Theoklis E Zaoutis

University of Pennsylvania, Filadelfia, Pennsylvania, United States

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Publications (220)810.44 Total impact

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    ABSTRACT: Objectives The objectives were to estimate the frequency of pregnancy testing in emergency department (ED) visits by reproductive-aged women administered or prescribed teratogenic medications (Food and Drug Administration categories D or X) and to determine factors associated with nonreceipt of a pregnancy test.Methods This was a retrospective cross-sectional study using 2005 through 2009 National Hospital Ambulatory Medical Care Survey data of ED visits by females ages 14 to 40 years. The number of visits was estimated where teratogenic medications were administered or prescribed and pregnancy testing was not conducted. The association of demographic and clinical factors with nonreceipt of pregnancy testing was assessed using multivariable logistic regression.ResultsOf 39,859 sampled visits, representing an estimated 141.0 million ED visits by reproductive-aged females nationwide, 10.1 million (95% confidence interval [CI] = 8.9 to 11.3 million) estimated visits were associated with administration or prescription of teratogenic medications. Of these, 22.0% (95% CI = 19.8% to 24.2%) underwent pregnancy testing. The most frequent teratogenic medications administered without pregnancy testing were benzodiazepines (52.2%; 95% CI = 31.1% to 72.7%), antibiotics (10.7%; 95% CI = 5.0% to 16.3%), and antiepileptics (7.7%; 95% CI = 0.12% to 15.5%). The most common diagnoses associated with teratogenic drug prescription without pregnancy testing were psychiatric (16.1%; 95% CI = 13.6% to 18.6%), musculoskeletal (12.7%; 95% CI = 10.8% to 14.5%), and cardiac (9.5%; 95% CI = 7.6% to 11.3%). In multivariable analyses, visits by older (adjusted odds ratio [AOR] = 0.57, 95% CI = 0.42 to 0.79), non-Hispanic white females (AOR = 0.71; 95% CI = 0.54 to 0.93); visits in the Northeast region (AOR = 0.60; 95% CI = 0.42 to 0.86); and visits during which teratogenic medications were administered in the ED only (AOR = 0.74; 95% CI = 0.57 to 0.97) compared to prescribed at discharge only were less likely to have pregnancy testing.ConclusionsA minority of ED visits by reproductive-aged women included pregnancy testing when patients were prescribed category D or X medications. Interventions are needed to ensure that pregnancy testing occurs before women are prescribed potentially teratogenic medications, as a preventable cause of infant morbidity.
    Academic Emergency Medicine 01/2015; · 2.20 Impact Factor
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    ABSTRACT: The prevalence of high-MIC fluoroquinolone-susceptible Escherichia coli (FQSEC) has been increasing. These isolates are one step closer to full fluoroquinolone (FQ) resistance and may lead to delayed response to FQ therapy. Our study aimed to investigate the epidemiology of high-MIC FQSEC in ambulatory urinary tract infections (UTIs). A case-control study was conducted at outpatient services within the University of Pennsylvania Health System, Philadelphia. All female subjects with non-recurrent UTI caused by FQSEC (levofloxacin MIC < 4 mg/L) were enrolled. Cases were subjects with high-MIC FQSEC UTI (levofloxacin MIC >0.12 but < 4 mg/L) and controls were subjects with low-MIC FQSEC UTI (levofloxacin MIC ≤0.12 mg/L). Data on microbiology results and baseline characteristics were extracted from electronic medical records. During the 3 year study period (May 2008-April 2011), 11 287 episodes of E. coli bacteriuria were identified. The prevalence of FQSEC, FQ-intermediate susceptible E. coli and FQ-resistant E. coli was 75.0%, 0.4% and 24.6%, respectively. A total of 2001 female subjects with FQSEC UTI were enrolled into our study (165 cases and 1836 controls). Independent risk factors for high-MIC FQ susceptibility included Asian race (OR = 2.92; 95% CI = 1.29-6.58; P = 0.02), underlying renal disease (OR = 2.18; 95% CI = 1.15-4.14; P = 0.02) and previous nitrofurantoin exposure (OR = 8.86; 95% CI = 1.95-40.29; P = 0.005). Asian race, underlying renal disease and previous exposure to nitrofurantoin were identified as independent risk factors for high-MIC FQSEC. There may be some factors that are more common in Asians, which may result in the selection of high-MIC FQSEC. Further studies are necessary to explore these findings. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail:
