Receipt Of Antibiotics Research Articles

A Population-based Study of Perinatal Infection Risk in Women with and without Systemic Lupus Erythematosus and their Infants.

Increased risk of adverse birth outcomes is well described in women with systemic lupus erythematosus (SLE), but risk of maternal or infant infection in the peripartum period has not been well studied. We conducted a population-based cohort study of infection risk in women with and without SLE and their infants. Linked birth-hospital discharge data identified 1297 deliveries to women with SLE and a 4:1 comparison cohort of deliveries to women without SLE in Washington State, 1987-2013. Maternal and infant infections during the first 30 days after delivery were identified. Relative risks (RR) and 95% confidence intervals (CI) were estimated. Women with SLE were 1.7 times more likely (95% CI 1.4, 2.0) to have an infection during the birth hospitalisation and more likely to receive antibiotics during labour (RR 1.3, 95% CI 1.1, 1.5), though there was no increased risk of chorioamnionitis in women with SLE. Infants of women with SLE had an increased risk for an infection during the birth hospitalisation (RR 2.2, 95% CI 1.3, 3.5), although the size of the difference was smaller when adjusted for gestational age (RR 1.4, 95% CI 0.9, 2.1). Risks of neonatal infection, sepsis, receipt of antibiotics, and admission to neonatal intensive care were also increased, and were also attenuated after adjustment for gestational age. Women with SLE have an increased risk of peripartum infections and antibiotic exposure. Their neonates have a greater likelihood of infection, much of which is attributable to preterm birth.

Determinants of Integrated Management of Childhood Illness (IMCI) non-severe pneumonia classification and care in Malawi health facilities: Analysis of a national facility census.

BackgroundResearch shows inadequate Integrated Management of Childhood Illness (IMCI)–pneumonia care in various low–income settings but evidence is largely from small–scale studies with limited evidence of patient–, provider– and facility–levels determinants of IMCI non–severe pneumonia classification and its management.MethodsThe Malawi Service Provision Assessment 2013–2014 included 3149 outpatients aged 2–59 months with completed observations, interviews and re–examinations. Mixed–effects logistic regression models quantified the influence of patient–, provider and facility–level determinants on having IMCI non–severe pneumonia and its management in observed consultations.FindingsAmong 3149 eligible outpatients, 590 (18.7%) had IMCI non–severe pneumonia classification in re–examination. 228 (38.7%) classified cases received first–line antibiotics and 159 (26.9%) received no antibiotics. 18.6% with cough or difficult breathing had 60–second respiratory rates counted during consultations, and conducting this assessment was significantly associated with IMCI training ever received (odds ratio (OR) = 2.37, 95% confidence interval (CI): 1.29–4.31) and negative rapid diagnostic test results (OR = 3.21, 95% CI: 1.45–7.13). Older children had lower odds of assessments than infants (OR = 48–59 months: 0.35, 95% CI: 0.16–0.75). Children presenting with any of the following complaints also had reduced odds of assessment: fever, diarrhea, skin problem or any danger sign. First–line antibiotic treatment for classified cases was significantly associated with high temperatures (OR = 3.26, 95% CI: 1.24–8.55) while older children had reduced odds of first–line treatment compared to infants (OR = 48–59 months: 0.29, 95% CI: 0.10–0.83). RDT–confirmed malaria was a significant predictor of no antibiotic receipt for IMCI non–severe pneumonia (OR = 10.65, 95% CI: 2.39–47.36).ConclusionsIMCI non–severe pneumonia care was sub–optimal in Malawi health facilities in 2013–2014 with inadequate assessments and prescribing practices that must be addressed to reduce this leading cause of mortality. Child’s symptoms and age, malaria diagnosis and provider training were primary influences on assessment and treatment practices. Current evidence could be used to better target IMCI training and support to improve pneumonia care for sick children in Malawi facilities.

Risk of Subsequent Sepsis Within 90 Days After a Hospital Stay by Type of Antibiotic Exposure.

