Comparative Effectiveness of Antibiotic Treatment Duration in Children With Pyelonephritis.

2020

e203951

2020 May 01

2574-3805

<p><strong>Importance: </strong>National guidelines recommend treating children with pyelonephritis for 7 to 14 days of antibiotic therapy, yet data are lacking to suggest a more precise treatment duration.</p>

<p><strong>Objective: </strong>To compare the clinical outcomes of children receiving a short-course vs a prolonged-course of antibiotic treatment for pyelonephritis.</p>

<p><strong>Design, Setting, and Participants: </strong>Retrospective observational study using inverse probability of treatment weighted propensity score analysis of data from 5 hospitals in Maryland between July 1, 2016, and October 1, 2018. Participants were children aged 6 months to 18 years with a urine culture growing Escherichia coli, Klebsiella species, or Proteus mirabilis with laboratory and clinical criteria for pyelonephritis.</p>

<p><strong>Exposures: </strong>Treatment of pyelonephritis with a short-course (6 to 9 days) vs a prolonged-course (10 or more days) of antibiotics.</p>

<p><strong>Main Outcomes and Measures: </strong>Composite outcome of treatment failure within 30 days of completing antibiotic therapy: (a) unanticipated emergency department or outpatient visits related to urinary tract infection symptoms, (b) hospital readmission related to UTI symptoms, (c) prolongation of the planned, initial antibiotic treatment course, or (d) death. A subsequent urinary tract infection caused by a drug-resistant bacteria within 30 days was a secondary outcome.</p>

<p><strong>Results: </strong>Of 791 children who met study eligibility criteria (mean [SD] age 9.2 [6.3] years; 672 [85.0%]) were girls, 297 patients (37.5%) were prescribed a short-course and 494 patients (62.5%) were prescribed a prolonged-course of antibiotics. The median duration of short-course therapy was 8 days (interquartile range, 7-8 days), and the median duration of prolonged-course therapy was 11 days (interquartile range, 11-12 days). Baseline characteristics were similar between the groups in the inverse probability of treatment weighted cohort. There were 79 children (10.1%) who experienced treatment failure. The odds of treatment failure were similar for patients prescribed a short-course vs a prolonged-course of antibiotics (11.2% vs 9.4%; odds ratio, 1.22; 95% CI, 0.75-1.98). There was no significant difference in the odds of a drug-resistant uropathogen for patients with a subsequent urinary tract infection within 30 days when prescribed a short-courses vs prolonged-course of antibiotics (40% vs 64%; odds ratio, 0.36; 95% CI, 0.09-1.43).</p>

<p><strong>Conclusions and Relevance: </strong>The study findings suggest that short-course antibiotic therapy may be as effective as prolonged-courses for children with pyelonephritis, and may mitigate the risk of future drug-resistant urinary tract infections. Additional studies are needed to confirm these findings.</p>

10.1001/jamanetworkopen.2020.3951

JAMA Netw Open

32364593

Multicenter initial guidance on use of antivirals for children with COVID-19/SARS-CoV-2.

2020

2020 Apr 22

2048-7207

<p><strong>BACKGROUND: </strong>Although Coronavirus Disease 2019 (COVID-19) is mild in nearly all children, a small proportion of pediatric patients develops severe or critical illness. Guidance is therefore needed regarding use of agents with potential activity against severe acute respiratory syndrome coronavirus 2 in pediatrics.</p>

<p><strong>METHODS: </strong>A panel of pediatric infectious diseases physicians and pharmacists from 18 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a set of guidance statements was developed and refined based on review of best available evidence and expert opinion.</p>

<p><strong>RESULTS: </strong>Given the typically mild course of pediatric COVID-19, supportive care alone is suggested for the overwhelming majority of cases. The panel suggests a decision-making framework for antiviral therapy that weighs risks and benefits based on disease severity as indicated by respiratory support needs, with consideration on a case-by-case basis of potential pediatric risk factors for disease progression. If an antiviral is used, the panel suggests remdesivir as the preferred agent. Hydroxychloroquine could be considered for patients who are not candidates for remdesivir or when remdesivir is not available. Antivirals should preferably be used as part of a clinical trial if available.</p>

<p><strong>CONCLUSIONS: </strong>Antiviral therapy for COVID-19 is not necessary for the great majority of pediatric patients. For those rare children who develop severe or critical disease, this guidance offer an approach for decision-making regarding antivirals, informed by available data. As evidence continues to evolve rapidly, the need for updates to the guidance is anticipated.</p>

10.1093/jpids/piaa045

J Pediatric Infect Dis Soc

32318706

Association of a blood culture utilization intervention on antibiotic use in a pediatric intensive care unit.

