Clinical Infectious Diseases Advance Access published January 6, 2014
1 Impact of IDSA/PIDS Guidelines on Treatment of Community-Acquired Pneumonia in
cr ipt
Hospitalized Children
Rachael K. Ross1, Adam L. Hersh2, Matthew P. Kronman3, Jason G. Newland4, Talene A. Metjian5, A. Russell Localio6, Theoklis E. Zaoutis7, Jeffrey S. Gerber7
Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, The
Children’s Hospital of Philadelphia, Philadelphia, PA
Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Utah, Salt
an
Lake City, UT
Division of Infectious Diseases, Seattle Children’s Hospital, Seattle, WA
4
Division of Infectious Diseases, Children’s Mercy Hospitals and Clinics, Kansas City, KS
5
Office of Patient Safety and Quality, The Children’s Hospital of Philadelphia, Philadelphia, PA
6
Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of
M
3
7
pt ed
Pennsylvania, Philadelphia, PA
Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, The
Children’s Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
ce
Address for Correspondence: Rachael K. Ross, MPH, The Children’s Hospital of Philadelphia, 3535 Market Street, Suite 1514, Philadelphia, PA 19104. Phone (267) 426-1380. Fax (215) 590-
Ac
2025. Email: [email protected] Alternate Corresponding Author: Jeffrey S. Gerber, MD, PhD, The Children’s Hospital of Philadelphia, 3535 Market Street, Suite 1518, Philadelphia, PA 19104. Phone (267) 426‐ 8775. Fax (267) 426‐0380. Email: [email protected]
© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e‐mail: [email protected].
Downloaded from http://cid.oxfordjournals.org/ at Aston University on January 21, 2014
2
us
1
2 Key Points: Following the publication of PIDS/IDSA guidelines for management of community-acquired pneumonia, prescribing of ampicillin and amoxicillin for children
cr ipt
hospitalized with pneumonia has increased but remains low. Cephalosporin and macrolide prescribing has decreased but remains common.
ABSTRACT
children hospitalized with community-acquired pneumonia. Prescribing of ampicillin/amoxicillin
an
increased following guideline publication, but remains low. Cephalosporin and macrolide prescribing decreased but remains common. Further studies exploring outcomes of and reasons
Ac
ce
pt ed
M
for compliance with guidelines are warranted.
Downloaded from http://cid.oxfordjournals.org/ at Aston University on January 21, 2014
us
We examined the impact of PIDS/IDSA guidelines that recommend ampicillin or amoxicillin for
3 INTRODUCTION Pediatric community-acquired pneumonia (CAP) accounts for over 500,000 emergency
cr ipt
department visits and 7% of pediatric hospitalizations in the US annually [1, 2]. Pneumonia
accounts for more days of antimicrobial therapy than any other indication for admission to US children’s hospitals [3].
Society of America (IDSA) published guidelines for the management of CAP in children [4].
an
Because Streptococcus pneumoniae is the most common bacterial cause of pediatric CAP and narrow-spectrum -lactam antibiotics effectively target S. pneumoniae, these guidelines
hospitalized with CAP.
M
recommended penicillin or ampicillin/amoxicillin as first-line therapy for most children
pt ed
Prior to the publication of the guidelines, fewer than 10% of hospitalized children with CAP received penicillin or ampicillin/amoxicillin; most children received cephalosporins, and prescribing varied significantly across physicians and institutions [3, 5-7]. The objective of this study was to investigate the impact of the PIDS/IDSA guidelines on antibiotic prescribing for
ce
children hospitalized with non-severe, uncomplicated CAP.
Ac
METHODS
Study Design and Data Source We performed a longitudinal analysis to examine the effect of PIDS/IDSA CAP guideline publication on antibiotic choice for children hospitalized with CAP. Data were obtained from the
Downloaded from http://cid.oxfordjournals.org/ at Aston University on January 21, 2014
us
In October 2011, the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases
4 Pediatric Health Information System (PHIS), a comparative clinical and administrative database that contains information from 43 freestanding U.S. children’s hospitals, which represent 17 of
cr ipt
the 20 major metropolitan areas. The analysis was restricted to 38 hospitals after excluding institutions with data quality issues with service date and prescribing data.
