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Clin Res Infect Dis. Author manuscript; available in PMC 2015 April 13. Published in final edited form as: Clin Res Infect Dis. 2015 January 10; 2(1): .
Guideline-concordant antibiotic prescribing for pediatric outpatients with otitis media, community-acquired pneumonia, and skin and soft tissue infections in a large multispecialty healthcare system Ezzeldin A. Saleh1,*, Darrell R. Schroeder2, Andrew C. Hanson2, and Ritu Banerjee3
Author Manuscript
1Department
of Pediatrics, Division of Pediatric Infectious Diseases, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA
2Division
of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA 3Department
of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
Abstract
Author Manuscript
Antibiotics are commonly prescribed in pediatric outpatient settings; however, efforts to decrease inappropriate use have largely focused on inpatients. We obtained baseline metrics to identify conditions that may benefit from establishment of outpatient antimicrobial stewardship interventions (ASP). We evaluated rates and appropriateness of antibiotic prescribing for children with acute otitis media (AOM), community acquired pneumonia (CAP), and skin and soft tissue infections (SSTI) in ambulatory settings within a large healthcare system in the US Midwest. We retrospectively reviewed 77,821 visits and associated diagnostic codes for children less than 17 years seen in ambulatory settings within our health system from August 1, 2009 to July 31, 2010. We measured rates of antibiotic prescribing by location, provider type, patient age, and diagnosis, and assessed concordance with treatment guidelines for AOM, CAP, and SSTI. AOM, CAP, and SSTI comprised about 1/3 of all infections in the study population. Antibiotics were prescribed in 14,543 (18.7%) visits. Antibiotic prescribing rates were 1.1 to 1.2 times higher among Emergency Room (ER) providers compared to Pediatricians and Family Physicians. Antibiotics prescribed for AOM and SSTI were concordant with guidelines in approximately 97% of cases. In contrast, 47% of antibiotics prescribed for treatment of CAP in children < 5 years old were macrolides, which are not recommended first line therapy for CAP in this age group. Antibiotic prescribing for pediatric outpatients within our health system is not guideline-concordant for treatment of CAP.
Author Manuscript
Keywords Pediatrics; Antimicrobial stewardship; Otitis Media; Pneumonia; Skin and soft tissue infections
*
Corresponding author: Ezzeldin A. Saleh, M.B.B.S, Department of Pediatrics, Division of Pediatric Infectious Diseases, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA; Tel: 919-684-6335; Fax: 919-668-4859; [email protected]. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH.
Saleh et al.
Page 2
Author Manuscript
Introduction Antibiotics are the most commonly prescribed medications to children across all age groups. One fifth of all pediatric ambulatory visits result in an antibiotic prescription [1]. Despite an overall decline in antibiotic prescribing for US children [2,3] inappropriate use of expensive broad-spectrum antibiotics is rising [4], which substantially increases health costs, promotes bacterial resistance, and contributes to increasing rates of antibiotic-associated adverse effects. Outpatient antibiotic overuse has been correlated with higher rates of antibioticresistant pathogens [5,6].
Author Manuscript
In an effort to combat the emergence of drug-resistance, the Infectious Diseases Society of America (IDSA) published guidelines for developing antimicrobial stewardship programs (ASPs). ASPs are coordinated interventions designed to measure and improve the appropriate use of antibiotics, with goals of improving clinical outcomes, minimizing adverse events, limiting emergence of drug-resistance and reducing costs [7]. Development and implementation of clinical pathways for management of common infections is an integral part of ASPs. Accordingly, clinical practice guidelines have been developed for management of common infections including AOM [8], CAP [9], and a common cause of skin and soft tissue infections, methicillin-resistant Staphylococcus aureus infections (MRSA)[10]. Notably, both AOM and pediatric CAP guidelines emphasize the use of narrow-spectrum antibiotics as first line therapy for these conditions [8,9,11,12].
Author Manuscript
Despite increasing data about inpatient pediatric ASPs, relatively few studies describe the effectiveness of ASPs in pediatric ambulatory settings [13,14]. Further research is needed to describe antibiotic use in community settings and design and implement targeted interventions that optimize antibiotic use among outpatients. The objective of this study was to evaluate the rates and appropriateness of outpatient antibiotic prescribing for children with three common infectious diseases, AOM, CAP and SSTI, in order to identify areas for outpatient stewardship interventions.