    Journal of Antimicrobial Chemotherapy 01/2015; · 5.34 Impact Factor
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    ABSTRACT: Antimicrobial stewardship is pivotal to improving patient outcomes, reducing adverse events, decreasing healthcare costs, and preventing further emergence of antimicrobial resistance. In an era in which antimicrobial resistance is increasing, judicious antimicrobial use is the responsibility of every healthcare provider. While antimicrobial stewardship programs (ASPs) have made headway in improving antimicrobial prescribing using such "top-down" methods as formulary restriction and prospective audit with feedback, engagement of prescribers has not been fully explored. Strategies that include frontline prescribers and other unit-based healthcare providers have the potential to expand stewardship, both to augment existing centralized ASPs and to provide alternative approaches to perform stewardship at healthcare facilities with limited resources. This review discusses interventions focusing on antimicrobial prescribing at the point of prescription as well as a pilot project to engage unit-based healthcare providers in antimicrobial stewardship. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail:
    Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 01/2015;
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    ABSTRACT: The objective of this study was to describe the diagnostic yield and complication rate of bronchoalveolar lavage (BAL) and lung biopsy in the evaluation of pulmonary lesions in patients with cancer and recipients of hematopoietic stem-cell transplantation (HSCT). We conducted a systematic literature review and performed electronic searches of Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Studies were included if patients had cancer or were recipients of HSCT, and if they underwent BAL or lung biopsy for the evaluation of pulmonary lesions. Only English language publications were included. In all, 14,148 studies were screened; 72 studies of BAL and 31 of lung biopsy were included. The proportion of procedures leading to any diagnosis was similar by procedure type (0.53 v 0.54; P = .94) but an infectious diagnosis was more common with BAL compared with lung biopsy (0.49 v 0.34; P < .001). Lung biopsy more commonly led to a noninfectious diagnosis (0.43 v 0.07; P < .001) and was more likely to change how the patient was managed (0.48 v 0.31; P = .002) compared with BAL. However, complications were more common with lung biopsy (0.15 v 0.08; P = .006), and procedure-related mortality was four-fold higher for lung biopsy (0.0078) compared with BAL (0.0018). BAL may be the preferred diagnostic modality for the evaluation of potentially infectious pulmonary lesions because of lower complication and mortality rates; thus, choice of procedure depends on clinical suspicion of infection. Guidelines to promote consistency in the approach to the evaluation of lung infiltrates may improve clinical care of patients. © 2015 by American Society of Clinical Oncology.
    Journal of Clinical Oncology 01/2015; 33(5). · 17.88 Impact Factor
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    ABSTRACT: Early diagnosis and initiation of amphotericin B (AmB) for treatment of mucormycosis increases survival from approximately 40% to 80%. The central objective of a new study of the European Confederation of Medical Mycology (ECMM) and the International Society for Human and Animal Mycology (ISHAM) Zygomycosis Working Group is to improve the clinical and laboratory diagnosis of mucormycosis. The diagnostic tools generated from this study may help to significantly improve survival from mucormycosis worldwide. The study has three major objectives: to conduct a prospective international registration of patients with mucormycosis using a well-established global network of centres; to construct a predictive risk model for patients at risk for mucormycosis; and to establish an international archive of specimens of tissues, fluids, and organisms linked from the patients enrolled into the registry that will be used for development of leading edge molecular, proteomic, metabolic and antigenic systems for mucormycosis. © 2014 Blackwell Verlag GmbH.