2019

482-484

2019 04

1559-6834

<p>Blood cultures are essential for the evaluation of sepsis. However, they may sometimes be obtained inappropriately, leading to high false-positive rates, largely due to contamination.1 As a quality improvement project, clinician decision-support tools for evaluating patients with fever or signs and symptoms of sepsis were implemented in April 2014 in our pediatric intensive care unit (PICU). This initiative resulted in a 46% decrease in blood culture obtainment2 and has been replicated in other institutions.3 It is important to evaluate antibiotic use as a balancing measure because a reduction in blood cultures could lead to an increase in antibiotic treatment days if clinicians continued empiric treatment in scenarios when blood culture results were not available. The objective of this study was to evaluate whether antibiotic use in the PICU changed in association with a reduction in blood culture utilization.</p>

10.1017/ice.2019.10

Infect Control Hosp Epidemiol

30767809

Treatment of Carbapenem-Resistant Enterobacteriaceae Infections in Children.

2019

2019 Dec 21

2048-7207

<p>Infections due to carbapenem-resistant Enterobacteriaceae (CRE) are increasingly prevalent in children and are associated with poor clinical outcomes. Optimal treatment strategies for CRE infections continue to evolve. A lack of pediatric-specific comparative effectiveness data, uncertain pediatric dosing regimens for several agents, and a relative lack of new antibiotics with pediatric indications approved by the US Food and Drug Administration (FDA) collectively present unique challenges for children. In this review, we provide a framework for antibiotic treatment of CRE infections in children, highlighting relevant microbiologic considerations and summarizing available data related to the evaluation of FDA-approved antibiotics (as of September 2019) with CRE activity, including carbapenems, ceftazidime-avibactam, meropenem-vaborbactam, imipenem/cilastatin-relebactam, polymyxins, tigecycline, eravacycline, and plazomicin.</p>

10.1093/jpids/piz085

J Pediatric Infect Dis Soc

31872226

The inconvincible patient: how clinicians perceive demand for antibiotics in the outpatient setting.

2019

2019 Nov 06

1460-2229

<p><strong>BACKGROUND: </strong>Perceived patient demand for antibiotics drives unnecessary antibiotic prescribing in outpatient settings, but little is known about how clinicians experience this demand or how this perceived demand shapes their decision-making.</p>

<p><strong>OBJECTIVE: </strong>To identify how clinicians perceive patient demand for antibiotics and the way these perceptions stimulate unnecessary prescribing.</p>

<p><strong>METHODS: </strong>Qualitative study using semi-structured interviews with clinicians in outpatient settings who prescribe antibiotics. Interviews were analyzed using conventional and directed content analysis.</p>

<p><strong>RESULTS: </strong>Interviews were conducted with 25 clinicians from nine practices across three states. Patient demand was the most common reason respondents provided for why they prescribed non-indicated antibiotics. Three related factors motivated clinically unnecessary antibiotic use in the face of perceived patient demand: (i) clinicians want their patients to regard clinical visits as valuable and believe that an antibiotic prescription demonstrates value; (ii) clinicians want to avoid negative repercussions of denying antibiotics, including reduced income, damage to their reputation, emotional exhaustion, and degraded relationships with patients; (iii) clinicians believed that certain patients are impossible to satisfy without an antibiotic prescription and felt that efforts to refuse antibiotics to such patients wastes time and invites the aforementioned negative repercussions. Clinicians in urgent care settings were especially likely to describe being motivated by these factors.</p>

<p><strong>CONCLUSION: </strong>Interventions to improve antibiotic use in the outpatient setting must address clinicians' concerns about providing value for their patients, fear of negative repercussions from denying antibiotics, and the approach to inconvincible patients.</p>

10.1093/fampra/cmz066

Fam Pract

31690948

Research needs in antibiotic stewardship.

