evaluation of appropriate antibiotic usage in...
TRANSCRIPT
Methods!
Study Design: Retrospective chart review!!Patient Population: Pediatric patients admitted to the 5th floor of UAMC Diamond Children’s Medical Center between January 22, 2013 and April 4, 2013.!!Inclusion Criteria:!o Positive chest x-ray for pneumonia!o Inpatient order for antibiotic therapy!o Age > 3 months and < 18 years!!Exclusion Criteria: !o Aspiration pneumonia !o History of antibiotics for the treatment of pneumonia within the previous
month!o Cystic fibrosis !o Viral pneumonia!!Procedures: !Data Collection: !o Electronic medical records of patients admitted to the 5th floor of UAMC
Diamond Children’s Medical Center were evaluated. !o For patients who met the inclusion criteria, the following information was
collected: sex, allergies, weight, age, antibiotic prescribed (date and dose), history of lung disease, chest x-ray results, and history of readmission due to pneumonia.!
o Pre-intervention data collection was conducted January 22, 2013 to February 14, 2013.!
o Post-intervention data collection was conducted March 7, 2013 to April 4, 2013.!
!Intervention: !o A brief presentation on the pre-intervention results and the IDSA pediatric
CAP guidelines (accounting for local resistance patterns and hospital formulary) was given to pediatric medical residents at teaching day on March 6, 2013.!
o Pediatric residents were provided with a laminated reference card containing guideline recommendations on antibiotic selection and dosing to attach to their lanyards [Figure 1].!
!Statistical Methods: Chi-square test, a priori alpha < 0.05!
Figure 1. Pediatric Pneumonia Guidelines Reference Card Intervention!
Background and Introduction!
Objectives!
Background:!!
o In 2011, the Infectious Diseases Society of America (IDSA) released clinical practice guidelines for the treatment of Community-Acquired Pneumonia (CAP) in pediatric patients.1 These guidelines recommend ampicillin as the preferred parenteral therapy and amoxicillin as the preferred oral therapy for the treatment of non-complicated pneumonia due to Streptococcus pneumoniae.!
o Adherence to evidence-based guidelines has been shown to decrease morbidity and mortality.2!
o This project focuses on the prescribing portion of the medication use process at The University of Arizona Medical Center (UAMC)-Diamond Children’s. UAMC is a teaching hospital in Tucson, Arizona and Diamond Children’s Medical Center treats pediatric patients with a variety of conditions. !
!Supportive Research:!!
o Newman et al. found that implementation of clinical practice guidelines and an antimicrobial stewardship program in a children’s hospital led to a significant increase in use of ampicillin for the treatment of uncomplicated CAP and speculated that this has the potential to minimize the development of resistant strains of bacteria.3!
o Smith et al. analyzed the importance of education and the use of guidelines for CAP in a pediatric setting and found significant changes in the prescription patterns after the creation of an antimicrobial stewardship task force and the release of the guidelines.4 !
o McCabe et al. examined the use of CAP guidelines in adults and discovered that the implementation resulted in a decrease in length of stay, duration of parenteral treatment, and in-hospital deaths.5!
o Dean et al. discovered an association between 30 day mortality, length of hospital stay, and readmission rate in CAP inpatient treatments when guidelines were appropriately used.2!
!Goal:!!
o It is important to investigate prescribing patterns and assess adherence to guideline recommendations because this could improve patient outcomes and decrease antibiotic resistance.!
o Examine prescribing patterns for the treatment of CAP in pediatric patients in comparison to the IDSA treatment guidelines.!
!
o Assess the effect of a brief educational intervention on prescribing practices.!
o The pneumonia season time frame limited the total number of collected cases. !o The lack of patient outcomes measurements in comparison to antibiotic
prescribed.!o The inability to measure the effects of antibiotic resistance in relation to
guideline adherence.!o The ability to distinguish between antibiotics prescribed in the emergency
department versus the pediatric floor based on electronic medical records.!
Evaluation of Appropriate Antibiotic Usage in Community-Acquired Pneumonia! in Hospitalized Pediatric Patients: A Quality Improvement Project!
