Uncomplicated Community-acquired Pneumonia Research Articles

Controversies in the management of community-acquired pneumonia in adults.

Community-acquired pneumonia (CAP) is a common infectious syndrome in Australia and a leading global cause of morbidity and mortality. It drives a significant amount of antimicrobial prescribing in Australia. Accurate assessment and stratification of CAP severity is important. However, adequate evaluation is challenging and controversy remains about the optimal method. Streptococcus pneumoniae is the most commonly identified bacterial pathogen causing CAP. As such, oral amoxicillin monotherapy is the mainstay of empirical therapy for low-severity CAP. The need to start empirical therapy for pathogens such as Mycoplasma pneumoniae and Legionella species in low-severity CAP remains controversial; evaluating the causative pathogen on clinical grounds alone is difficult. Oral antibiotics recommended for CAP (e.g. amoxicillin, doxycycline) have excellent bioavailability and may be used instead of intravenous therapy in some hospitalised patients. A duration of 5 days of antibiotic therapy is recommended in clinical practice guidelines for patients with uncomplicated CAP who meet stability criteria at follow-up.

Length of antibiotic therapy among adults hospitalized with uncomplicated community-acquired pneumonia, 2013-2020.

The 2014 US National Strategy for Combating Antibiotic-Resistant Bacteria (CARB) aimed to reduce inappropriate inpatient antibiotic use by 20% for monitored conditions, such as community-acquired pneumonia (CAP), by 2020. We evaluated annual trends in length of therapy (LOT) in adults hospitalized with uncomplicated CAP from 2013 through 2020. We conducted a retrospective cohort study among adults with a primary diagnosis of bacterial or unspecified pneumonia using International Classification of Diseases Ninth and Tenth Revision codes in MarketScan and the Centers for Medicare & Medicaid Services databases. We included patients with length of stay (LOS) of 2-10 days, discharged home with self-care, and not rehospitalized in the 3 days following discharge. We estimated inpatient LOT based on LOS from the PINC AI Healthcare Database. The total LOT was calculated by summing estimated inpatient LOT and actual postdischarge LOT. We examined trends from 2013 to 2020 in patients with total LOT >7 days, which was considered an indicator of likely excessive LOT. There were 44,976 and 400,928 uncomplicated CAP hospitalizations among patients aged 18-64 years and ≥65 years, respectively. From 2013 to 2020, the proportion of patients with total LOT >7 days decreased by 25% (68% to 51%) among patients aged 18-64 years and by 27% (68%-50%) among patients aged ≥65 years. Although likely excessive LOT for uncomplicated CAP patients decreased since 2013, the proportion of patients treated with LOT >7 days still exceeded 50% in 2020. Antibiotic stewardship programs should continue to pursue interventions to reduce likely excessive LOT for common infections.

Multidisciplinary Initiative to Increase Guideline-concordant Antibiotic Prescription at Discharge for Hospitalized Children with Uncomplicated Community-acquired Pneumonia

Background: Clinical practice guidelines recommend using narrow-spectrum antibiotics to treat uncomplicated pneumonia in children. This quality improvement (QI) project aimed to evaluate if QI methods could improve guideline-concordant antibiotic prescribing at hospital discharge for children with uncomplicated pneumonia. Methods: For this single-center QI project, we implemented QI interventions in serial plan-do-study-act cycles, focusing on the key drivers targeting general pediatric inpatient resident teams. Interventions included: (1)Small bimonthly group didactic sessions, (2)Visual job aids posted in resident work areas, and (3) A noon conference session. Balancing measures included postdischarge emergency room visits, readmission and adverse drug reactions. Results: To establish a baseline rate, we conducted a chart review of 112 children diagnosed with uncomplicated community-acquired pneumonia during hospitalization from July 2017 through January 2019. The average monthly percentage of children discharged with guideline-concordant antibiotics was 67%. The intervention period was from February 2019 through February 2020, with 118 children meeting the criteria after a review of 262 charts. After our interventions, the average monthly percentage of children discharged with guideline-concordant antibiotics increased to 87%, with the increase persisting for at least 12 months. There were no significant differences in balancing measures pre- and post-interventions. Conclusions: Our QI initiative sustained increased rates of uncomplicated community-acquired pneumonia guideline-concordant antibiotic prescribing at discharge over 12 months without an increase in balancing measures. The enduring changes in prescribing behavior suggest a lasting impact of our interventions.

Diagnostic utility of oropharyngeal swabs as an alternative to lower respiratory tract samples for PCR-based syndromic testing in patients with community-acquired pneumonia.