Study Population
March 31, 2013 with CAP identified using a previously validated algorithm [8]. The algorithm
an
was validated in the PHIS database using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes and had a positive predictive value (PPV) of
M
89.6% for identifying CAP using a primary diagnosis of pneumonia, excluding patients with complex chronic conditions (CCC) [9]. To restrict the population to children with non-severe, uncomplicated pneumonia, we excluded patients with an ICD-9 code for effusion or empyema;
pt ed
two or more consecutive days of mechanical ventilation and/or vasopressors; or an ICD-9 code for colonization, infection, or history of methicillin-resistant Staphylococcus aureus (MRSA) infection.
ce
Outcomes
The primary outcome was the rate of prescribing of guideline recommended first-line antibiotic
Ac
therapy, defined as one or more days of amoxicillin, ampicillin or penicillin. Secondary outcomes included the rate of prescribing of cephalosporins and macrolides.
Downloaded from http://cid.oxfordjournals.org/ at Aston University on January 21, 2014
us
We included patients from 6 months to 18 years of age discharged between October 1, 2009 and
5 Statistical Analysis Using a longitudinal piece-wise logistic model with a knot at October 2011 (guideline
cr ipt
publication date), we modeled the trajectory of prescribing before and after guideline publication [10]. Patients were grouped by month, which was included as a linear variable. We examined potential confounders including age, sex and insurance status; none of these variables
meaningfully changed the model estimates and thus were not included in final models. Standard
probabilities of prescribing for each month. For macrolides, probabilities were standardized by
an
season because of seasonal variation.
M
To investigate the effect of the guidelines by hospital, we fit piece-wise logistic models for each of 18 hospitals that provided data for at least 75% of the time period and averaged at least 20 patients per month. The marginal analysis results for recommended first-line therapy of these 18
pt ed
hospitals were similar to the results of the analysis of all 38 hospitals.
Analyses were conducted using Stata version 12.1 (Stata, Corp.; College Station, TX).
ce
RESULTS
There were 44,133 admissions for children with CAP across 38 hospitals. After excluding
Ac
children with effusion, empyema, mechanical ventilation, vasopressor use, or MRSA, 38,819 admissions were included.
Downloaded from http://cid.oxfordjournals.org/ at Aston University on January 21, 2014
us
errors were adjusted for clustering by hospital. For each antibiotic therapy, we obtained the
6 Guideline Recommended First-line Therapy During the 42-month study period, 28% of all hospitalized children received ampicillin or
cr ipt
amoxicillin (
1 Impact of IDSA/PIDS Guidelines on Treatment of Community-Acquired Pneumonia in
cr ipt
Hospitalized Children
Rachael K. Ross1, Adam L. Hersh2, Matthew P. Kronman3, Jason G. Newland4, Talene A. Metjian5, A. Russell Localio6, Theoklis E. Zaoutis7, Jeffrey S. Gerber7
Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, The
Children’s Hospital of Philadelphia, Philadelphia, PA
Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Utah, Salt
an
Lake City, UT
Division of Infectious Diseases, Seattle Children’s Hospital, Seattle, WA
4
Division of Infectious Diseases, Children’s Mercy Hospitals and Clinics, Kansas City, KS
5
Office of Patient Safety and Quality, The Children’s Hospital of Philadelphia, Philadelphia, PA
6
Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of
M
3
7
pt ed
Pennsylvania, Philadelphia, PA
Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, The
Children’s Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
ce
Address for Correspondence: Rachael K. Ross, MPH, The Children’s Hospital of Philadelphia, 3535 Market Street, Suite 1514, Philadelphia, PA 19104. Phone (267) 426-1380. Fax (215) 590-
Ac
2025. Email: [email protected] Alternate Corresponding Author: Jeffrey S. Gerber, MD, PhD, The Children’s Hospital of Philadelphia, 3535 Market Street, Suite 1518, Philadelphia, PA 19104. Phone (267) 426‐ 8775. Fax (267) 426‐0380. Email: [email protected]
© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e‐mail: [email protected].
Downloaded from http://cid.oxfordjournals.org/ at Aston University on January 21, 2014
2
us
1
2 Key Points: Following the publication of PIDS/IDSA guidelines for management of community-acquired pneumonia, prescribing of ampicillin and amoxicillin for children
cr ipt
hospitalized with pneumonia has increased but remains low. Cephalosporin and macrolide prescribing has decreased but remains common.
ABSTRACT
children hospitalized with community-acquired pneumonia. Prescribing of ampicillin/amoxicillin
an
increased following guideline publication, but remains low. Cephalosporin and macrolide prescribing decreased but remains common. Further studies exploring outcomes of and reasons
Ac
ce
pt ed
M
for compliance with guidelines are warranted.