We examined the risk of sepsis within 90 days after discharge from a previous hospital stay by type of antibiotic received during the previous stay. We retrospectively identified a cohort of hospitalized patients from the Truven Health MarketScan Hospital Drug Database. We examined the association between the use of certain antibiotics during the initial hospital stay, determined a priori, and the risk of postdischarge sepsis controlling for potential confounding factors in a multivariable logistic regression model. Our primary exposure was receipt of antibiotics more strongly associated with clinically important microbiome disruption. Our primary outcome was a hospital stay within 90 days of the index stay that included an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) discharge diagnosis of severe sepsis (ICD-9-CM code 995.92) or septic shock (785.52). Among 516 hospitals, we randomly selected a single stay for eligible patients. In 0.17% of these patients, severe sepsis/septic shock developed within 90 days after discharge. The risk of sepsis associated with exposure to our high-risk antibiotics was 65% higher than in those without antibiotic exposure. Our study identified an increased risk of sepsis within 90 days of discharge among patients with exposure to high-risk antibiotics or increased quantities of antibiotics during hospitalization. Given that a significant proportion of inpatient antimicrobial use may be unnecessary, this study builds on previous evidence suggesting that increased stewardship efforts in hospitals may not only prevent antimicrobial resistance, Clostridium difficile infection, and other adverse effects, but may also reduce unwanted outcomes potentially related to disruption of the microbiota, including sepsis.

Characteristics of Clostridium difficile infection in patients hospitalized with myelodysplastic syndrome or acute myelogenous leukemia.

AIMTo evaluate factors associated with Clostridium difficile infection (CDI) and outcomes of CDI in the myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) population.METHODSAfter IRB approval, all MDS/AML patients hospitalized at the University of Maryland Greenebaum Comprehensive Cancer Center between August 2011 and December 2013 were identified. Medical charts were reviewed for demographics, clinical information, development of CDI, complications of CDI, and mortality. Patients with CDI, defined as having a positive stool PCR done for clinical suspicion of CDI, were compared to those without CDI in order to identify predictors of disease. A t-test was used for comparison of continuous variables and chi-square or Fisher’s exact tests were used for categorical variables, as appropriate.RESULTSTwo hundred and twenty-three patients (60.1% male, mean age 61.3 years, 13% MDS, 87% AML) had 594 unique hospitalizations during the study period. Thirty-four patients (15.2%) were diagnosed with CDI. Factors significantly associated with CDI included lower albumin at time of hospitalization (P < 0.0001), prior diagnosis of CDI (P < 0.0001), receipt of cytarabine-based chemotherapy (P = 0.015), total days of neutropenia (P = 0.014), and total days of hospitalization (P = 0.005). Gender (P = 0.10), age (P = 0.77), proton-pump inhibitor use (P = 0.73), receipt of antibiotics (P = 0.66), and receipt of DNA hypomethylating agent-based chemotherapy (P = 0.92) were not significantly associated with CDI.CONCLUSIONCDI is common in the MDS/AML population. Factors significantly associated with CDI in this population include low albumin, prior CDI, use of cytarabine-based chemotherapy, and prolonged neutropenia. In this study, we have identified a subset of patients in which prophylaxis studies could be targeted.

Systematic Review of Professional Liability when Prescribing Β-Lactams for Patients with a Known Penicillin Allergy

BackgroundPatients labeled as penicillin allergic are more likely to receive second line non-β-lactam antibiotics, experience higher rates of treatment failure, and incur higher antibiotic costs. Fear of litigation has been identified as a reason clinicians avoid using β-lactams in a patient with a penicillin allergy. The systematic review objective is to describe medical negligence and malpractice cases in which known penicillin allergy patients received a β-lactam and experienced an adverse reaction.MethodsLexis-Nexus and Google Scholar were used to identify relevant legal cases. Variables collected from each case included date of publication, legal jurisdiction, date of injury, plaintiff and defendant demographics, health care setting, plaintiff clinical outcome, and legal outcome.ResultsTwenty-seven unique cases met inclusion criteria. The earliest case was published in 1959 and the most recent in 2013. The highest number of cases filed (n = 7) occurred in the most recent 10 year segment, from 2005 to 2015. Eighteen cases involved the receipt of a penicillin-based antibiotic; of these cases with a known legal outcome, the plaintiff (patient) prevailed or settled in 3 cases and defendants (providers) prevailed in 7 cases. Seven cases involved the receipt of a cephalosporin; of these cases with a known legal outcome, the plaintiff settled with physicians prior to trial in 1 case and defendants prevailed in 3 cases. Two cases involved the receipt of a carbapenem. Defendants prevailed in 1 case and the legal outcome of the other case is unknown. In cases where the defense successfully moved for summary judgment, judges cited a lack of scientific evidence demonstrating that a cephalosporin or carbapenem were contraindicated for a patient with a penicillin allergy.ConclusionThe cases with published legal outcomes found limited professional liability and identify clear precedence for clinicians who prescribed cephalosporins or carbapenems to a patient with a known penicillin allergy. These results should decrease litigation fears of providers and risk managers within healthcare systems.Disclosures All authors: No reported disclosures.