    Mycoses 12/2014; 57 Suppl 3:2-7. · 1.81 Impact Factor
  • Infection Control and Hospital Epidemiology 11/2014; 35(11):1425-7. · 3.94 Impact Factor
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    ABSTRACT: Background: Colonization with methicillin-resistant Staphylococcus aureus(MRSA) is associated with development of recurrent skin and soft tissue infections (SSTI). Several decolonization strategies have been used to try to decrease the burden of MRSA colonization, but these have not been shown to decrease recurrent SSTI, perhaps related to transmission of MRSA colonization between household members. Methods: We conducted a three-arm non-blinded randomized controlled trial from November 1, 2011 to May 31, 2013 at five academic medical centers. Adults and children presenting to ambulatory care settings with acute community-onset MRSA SSTI (i.e. index cases), along with their household members, were eligible. Enrolled households were randomized to one of three intervention groups: 1) education on routine hygiene measures; 2) education plus unsupervised decolonization with intra-nasal mupirocin ointment and chlorhexidine gluconate body wash; 3) education plus supervised decolonization (i.e. daily phone call or text message reminders). The primary endpoint was time to termination of colonization in the index case. The decolonization arms were combined in the primary analysis. Intention to treat and per-protocol analyses were performed. Results: One hundred sixty-eight households were enrolled. Fifty-seven households were randomized to education alone, 54 to decolonization without supervision and 57 to supervised decolonization. Intention-to-treat analysis showed no significant difference in time to termination of colonization between the education-only and decolonization groups (log-rank test p-value=0.57). In per-protocol analysis, at least 50% compliance with the decolonization protocol was associated with more rapid clearance of colonization as compared to the group that included those with less than 50% compliance to decolonization or who received education alone (p=0.02). Conclusion: Households that were at least 50% compliant with an intra-nasal mupirocin and chlorhexidine body wash decolonization protocol achieved more rapid clearance of MRSA colonization. Further studies need to determine the threshold of compliance necessary to affect clinical outcomes and potential ways to improve compliance.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: In January 2011, an electronic health record (EHR) based auto-stop feature, facilitated by mandatory antimicrobial order end dates, was enabled at our institution as part of an established Antimicrobial Stewardship Program (ASP). Previously, restricted antimicrobial orders remained as current medications in the EHR after the ASP-approved length of therapy (typically 48 hours) was complete. However another approval was required for the pharmacy to dispense more medication. Following the auto-stop implementation, the order expired from the current medications list after completion of the approved length of therapy. Methods: Repeated cross-sectional study to assess the impact of auto-stop on clinical outcomes of hospitalized children. Data on patients discharged between 2/1/2009 and 1/31/13 were obtained from the Pediatric Health Information System, a database containing medication billing data. A sub-cohort of patients with bacteremia was also identified using microbiology laboratory data. Outcomes included all-cause in-hospital mortality, readmission within 14-days and 30 days of discharge, and length of stay. Model-based pre-post comparisons were standardized by patient and clinical characteristics and accounted for clustering by physician. Results: During the 4-year study period, 26300 patients received restricted antibacterials. In-hospital all-cause mortality, 14-day and 30-day readmission, and length of stay were not significantly different before and after implementation of the auto-stop in all patients or the sub-cohort of children with bacteremia (Table). Conclusion: Implementation of an EHR-based antimicrobial auto-stop feature did not significantly impact clinical outcomes in hospitalized children. Future studies should examine the effects of this EHR-based tool on antimicrobial use. Table. Standardized clinical outcomes for patients receiving restricted antibiotics All Patients (n=26300) Bacteremia Patients (n=1405) Pre Post p-value Pre Post p-value Standardized Rate (%) In-hospital all-cause mortality 2.0 1.9 0.358 8.0 6.8 0.315 Readmission in 14 days 7.4 7.5 0.778 6.2 4.8 0.294 Readmission in 30 days 15.4 16.4 0.057 17.4 17.2 0.947 Standardized Length of Stay (days) 11.7 12.0 0.183 44.7 47.6 0.350
