Multidisciplinary interventions to improve narrow spectrum antibiotic use in pediatric community acquired pneumonia

Abstract Background Judicious use of antimicrobials is the cornerstone of action against antimicrobial resistance. Respiratory tract infections account for over 80% of pediatric antibiotic use in Japan. Antibiotics are generally used empirically for most hospitalized patients with pneumonia although it is becoming clearer that viral etiologies account for approximately 70% of these cases. Defining the characteristics of patients who are managed with a short course of antibiotics and subsequently do well, may lead to setting clinical criteria for early termination of antibiotics. Methods We performed a retrospective descriptive analysis. Medical charts of patients aged 3 months to 18 years, who were admitted with a diagnosis of pneumonia, bronchitis, bronchiolitis, or asthma to the Department of Interdisciplinary medicine at the National Center for Child Health and Development from March 2018 through February 2019 were reviewed. Those who had respiratory symptoms and were started on antibiotics within 48 hours of hospitalization were included. Those who had a focus of infection elsewhere or were immunocompromised were excluded. Results Of the 556 candidates, 80 patients met the criteria. The median age was 1.5 years which included 42.5% (34/80) with comorbidities. Underlying conditions included 9 with trisomy 21, and 8 with perinatal issues. Rapid antigen testing was performed and 7 patients with RSV, 5 patients with influenza, 1 patient with human metapneumovirus were identified. The average duration of antibiotic therapy was 7.2 days (range 2–14 days). There were no statistical differences in the characteristics of patients who received antibiotics for more or less than 5 days. The positivity of the rapid antigen test tended to be higher in those who received antibiotics for a shorter period (25% vs. 15%). There were no differences in the rate of readmission or complications between the two groups. Conclusion We were unable to identify a clear characteristic of patients who received short courses of antibiotics for pneumonia. The trend observed for those who had a point of care testing may suggest that the use of a multiplex PCR testing covering a greater number of pathogens would influence physician behavior in antibiotic use.

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Antibiotic Prescribing for Adults Hospitalized in the Etiology of Pneumonia in the Community Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx088 ◽

2017 ◽

Vol 4 (2) ◽

Cited By ~ 6

Author(s):

Sara Tomczyk ◽

Seema Jain ◽

Anna M Bramley ◽

Wesley H Self ◽

Evan J Anderson ◽

...

Keyword(s):

Antibiotic Use ◽

Community Acquired Pneumonia ◽

Community Study ◽

Antibiotic Prescribing ◽

Beta Lactam ◽

First Line ◽

Factors Associated ◽

Admission Ward ◽

Healthcare Associated ◽

To Receive

Abstract Background Community-acquired pneumonia (CAP) 2007 guidelines from the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) recommend a respiratory fluoroquinolone or beta-lactam plus macrolide as first-line antibiotics for adults hospitalized with CAP. Few studies have assessed guideline-concordant antibiotic use for patients hospitalized with CAP after the 2007 IDSA/ATS guidelines. We examine antibiotics prescribed and associated factors in adults hospitalized with CAP. Methods From January 2010 to June 2012, adults hospitalized with clinical and radiographic CAP were enrolled in a prospective Etiology of Pneumonia in the Community study across 5 US hospitals. Patients were interviewed using a standardized questionnaire, and medical charts were reviewed. Antibiotics prescribed were classified according to defined nonrecommended CAP antibiotics. We assessed factors associated with nonrecommended CAP antibiotics using logistic regression. Results Among enrollees, 1843 of 1874 (98%) ward and 440 of 446 (99%) ICU patients received ≥1 antibiotic ≤24 hours after admission. Ward patients were prescribed a respiratory fluoroquinolone alone (n = 613; 33%), or beta-lactam plus macrolide (n = 365; 19%), beta-lactam alone (n = 240; 13%), among other antibiotics, including vancomycin (n = 235; 13%) or piperacillin/tazobactam (n = 157; 8%) ≤24 hours after admission. Ward patients with known risk for healthcare-associated pneumonia (HCAP), recent outpatient antibiotic use, and in-hospital antibiotic use <6 hours after admission were significantly more likely to receive nonrecommended CAP antibiotics. Conclusions Although more than half of ward patients received antibiotics concordant with IDSA/ATS guidelines, a number received nonrecommended CAP antibiotics, including vancomycin and piperacillin/tazobactam; risk factors for HCAP, recent outpatient antibiotic, and rapid inpatient antibiotic use contributed to this. This hypothesis-generating descriptive epidemiology analysis could help inform antibiotic stewardship efforts, reinforces the need to harmonize guidelines for CAP and HCAP, and highlights the need for improved diagnostics to better equip clinicians.