Doing More About Health Care Disparities: Moving Past Description to Action.

In this issue of Pediatrics , Goyal et al1 report race- and ethnicity-based differences in the receipt of antibiotics for acute respiratory viral illnesses over a 1-year period from sites participating in the Pediatric Emergency Care Applied Research Network. In their report, Goyal et al1 demonstrate that, regardless of race, non-Hispanic white children were given or prescribed antibiotics at a higher rate than non-Hispanic black patients or Hispanic children. Unfortunately, the findings in this study do not come as a surprise. Not only have researchers in other studies found differences in prescribing antibiotics in various pediatric practice settings but differences in all aspects of care, such as use of diagnostic testing, pain management, and even hospitalization rates.2–5 One of the challenges in assessing racial and ethnic disparities is in understanding the degree to which they are attributable to confounding factors such as socioeconomic status and access to care. In their study, Goyal et al1 control for insurance status but no other measures of socioeconomic status. Nonetheless the overall weight of scientific evidence supports that significant disparities exist on the basis of race and ethnicity. There was a time when results like this would have shocked us. That time is gone. We must recognize that we are biased in our treatment of patients. This does not mean we accept this fact. We should strive to provide care in our clinics and emergency departments that is of high … Address correspondence to Marvin B. Harper, MD, Division of Emergency Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: marvin.harper{at}childrens.harvard.edu

Assessment of a Modified Antibiotic Prophylaxis Open Fracture Protocol

Background National guidelines support antibiotic prophylaxis for open fracture with cefazolin +/− aminoglycoside based on fracture grade and contamination. The purpose of this study was to assess a modified adult antibiotic prophylaxis open fracture protocol (AOFP) which recommended weight-based cefazolin for low-grade fractures or ciprofloxacin plus vancomycin for high-grade fractures.Methods Adult patients with open fractures admitted to Palmetto Health Richland between January 2012 and December 2016 were screened for study inclusion. Exclusion criteria were receipt of antibiotics for reasons other than open fracture, death prior to wound closure, and local admission time >48 hours after time of injury. Compliance to all elements of AOFP was assessed. Clinical endpoints including open fracture infection rates, epidemiology, and drug-related adverse events were compared between pre-implementation (January 2012 – December 2012) and post-implementation period (November 2015 – December 2016). χ 2 and t-tests as appropriate were used to compare outcomes between groups.ResultsFollowing exclusions 189 patients were included in the analysis (90 pre- vs. 99 post-AOFP, respectively). Post-AOFP, a 17% (16/93) adherence rate to all AOFP elements was found. Appropriate agents were selected in 82.8% (77/93). The most common reasons for non-adherence were incorrect dosing and prolonged antibiotic duration. Fracture site infection rates were 23.3% (21/90) and 7.1% (7/99) in pre- and post-AOFP groups, respectively (P = 0.001). Infections primary caused by Gram-negative pathogens in pre-AOFP and Gram-negative organisms comprised 62 and 40% of open fracture site infections in pre- and post-AOFP groups, respectively. Incidence of acute kidney injury, Clostridium difficile-associated diarrhea, and other antibiotic-associated AEs were rare and comparable between groups. Change in median days to infection (55.6 days vs. 56.55 days, P = 0.71) and median duration of antibiotics in hours (48.0 vs. 54.7, P = 0.59) was not significantly different post implementation.Conclusion Local adherence to all elements of the modified AOFP was low, yet the appropriate agent(s) was used in majority of cases. The modified AOFP was associated with a numerical decrease in infection rates post-open fracture and comparable AEs.Disclosures P. B. Bookstaver, Rock Pointe: Content Developer, Consulting fee

Evaluating the Role of Postoperative Oral Antibiotic Administration in Artificial Urinary Sphincter and Inflatable Penile Prosthesis Explantation: A Nationwide Analysis

To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown. We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates. We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation. Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.

