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Antibiotics for Children: When Less Is More

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Medical News & Perspectives

Antibiotics for Children: When Less Is More Anita Slomski, MA

W

hen Jason Newland, MD, MEd, launched a survey of freestanding children’s hospitals 3 years ago, he found that only 16 of 42 hospitals supported a formal antimicrobial stewardship program (ASP). But since then the number likely has increased. “There’s definitely more interest in them now,” said Newland, medical director of patient safety and reliability at Children’s Mercy Hospital in Kansas City, Missouri. He expects that President Obama’s recent executive order outlining a national strategy to combat antibiotic-resistant bacteria will further drive the development of pediatric ASPs (http://1.usa.gov/ZrXYwP). Another driver may be Newland’s recent research findings, which showed that stopping antibiotics or shortening their duration not only doesn’t harm hospitalized children, it sends them home earlier and keeps them from being readmitted (http: //bit.ly/1rDWENr). The findings may not surprise infectious disease specialists at adult hospitals, where ASPs have long been established and studies have demonstrated lower rates of Clostridium difficile infection, reduced mortality from sepsis, and more consults to infectious disease teams, leading to fewer treatment failures, according to David Haslam, MD, director of the ASP at Cincinnati Children’s Hospital Medical Center.

“Multidrug-resistant organisms have been present in adult hospitals longer than in children’s hospitals, and adults have longer lengths of stay and tend to get more aggressive antibiotic therapy,” prompting earlier attempts by adult hospitals to reduce excessive antibiotic use, Haslam said.

Most Frequent Advice: Stop the Antimicrobial The new 5-year study by Newland et al, presented recently to infectious disease specialists at IDWeek in Philadelphia, included 7051 children whose antibiotic use was reviewed by a physician and pharmacist (http://bit.ly/1rDWENr). Pediatric patients in intensive care, neonatal intensive care, and the hematology/oncology unit were excluded from the study. For 17% of the patients, a recommendation was issued to alter antibiotic use. “The most common recommendation by far was to stop the antimicrobial,” Newland said. Other recommendations included discontinuing 1 of 2 or more antibiotics, changing the dose, shortening the duration, or consulting an infectious disease specialist. In the study, 18% of physicians or other providers rejected the recommendations and continued giving their patients the antibiotics they had prescribed. Patients whose

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health care professionals didn’t follow those recommendations had a 3.5% readmission rate within 30 days and an 82-hour average length of stay. But when physicians and other providers did follow the guidance to stop or change an antimicrobial, their patients had no readmissions and a 68-hour average length of stay. Inappropriate antibiotic use most likely occurred in patients receiving ceftriaxone/ cefotaxime (62%), vancomycin (11%), and meropenem (5%). The most common diagnoses that triggered a recommendation to change antibiotic use were pneumonia (22%), urinary tract infection (19%), and presumed sepsis (9%). Not all sick children benefited equally from ASP interventions. When Newland and colleagues stratified the data into 3 groups—children admitted to surgical floors, those admitted to medical units, and those with complex chronic conditions—he found that readmission rates differed substantially only in children without chronic diseases on medical units whose physicians and other providers followed stewardship recommendations compared with those who did not. The ASP guidance was not associated with surgical patients’ readmission rates and produced only marginal improvement for children with chronic illnesses. Newland speculated that the readmission rates JAMA November 26, 2014 Volume 312, Number 20

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for those children were skewed because the study included only 150 children in each group. Nor did the study demonstrate an overall significant difference in average length of stay. “We had hoped to show that more kids were leaving the hospital sooner because they had stopped an antibiotic earlier or their physicians had switched them from an intravenous antibiotic to an oral one. But we didn’t see that,” Newland said.

Outcomes Data a Crucial First Step Regardless of the size of the effect, any improvement in clinical outcomes from a stewardship program is “a great first step toward getting physician buy-in,” said Jeffrey Gerber, MD, PhD, director of the ASP at the Children’s Hospital of Philadelphia (CHOP). “This study will go a long way in helping clinicians understand that recommendations to reduce or optimize antimicrobial use do not harm patients,” he said. Reducing antimicrobial use can also be the right decision financially. A 4-month study of the ASP at CHOP in 2008 found a savings of $50 090—which translates into $150 270 annually—in drug acquisition costs alone, even though the program had already been in existence for more than 15 years (Metjian TA et al. Pediatr Infect Dis J. 2008;27[2]:106-111). “That’s a very conservative number because it doesn’t take into account the cost of administering the drugs, the prolonged length of stay from adverse drug effects, or the potential for developing antimicrobialresistant infections,” said Gerber. Newland’s next step is to figure out why some physicians discount ASP recommendations. A review of hospitalists’ responses at Newland’s hospital, Children’s Mercy,

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Development of pediatric antimicrobial stewardship programs could help combat the emergence of antibiotic-resistant bacteria.

showed they were most likely to reject the recommendation to obtain an infectious disease consult, which might be triggered when a patient’s care is exceedingly complex or will require follow-up with an infectious disease specialist anyway, as in conditions such as complicated pneumonia, osteomyelitis, or endocarditis. “Our program works best when we try to collaborate instead of becoming the dictators of antibiotics, which means we have to understand why providers are disagreeing with our recommendations,” said Newland. In some cases, lack of solid evidence for stopping a particular antibiotic may lead to disagreements, Newland acknowledged.

For other physicians, “no” is more of a knee-jerk than an evidence-based decision, he added. Two years ago, Children’s Mercy’s ASP surveyed physicians’ attitudes about its work, discovering that 10% of providers felt that the recommendations challenged their autonomy, while another 3% admitted they felt threatened by the program. In time, however, the number of physicians who resist an ASP will be fewer, Newland said. “The newer generation of providers doesn’t view physician autonomy as such a big deal; they’re used to using guidelines and in collaborating,” he said. As for the threatened 3%: “That’s a hard feeling, but I can live with that.”

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Antibiotics for children: when less is more.

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