Materials and Methods Study Design and Setting
Author Manuscript
We performed a retrospective analysis of ambulatory pediatric visits within Franciscan Healthcare-Mayo Clinic Health System (FH-MCHS), which includes locations in western Wisconsin, eastern Minnesota and northeastern Iowa. FHS-MCHS employs 92 providers: 7 pediatricians, 56 family medicine physicians, 15 family medicine physician assistants and nurse practitioners, 13 ER and urgent care physicians, and 1 urgent care physician assistant. This study was approved by the FH-MCHS and Mayo Clinic institutional review boards. We abstracted patient age, encounter provider and location, and antibiotics prescribed from the electronic medical records (EMR). We excluded topical, antiviral and anti-parasitic antimicrobials. Diagnosis codes were extracted from the ambulatory billing claim system that uses the International Classification of Diseases, Ninth Revision (ICD-9) codes. These data were integrated with the EMR encounter before final analysis using Statistical Analysis
Clin Res Infect Dis. Author manuscript; available in PMC 2015 April 13.
Saleh et al.
Page 3
Author Manuscript
System software (SAS). We excluded inpatient hospital visits, subspecialty and nurse visits, and diagnostic codes for procedures and immunizations. Infection-related diagnostic codes were classified into four categories: AOM, CAP, SSTI, and other infections. Appropriate antibiotics for each indication were defined as those listed as first or second line therapy in published treatment guidelines [8–10]. For AOM treatment, penicillin, amoxicillin, and amoxicillin-clavulanate were considered first line agents, while macrolides, cephalosporins, tetracyclines, and clindamycin were considered second line agents. For CAP, penicillin or amoxicillin were considered first line treatments, as were macrolides in children >5 years, while amoxicillin-clavulanate and second or third generation cephalosporins (in case of penicillin allergy) were considered second line or alternative treatments. For SSTI, we were not able to differentiate purulent lesions from non-purulent lesions; therefore, in accordance with published guidelines [15] we considered agents with activity against either staphylococci or streptococci as first-line therapy: trimethoprim-sulfamethoxazole, clindamycin, doxycycline, minocycline, penicillin, amoxicillin and first generation cephalosporins. Amoxicillin-clavulanate was considered a second line agent for SSTI.
Author Manuscript
Study population We included all children ≤17 years, seen at the Franciscan Healthcare - Mayo Clinic Health System (FH-MCHS) from August 1, 2009 until July 31, 2010. Statistical Analysis
Author Manuscript
Visit rates for infections were calculated for each of the 4 categories (AOM, CAP, SSTI, and other) and expressed as the number of visits with the given diagnosis per 1,000 patient visits. Visit rates are presented using point estimates and 95% confidence intervals and compared across provider types using the Chi-Square test. Of patients diagnosed with an infection, the percentage prescribed antibiotics was calculated overall and also according to patient age and provider type. Prescription percentages are compared across groups using the ChiSquare test. P-values less than 0.05 were considered significant.
Results and Discussion Results
Author Manuscript
Approximately 22,576 children were evaluated during 88,887 visits. We excluded 11,066 (12.4%) visits and 3,350 (18%) medication orders, because of mismatching identifiers or visit dates. Among the 77,821 visits included in the study, antibacterials were prescribed in 14,543 (18.7 %). Patient volume varied widely among the various clinic locations, ranging from 1,967 (2%) to 21,953 (28%). Most patients were seen by providers in Family Medicine (63%), followed by Pediatrics (27%), and Emergency/Urgent care (10%). Across all sites, 27,298 visits (35%) resulted in infection-related diagnoses. The proportion of all infectionrelated diagnoses was 27.3% for AOM, 3.7% for SSTI, and 3.4% for CAP. Visit rates and antibiotic prescription rates for AOM, SSTI, and CAP differed significantly across the three provider types (Table 1). For all three diagnoses, visit rates and antibiotic prescription rates were greater in the ER compared to Family Medicine and Pediatric clinics (Table 1).
Clin Res Infect Dis. Author manuscript; available in PMC 2015 April 13.
Saleh et al.
Page 4
Author Manuscript
Antimicrobials were prescribed more frequently in patients with AOM compared to CAP or SSTI (79.5%, 61.3% and 69.3% for AOM, CAP and SSTI respectively; p
Clin Res Infect Dis. Author manuscript; available in PMC 2015 April 13. Published in final edited form as: Clin Res Infect Dis. 2015 January 10; 2(1): .