Association of Guideline-Adherent Antibiotic Treatment With Readmission of Children With Sickle Cell Disease Hospitalized With Acute Chest Syndrome

Acute chest syndrome (ACS) is a common, serious complication of sickle cell disease (SCD) and a leading cause of hospitalization and death in both children and adults with SCD. Little is known about the effectiveness of guideline-recommended antibiotic regimens for the care of children hospitalized with ACS. To use a large, national database to describe patterns of antibiotic use for children with SCD hospitalized for ACS and to determine whether receipt of guideline-adherent antibiotics was associated with lower readmission rates. Retrospective cohort study including 14 480 hospitalizations in 7178 children (age 0-22 years) with a discharge diagnosis of SCD and either ACS or pneumonia. Information was obtained from 41 children's hospitals submitting data to the Pediatric Health Information System from January 1, 2010, to December 31, 2016. National Heart, Lung, and Blood Institute guideline-adherent (macrolide with parenteral cephalosporin) vs non-guideline-adherent antibiotic regimens. Acute chest syndrome-related and all-cause 7- and 30-day readmissions. Of the 14 480 hospitalizations, 6562 (45.3%) were in girls; median (interquartile range) age was 9 (4-14) years. Guideline-adherent antibiotics were provided in 10 654 of 14 480 hospitalizations for ACS (73.6%). Hospitalizations were most likely to include guideline-adherent antibiotics for children aged 5 to 9 years (3230 of 4047 [79.8%]) and declined to the lowest level for children 19 to 22 years (697 of 1088 [64.1%]). Between-hospital variation in antibiotic regimens was wide, with use of guideline-adherent antibiotics ranging from 24% to 90%. Children treated with guideline-adherent antibiotics had lower 30-day ACS-related (odds ratio [OR], 0.71; 95% CI, 0.50-1.00) and all-cause (OR, 0.50; 95% CI, 0.39-0.64) readmission rates vs children who received other regimens (cephalosporin and macrolide vs neither drug class). Current approaches to antibiotic treatment in children with ACS vary widely, but guideline-adherent therapy appears to result in fewer readmissions compared with non-guideline-adherent therapy. Efforts to increase the dissemination and implementation of SCD treatment guidelines are warranted as is comparative effectiveness research to strengthen the underlying evidence base.

Procalcitonin Levels in Critically Ill Children With Status Asthmaticus.

Children with status asthmaticus (SA) often present with fever and are evaluated with chest radiographs (CXRs). In the absence of a confirmatory test for bacterial infection, antibiotics are started whenever there are radiological infiltrates or if there is a suspicion of pneumonia. We undertook this study to determine if serum procalcitonin (PCT) levels at admission are altered in critically ill children with SA. We also sought to determine if serum PCT levels are elevated in children with radiological infiltrates or in children who were treated with antibiotics. This is a prospective single-center observational study evaluating serum PCT levels in critically ill children with SA. Study subjects included children 1 to 21 years old, admitted to a pediatric intensive care unit (PICU) with SA between March 2012 and April 2013. For the purposes of this study, patients whose CXRs were read by the radiologist as probable bacterial pneumonia was defined as having "radiological bacterial pneumonia," whereas patients who received antibiotics by the treating physician were defined as having "clinician-diagnosed pneumonia." Sixty-one patients with a median age of 7.3 years (interquartile range, 4-10 years) were included in the study. Fifty-one percent were male. Average Pediatric Risk of Mortality III score was 2.7 (SD, 2.9). Three patients (5%) were determined to have radiological bacterial pneumonia, whereas 52 (85%) did not. Six patients (10%) were indeterminate. The mean PCT level for all patients was 0.65 (SD, 1.54) ng/mL, whereas the median PCT level was 0.3 ng/mL. There was no significant difference in the mean PCT levels between the patients with and without clinician-diagnosed pneumonia (0.33 [SD, 0.36] vs 0.69 [SD, 1.67], P = 0.44). Using a PCT cutoff level of 0.5 ng/mL, a significant association was found with the presence of fever (P = 0.004), but no significant association was found with the presence of CXR infiltrates, radiological bacterial pneumonia, hospital length of stay, PICU length of stay, Pediatric Risk of Mortality III scores, or receipt of antibiotics. Serum PCT level was not elevated to greater than 0.5 ng/mL in 75% of this cohort of critically ill children with SA admitted to PICU. Presence of CXR infiltrates was not associated with higher PCT levels. Large clinical trials are needed to study the diagnostic and predictive role of PCT in this patient population.