Downloaded from http://cid.oxfordjournals.org/ at Aston University on January 21, 2014
us
We examined the impact of PIDS/IDSA guidelines that recommend ampicillin or amoxicillin for
3 INTRODUCTION Pediatric community-acquired pneumonia (CAP) accounts for over 500,000 emergency
cr ipt
department visits and 7% of pediatric hospitalizations in the US annually [1, 2]. Pneumonia
accounts for more days of antimicrobial therapy than any other indication for admission to US children’s hospitals [3].
Society of America (IDSA) published guidelines for the management of CAP in children [4].
an
Because Streptococcus pneumoniae is the most common bacterial cause of pediatric CAP and narrow-spectrum -lactam antibiotics effectively target S. pneumoniae, these guidelines
hospitalized with CAP.
M
recommended penicillin or ampicillin/amoxicillin as first-line therapy for most children
pt ed
Prior to the publication of the guidelines, fewer than 10% of hospitalized children with CAP received penicillin or ampicillin/amoxicillin; most children received cephalosporins, and prescribing varied significantly across physicians and institutions [3, 5-7]. The objective of this study was to investigate the impact of the PIDS/IDSA guidelines on antibiotic prescribing for
ce
children hospitalized with non-severe, uncomplicated CAP.
Ac
METHODS
Study Design and Data Source We performed a longitudinal analysis to examine the effect of PIDS/IDSA CAP guideline publication on antibiotic choice for children hospitalized with CAP. Data were obtained from the
Downloaded from http://cid.oxfordjournals.org/ at Aston University on January 21, 2014
us
In October 2011, the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases
4 Pediatric Health Information System (PHIS), a comparative clinical and administrative database that contains information from 43 freestanding U.S. children’s hospitals, which represent 17 of
cr ipt
the 20 major metropolitan areas. The analysis was restricted to 38 hospitals after excluding institutions with data quality issues with service date and prescribing data.
Study Population
March 31, 2013 with CAP identified using a previously validated algorithm [8]. The algorithm
an
was validated in the PHIS database using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes and had a positive predictive value (PPV) of
M
89.6% for identifying CAP using a primary diagnosis of pneumonia, excluding patients with complex chronic conditions (CCC) [9]. To restrict the population to children with non-severe, uncomplicated pneumonia, we excluded patients with an ICD-9 code for effusion or empyema;
pt ed
two or more consecutive days of mechanical ventilation and/or vasopressors; or an ICD-9 code for colonization, infection, or history of methicillin-resistant Staphylococcus aureus (MRSA) infection.
ce
Outcomes
The primary outcome was the rate of prescribing of guideline recommended first-line antibiotic
Ac
therapy, defined as one or more days of amoxicillin, ampicillin or penicillin. Secondary outcomes included the rate of prescribing of cephalosporins and macrolides.
Downloaded from http://cid.oxfordjournals.org/ at Aston University on January 21, 2014
us
We included patients from 6 months to 18 years of age discharged between October 1, 2009 and
5 Statistical Analysis Using a longitudinal piece-wise logistic model with a knot at October 2011 (guideline
cr ipt
publication date), we modeled the trajectory of prescribing before and after guideline publication [10]. Patients were grouped by month, which was included as a linear variable. We examined potential confounders including age, sex and insurance status; none of these variables
meaningfully changed the model estimates and thus were not included in final models. Standard
probabilities of prescribing for each month. For macrolides, probabilities were standardized by
an
season because of seasonal variation.
M
To investigate the effect of the guidelines by hospital, we fit piece-wise logistic models for each of 18 hospitals that provided data for at least 75% of the time period and averaged at least 20 patients per month. The marginal analysis results for recommended first-line therapy of these 18
pt ed
hospitals were similar to the results of the analysis of all 38 hospitals.
Analyses were conducted using Stata version 12.1 (Stata, Corp.; College Station, TX).
ce
RESULTS
There were 44,133 admissions for children with CAP across 38 hospitals. After excluding
Ac
children with effusion, empyema, mechanical ventilation, vasopressor use, or MRSA, 38,819 admissions were included.
Downloaded from http://cid.oxfordjournals.org/ at Aston University on January 21, 2014
us
errors were adjusted for clustering by hospital. For each antibiotic therapy, we obtained the
6 Guideline Recommended First-line Therapy During the 42-month study period, 28% of all hospitalized children received ampicillin or
cr ipt
amoxicillin (
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