Variability in Pediatric Infectious Disease Consultants' Recommendations for Management of Community-Acquired Pneumonia

Pediatric Infectious Diseases, University of Utah, Salt Lake City, Utah, United States of America.
PLoS ONE (Impact Factor: 3.23). 05/2011; 6(5):e20325. DOI: 10.1371/journal.pone.0020325
Source: PubMed


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.

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    • "Infectious diseases (ID)-trained physicians are considered integral to antimicrobial stewardship programs (ASPs), conferring program legitimacy with regards to other hospital physicians and ensuring that ASP activities do not put patients at greater risk of adverse outcomes [1]. However, there can be considerable variability in the antibiotic prescribing practices of ID physicians [2,3], particularly if they had received training at different institutions. "
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    ABSTRACT: The optimal way for antimicrobial stewardship programs (ASPs) to interact with existing infectious disease physician (IDP) services within the same institution is unknown. In our institution, IDPs and our prospective audit and feedback ASP operate independently, with occasionally differing recommendations offered for the same inpatient. We performed a retrospective audit on inpatients that had been reviewed by both IDPs and ASP within a 7-day period, focusing on cases where different therapy-modifying recommendations had been offered. We analyzed the outcomes in inpatients where the ASP recommendations were accepted and compared these with the inpatients where the IDP recommendations were accepted instead. Outcomes assessed were 30-day mortality post-ASP review, unplanned re-admission within 30 days post-discharge from hospital, and clinical deterioration at 7 days post-ASP review. There were 143 (18.9%) patients where differing recommendations had been offered, with primary physicians accepting 69.9% of ASP recommendations. No significant differences in terms of demographics, clinical characteristics, 30-day mortality, and re-admission rates were observed, although clinical deterioration rates were lower in patients where the ASP recommendation was accepted (8.0% vs. 27.9%; p=0.002). On multivariate analysis, hematology-oncology inpatients were associated with unplanned readmission. Increasing age and hematology-oncology inpatients were associated with clinical deterioration 7 days post-recommendation, whereas acceptance of ASP recommendations was protective. No characteristic was independently associated with 30-day mortality. In conclusion, independent reviews by both IDPs and ASPs can be compatible within large tertiary hospitals, providing primary physicians even in situations of conflicting recommendations viable alternative antimicrobial prescribing advice.
    11/2013; 2(1):29. DOI:10.1186/2047-2994-2-29
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    • "In subsequent analyses, we categorized ampicillin, ampicillin/sulbactam, and cephalosporins as beta-lactam antibiotics and vancomycin, clindamycin, and linezolid as antimethicillin-resistant Staphylococcus aureus antibiotics. Respondents were asked to select the duration of antibiotic therapy they would recommend for uncomplicated and parapneumonic empyema cases using the following categories: 3–5 days, 6-7 days, 8–10 days, 11–14 days, 15–21 days, and >21 days [11]. Empirical antibiotic administration is relied upon in most instances to meet the public health goal of reducing child mortality due to pneumonia. "
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    ABSTRACT: Objective. To assess the efficacy and safety of Chinese medicinal herbs for Childhood Pneumonia. Methods. We included randomized controlled trials (RCTs). The searched electronic databases included PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, CBM, CNKI, and VIP. All studies included were assessed for quality and risk bias. Review Manager 5.1.6 software was used for data analyses, and the GRADEprofiler software was applied to classify the systematic review results. Results. Fourteen studies were identified (n = 1.824). Chinese herbs may increase total effective rate (risk ratio (RR) 1.18; 95% confidence interval (CI), 1.11-1.26) and improve cough (total mean difference (MD), -2.18; 95% CI, (-2.66)-(-1.71)), fever (total MD, -1.85; 95% CI, (-2.29)-(-1.40)), rales (total MD, -1.53; 95% CI, (-1.84)-(-1.23)), and chest films (total MD, -3.10; 95% CI, (-4.11)-(-2.08)) in Childhood Pneumonia. Chinese herbs may shorten the length of hospital stay (total MD, -3.00; 95% CI, (-3.52)-(-2.48)), but no significant difference for adverse effects (RR, 0.39; 95% CI, 0.09-1.72) was identified. Conclusion. Chinese herbs may increase total effective rate and improve symptoms and signs. However, large, properly randomized, placebo-controlled, double-blind studies are required.
    Evidence-based Complementary and Alternative Medicine 03/2013; 2013(s2):203845. DOI:10.1155/2013/203845 · 1.88 Impact Factor
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    • "However, simultaneously providing rotational consultant oversight would not have resolved all issues, particularly those of conflicting opinions [5], and lack of ownership. In reality, only a fraction of ID specialists elect to participate in antimicrobial stewardship, and most trainees and consultants face major challenges in making therapeutic recommendations without direct patient contact. "
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    ABSTRACT: Our prospective-audit-and-feedback antimicrobial stewardship (AS) program for hematology and oncology inpatients was switched from one led by dedicated clinicians to a rotating team of infectious diseases trainees in order to provide learning opportunities and attempt a "de-escalation" of specialist input towards a more protocol-driven implementation. However, process indicators including number of and compliance to recommendations fell significantly during the year, with accompanying increases in broad-spectrum antibiotic prescription. The trends were reversed only upon reverting to the original setup. Dedicated clinicians play a crucial role in AS programs involving immunocompromised patients. Structured training and adequate succession/contingency planning is critical for sustainability.
    11/2012; 1(1):36. DOI:10.1186/2047-2994-1-36
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