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Staphylococcus aureus - selective reporting of antibiogram results and its impact on antibiotic use: Interventional study with a reference group on the effect of switching from non-selective to selective antibiotic reporting

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-021-01021-7 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Franka Lestin-Bernstein ◽

Ramona Harberg ◽

Ingo Schumacher ◽

Lutz Briedigkeit ◽

Oliver Heese ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Antibiotic Use ◽

Antibiotic Consumption ◽

Selective Reporting ◽

Beta Lactams ◽

Interventional Study ◽

Patient Level ◽

Narrow Spectrum ◽

Bed Days ◽

The Impact

Abstract Background Antimicrobial stewardship (AMS) strategies worldwide focus on optimising the use of antibiotics. Selective susceptibility reporting is recommended as an effective AMS tool although there is a lack of representative studies investigating the impact of selective susceptibility reporting on antibiotic use. The aim of this study was to investigate the impact of selective susceptibility reporting of Staphylococcus aureus (S. aureus) on antibiotic consumption. Enhancing the use of narrow-spectrum beta-lactam antibiotics such as flucloxacillin/cefazolin/cefalexin is one of the main goals in optimising antibiotic therapy of S. aureus infections. Methods This interventional study with control group was conducted at a tertiary care hospital in Germany. During the one-year interventional period susceptibility reports for all methicillin-sensitive S. aureus (MSSA) were restricted to flucloxacillin/cefazolin/cefalexin, trimethoprim-sulfamethoxazole, clindamycin, gentamicin and rifampin/fosfomycin, instead of reporting all tested antibiotics. The impact of implementing selective reporting was analysed by monitoring total monthly antibiotic consumption in our hospital and in a reference hospital (recommended daily dose/100 occupied bed days: RDD/100 BD), as well as on an individual patient level by analysing days of therapy adjusted for bed days (DOT/ 100 BD) for patients with S. aureus bacteremia (SAB) and respectively skin and soft tissue infections (SSTI). Results MSSA-antibiograms were acquired for 2836 patients. The total use of narrow-spectrum beta-lactams more than doubled after implementing selective reporting (from 1.2 to 2.8 RDD/100 BD, P < 0.001). The use of intravenous flucloxacillin/cefazolin for SAB rose significantly from 52 to 75 DOT/100 BD (plus 42%), just as the use of oral cefalexin for SSTI (from 1.4 to 9.4 DOT/100 BD, from 3 to 17 of 85/88 patients). Considering the overall consumption, there was no decrease in antibiotics omitted from the antibiogram. This was probably due to their wide use for other infections. Conclusions As narrow-spectrum beta-lactams are not widely used for other infections, their increase in the overall consumption of the entire hospital was a strong indicator that selective reporting guided clinicians to an optimised antibiotic therapy of S. aureus infections. On a patient level, this assumption was verified by a significant improved treatment of S. aureus infections in the subgroups of SAB and SSTI. As useful AMS tool, we recommend implementing selective reporting rules into the national/international standards for susceptibility reporting.

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Multimicrobial Pneumonia during the Early Stages of a Global Pandemic

Journal of Family Medicine ◽

10.26420/jfammed.2021.1265 ◽

2021 ◽

Vol 8 (6) ◽

Author(s):

Jalal H ◽

◽

Henriksen G ◽

Keyword(s):

Staphylococcus Aureus ◽

Pseudomonas Aeruginosa ◽

Methicillin Resistant Staphylococcus Aureus ◽

Acute Infection ◽

Standard Of Care ◽

Antibiotic Use ◽

Lung Parenchyma ◽

Community Acquired Pneumonia ◽

Methicillin Resistant ◽

Global Pandemic

Community-acquired pneumonia is an acute infection of lung parenchyma which causes local and systemic inflammatory changes via cytokines. Several bacteria and viruses are responsible for this type of pneumonia, and the most common bacterial cause is Streptococcus pneumoniae. The classic symptoms are cough, fever, and pleuritic chest pain. In the Winter of 2020, a new strain of coronavirus known as SARS-CoV-2 spread throughout the world and was responsible for a global pandemic that transformed the way we live our lives. A 93-year old female presented to the hospital with respiratory distress and was found to have not only COVID-19 pneumonia but also superimposed Methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa pneumonia. Following the most up-to-date guidelines, she was determined to have community-acquired pneumonia. Methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa are uncommon causes of communityacquired pneumonia. She was treated with the standard of care at the time, which included vancomycin, piperacillin-tazobactam, and hydroxychloroquine. This case highlights the rarity of this specific presentation of community acquired pneumonia in regards to microbial etiology. It showcases that patients may develop certain diseases despite not having any risk factors. A major takeaway point is that apt decision making is a critical and time sensitive matter when determining whether a bacterial co-infection is present since it can affect patient outcomes. Since co-infections are relatively infrequent, antibiotic use in COVID-19 positive patients needs to be tailored accordingly. At the same time, it is crucial to keep in mind that co-infections are associated with increased severity of COVID-19 as well as poorer outcomes.