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Patient-level review of adult clinical trial data concluded that echinocandin therapy for treatment of candidemia was associated with a decreased mortality rate. Limited data are available comparing options for systemic antifungal therapy in children. We compared the effectiveness of fungicidal versus fungistatic agents as definitive therapy for pediatric candidemia on 30-day all-cause mortality. Methods: All pediatric inpatients (> 6 months and <19 years of age) diagnosed with candidemia between 2000 and 2012 at the Children’s Hospital of Philadelphia were retrospectively identified. Clinical and laboratory data were abstracted using a structured data collection tool. Candidemic patients were included in the final data analysis if they received the same antifungal agent for two consecutive days following candidemia onset. Amphotericin products and echinocandins were categorized as fungicidal and fluconazole as fungistatic. A propensity score model was used to generate inverse probability weights for receiving a fungicidal agent. These inverse weights were included in a weighted logistic regression model to compare 30-day mortality in fungicidal versus fungistatic recipients. Results: Among 203 children with candidemia that received the same antifungal agent for two consecutive days after culture was known positive, 151 (74.4%) received either amphotericin (n = 134) or caspofungin (n = 17) and 52 (25.6%) received fluconazole. Overall, 18 (8.9%) patients died within 30 days. In the weighted logistic regression model there was no statistically significant difference in mortality between patients that started on a fungicidal agent as compared to fungistatic therapy (OR: 2.19, 95% CI: 0.42 to 11.48). Conclusion: In a propensity score weighted model, initiation of definitive therapy with a fungicidal agent did not result in a significant decrease in 30-day mortality. These data suggest that both fungicidal and fungistatic agents can be considered as definitive therapy for pediatric candidemia. The results should be interpreted with caution given the small sample size and resultant wide confidence intervals. Larger pediatric cohort studies are needed to further compare antifungal therapeutic options and outcomes.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Candidemia causes significant morbidity and mortality among hospitalized children. Prompt removal of a central venous catheter (CVC) is often recommended for adults with candidemia to decrease the likelihood of persistent and metastatic infection, but pediatric specific data are limited. We investigated the association of CVC retention and 30-day all cause mortality in a pediatric specific cohort. Methods: We performed a retrospective cohort study of inpatients (age 0 to <19 years) with candidemia at the Children’s Hospital of Philadelphia between 2000 and 2012 who had survived and retained their CVC at least one day beyond the blood culture being positive for yeast. A structured data collection instrument was used to retrieve clinical and laboratory data. A discrete time failure model was used to assess the association of CVC retention and 30-day all cause mortality. CVC exposure was not considered until the day after the culture was known to be positive for a Candida species. We adjusted for age and the complexity of clinical care prior to onset of candidemia. Complexity of clinical care included recent exposure to immune suppressive agents, recent requirement for parenteral nutrition, and admission to the ICU at time of blood culture. Results: Of the 436 incident cases of candidemia, 289 (64%) had a CVC in place at the time of blood culture and survived at least one day after candidemia onset. Among these 289 patients, 30 (10%) died within 30 days of candidemia diagnosis. CVC retention was significantly associated with an increased risk of death on a given day (OR: 2.53, 95% CI: 1.07 to 5.98). Conclusion: Retention of a CVC was associated with an increased risk of death after adjusting for age and complexity of care at candidemia onset. These results need to be interpreted with caution, as there is likely persistence of unmeasured confounding. However, given the negative association between catheter retention and death, our data suggest that early CVC removal should be strongly considered in pediatric patients with candidemia.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Candidemia is associated with significant morbidity and mortality and pediatric intensive care unit (PICU) patients with candidemia are at particular high risk for death. A clinical prediction rule for early detection of candidemia in the PICU was previously derived at a single center. Multi-center validation is necessary prior to routine application. Methods: Patients <19 years of age with candidemia were identified prospectively from six pediatric institutions (1/1/2005 - 12/31/2009). Cases were matched to two controls in the same PICU by incidence density sampling. Conditional logistic regression was performed to evaluate the association of candidemia with the previously derived predictor variables. Results: Ninety-six patients with candidemia were identified with a median age of 4 years (range 43 days to 18 years) and matched to similar controls. The proportion of predictors of candidemia for cases and controls varied significantly by study site (table) and only the presence of a central venous catheter was associated with candidemia (OR: 9.6; 95% CI: 3.4-27.3). Conclusion: Our multi-center study did not validate the previously derived prediction rule due to significant variability in predictors across hospitals and time. Consideration should be given to including biomarkers in future prediction rules.