2019

1-10

2019 Oct 30

1559-6834

<p>Antibiotic-resistant bacteria infect 2 million Americans annually, resulting in up to 100,000 deaths and excess healthcare costs exceeding $20 billion. Antibiotic use is a major contributor to antibitotic resistance, <em>Clostridioides difficile</em> infections (CDI), and antibiotic-associated adverse events. Antibiotics are frequently used across all healtcare settings in the United States, although much of this use is unnecessary. In response, antibiotic stewardship programs (ASPs) have sought to coordinate efforts to improve antibiotic prescribing. Although there has been much progress with antibiotic stewardship (AS) over the past decade, gaps in optimizing the reach and effectiveness of AS remain. We convened a diverse, multidisciplinary group of AS clinicians and researchers to delineate and prioritize these research gaps from a US human health perspective.</p>

<p>We highlight 4 broad categories in which gaps exist (Table 1): (1) a scientifically rigorous evidence base to define optimal antibiotic prescribing practices, which adequately inform AS interventions across a variety of patient populations and settings; (2) effective AS approaches to recognize effective interventions, knowledge of how these interventions can be adapted for implementation both locally and across diverse settings, and an understanding of how interventions can be sustained once implemented; (3) standardized process and outcome metrics; and (4) advanced study designs with appropriate analytic methods, accompanied by infrastructure to support data collection and sharing.</p>

10.1017/ice.2019.276

Infect Control Hosp Epidemiol

31662139

Antibiotic stewardship in the intensive care unit: Challenges and opportunities.

2019

1-6

2019 May 03

1559-6834

<p>Infections due to antibiotic-resistant organisms are increasing in prevalence and represent a major public health threat. Antibiotic overuse is a major driver of this epidemic, and antibiotic stewardship an important means of limiting antibiotic resistance. The intensive care unit (ICU) setting presents an intersection of opportunities and challenges for effective antibiotic stewardship, but limited data inform optimal stewardship interventions in this setting. In this review, we present unique considerations for stewardship interventions the ICU setting and summarize available data evaluating the impact of prospective audit and feedback, diagnostic test stewardship, rapid molecular diagnostic tests, and procalcitonin-guided algorithms for antibiotic discontinuation. The existing knowledge gaps ripe for future research are emphasized.</p>

10.1017/ice.2019.74

Infect Control Hosp Epidemiol

31046851

Increased 30-Day Mortality Associated With Carbapenem-Resistant Enterobacteriaceae in Children.

2018

ofy222

2018 Oct

2328-8957

<p>In this multicenter study, we identified an increased risk of 30-day mortality among hospitalized children with carbapenem-resistant Enterobacteriaceae (CRE) isolated from clinical cultures compared with those with carbapenem-susceptible Enterobacteriaceae. We additionally report significant variation in antibiotic treatment for children with CRE infections with infrequent use of combination therapy.</p>

10.1093/ofid/ofy222

Open Forum Infect Dis

30338267

Expanding Existing Antimicrobial Stewardship Programs in Pediatrics: What Comes Next.

2017

2017 Dec 18

2048-7207

<p>The prevalence of pediatric antimicrobial stewardship programs (ASPs) is increasing in acute care facilities across the United States. Over the past several years, the evidence base used to inform effective stewardship practices has expanded, and regulatory interest in stewardship programs has increased. Here, we review approaches for established, hospital-based pediatric ASPs to adapt and report standardized metrics, broaden their reach to specialized populations, expand to undertake novel stewardship initiatives, and implement rapid diagnostics to continue their evolution in improving antimicrobial use and patient outcomes.</p>

10.1093/jpids/pix104

J Pediatric Infect Dis Soc

29267871

Association Between Vancomycin Trough Concentrations and Duration of Methicillin-Resistant Staphylococcus aureus Bacteremia in Children.

2018

338-341

2018 Dec 3

2048-7207

<p>In a multicenter retrospective study, we sought to determine the optimal vancomycin trough concentration that would impact the duration of methicillin-resistant Staphylococcus aureus bacteremia in children. We found that a median vancomycin trough concentration of &lt;10 µg/mL within the first 72 hours may be associated with a longer duration of bacteremia compared to a median trough concentration of ≥10 µg/mL.</p>

10.1093/jpids/pix068

J Pediatric Infect Dis Soc

28992126