National Patterns of Urine Testing During Inpatient Admission.

Overuse of urine testing is a driver of inappropriate antimicrobial use. Limiting wasteful testing is important for patient safety. We examined the national prevalence and patterns of urine testing during adult inpatient admission in the United States. We performed a retrospective cohort study using a national dataset of inpatient admissions from 263 hospitals in the United States from 2009 to 2014. We included all adult inpatient admissions, excluding those related to pregnancy, urology procedures, and with lengths of stay >30 days. A facility-level fixed-effects quasi-Poisson regression model was used to examine the incidence of urinalysis and urine culture testing for select diagnoses and patient factors. The cohort included 4473655 admissions. Charges for urinalysis were present for 2086697 (47%) admissions, with 584438 (13%) including >1 urinalysis. Charges for urine culture were present for 1197242 (27%) admissions, with 246211 (6%) having >1 culture. Urine culture testing varied by principal diagnosis. Heart failure and acute myocardial infarction had 29% and 35% fewer cultures sent on the first day of admission compared to all other admissions (P < .001). Female sex and receipt of antibiotics during the hospital admission consistently predicted increased culture testing, regardless of principal diagnosis or age. Urine testing was common and frequently repeated during inpatient admission, suggesting large-scale overuse. The variation in testing by diagnosis suggests that clinical presentation modifies test use. The sex bias in urine testing is not clinically supported and must be addressed in interventions aimed at reducing excess urine testing.

Multidrug-resistant Acinetobacter: Risk factors and outcomes in veterans with spinal cord injuries and disorders

Multidrug-resistant (MDR) Acinetobacter is a growing concern and has been identified as a serious threat by the Centers for Disease Control and Prevention. However, there is little information on MDR Acinetobacter in individuals with spinal cord injuries and disorders (SCI/Ds). Therefore, the objective of this study was to identify risk factors for, and assess outcomes of, MDR Acinetobacter in veterans with SCI/Ds. This was a retrospective cohort study from January 1, 2012-December 31, 2013, using national Veterans Affairs medical encounter and microbiology data. A total of 773 Acinetobacter cultures were identified in 571 patients, of which 58.9% were MDR. Inpatient culture, sputum and other specimen type, receipt of antibiotics within 90 days before culture date, and pressure ulcers were identified as independent predictors of MDR Acinetobacter. Highest odds of MDR Acinetobacter were seen with previous antibiotic use (odds ratio, 7.27; 95% confidence interval, 2.59-20.54). Thirty-day mortality was 5.3% in this study. Multidrug resistance, previous mechanical ventilation 90 days before the culture, and cancer were all independent risk factors for 30-day mortality. There should be increased efforts to highlight the importance of antimicrobial stewardship to improve infection control to help limit spread of Acinetobacter in health care settings.

Urinary tract infection after retrograde urethrogram in children: A multicenter study