Guideline-concordant antibiotic prescribing for pediatric outpatients with otitis media, community-acquired pneumonia, and skin and soft tissue infections in a large multispecialty healthcare system Ezzeldin A. Saleh1,*, Darrell R. Schroeder2, Andrew C. Hanson2, and Ritu Banerjee3
Author Manuscript
1Department
of Pediatrics, Division of Pediatric Infectious Diseases, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA
2Division
of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA 3Department
of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
Abstract
Author Manuscript
Antibiotics are commonly prescribed in pediatric outpatient settings; however, efforts to decrease inappropriate use have largely focused on inpatients. We obtained baseline metrics to identify conditions that may benefit from establishment of outpatient antimicrobial stewardship interventions (ASP). We evaluated rates and appropriateness of antibiotic prescribing for children with acute otitis media (AOM), community acquired pneumonia (CAP), and skin and soft tissue infections (SSTI) in ambulatory settings within a large healthcare system in the US Midwest. We retrospectively reviewed 77,821 visits and associated diagnostic codes for children less than 17 years seen in ambulatory settings within our health system from August 1, 2009 to July 31, 2010. We measured rates of antibiotic prescribing by location, provider type, patient age, and diagnosis, and assessed concordance with treatment guidelines for AOM, CAP, and SSTI. AOM, CAP, and SSTI comprised about 1/3 of all infections in the study population. Antibiotics were prescribed in 14,543 (18.7%) visits. Antibiotic prescribing rates were 1.1 to 1.2 times higher among Emergency Room (ER) providers compared to Pediatricians and Family Physicians. Antibiotics prescribed for AOM and SSTI were concordant with guidelines in approximately 97% of cases. In contrast, 47% of antibiotics prescribed for treatment of CAP in children < 5 years old were macrolides, which are not recommended first line therapy for CAP in this age group. Antibiotic prescribing for pediatric outpatients within our health system is not guideline-concordant for treatment of CAP.
Author Manuscript
Keywords Pediatrics; Antimicrobial stewardship; Otitis Media; Pneumonia; Skin and soft tissue infections
*
Corresponding author: Ezzeldin A. Saleh, M.B.B.S, Department of Pediatrics, Division of Pediatric Infectious Diseases, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, USA; Tel: 919-684-6335; Fax: 919-668-4859; [email protected]. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH.
Saleh et al.
Page 2
Author Manuscript
Introduction Antibiotics are the most commonly prescribed medications to children across all age groups. One fifth of all pediatric ambulatory visits result in an antibiotic prescription [1]. Despite an overall decline in antibiotic prescribing for US children [2,3] inappropriate use of expensive broad-spectrum antibiotics is rising [4], which substantially increases health costs, promotes bacterial resistance, and contributes to increasing rates of antibiotic-associated adverse effects. Outpatient antibiotic overuse has been correlated with higher rates of antibioticresistant pathogens [5,6].
Author Manuscript
In an effort to combat the emergence of drug-resistance, the Infectious Diseases Society of America (IDSA) published guidelines for developing antimicrobial stewardship programs (ASPs). ASPs are coordinated interventions designed to measure and improve the appropriate use of antibiotics, with goals of improving clinical outcomes, minimizing adverse events, limiting emergence of drug-resistance and reducing costs [7]. Development and implementation of clinical pathways for management of common infections is an integral part of ASPs. Accordingly, clinical practice guidelines have been developed for management of common infections including AOM [8], CAP [9], and a common cause of skin and soft tissue infections, methicillin-resistant Staphylococcus aureus infections (MRSA)[10]. Notably, both AOM and pediatric CAP guidelines emphasize the use of narrow-spectrum antibiotics as first line therapy for these conditions [8,9,11,12].
Author Manuscript
Despite increasing data about inpatient pediatric ASPs, relatively few studies describe the effectiveness of ASPs in pediatric ambulatory settings [13,14]. Further research is needed to describe antibiotic use in community settings and design and implement targeted interventions that optimize antibiotic use among outpatients. The objective of this study was to evaluate the rates and appropriateness of outpatient antibiotic prescribing for children with three common infectious diseases, AOM, CAP and SSTI, in order to identify areas for outpatient stewardship interventions.
