outpatient CAP. We aimed to determine the comparative effectiveness of β-lactam vs. macrolide antibiotics for the treatment of CAP. Methods We conducted a retrospective cohort study in 31 pediatric primary care practices. Patients 3 months to 18 years of age with CAP diagnosed between January 1, 2009 and December 31, 2013 were identified by ICD-9-CM codes. Clinical data were abstracted electronically. Treatment failure was defined as change in antibiotic by the pediatrician, emergency department (ED) visit, or hospitalization for pneumonia in the 2 weeks following diagnosis. Multivariable logistic regression models including children prescribed monotherapy of amoxicillin, broad-spectrum β-lactam antibiotics, or macrolides were built to determine the association of each class with treatment failure, adjusting for clinical and demographic characteristics. Results Of 10,470 children who received antibiotics for pneumonia, 4252 (40.6%) received amoxicillin, 4459 (42.6%) received macrolides, and 1759 (16.8%) received broad-spectrum β-lactams. The groups differed by age category, proportion of black patients, insurance type, documented fever, ordering of a chest X-ray, and prior antibiotic exposure. Treatment failure occurred in 633 children (6.1%); 418 required a change in antibiotic by the pediatrician, 169 required an ED visit, and 47 required hospitalization. In the adjusted model, macrolide prescribing was associated with a decreased odds of treatment failure in children <5 years old (aOR = 0.52, 95% CI 0.34, 0.78) and in children ≥5 years old (aOR = 0.32, 95% CI 0.25, 0.41). In practices with the lowest macrolide use, this relationship persisted (OR 0.46; 95% CI 0.23, 0.92). Conclusion While rates of treatment failure in children diagnosed with CAP in the outpatient setting were low, macrolides were associated with a lower failure rate than treatment with β-lactams. This may be due to residual confounding by indication or changing epidemiology of outpatient pneumonia. Disclosures T. Zaoutis, Astellas: Consultant, Consulting fee; Merck: Grant Investigator, Research grant; nabriva: Consultant, Consulting fee.

Impact of Personalized Audit and Feedback on Management of Pediatric Outpatient Community-Acquired Pneumonia

Abstract Background Community-acquired pneumonia (CAP) is a common infection in children. Guidelines recommend amoxicillin as first line therapy for CAP, while macrolides are recommended for school-aged children with atypical pneumonia. Despite guidelines, antibiotic choice for CAP varies widely among providers. We aimed to determine the impact of outpatient audit and feedback to individual providers on adherence with published guidelines. Methods We conducted a randomized controlled trial of primary care clinicians in a multi-state primary care network from 8/2016–2/2017. Providers received baseline education. The intervention included personalized feedback from investigators at 1-month intervals on the provider’s management of a case of CAP identified by ICD-10-CM codes. Prescription counts of guideline-recommended antibiotic therapy were compared between groups by Pearson’s chi-squared. Performance scores incorporating diagnostic and treatment decisions such as physical examination elements, antibiotics and medication dosing appropriate for a CAP encounter as defined by clinical practice guidelines were calculated for each encounter during study intervals. Results Among the 43 providers, the majority were physicians (76% control, 86% intervention). There were no significant differences in work hours, years since board certification, sex or race between groups. 316 distinct cases of CAP were diagnosed (214 control; 102 intervention). In patients <5 years, there was no significant difference in prescription of amoxicillin between groups (61/103 (59.2%) control; 23/48 (47.9%) intervention, P = 0.19). In patients ≥5 years, there was a significant difference in prescription of guideline recommended antibiotics of amoxicillin or azithromycin (81/103 (78.6%) control; 48/51 (94.1%) intervention, P < 0.05). There was a small, but apparent upward trend in mean performance scores in the intervention group (Figure 1). Conclusion Personalized, scheduled audit and feedback in the outpatient setting had a small but measurable impact on improving physician adherence with guidelines. Audit and feedback alone is insufficient to substantially improve guideline adherence in the management of CAP and should be combined with other antimicrobial stewardship interventions. Disclosures All authors: No reported disclosures.