The risk of post-procedural urinary tract infection (ppUTI) after retrograde urethrogram (RUG) has not been well quantified. Prophylactic antibiotics may reduce the risk, but must be weighed against the risks of antibiotic resistance. Prior research has shown that this risk is variable after voiding cystourethrogram (0-42% reported ppUTI rate) and appears to be low after urodynamics (0-4.8%) but this risk has not been well documented for patients undergoing RUG. We aimed to (1) describe the rate of ppUTI after RUG, and (2) examine factors associated with use of antibiotics at the time of RUG. We conducted a retrospective cohort study of children undergoing RUG at two hospitals January 1, 2004, to December 31, 2014. ppUTI within 7 days was measured. Antibiotic prophylaxis was determined. Relationships between clinical characteristics and receipt of pre-procedure antibiotics were evaluated using univariate statistics. Forty-two patients (100% male, median age 11.7 years) underwent 47 RUGs. Indications included trauma (27%), hypospadias (17%), and non-hypospadias (27%) stricture. Study indication and antibiotic administration practices are illustrated in the Figure. Three patients (6.4%) had a history of posterior urethral valves (PUV); one had neurogenic bladder (NGB) (2.4%). Two (4%) studies were performed within 30 days of a clinical UTI and 11% had a positive urinalysis or culture within 30 days pre-RUG. UTI in the 30 days before RUG was not associated with antibiotic prescription (p>0.99). One child (2.1%; 95% CI 0-6.3%) had a ppUTI: a 7-year-old, uncircumcised male with a history of PUV and voiding dysfunction who was asymptomatic at the time of RUG. Although the risk of ppUTI after RUG appears to be low, the rare occurrence of an iatrogenic UTI can lead to high cost and patient morbidity, particularly in cases similar to our patients who required inpatient admission for intravenous antibiotics. To help balance the risk of UTI with the associated healthcare costs and morbidity with the concerns about antibiotic overuse and potential exposure to drug reaction, data from this study may inform future development of evidence-based guidelines targeting only patients at highest risk for ppUTI with antibiotic prophylaxis. The risk of ppUTI after RUG is low. Antibiotic prophylaxis was unrelated pre-RUG UTI in our population. These results indicate the need for pre-procedural antibiotic prescribing guidelines, and suggest that routine antibiotics prior to RUG are not indicated unless the patient has another indication for antibiotics.

Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland

Objectives To assess self reported outcomes and adverse events after self sourced medical abortion through online telemedicine.Design Population based study.Setting Republic of Ireland and Northern Ireland, where abortion is unavailable...

Identification of novel risk factors for community-acquired Clostridium difficile infection using spatial statistics and geographic information system analyses.

BackgroundThe rate of community-acquired Clostridium difficile infection (CA-CDI) is increasing. While receipt of antibiotics remains an important risk factor for CDI, studies related to acquisition of C. difficile outside of hospitals are lacking. As a result, risk factors for exposure to C. difficile in community settings have been inadequately studied.Main objectiveTo identify novel environmental risk factors for CA-CDIMethodsWe performed a population-based retrospective cohort study of patients with CA-CDI from 1/1/2007 through 12/31/2014 in a 10-county area in central North Carolina. 360 Census Tracts in these 10 counties were used as the demographic Geographic Information System (GIS) base-map. Longitude and latitude (X, Y) coordinates were generated from patient home addresses and overlaid to Census Tracts polygons using ArcGIS; ArcView was used to assess “hot-spots” or clusters of CA-CDI. We then constructed a mixed hierarchical model to identify environmental variables independently associated with increased rates of CA-CDI.ResultsA total of 1,895 unique patients met our criteria for CA-CDI. The mean patient age was 54.5 years; 62% were female and 70% were Caucasian. 402 (21%) patient addresses were located in “hot spots” or clusters of CA-CDI (p<0.001). “Hot spot” census tracts were scattered throughout the 10 counties. After adjusting for clustering and population density, age ≥ 60 years (p = 0.03), race (<0.001), proximity to a livestock farm (0.01), proximity to farming raw materials services (0.02), and proximity to a nursing home (0.04) were independently associated with increased rates of CA-CDI.ConclusionsOur study is the first to use spatial statistics and mixed models to identify important environmental risk factors for acquisition of C. difficile and adds to the growing evidence that farm practices may put patients at risk for important drug-resistant infections.

Results from a Patient-Based Health Education Intervention in Reducing Antibiotic Use for Acute Upper Respiratory Tract Infections in the Private Sector Primary Care Setting in Singapore.