Syndromic PCR-based analysis of lower respiratory tract (LRT) samples in patients with community-acquired pneumonia (CAP) improves the bacterial yield and time-to-results compared to culture-based methods. However, obtaining adequate sputum samples can be challenging and is frequently not prioritized in the emergency department (ED). In this study, we assess the concordance of microbiological detections between oropharyngeal- (OP) and LRT samples from patients presenting to the ED with CAP using a syndromic PCR-based respiratory panel [Biofire FilmArray Pneumonia plus (FAP plus)]. Paired OP- and high-quality LRT samples were collected from 103 patients with confirmed CAP, who had been included in a randomized controlled trial (NCT04660084) or a subsequent observational study at Haukeland University Hospital, and analyzed using the FAP plus. The LRT samples were obtained mainly by sputum induction (88%). Using the LRT samples as a reference standard, the positive percent agreement (PPA), negative percent agreement (NPA), and overall percent agreement for the most common bacterial pathogens in CAP, Streptococcus pneumoniae and Haemophilus influenzae, were 85%, 99% and 95%, and 86%, 98% and 93%, respectively. For Moraxella catarrhalis, the PPA was lower (74%), while the NPA was 100%. For bacteria that are less likely causes of uncomplicated CAP (e.g., Staphylococcus aureus and Enterobacterales) the results were more divergent. In conclusion, the FAP plus detects the most common CAP pathogens S. pneumoniae and H. influenzae from OP samples with high PPAs and excellent NPAs when compared with LRT samples. For these pathogens, the PPAs for OP samples were higher than previous reports for nasopharyngeal samples. This suggests that analysis of OP samples with syndromic PCR panels could represent an alternative approach for rapid microbiological testing in the ED, especially in patients where LRT samples are difficult to obtain. Divergent results for bacteria that are less likely to cause uncomplicated CAP do, however, emphasize the need for clinical evaluation of positive test results.

Novel protein biomarkers for pneumonia and acute exacerbations in COPD: a pilot study.

Community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD) result in high morbidity, mortality, and socio-economic burden. The usage of easily accessible biomarkers informing on disease entity, severity, prognosis, and pathophysiological endotypes is limited in clinical practice. Here, we have analyzed selected plasma markers for their value in differential diagnosis and severity grading in a clinical cohort. A pilot cohort of hospitalized patients suffering from CAP (n = 27), AECOPD (n = 10), and healthy subjects (n = 22) were characterized clinically. Clinical scores (PSI, CURB, CRB65, GOLD I-IV, and GOLD ABCD) were obtained, and interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-2-receptor (IL-2R), lipopolysaccharide-binding protein (LBP), resistin, thrombospondin-1 (TSP-1), lactotransferrin (LTF), neutrophil gelatinase-associated lipocalin (NGAL), neutrophil-elastase-2 (ELA2), hepatocyte growth factor (HGF), soluble Fas (sFas), as well as TNF-related apoptosis-inducing ligand (TRAIL) were measured in plasma. In CAP patients and healthy volunteers, we found significantly different levels of ELA2, HGF, IL-2R, IL-6, IL-8, LBP, resistin, LTF, and TRAIL. The panel of LBP, sFas, and TRAIL could discriminate between uncomplicated and severe CAP. AECOPD patients showed significantly different levels of LTF and TRAIL compared to healthy subjects. Ensemble feature selection revealed that CAP and AECOPD can be discriminated by IL-6, resistin, together with IL-2R. These factors even allow the differentiation between COPD patients suffering from an exacerbation or pneumonia. Taken together, we identified immune mediators in patient plasma that provide information on differential diagnosis and disease severity and can therefore serve as biomarkers. Further studies are required for validation in bigger cohorts.

Analysis of clinical and paraclinical findings in children with community-acquired pneumonia and comorbid chronic tonsillitis