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Staphylococcus Aureus: Selective Reporting of Antibiogram Results and Its Impact on Antibiotic Use. Interventional Study with a Reference Group on the Effect of Switching from Non-Selective to Selective Antibiotic Reporting

10.21203/rs.3.rs-41131/v1 ◽

2020 ◽

Author(s):

Franka Lestin-Bernstein ◽

Ramona Harberg ◽

Ingo Schumacher ◽

Lutz Briedigkeit ◽

Oliver Heese ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Antibiotic Therapy ◽

Antibiotic Use ◽

Antibiotic Consumption ◽

Selective Reporting ◽

Care Hospital ◽

Beta Lactams ◽

Interventional Study ◽

Narrow Spectrum ◽

The Impact

Abstract Background:Antimicrobial stewardship (AMS) strategies worldwide focus on optimised antibiotic use. Selective susceptibility reporting is recommended as an effective AMS tool, although there is a lack of representative studies investigating the impact of selective susceptibility reporting on antibiotic use.The aim of this study was to investigate the impact of selective susceptibility reporting of Staphylococcus aureus (S. aureus) on antibiotic consumption. Enhancing the use of narrow-spectrum beta-lactam antibiotics such as flucloxacillin/cefazolin/cefalexin is one of the main goals in optimising antibiotic therapy of S. aureus infections.Methods:This interventional study with control group was conducted at a tertiary care hospital in Germany. During the one-year interventional period, susceptibility reports for all methicillin-sensitive S. aureus (MSSA) were restricted to flucloxacillin/cefazolin/oral cefalexin, trimethoprim-sulfamethoxazole, clindamycin, gentamicin and rifampin/fosfomycin; instead of reporting all tested antibiotics during the year before the intervention and in the reference clinic. The impact of the intervention was analysed by monitoring antibiotic consumption (recommended daily dose/100 occupied bed days: RDD/100 BD).Results:MSSA-antibiograms were reported for 2836 patients. Total use of narrow-spectrum beta-lactams more than doubled during the intervention (from 1.2 to 2.8 RDD/100 BD, P<0.001; P<0.001 compared to the reference clinic); the percentage of total antibiotic use increased from 2.6% to 6.2%. A slight, but significant increase in the use of trimethoprim-sulfamethoxazole was also observed (+ 0.37 RDD/100 BD).There was no decrease in antibiotics withdrawn from the antibiogram, probably as a consequence of their wide use for indications other than S. aureus infections.Conclusions:As narrow-spectrum beta-lactams are not widely used for other infections, there is a strong indication that selective reporting guided clinicians to optimised antibiotic therapy of S. aureus infections.As useful AMS tool, we recommend implementing selective reporting rules into the national/international standards for susceptibility reporting.

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Impact of Order-Set Modifications and Provider Education Following Guideline Updates on Broad-Spectrum Antibiotic Use in Patients Admitted With Community Acquired Pneumonia

Hospital Pharmacy ◽

10.1177/00185787211055797 ◽

2021 ◽

pp. 001857872110557

Author(s):

Jessica L. Colmerauer ◽

Kristin E. Linder ◽

Casey J. Dempsey ◽

Joseph L. Kuti ◽

David P. Nicolau ◽

...

Keyword(s):

Broad Spectrum ◽

Antibiotic Use ◽

Community Acquired Pneumonia ◽

Intervention Period ◽

Provider Education ◽

Broad Spectrum Antibiotic ◽

Post Intervention ◽

Post Intervention Period ◽

Days Of Therapy ◽

Order Set

Purpose: Following updates to the Infectious Diseases Society of America (IDSA) practice guidelines for the Diagnosis and Treatment of Adults with Community-acquired Pneumonia in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for the prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education. Methods: This was a multi-center, quasi-experimental, retrospective study of patients with a diagnosis of CAP from September 1, 2019 to October 31, 2019 (pre-intervention) and September 1, 2020 to October 31, 2020 (post-intervention). Patients were identified using ICD-10 codes (A48.1, J10.00-J18.9) indicating lower respiratory tract infection. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS). Results: A total of 331 and 352 patients were included in the pre- and post-intervention cohorts, respectively. There were no differences in order-set usage (10% vs 11.3%, P = .642) between the pre- and post-intervention cohort, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period ( P < .001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs [190/312] 60.9%; P = .003). Hospital LOS was shorter in the post-intervention cohort (4.8 days [2.9-7.2 days] vs 5.3 days [IQR 3.5-8.5 days], P = .002). Conclusion: Implementation of an updated CAP order-set with accompanying provider education was associated with reduced use of broad-spectrum antibiotics. Opportunities to improve compliance and thus further increase guideline-concordant therapy require investigation.

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