ABSTRACTWe investigated the efficacy of patient-targeted education in reducing antibiotic prescriptions for upper respiratory tract infections (URTIs) among adults in the private primary care setting in Singapore. Our randomized controlled trial enrolled patients aged 21 years and above presenting at general practitioner (GP) clinics with URTI symptoms for 7 days or less. Intervention arm patients were verbally educated via pamphlets about the etiology of URTIs, the role of antibiotics in treating URTIs, and the consequences of inappropriate antibiotic use. Control arm patients were educated on influenza vaccinations. Both arms were compared regarding the proportions prescribed antibiotics and the patients' postconsultation views. A total of 914 patients consulting 35 doctors from 24 clinics completed the study (457 in each arm). The demographics of patients in both arms were similar, and 19.1% were prescribed an antibiotic, but this varied from 0% to 70% for individual GPs. The intervention did not significantly reduce antibiotic prescriptions (odds ratio [OR], 1.20; 95% confidence interval [CI], 0.83–1.73) except in patients of Indian ethnicity (OR, 0.28; 95% CI, 0.09–0.93). Positive associations between the intervention and the view that antibiotics were not needed most of the time for URTIs (P = 0.047) and on being worried about the side effects of antibiotics (P = 0.018) were restricted to the Indian subgroup. GPs in limited liability partnerships or clinic chains prescribed less (OR, 0.36; 95% CI, 0.14 to 0.92), while certain inappropriate patient responses were associated with the receipt of antibiotics. Follow-up studies to investigate differences in responses to educational programs between ethnicities and to explore GP-targeted interventions are recommended.

Risk Factors For and Outcomes of Multidrug-Resistant Escherichia coli Infections in Children.

IntroductionThe recent increase in multidrug-resistant (MDR) Escherichia coli infections is not well described in children. We determined the risk factors and outcomes of extraintestinal E. coli infections in children in our region.MethodsWe conducted a retrospective cohort study of children ≤18 years in Olmsted County, MN, USA, between January 1, 2012 and December 31, 2012. MDR isolates were defined as resistant to ≥3 antibiotic classes.ResultsA total of 368 children each contributed 1 isolate. Isolates were predominantly community-associated (82%) and from urine (90%), and outpatients (86%); 46 (13%) isolates were MDR. In multivariable analysis, genitourinary (GU) tract anomaly (OR 2.42, 95% CI 1.03–5.68), invasive devices (OR 3.48, 95% CI 1.37–8.83) and antibiotic use at presentation (OR 2.62, 95% CI 1.06–6.47) were associated with MDR E. coli. Children with MDR infections were more likely to have a complex infection (35% vs. 17%, P = 0.026), less likely to receive effective empiric antibiotics (47% vs. 74%, P < 0.001), had longer time to receipt of effective antibiotics (median 19.2 vs. 0.6 h, P < 0.001), and longer hospitalization (median 10 vs. 4 days, P = 0.029) than children with non-MDR infections.ConclusionPediatric MDR E. coli infection was associated with GU tract anomaly, invasive devices, antibiotic use, delays in effective therapy and longer hospitalization.

Variability in Antibiotic Prescribing for Community-Acquired Pneumonia.

Published guidelines recommend amoxicillin for most children with community-acquired pneumonia (CAP), yet macrolides and broad-spectrum antibiotics are more commonly prescribed. We aimed to determine the patient and clinician characteristics associated with the prescription of amoxicillin versus macrolide or broad-spectrum antibiotics for CAP. Retrospective cohort study in an outpatient pediatric primary care network from July 1, 2009 to June 30, 2013. Patients prescribed amoxicillin, macrolides, or a broad-spectrum antibiotic (amoxicillin-clavulanic acid, cephalosporin, or fluoroquinolone) for CAP were included. Multivariable logistic regression models were implemented to identify predictors of antibiotic choice for CAP based on patient- and clinician-level characteristics, controlling for practice. Of 10 414 children, 4239 (40.7%) received amoxicillin, 4430 (42.5%) received macrolides and 1745 (16.8%) received broad-spectrum antibiotics. The factors associated with an increased odds of receipt of macrolides compared with amoxicillin included patient age ≥5 years (adjusted odds ratio [aOR]: 6.18; 95% confidence interval [CI]: 5.53-6.91), previous antibiotic receipt (aOR: 1.79; 95% CI: 1.56-2.04), and private insurance (aOR: 1.47; 95% CI: 1.28-1.70). The predicted probability of a child being prescribed a macrolide ranged significantly between 0.22 and 0.83 across clinics. The nonclinical characteristics associated with an increased odds of receipt of broad-spectrum antibiotics compared with amoxicillin included suburban practice (aOR: 7.50; 95% CI: 4.16-13.55) and private insurance (aOR: 1.42; 95% CI: 1.18-1.71). Antibiotic choice for CAP varied widely across practices. Factors unlikely related to the microbiologic etiology of CAP were significant drivers of antibiotic choice. Understanding drivers of off-guideline prescribing can inform targeted antimicrobial stewardship initiatives.