Background. Respiratory morbidity is the most frequent cause for children consulting a doctor, accounting for about one-quarter of primary care consultations. The current research aimed to analyze the clinical and paraclinical features of community-acquired pneumonia (CAP) with comorbid chronic tonsillitis in children and to assess the prognostic value of the proposed diagnostic procedures to optimize the management of patients. Materials and methods. The study was conducted at the Pulmonology and Allergology and Infectious Department of the Municipal Medical Establishment “Chernivtsi Regional Children’s Clinical Hospital”, Ukraine. Clinical group I included 20 children (mean age 9.40 ± 1.56 years) with uncomplicated community-acquired pneumonia and concomitant chronic tonsillitis, and the clinical group II consisted of 16 patients (mean age 9.60 ± 1.13 years) with CAP without concomitant pathology of the upper respiratory tract. Results. Community-acquired pneumonia in children with comorbid chronic tonsillitis is characterized by an intense proinflammatory response in the airways, which manifests itself in fever (odds ratio (OR) 6.0), malaise and fatigue (OR 14.3), persistent cough and dyspnea (OR 3.7), leukocytosis (OR 2.0), high levels of acute phase proteins (OR 4.5), activation of the oxidative protein modification according to the exhaled breath condensate examination (OR 6.0–30.0), and more frequent fungal-bacterial association according to the microbiological examination of sputum and oropharyngeal swab (OR 11.1). The obtained data suggest that parenteral antibiotic therapy was used in 20 % of patients from group I and 12.5 % from group II, while 6.3 % of children from group II received only oral antibiotics. In children with CAP and chronic tonsillitis versus comparison group, the ОR of receiving parenteral antibiotic therapy for longer than 7 days reached 10.0, and the OR of oral antibiotic therapy for longer than 5 days reached 4.0. Conclusions. The results obtained from the study show that children with CAP and comorbid chronic tonsillitis have more pronounced clinical symptoms, accompanied by paraclinical signs of inflammation that last longer during hospital treatment and require comprehensive therapy (OR 3.3) of longer duration (OR 4.0–10.0).

Length of antibiotic therapy among adults aged ≥65 years hospitalized with uncomplicated community-acquired pneumonia, 2013-2020

Background: The 2014 US National Strategy for Combating Antibiotic-Resistant Bacteria aimed to reduce inappropriate inpatient antibiotic use by 20% for monitored conditions, such as community-acquired pneumonia (CAP), by 2020. Clinical guidelines recommend treating uncomplicated CAP with a minimum of 5 days of antibiotic therapy. Total length of therapy (LOT) >7 days or >3 days after clinical improvement is rarely necessary. In a previous study estimating LOT in uncomplicated CAP patients, 71% of patients ≥65 years exceeded recommended duration of antibiotics in 2012–2013 (Yi et al, 2018). We evaluated annual trends in LOT in adults ≥65 years hospitalized with uncomplicated CAP from 2013 to 2020. Methods: We conducted a retrospective cohort study among patients in the CMS database with a primary diagnosis of bacterial or unspecified pneumonia using International Classification of Diseases 9th and 10th Revision codes, length of stay (LOS) of 2–10 days, discharged home with self-care, and not rehospitalized in the 3 days following discharge. Discharge home was used as a surrogate for clinical improvement. Because inpatient LOT is not available in CMS data, we used linear regression to model inpatient LOT as a function of LOS using data on CAP patients ≥65 years from the PINC AI healthcare database. Postdischarge LOT was based on prescriptions filled following discharge. Total LOT was calculated by summing estimated inpatient LOT and actual postdischarge LOT (Fig. 1). Total LOT >7 days and postdischarge LOT >3 days were considered indicators of likely excessive LOT. We reported trends in the proportion of patients with likely excessive LOT during the study period. Results: From 2013 through 2020, there were 400,928 uncomplicated CAP hospitalizations among patients aged ≥65 years. Patients were more likely to be female (55%), and they had a median age of 76 years and a median LOS of 3 days. The median total LOT decreased from 9.5 days in 2013 to 7.7 days in 2020. The proportion of patients with total LOT >7 days decreased from 68% in 2013 to 50% in 2020 (% change, −27%); the proportion with postdischarge LOT >3 days decreased from 73% in 2013 to 62% in 2020 (% change, −16%) (Fig. 2). Conclusions: Likely excessive total LOT for adults ≥65 years hospitalized with uncomplicated CAP decreased by 27% in 2020, a considerable improvement from 2013. However, the high proportion of patients with likely excessive postdischarge LOT in 2020 (62%) demonstrates the need for antibiotic stewardship to optimize prescribing at hospital discharge.Disclosures: None

Electronic phenotyping of community-acquired pneumonia: A tool for inpatient syndrome-specific antimicrobial stewardship