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: We completed a successful outpatient antimicrobial stewardship intervention combining education with prescribing audit and feedback across a large, pediatric primary care network. The intervention significantly reduced broad-spectrum antibiotic prescribing in intervention sites relative to controls. To assess durability of this intervention, we followed antibiotic prescribing across intervention and control sites for 18 months after termination of clinician audit and feedback. Methods: We conducted a cluster-randomized trial of outpatient antimicrobial stewardship within 18 community-based pediatric primary care practices using a common EHR. The intervention included clinician education with audit and feedback of antibiotic prescribing to children with sinusitis, streptococcal pharyngitis, and pneumonia. The primary outcome was broad-spectrum (off-guideline) antibiotic prescribing. Twelve months after initiating the intervention, we stopped providing antibiotic prescribing audit and feedback to providers in the intervention arm and extended our observation period for 18 months. Using a piecewise generalized linear model with knots at month 0 (intervention start) and 12 (end of audit and feedback), we modeled the trajectory of the log odds of prescribing between treatment and control practices standardized for patient-level covariates. Results: There were 1,259,938 office visits by 185,868 unique patients to 180 clinicians at 18 practices during the 50-month study period. During the 12-month intervention, the overall proportion of antibiotic prescriptions that were broad-spectrum decreased from 26.8% to 14.3% in the intervention group and from 28.4% to 22.6% in control practices, which was a statistically significant difference in trajectories between groups (p=0.01). Following termination of audit and feedback, however, broad-spectrum antibiotic prescribing reverted to near baseline levels for both the intervention group (28%) and control group (30%) (Figure). Conclusion: The initial benefits of an outpatient antimicrobial stewardship intervention were reversed after discontinuation of audit and feedback of clinician prescribing.
    JAMA The Journal of the American Medical Association 10/2014; · 30.39 Impact Factor
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    ABSTRACT: Background: In adult liver transplant recipients, candidemia is of significant concern in the post transplant period. Prophylaxis is recommended in adult high-risk patients, such as those with prolonged operative time, retransplantation or high-volume transfusion requirement. There are limited data on the incidence of candidemia in pediatric liver transplant recipients. We aimed to describe the incidence of candidemia in the 30 days post-liver transplant and frequency of perioperative antifungal therapy at a large pediatric institution. Methods: All liver transplant patients from 2000 to 2011 at the Children’s Hospital of Philadelphia were retrospectively reviewed. Data on perioperative antifungal therapy and blood culture results were collected. Patients were followed for 30 days post-transplant to evaluate for the onset of candidemia. Results: 134 patients underwent liver transplantation over the 12-year study period. Candidemia was diagnosed in the first 30 days post transplant in 10 (7.1%) patients. Rates of candidemia varied with each three-year period with the lowest rate being in the last three years of the study (Table). Perioperative antifungal therapy was infrequently used. Rates increased between the periods of 2000 to 2002 and 2003 to 2005 but then remained stable (Table). Conclusion: The incidence of candidemia among pediatric liver transplant patients appears to have decreased over time in this single center cohort. The overall rate of perioperative antifungal therapy remained low and did not increase in accordance with the decrease in candidemia. Further investigation in multicenter cohorts is warranted to determine sources for decreasing candidemia rates such as improved infection control practices and operating room factors. Table. Rates of candidemia and perioperative antifungal therapy by 3 year time periods Liver transplant patients Candidemia (n, %) Perioperative antifungal therapy (n, %) 2000-02 30 2, 6.7% 2, 6.7% 2003-05 24 4, 16.6% 3, 12.5% 2006-08 35 3, 8.6% 4, 11.4% 2009-11 45 1, 2.2% 5, 11.1% Total 134 10, 7.4% 14, 10.4%