Sarah Deitering1, Emily Kilber1, Amy Nguyen1, Elaine Truong1, and Megan Brandon, PharmD2!
1. University of Arizona College of Pharmacy, 2. University of Arizona Medical Center-Diamond Children’s!
Conclusion and Discussion!
Recommendations & Future Research!
References!
Results!
Limitations!
o Expand this quality improvement project to other locations in the hospital, including the emergency department.!
!
o Examine the relationship between patient outcomes (e.g. length of stay and/or length of infusion therapy) and antibiotic prescribed. !
1. Bradley JS, Byington CL, Shah SS et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the pediatric infectious diseases society and the infectious diseases society of america. Clin Infect Dis. 2011;53(7):e25-76.!2. Dean NC, Bateman KA, Donnelly SM et al. Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest. 2006;130(3):794-9.!3. Newman RE, Hedican EB, Herigon JC et al. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics. 2012;129(3):e597-604.!4. Smith MJ, Kong M, Cambon A et al. Effectiveness of antimicrobial guidelines for community-acquired pneumonia in children. Pediatrics. 2012;129(5):e1326-33.!5. McCabe C, Kirchner C, Zhang H et al. Guideline-concordant therapy and reduced mortality and length of stay in adults with community-acquired pneumonia: Playing by the rules. Arch Intern Med. 2009;169(16):1525-31.!6. Preacher, KJ. Calculation for the chi-square test: An interactive calculation tool for chi-square tests of goodness of fit and independence [Computer software]. Retrieved at http://quantpsy.org. Accessed 15 Apr 2013. !
Table 1. Patient Characteristics (n=45)!Pre-Intervention! Post-Intervention!
Age Range! 6 months – 10 years! 5 months – 15 years!Mean Age! 3.3 years! 4.0 years!Median Age! 3.0 years! 1.8 years!Number of Males! 18! 12!Number of Females! 6! 9!Total Number of Patients! 24! 21!
Table 2. Antibiotic Usage in Pediatric Pneumonia Patients (n=81)!
Antibiotic!Pre-Intervention! Post-Intervention!
n (%)! n (%)!
amoxicillin! 18 (41)! 14 (38)!
ceftriaxone! 10 (23)! 3 (8)!
azithromycin! 5 (11)! 7 (19)!
other! 5 (11)! 0 (0)!
ampicillin! 3 (7)! 12 (32)*!
Augmentin! 2 (5)! 0 (0)!
cefdinir! 1 (2)! 1 (3)!
Total! 44 (100)! 37 (100)!* ampicillin P value = 0.015!
41%!
23%!
11%! 11%!
7%!5%!
2%!
38%!
8%!
19%!
0%!
32%!
0%!
3%!
0%!
5%!
10%!
15%!
20%!
25%!
30%!
35%!
40%!
45%!
PER
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F A
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PRES
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IBED!
ANTIBIOTIC!
PRE-INTERVENTION!POST-INTERVENTION!
Figure 2. Antibiotic Usage in Pediatric Pneumonia Patients (n=81)!
For more information, please contact:!Sarah Deitering: [email protected]!Emily Kilber: [email protected]!Amy Nguyen: [email protected] !Elaine Truong: [email protected]!Megan Brandon: [email protected]!
Results!o Over a time period of 72 days, the medical records of 45 pediatric pneumonia
patients between the ages of 5 months and 15 years were analyzed [Table 1].!o Forty-four antibiotic treatments were recorded during the pre-intervention
period and 37 were recorded during the post-intervention period [Table 2].!o There was a statistically significant difference between pre- and post-
intervention ampicillin prescribing (P=0.015) [Table 2].!
o Adherence to the IDSA pediatric CAP guidelines for parenteral therapy improved.!• After the intervention, there was a statistically significant 5-fold increase
in ampicillin prescribing. !• Additionally, there was a 3-fold decrease in ceftriaxone prescribing.!
o Adherence to the IDSA CAP guidelines for amoxicillin was appropriate prior to the intervention and remained similar during the post-intervention period. !
o Educational interventions improve adherence and may improve outcomes.!