Background: Using patient data from the electronic health record (EHR) and computer logic, an “electronic phenotype” can be created to identify patients with community-acquired pneumonia (CAP) in real time to assist with syndrome-specific antimicrobial stewardship efforts.1 We adapted and validated the performance of an inpatient CAP electronic phenotype for antimicrobial stewardship interventions. Methods: An automated scoring system was created within the EHR (Epic Systems) to identify hospitalized patients with CAP based on the variables and logic listed in Fig. 1B. We adapted a score used by the Michigan Hospital Medicine Safety Consortium (HMS) to identify patients with CAP, with additions made to improve sensitivity (Fig. 1).1 The score can be displayed in a column within the EHR patient list (Fig. 2). We validated the electronic phenotype via chart review of all hospitalized patients on systemic antimicrobials admitted to a medicine team consecutively between November 8 and 18, 2021. Patients who were readmitted within the validation time frame were excluded. We assessed the performance of the electronic phenotype by comparing the score to manual chart review, where “CAP diagnosis” was defined as (1) mention of “pneumonia” or “CAP” as part of the differential diagnosis in the admission documentation, (2) antimicrobials were started within 48 hours of admission, and (3) radiographic findings were suggestive of pneumonia. After initial evaluation, the scoring system was adjusted, and performance was re-evaluated during prospective audit and feedback performed on EHR CAP–positive patients over 13 days between July 2022 and December 2022. Results: We included 191 patients in our initial validation cohort. The CAP score had high sensitivity (95.83%), specificity (92.2%), and negative predictive value (99.35%), though lower positive predictive value (63.89%) was noted (Table 2). The rules were further refined to include bloodstream infection only with Haemophilus influenza or Streptococcus pneumoniae in rule 2B, and azithromycin was removed from “CAP antibiotics.” After these changes, repeated evaluation of 88 patients with positive CAP EHR score was performed, and only 20 (23%) were considered false-positive results. Conclusions: Electronic phenotypes can be used to create automated tools to identify patients with CAP with reasonable performance. Data from this tool can be used to guide more focused antimicrobial stewardship interventions and clinical decision support in the future. Reference: Vaughn VM, et al. A statewide collaborative quality initiative to improve antibiotic duration and outcomes in patients hospitalized with uncomplicated community-acquired pneumonia. Clin Infect Dis 2022;75:460–467.Disclosures: None

Antibiotic treatment duration for community-acquired pneumonia in children.

A 4-year-old child was seen in our clinic with a clinical presentation consistent with community-acquired pneumonia (CAP). He was prescribed oral amoxicillin and a colleague asked about the duration of treatment. What is the current available evidence for treatment duration for uncomplicated CAP in an outpatient setting? Previously the recommended duration of antibiotic treatment of uncomplicated CAP was 10 days. Recent evidence from several randomized controlled trials suggests that a 3- to 5-day duration is noninferior to a longer treatment course. In an effort to prescribe the shortest effective duration of antibiotics to minimize the risk of antimicrobial resistance associated with prolonged antibiotic use, family physicians should offer 3 to 5 days of appropriate antibiotics and monitor the recovery of children with CAP.

Empiric antibiotic selection for community-acquired pneumonia in US hospitals, 2013–2020

Background: Community-acquired pneumonia (CAP) is a common indication for antibiotic prescribing in hospitalized patients. Professional societies’ clinical guidelines recommend specific antibiotics for empiric treatment of CAP based on clinical factors. Manual assessments of appropriateness are time-consuming and are often conducted on a smaller scale. We evaluated empiric antibiotic selection among a large cohort of adults hospitalized with CAP using electronic health records. Methods: In this study, we used the PINC-AI healthcare database to define a cohort of adults hospitalized with CAP from 2013 to 2020. CAP was identified by International Classification of Diseases (ICD) diagnosis codes. Exclusions were applied to identify uncomplicated CAP (Fig. 1). Treatment was only evaluated if a chest radiograph or computerized tomography (CT) scan was charged during the first 2 days of hospitalization, otherwise it was considered an inadequate CAP evaluation. Administrative billing data were used to identify antibiotics charged within the first 2 days of hospitalization. Empiric guideline-recommended treatment was determined based on 2019 CAP guidelines and more recent studies. Patients who received nonrecommended treatment were evaluated for antibiotic allergies in the current hospitalization or methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection in the year prior or on admission using International Classification of Disease, Tenth Revision (ICD-10) diagnosis codes. Results: We identified 4.47 million adult hospitalizations with CAP from 2013 to 2020; 32% (1.43 million) were included in this analysis (Fig. 1). Among discharges with adequate CAP evaluation (1.37 million), 59.7% received recommended antibiotics in the first 2 days of hospitalization, ranging from 62.6% in 2013 to 57.5% in 2019. Overall, 34.8% of our study population received a nonrecommended antibiotic without documentation of an antibiotic allergy or MRSA colonization (2013: 32.5%; 2018: 36.7%) (Fig. 2). Most patients in our study population received >1 antibiotic (92.3%) in the first 2 days of hospitalization. The most common antibiotics among patients receiving recommended treatment were ceftriaxone (74.2% of patients receiving recommended treatment), azithromycin (67.2%), and levofloxacin (31.8%) (Fig. 3a). The most common nonrecommended antibiotics were vancomycin (57.2% of patients receiving nonrecommended treatment), piperacillin-tazobactam (48.1%), and cefepime (25.7%) (Fig. 3b). From 2013 to 2020, cefepime charges consistently increased among CAP patients treated with nonrecommended antibiotics, whereas levofloxacin charges consistently decreased among CAP patients treated with only recommended antibiotics. Conclusions: Approximately one-third of patients with uncomplicated CAP received nonrecommended empiric antibiotics, and from 2013 to 2020 that proportion increased by 9%. Additional strategies are needed to help identify opportunities to optimize antibiotic selection among patients with CAP.Disclosures: None