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Antibiotic exposure has been shown to promote weight gain in livestock and has been associated with increased adiposity and altered metabolism in experimental animal models, mediated by alterations in the gut microbiome. Infancy and early childhood represent both an influential period of growth trajectory and a time during which antibiotic exposure is common and often inappropriate. Therefore, we sought to determine the impact of real world, early life antibiotic exposures on childhood weight gain. Methods: A longitudinal, retrospective study was conducted using a socioeconomically and racially diverse pediatric healthcare network serving > 200,000 children at 31 practices. We included children born between 2001 and 2011 who presented for a preventive health visit in the first 14 days of life and had at least 2 additional visits in the first year. We excluded children born < 35 weeks gestational age; birthweight <2000 grams or below 5% for gestational age; with chronic medical conditions, prophylactic antibiotic use, or frequent steroid use. Exposures included all systemic antibiotic exposures in the first 6 months of life. The primary outcome was weight through age 8, standardized to WHO/CDC reference populations. A longitudinal mixed effects model was used to assess the association between standardized weight and age by antibiotic exposure interaction, adjusting for sex, race, insurance type, birthweight, preventive health care compliance, household size, birth year, baseline height and primary care practice site. A second analysis, including sets of twins where only one twin had early antibiotic exposure, used a longitudinal mixed effects model to assess the association between paired weight difference and age, adjusting for differences in sex, birthweight, and baseline height. Results: Of 38,756 children included in the analysis, 5,312 (13.7%) received antibiotics in the first 6 months of life. After adjustment for clinical and demographic variables, antibiotic exposure was associated with a decrease of 0.03 in weight z-score per year (p<0.001). Of 47 sets of twins discordant in early antibiotic use, antibiotic exposure was not associated with a change in weight (p=0.59). Conclusion: Using data from a large birth cohort, infant antibiotic exposure did not increase early childhood weight gain.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Factors associated with duration of methicillin-resistant Staphylococcus aureus (MRSA) colonization in the community setting are unknown. The objective of this study was to assess the duration of MRSA colonization and factors associated with termination of colonization among subjects presenting with MRSA acute skin and soft tissue infection (SSTI). Methods: A prospective cohort study was conducted from January 1, 2010 through December 31, 2012 at five academic medical centers. Patients presenting with acute SSTI (i.e. index cases) and their household members were followed with serial surveillance cultures for MRSA colonization every two weeks for six months. Duration of colonization was calculated using a Kaplan-Meier estimate. A Cox proportional hazards regression model was developed to identify factors associated with termination of colonization with MRSA. Results: Median duration of MRSA colonization among index cases was 36 days (inter-quartile range [IQR] 21-91 days). Fifty-three index cases (19.4%) remained colonized with MRSA at the end of the study period. Factors associated with more rapid termination of MRSA colonization included: treatment of the MRSA SSTI with clindamycin (adjusted hazard ratio (HR), 1.55; 95% confidence interval (CI), 1.16-2.07; P=0.003) and non-white race (HR, 1.43; 95% CI, 1.08-1.89; P=0.01). Neither presence of family members under the age of 18 nor MRSA colonization in household members at study entry were associated with duration of MRSA colonization (HR, 1.17; 95% CI, 0.87-1.56; P=0.30 and HR, 0.91 95% CI, 0.74-1.10; P=0.33, respectively). Conclusion: Among individuals with an acute MRSA SSTI, duration of colonization with MRSA was shorter than has been reported in other studies, due perhaps to a more systematic sampling approach; however, approximately 20% of subjects remained colonized at the end of six months. The association between clindamycin and shorter duration of MRSA colonization may indicate a unique role for this antibiotic in treatment of MRSA SSTI. Interestingly, presence of colonization in a household member was not significantly associated with duration of colonization. Future studies of household decolonization should look at the impact of this on duration of colonization in the index case.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Hand hygiene (HH) is the most effective way to prevent health care-associated infections and the spread of antimicrobial-resistant pathogens. The aim of our study was to assess the existing HH resources and current HH practices at 2 hospitals in Athens, Greece.