Materials and Methods Study Design and Setting
Author Manuscript
We performed a retrospective analysis of ambulatory pediatric visits within Franciscan Healthcare-Mayo Clinic Health System (FH-MCHS), which includes locations in western Wisconsin, eastern Minnesota and northeastern Iowa. FHS-MCHS employs 92 providers: 7 pediatricians, 56 family medicine physicians, 15 family medicine physician assistants and nurse practitioners, 13 ER and urgent care physicians, and 1 urgent care physician assistant. This study was approved by the FH-MCHS and Mayo Clinic institutional review boards. We abstracted patient age, encounter provider and location, and antibiotics prescribed from the electronic medical records (EMR). We excluded topical, antiviral and anti-parasitic antimicrobials. Diagnosis codes were extracted from the ambulatory billing claim system that uses the International Classification of Diseases, Ninth Revision (ICD-9) codes. These data were integrated with the EMR encounter before final analysis using Statistical Analysis
Clin Res Infect Dis. Author manuscript; available in PMC 2015 April 13.
Saleh et al.
Page 3
Author Manuscript
System software (SAS). We excluded inpatient hospital visits, subspecialty and nurse visits, and diagnostic codes for procedures and immunizations. Infection-related diagnostic codes were classified into four categories: AOM, CAP, SSTI, and other infections. Appropriate antibiotics for each indication were defined as those listed as first or second line therapy in published treatment guidelines [8–10]. For AOM treatment, penicillin, amoxicillin, and amoxicillin-clavulanate were considered first line agents, while macrolides, cephalosporins, tetracyclines, and clindamycin were considered second line agents. For CAP, penicillin or amoxicillin were considered first line treatments, as were macrolides in children >5 years, while amoxicillin-clavulanate and second or third generation cephalosporins (in case of penicillin allergy) were considered second line or alternative treatments. For SSTI, we were not able to differentiate purulent lesions from non-purulent lesions; therefore, in accordance with published guidelines [15] we considered agents with activity against either staphylococci or streptococci as first-line therapy: trimethoprim-sulfamethoxazole, clindamycin, doxycycline, minocycline, penicillin, amoxicillin and first generation cephalosporins. Amoxicillin-clavulanate was considered a second line agent for SSTI.
Author Manuscript
Study population We included all children ≤17 years, seen at the Franciscan Healthcare - Mayo Clinic Health System (FH-MCHS) from August 1, 2009 until July 31, 2010. Statistical Analysis
Author Manuscript
Visit rates for infections were calculated for each of the 4 categories (AOM, CAP, SSTI, and other) and expressed as the number of visits with the given diagnosis per 1,000 patient visits. Visit rates are presented using point estimates and 95% confidence intervals and compared across provider types using the Chi-Square test. Of patients diagnosed with an infection, the percentage prescribed antibiotics was calculated overall and also according to patient age and provider type. Prescription percentages are compared across groups using the ChiSquare test. P-values less than 0.05 were considered significant.
Results and Discussion Results
Author Manuscript
Approximately 22,576 children were evaluated during 88,887 visits. We excluded 11,066 (12.4%) visits and 3,350 (18%) medication orders, because of mismatching identifiers or visit dates. Among the 77,821 visits included in the study, antibacterials were prescribed in 14,543 (18.7 %). Patient volume varied widely among the various clinic locations, ranging from 1,967 (2%) to 21,953 (28%). Most patients were seen by providers in Family Medicine (63%), followed by Pediatrics (27%), and Emergency/Urgent care (10%). Across all sites, 27,298 visits (35%) resulted in infection-related diagnoses. The proportion of all infectionrelated diagnoses was 27.3% for AOM, 3.7% for SSTI, and 3.4% for CAP. Visit rates and antibiotic prescription rates for AOM, SSTI, and CAP differed significantly across the three provider types (Table 1). For all three diagnoses, visit rates and antibiotic prescription rates were greater in the ER compared to Family Medicine and Pediatric clinics (Table 1).
Clin Res Infect Dis. Author manuscript; available in PMC 2015 April 13.
Saleh et al.
Page 4
Author Manuscript
Antimicrobials were prescribed more frequently in patients with AOM compared to CAP or SSTI (79.5%, 61.3% and 69.3% for AOM, CAP and SSTI respectively; p