Terapia per la polmonite acquisita in comunità non complicata in bambini in età prescolare dimessi a domicilio: confronto tra Amoxicillina a basso o alto dosaggio per 3 o 7 giorni. I risultati del RCT inglese CAP-IT

Therapy for uncomplicated community-acquired pneumonia in preschool children discharged from ED: comparison of low-dose or high-dose Amoxicillin for 3 or 7 days. Results of the English RCT CAP-IT This study is the first one performed in Western countries that used a 3-day therapy for uncomplicated community-acquired pneumonia (CAP), already tested several times in low- and medium-income countries. This study, carried out in UK, is a double-blind RCT of good methodological quality. The study compared the efficacy of 4 different therapeutic regimens by dose (high or low) and by duration (3 or 7 days) versus placebo, in the treatment of 824 children older than 6 months and weighing between 6 and 24kg with CAP, discharged from emergency room or hospital. Approximately 12% of cases across all regimens require further antibiotic therapy for a new respiratory infection within 28 days from randomization; 5% of children enrolled experienced a severe adverse event requiring hospitalization. Both groups demonstrated noninferiority with no significant interaction between doses and duration. In the subgroup with more severe symptoms at enrolment (i.e., those with at least two altered thoracic physiologic parameters) 17.3% of recipients of a lower dose versus 13.5% of those treated with the higher dose require additional antibiotic therapy by 28th day, but the difference is not statistically significant. The limitations related to the non-inferiority design and the composition of the studied population, which limit the transferability of the results, are discussed.

The Role of Computed Tomography in Diagnosing and Treating Community-Acquired Bacterial or Viral Pneumonia in Children

Diagnostic imaging plays a significant role in both the diagnosis and treatment of complications of pneumonia in children and chest radiography is the imaging modality of choice. Computed tomography (CT) on the other hand, is not currently a first-line imaging tool for children with suspected uncomplicated community-acquired pneumonia and is largely reserved for when complications of pneumonia are suspected or there is difficulty in differentiating pneumonia from other pathology. This review outlines the situations where CT needs to be considered in children with pneumonia, describes the imaging features of the parenchymal and pleural complications of pneumonia, discusses how CT may have a wider role in developing countries where human immunodeficiency virus (HIV) and tuberculosis are prevalent, makes note of the role of CT scanning for identifying missed foreign body aspiration and, lastly, addresses radiation concerns.

1810. Trends in the Length of Antibiotic Therapy Among Hospitalized Adults with Uncomplicated Community-Acquired Pneumonia, 2013-2020

Abstract Background The 2014 United States National Strategy aimed to reduce inappropriate inpatient antibiotic use by 20% for monitored conditions by 2020. The Hospital Core Elements of Antibiotic Stewardship highlight opportunities to improve treatment of common infections, including optimizing length of therapy (LOT) for community-acquired pneumonia (CAP). A minimum of 5 days of antibiotic therapy for patients with uncomplicated CAP is recommended, with > 7 days, or > 3 days after clinical improvement, rarely necessary. In this study, we evaluated annual trends in LOT from 2013-2020. Methods We conducted a retrospective cohort study using IBM MarketScan® database to evaluate LOT annual trends among adults 18-64 years in the United States hospitalized with uncomplicated CAP from 2013-2020. We included patients with a primary diagnosis of bacterial or unspecified pneumonia using International Classification of Diseases 9th and 10th revision codes, length of stay (LOS) of 2-10 days, discharged home with self-care, and not re-hospitalized in the 3 days following discharge. Discharge home was used as a surrogate for clinical improvement. We obtained inpatient LOS and post-discharge LOT data from MarketScan. We estimated annual inpatient LOT based on LOS from the Premier Healthcare Database (PHD). Total LOT was calculated by summing predicted inpatient LOT (from PHD) and actual post-discharge LOT (from MarketScan). Proportion of total LOT > 7 days and post-discharge LOT > 3 days were considered indicators of likely excessive LOT. Results There were 44,976 uncomplicated CAP hospitalizations among patients 18–64 years in MarketScan, 2013-2020. Patients had a median age of 54 years, median LOS of 3 days, were more likely to be female (56%) and in the South region (49%). The median LOT decreased from 9.6 days in 2013 to 8.6 days in 2020. The proportion of patients with total LOT > 7 days decreased from 68% in 2013 to 51% in 2020 (% change: -25%); the proportion with post-discharge LOT > 3 days decreased from 73% in 2013 to 63% in 2020 (% change: -14%; Figure 1). Conclusion The proportion of CAP patients with likely excessive LOT decreased by 25% from 2013-2020, surpassing the 2020 goal. Antibiotic stewardship programs should continue to pursue interventions to reduce excessive length of therapy for common infections. Disclosures All Authors: No reported disclosures.