    The Pediatric Infectious Disease Journal 10/2014; 33(10):e247-51. · 3.14 Impact Factor
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    ABSTRACT: Objective. Inappropriate antibiotic prescribing commonly occurs in pediatric outpatients with acute respiratory tract infections. Antimicrobial stewardship programs are recommended for use in the hospital, but less is known about whether and how they will work in the ambulatory setting. Following a successful cluster-randomized trial to improve prescribing for common acute respiratory tract infections using education plus audit and feedback in a large, pediatric primary care network, we sought to explore the perceptions of the intervention and antibiotic overuse among participating clinicians. Methods. We conducted a qualitative study using semistructured interviews with 24 pediatricians from 6 primary care practices who participated in an outpatient antimicrobial stewardship intervention. All interviews were transcribed and analyzed using a modified grounded theory approach. Results. Deep skepticism of the audit and feedback reports emerged. Respondents ignored reports or expressed distrust about them. One respondent admitted to gaming behavior. When asked about antibiotic overuse, respondents recognized it as a problem, but they believed it was driven by the behaviors of nonpediatric physicians. Parent pressure for antibiotics was identified by all respondents as a major barrier to the more judicious use of antibiotics. Respondents reported that they sometimes "caved" to parent pressure for social reasons. Conclusions. To improve the effectiveness and sustainability of outpatient antimicrobial stewardship, it is critical to boost the credibility of audit data, engage primary care pediatricians in recognizing that their behavior contributes to antibiotic overuse, and address parent pressure to prescribe antibiotics.
    Infection Control and Hospital Epidemiology 10/2014; 35(S3):S69-S78. · 3.94 Impact Factor
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    ABSTRACT: Objective. To compare practice patterns regarding the diagnosis and management of streptococcal pharyngitis across pediatric primary care practices. Design. Retrospective cohort study. Setting. All encounters to 25 pediatric primary care practices sharing an electronic health record. Methods. Streptococcal pharyngitis was defined by an International Classification of Diseases, Ninth Revision code for acute pharyngitis, positive laboratory test, antibiotic prescription, and absence of an alternative bacterial infection. Logistic regression models standardizing for patient-level characteristics were used to compare diagnosis, testing, and broad-spectrum antibiotic treatment for children with pharyngitis across practices. Fixed-effects models and likelihood ratio tests were conducted to analyze within-practice variation. Results. Of 399,793 acute encounters in 1 calendar year, there were 52,658 diagnoses of acute pharyngitis, including 12,445 diagnoses of streptococcal pharyngitis. After excluding encounters by patients with chronic conditions and standardizing for age, sex, insurance type, and race, there was significant variability across and within practices in the diagnosis and testing for streptococcal pharyngitis. Excluding patients with antibiotic allergies or prior antibiotic use, off-guideline antibiotic prescribing for confirmed group A streptococcal pharyngitis ranged from 1% to 33% across practices (P < .001). At the clinician level, 13 of 25 sites demonstrated significant within-practice variability in off-guideline antibiotic prescribing (P ≤ .05). Only 18 of the 222 clinicians in the network accounted for half of all off-guideline antibiotic prescribing. Conclusions. Significant variability in the diagnosis and treatment of pharyngitis exists across and within pediatric practices, which cannot be explained by relevant clinical or demographic factors. Our data support clinician-targeted interventions to improve adherence to prescribing guidelines for this common condition.
