Variability in Antibiotic Use at Children's Hospitals
ABSTRACT Variation in medical practice has identified opportunities for quality improvement in patient care. The degree of variation in the use of antibiotics in children's hospitals is unknown.
We conducted a retrospective cohort study of 556,692 consecutive pediatric inpatient discharges from 40 freestanding children's hospitals between January 1, 2008, and December 31, 2008. We used the Pediatric Health Information System to acquire data on antibiotic use and clinical diagnoses.
Overall, 60% of the children received at least 1 antibiotic agent during their hospitalization, including >90% of patients who had surgery, underwent central venous catheter placement, had prolonged ventilation, or remained in the hospital for >14 days. Even after adjustment for both hospital- and patient-level demographic and clinical characteristics, antibiotic use varied substantially across hospitals, including both the proportion of children exposed to antibiotics (38%-72%) and the number of days children received antibiotics (368-601 antibiotic-days per 1000 patient-days). In general, hospitals that used more antibiotics also used a higher proportion of broad-spectrum antibiotics.
Children's hospitals vary substantially in their use of antibiotics to a degree unexplained by patient- or hospital-level factors typically associated with the need for antibiotic therapy, which reveals an opportunity to improve the use of these drugs.
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ABSTRACT: Community-acquired pneumonia (CAP) is a common childhood infection. CAP complications, such as parapneumonic empyema (PPE), are increasing and are frequently caused by antibiotic-resistant organisms. No clinical guidelines currently exist for management of pediatric CAP and no published data exist about variations in antibiotic prescribing patterns. Our objectives were to describe variation in CAP clinical management for hospitalized children by pediatric infectious disease consultants and to examine associations between recommended antibiotic regimens and local antibiotic resistance levels. We surveyed pediatric members of the Emerging Infections Network, which consists of 259 pediatric infectious disease physicians. Participants responded regarding their recommended empiric antibiotic regimens for hospitalized children with CAP with and without PPE and their recommendations for duration of therapy. Participants also provided information about the prevalence of penicillin non-susceptible S. pneumoniae and methicillin-resistant S. aureus (MRSA) in their community. We received 148 responses (57%). For uncomplicated CAP, respondents were divided between recommending beta-lactams alone (55%) versus beta-lactams in combination with another class (40%). For PPE, most recommended a combination of a beta-lactam plus an anti-MRSA agent, however, they were divided between clindamycin (44%) and vancomycin (57%). The relationship between reported antibiotic resistance and empiric regimen was mixed. We found no relationship between aminopenicillin use and prevalence of penicillin non-suscepetible S. pneumoniae or clindamycin use and clindamycin resistance, however, respondents were more likely to recommend an anti-MRSA agent when MRSA prevalence increased. Substantial variability exists in recommendations for CAP management. Development of clinical guidelines via antimicrobial stewardship programs and dissemination of data about local antibiotic resistance patterns represent opportunities to improve care.PLoS ONE 05/2011; 6(5):e20325. DOI:10.1371/journal.pone.0020325 · 3.53 Impact Factor
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ABSTRACT: The aim of this study was to determine the influence of pneumococcal penicillin-nonsusceptibility patterns on individual antibiotic prescription among 33 children's hospitals using a multilevel, random- intercept, logistic regression analysis. It was a multilevel cross-sectional study. The participants were children, 1-18 years of age, with community-acquired pneumonia (CAP) who were discharged in 2006. Hospital antibiotic susceptibility data were collected from surveys, and patient data were obtained from an administrative database. The primary exposure was the proportion of penicillin-nonsusceptible pneumococcal isolates reported in 2005 by each hospital. A secondary exposure included using the proportion of penicillin-resistant pneumococcal isolates to determine whether a threshold of susceptibility existed. Receipt of broad-spectrum empiric antibiotic therapy in 2006 (ie, antibiotics other than penicillins or aminopenicillins) was the main outcome measure. Four thousand eight hundred eighty-eight children diagnosed with CAP were eligible. The proportion of penicillin-nonsusceptible isolates ranged from 9% to 70% across hospitals whereas the proportion of penicillin-resistant isolates ranged from 0% to 60%. Broad-spectrum antibiotics were prescribed to 93% of patients; 45% of patients received cephalosporin class antibiotics alone. There was no significant association between the proportion of pencillin-nonsusceptible pneumococcal isolates at individual hospitals and narrow-spectrum prescribing. However, every 10% increase in penicillin-resistant pneumococcal isolates was associated with a 39% increase in broad-spectrum antibiotic prescribing (adjusted odds ratio: 1.39; 95% confidence interval: 1.08-1.69). There was substantial variability in empiric antibiotic prescribing for CAP among children's hospitals in the United States. High-levels (ie, resistant) but not modest-levels (ie, intermediate susceptibility) of penicillin resistance were associated with broad-spectrum antibiotic prescribing.The Pediatric Infectious Disease Journal 01/2012; 31(4):331-6. DOI:10.1097/INF.0b013e3182489cc4 · 3.14 Impact Factor
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ABSTRACT: The WHO anatomical therapeutic chemical (ATC)/defined daily dose (DDD) methodology is a standardized method of comparing antimicrobial use. The ATC/DDD is defined as the average maintenance daily dose of a drug used in a 70 kg adult, ignoring the considerable differences in body weight of neonates and children. The aim of this study was to develop a new standardized way of comparing rates of antimicrobial prescribing between European children's hospitals. This pilot study at four European children's hospitals (in the UK, Greece and Italy) collected data including demographics, antibiotic use, dosing and indication in children and neonates over a 14 day period. A total of 1217 antibiotic prescriptions were issued with 47 different antibiotics used. Approximately half of all children and a third of all neonates received antibiotics, with wide variation between centres in the type and dose of antibiotic used. We propose a new pragmatic three-step algorithm. The first step includes a simple comparison of the proportion of hospitalized children on antibiotics by weight bands and the number of antimicrobials that account for 90% of total DDD drug usage (DU90%). The second step is a comparison of the dosing used (mg/kg/day). The third step is to compare overall drug exposure using DDD/100 bed days for standardized weight bands between centres. This novel method has the potential to be a useful tool to provide antibiotic use comparator data and requires validation in a large prospective point prevalence study.Journal of Antimicrobial Chemotherapy 02/2012; 67(5):1278-86. DOI:10.1093/jac/dks021 · 5.44 Impact Factor