566. The Impact of a Clinical Practice Guideline and Educational Interventions on the Management of Children Hospitalized with Uncomplicated Community Acquired Pneumonia

Abstract Background The 2011 guidelines for management of pediatric uncomplicated community acquired pneumonia (CAP) recommend the use of ampicillin or penicillin first line. We sought to evaluate improvement in adherence to these guidelines through antimicrobial stewardship interventions at a single institution to minimize unnecessary broad antimicrobials. Methods A retrospective chart review was conducted of admitted patients aged 2 months - 21 years old with uncomplicated CAP. The pre-intervention phase was September 1, 2019-February 29, 2020 and the post-intervention phase included September 1-February 28 of 2021 and 2022. Antimicrobial stewardship interventions included the incorporation of clinical practice guidelines (CPG) into a new institutional CAP pathway (approved in June 2020) and subsequent education to ordering providers in the spring of 2020. Patients with complicated pneumonia or with comorbidities including sickle cell disease, chronic lung disease, neurologic conditions, congenital heart disease or patients who were immunocompromised were excluded. The prescribing patterns of specific physicians were recorded and adherence to CPG recommendations were assessed. The primary endpoint was to measure the reduction of broad spectrum antibiotics (vancomycin, clindamycin, ceftriaxone, levofloxacin and cefdinir) to narrow spectrum antibiotics (ampicillin, amoxicillin, and amoxicillin-clavulanate). Results A total of 114 patients were included in the study; 72 pre-intervention and 42 post-intervention. Mean age was 5.4 years pre- and 6.5 years post-intervention. A significant reduction in broad spectrum antibiotic use was noted in the ED (p=< 0.0001), during the first 24 hours of admission (p=0.0034) and for discharge antibiotics (p=0.0003) (Figures 1-3) between the pre- and post-intervention groups. Guideline adherence was 78.5%. No change in length of stay or treatment failure were observed. Antibiotic Prescriptions in the Emergency Department After the implementation of the CPG guideline there was a 17% reduction in the number of times a combination of antibiotics were used, a 7.2% reduction of broad spectrum antibiotics and a 24% increase in the utilization of narrow spectrum antibiotics, p-value= <0.0001. Antibiotic Utilization 24 hours After Hospital Admission After the implementation of the CPG guideline there was a 20% reduction in the number of times a broad spectrum antibiotic was prescribed, p-value =0.0034. Discharge Antibiotic Prescriptions After the implementation of the CPG guideline there was a 18% reduction of broad spectrum antibiotics and a 34% increase in the utilization of narrow spectrum antibiotics, p=0.0003. Conclusion The CPG and educational interventions had a positive impact on the antibiotic management of children hospitalized, with an overall 4.7% reduction of broad spectrum antibiotics and a 28% increase in the utilization of narrow spectrum antibiotics. Continued education may improve CPG adherence. Disclosures All Authors: No reported disclosures.