    Infection Control and Hospital Epidemiology 10/2014; 35(S3):S79-S85. · 3.94 Impact Factor
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    ABSTRACT: (See the commentary by Van Schooneveld and Rupp, on pages 1100-1102 .) Objective. Although prior authorization and prospective audit with feedback are both effective antimicrobial stewardship program (ASP) strategies, the relative impact of these approaches remains unclear. We compared these core ASP strategies at an academic medical center. Design. Quasi-experimental study. Methods. We compared antimicrobial use during the 24 months before and after implementation of an ASP strategy change. The ASP used prior authorization alone during the preintervention period, June 2007 through May 2009. In June 2009, many antimicrobials were unrestricted and prospective audit was implemented for cefepime, piperacillin/tazobactam, and vancomycin, marking the start of the postintervention period, July 2009 through June 2011. All adult inpatients who received more than or equal to 1 dose of an antimicrobial were included. The primary end point was antimicrobial consumption in days of therapy per 1,000 patient-days (DOT/1,000-PD). Secondary end points included length of stay (LOS). Results. In total, 55,336 patients were included (29,660 preintervention and 25,676 postintervention). During the preintervention period, both total systemic antimicrobial use (-9.75 DOT/1,000-PD per month) and broad-spectrum anti-gram-negative antimicrobial use (-4.00 DOT/1,000-PD) declined. After the introduction of prospective audit with feedback, however, both total antimicrobial use (+9.65 DOT/1,000-PD per month; P < .001) and broad-spectrum anti-gram-negative antimicrobial use (+4.80 DOT/1,000-PD per month; P < .001) increased significantly. Use of cefepime and piperacillin/tazobactam both significantly increased after the intervention (P = .03). Hospital LOS and LOS after first antimicrobial dose also significantly increased after the intervention (P = .016 and .004, respectively). Conclusions. Significant increases in antimicrobial consumption and LOS were observed after the change in ASP strategy.
    Infection Control and Hospital Epidemiology 09/2014; 35(9):1092-1099. · 3.94 Impact Factor
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    ABSTRACT: Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) has emerged as the most common cause of skin and soft-tissue infections (SSTI) in the United States. A nearly three-fold increase in SSTI visit rates had been documented in the nation's emergency departments (ED). The objective of this study was to determine characteristics associated with ED performance of incision and drainage (I+D) and use of adjuvant antibiotics in the management of skin and soft tissue infections (SSTI).
    The western journal of emergency medicine 07/2014; 15(4):491-8.

Publication Stats

5k Citations
810.44 Total Impact Points


  • 2003–2015
    • University of Pennsylvania
      • • Division of Infectious Disease
      • • Center for Clinical Epidemiology and Biostatistics
      Filadelfia, Pennsylvania, United States
    • University of Nebraska at Omaha
      • Department of Pediatrics
      Omaha, NE, United States
  • 2003–2014
    • The Children's Hospital of Philadelphia
      • • Department of Pediatrics
      • • Division of Infectious Diseases
      • • Division of General Pediatrics
      Philadelphia, Pennsylvania, United States
  • 2013
    • George Washington University
      • Children's National Medical Center
      Washington, D. C., DC, United States
  • 2010–2013
    • Case Western Reserve University
      • • Division of Hematology and Oncology
      • • Rainbow Babies and Children's Hospital
      Cleveland, OH, United States
  • 2012
    • Centre Hospitalier Universitaire de Bordeaux
      Burdeos, Aquitaine, France
    • Seattle Children's Hospital
      Seattle, Washington, United States
  • 2009–2012
    • Aristotle University of Thessaloniki
      • Department of Pediatrics II
      Saloníki, Central Macedonia, Greece
    • Christiana Care Health System
      Wilmington, Delaware, United States
    • University of Washington Seattle
      Seattle, Washington, United States
    • Statens Serum Institut
      København, Capital Region, Denmark
    • University Hospital Frankfurt
      Frankfurt, Hesse, Germany
  • 2005–2012
    • Hospital of the University of Pennsylvania
      • • Department of Pediatrics
      • • Department of Biostatistics and Epidemiology
      Philadelphia, Pennsylvania, United States
  • 2011
    • University of California, San Francisco
      • Department of Pediatrics
      San Francisco, CA, United States
  • 2009–2010
    • Columbia University
      • Department of Pediatrics
      New York City, NY, United States
  • 2008
    • National Institutes of Health
      • Department of Laboratory Medicine
      Bethesda, MD, United States
    • Duke University Medical Center
      Durham, North Carolina, United States
    • National Cancer Institute (USA)
      • Pediatric Oncology Branch
      Maryland, United States
  • 2006
    • University of Arkansas at Little Rock
      Little Rock, Arkansas, United States