Risk Factors for Outpatient Use of Antibiotics in Children with Acute Respiratory Illnesses.

Antibiotics for acute respiratory illness (ARI) constitute most pediatric medication use and contribute to the emergence of antimicrobial resistance. We investigated antibiotic prescription risk factors for ARI in pediatric clinics and clinical follow-up in individuals prescribed and not prescribed antibiotics. In this observational study, we enrolled children ages 2 to 17 years old presenting with ARI with fever to two academic pediatric primary care outpatient clinics during influenza season 2013-2014. We collected information on demographics, initial symptoms, medical conditions, laboratory tests, discharge diagnoses, treatments, and 30 days of follow-up medical encounters. Factors associated with antibiotic prescription receipt were evaluated using logistic regression. Of 206 consented and enrolled children, 59 (29%) were prescribed antibiotics, 51 of 59 (86%) for indicated diagnoses: 34 for streptococcal pharyngitis, 15 for acute otitis media (AOM), and 2 for pneumonia. Discharge diagnoses were the only factors independently associated with an antibiotic prescription. Of children prescribed/not prescribed an antibiotic, 17%/17% received follow-up telephone calls and 27%/17% had follow-up visits related to ARI within 30 days. Two children with AOM were prescribed a second antibiotic during follow-up, and one developed Clostridium difficile colitis. Eighteen of 206 (9%) additional children were prescribed antibiotics within 30 days for ARI symptoms, 17 for streptococcal pharyngitis, AOM, pneumonia, or sinusitis; one was prescribed antibiotics for influenza-like illness. Among study children 2 to 17 years old with outpatient ARI, 29% were prescribed antibiotics at the initial visit and another 9% were prescribed antibiotics during the 30-day follow-up (most were for appropriate indications). Further decreasing antibiotic use in similar settings will likely require wider implementation of watchful waiting for AOM, a change in guidelines for pharyngitis management, and/or reductions in these diseases.

Effect of prior receipt of antibiotics on the pathogen distribution and antibiotic resistance profile of key Gram-negative pathogens among patients with hospital-onset urinary tract infections

BackgroundThis retrospective cohort study characterized the impact of prior antibiotic exposure on distribution and nonsusceptibility profiles of Gram-negative pathogens causing hospital-onset urinary tract infections (UTI).MethodsHospital patients with positive urine culture for Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and other Enterobacteriaceae ≥3 days after hospital admission were included. Assessment outcomes included the distribution of bacteria in urine cultures, antibiotic susceptibility patterns, and the effect of prior antibiotic exposure, defined as 0, 1, or ≥2 prior antibiotics, on the distribution and antibiotic susceptibility profiles of the Gram-negative organisms.ResultsThe most commonly isolated pathogens from 5574 unique UTI episodes (2027 with and 3547 without prior antibiotic exposure) were E. coli (49.5%), K. pneumoniae (17.1%), and P. aeruginosa (8.2%). P. aeruginosa was significantly more commonly isolated in patients with ≥2 prior antibiotic exposures (12.6%) compared with no exposure (8.2%; p = 0.036) or 1 prior exposure (7.9%; p = 0.025). Two or more prior antibiotic exposures were associated with slightly higher incidences of fluoroquinolone nonsusceptibility, multidrug resistance, and extended-spectrum β-lactamase phenotype compared with 0 or 1 exposure, suggesting an increased risk for resistant Gram-negative pathogens among hospital patients with urinary tract infections occurring ≥3 days after admission.ConclusionsClinicians should critically assess prior antibiotic exposure when selecting empirical therapy for patients with hospital-onset urinary tract infections caused by Gram-negative pathogens.