554. Discharge Antibiotic Prescribing at Children’s Hospitals with Established Antimicrobial Stewardship Programs

Abstract Background Antibiotic stewardship programs optimize antibiotic use in hospitalized children, but most do not routinely review antibiotic prescriptions at discharge. Up to 30% of discharged children receive additional days of antibiotics, and one single-center study found that 27% of discharge prescriptions were suboptimal. Methods We conducted a retrospective cohort study to evaluate duration of therapy (DOT) and antibiotic choice for children < 18 years admitted to 4 children’s hospitals from January 1, 2019 - December 31, 2019 and prescribed antibiotics at discharge for uncomplicated community-acquired pneumonia (CAP), skin and soft tissue infection (SSTI), or urinary tract infection (UTI). We excluded children with complex medical conditions, > 1 infection requiring antibiotics, > 7 day hospital stay, or intensive care unit stay. The primary outcomes were the percentage of subjects prescribed optimal (1) total (inpatient plus outpatient) DOT (4-6 days for CAP and SSTI, ≤8 days for UTI), and (2) antibiotic choice (CAP: amoxicillin; SSTI: clindamycin, amoxicillin-clavulanate, cephalexin, or trimethoprim-sulfamethoxazole (TMP/SMX); UTI: cephalexin, amoxicillin, amoxicillin-clavulanate, TMP/SMX, or nitrofurantoin) based on current national guidelines and available evidence. Results 2105 encounters were included: 783 CAP, 916 SSTI, and 406 UTI. Median age was 4 years and 49% were female. DOT for each condition are shown in Figure 1 and antibiotic choice in Figure 2. Antibiotic choice was optimal for 66% with CAP, 98% with SSTI, and 88% with UTI. DOT was optimal for 11% with CAP, 4% with SSTI, and 21% with UTI. Both DOT and choice were optimal for 2% with CAP, 4% with SSTI, and 19% with UTI. For all indications, antibiotic choice was optimal for 84% and DOT was optimal for 10%, while only 6% of antibiotic courses included both optimal DOT and antibiotic choice. Total duration of therapy for 2105 children discharged with antibiotics for community-acquired pneumonia, urinary tract infection, and skin and soft tissue infection. Figure 1.Median duration of antibiotic therapy prescribed for 783 children with community-acquired pneumonia, 406 with urinary tract infection, and 916 with skin and soft tissue infection. The box and whiskers within each plot depict the median (white dot), interquartile range (box) and 5th/95th percentiles (whiskers); the width of each plot represents the number of courses that received that value for overall antibiotic duration. Discharge antibiotic choices for 2105 children with community-acquired pneumonia, urinary tract infection, and skin and soft tissue infection. Figure 2.The most commonly prescribed antibiotics at discharge for 2105 children with community-acquired pneumonia, urinary tract infection, or skin and soft tissue infection. Percentages based on total number of antibiotic prescriptions. Other antibiotics include: Cefadroxil, Cefdinir, Cefixime, Doxycycline, Levofloxacin, Linezolid, Nitrofurantoin, trimethoprim-sulfamethoxazole. Conclusion At 4 children’s hospitals with established antimicrobial stewardship programs, 94% of discharge antibiotic courses for CAP, UTI, and SSTI were suboptimal either by choice of antibiotic or duration of therapy. Discharge antibiotic prescribing represents a significant opportunity to improve antibiotic use in children. Disclosures Jason Newland, MD, AHRQ: Grant/Research Support|Merck: Grant/Research Support|NIH: Grant/Research Support|PEW Charitable Trust: Grant/Research Support|Pfizer: Grant/Research Support.

Novel care pathway to optimise antimicrobial prescribing for uncomplicated community-acquired pneumonia: study protocol for a prospective before–after cohort study in the emergency department of a tertiary care Canadian children’s hospital

IntroductionEvidence-based recommendations for paediatric community-acquired pneumonia (CAP) diagnosis and management are needed. Uncomplicated CAP is often caused by respiratory viruses, especially in younger children; these episodes self-resolve without antibiotic treatment....

Shorter versus longer duration of Amoxicillin-based treatment for pediatric patients with community-acquired pneumonia: a systematic review and meta-analysis.

These findings suggest that a short course of Amoxicillin (5days) is just as effective as a longer course (10days) for uncomplicated CAP in children under 10years old. Nevertheless, generalizations should be made with caution considering the socioeconomic settings of the studies included.PROSPERO Identifier: CRD42022328519. •In the outpatient setting, a few international guidelines recommend a 10-day Amoxicillin course as first-line treatment for community-acquired pneumonia (CAP). • Recent trials have shown that shorter courses of Amoxicillin may be as effective as 10-day regimens in uncomplicated pneumonia. •When comparing 5-day to 10-day Amoxicillin regimens, evidence suggests no significant difference in clinical cure rates for uncomplicated CAP in outpatient settings. • Generalizations should be made with caution considering the socioeconomic context of the population within the included studies.

Antibiotic Use and Outcomes in Young Children Hospitalized With Uncomplicated Community-Acquired Pneumonia.

BackgroundWe aimed to compare children aged 36 months or younger hospitalized with uncomplicated community-acquired pneumonia (CAP) who are not treated with antibiotics to those treated with antibiotics in terms of clinical features and outcome measures.MethodsAdministrative data and medical record review were used to identify patients from 3 to 36 months of age hospitalized from 2011 to 2019 with uncomplicated CAP. Patients were considered treated if they received antibiotics for >2 inpatient days and/or at discharge, and not treated if they received ≤2 inpatient days and no antibiotics at discharge. Untreated patients were compared to treated patients based on demographic features, clinical and laboratory results, and outcomes of interest, including illness severity, length of stay, and 30-day hospital readmissions.ResultsThree hundred twenty-two CAP cases were included; 266 (83%) received antibiotics for >48 hours and/or at discharge. Fifty-six patients received ≤2 inpatient days of antibiotics and no antibiotics at discharge; the majority received no inpatient antibiotics. There were no differences between the 2 groups in illness severity, length of stay, or hospital readmissions. The proportion of patients treated with antibiotics decreased from 88% (2011–2013) to 66% during the most recent years studied (2017–2019).ConclusionsThere was no difference in outcome of uncomplicated CAP in previously healthy children <36 months of age between those treated and not treated with antibiotics. Additional tools are needed to facilitate identification of viral CAP in young children and decrease unnecessary antibiotic use.

Інформативність загальноприйнятих запальних маркерів крові у верифікації гострих інфекційно-запальних процесів нижніх дихальних шляхів у дітей

Verification of acute infectious inflammatory processes of the lower respiratory tract and indication for antibiotic therapy are often based on the evaluation of the activity of inflammatory blood markers, but the data on their informative value in the diagnosis of acute pneumonia and bronchitis in children are controversial and conflicting. Purpose - to study the diagnostic value of some inflammatory blood markers in the verification of uncomplicated community-acquired pneumonia and acute obstructive bronchitis with the purpose of management’s optimization of infectious inflammatory diseases of the lower respiratory tract in children. Materials and methods. At the pulmonological department of the Regional children’s clinical hospital in Chernivtsi city 75 children have been examined. In the I clinical group 51 patients with diagnosis of «community-acquired pneumonia» were enrolled, and the second (II) group consisted of 24 children with acute obstructive bronchitis. According to the main clinical characteristics, the comparison groups have been comparable. The results of the study have been analyzed by parametric («P», Student’s criterion) and non-parametric («Рφ», Fisher’s angular transform method) calculation methods, and methods of clinical epidemiology with an evaluation of the diagnostic value of the tests has been performed taking into account their sensitivity (Se) and specificity (Sp), as well as the odd ratio (OR) of the event, taking into account their 95% confidence intervals (95% CI). Results. The analysis of the obtained dada has showed that in the patients with community-acquired pneumonia such common inflammatory blood markers (leukocytosis, relative neutrophilosis, shift of leukocyte formula to the left, elevation of erythrocyte sedimentation rate (ESR) or high level of С-reactive protein - CRP) are characterized by low sensitivity (Se in range between 11% and 63%) indicating that they are inadvisable for use as the screening tests for the verification of pneumonia. At the same time, it has been shown that these inflammatory blood markers are characterized by sufficient specificity (in the range from 75% to 93%) in the verification of pneumonia only under their significant increase (total leukocyte count &gt;15.0x10⁹, ESR &gt;10 mm/h and СRP level in blood &gt;6 mg/ml), indicating that they are relevant enough, but only for confirming inflammation of the lung parenchyma. It has been found that the normal level of leukocytes (&lt;10.0x109) in the hemogram did not have sufficient diagnostic (the number of false-negative and false-positive results was 46% and 45%, respectively) or probable predictor role (OR=1.44; 95%CI: 0.54-3.81) in the diagnosis of acute obstructive bronchitis, and therefore could not influence the composition of etiotropic treatment, namely to cancellation of antibiotic therapy. However, the number of rod neutrophils ≤5% in the common blood count has been characterized by a small number (16%) of false-positive results, which allows the use of this marker as confirming the diagnosis of acute obstructive bronchitis, and as well, as indication for antibiotic therapy discontinuation, but not as a predictor (OR=2.21; 95% CI: 0.69-7.06) or screening index (Se=29%). Conclusions. Analysis of the data has showed that in children with community-acquired pneumonia such common indicators of inflammatory response (leukocytosis, relative neutrophilia, shift of leukocyte formula to the left, acceleration of ESR or high CRP level in the blood) are characterized by a large proportion of false-negative results, and thus indicates the inexpediency of their use as screening methods to verify pneumonia. At the same time, it has been shown that these inflammatory blood markers are characterized by sufficient specificity in the verification of pneumonia under their significant increase (number of blood leukocytes &gt;15.0 x10⁹, ESR ≥10 mm/h and CRP level &gt;6mg/ml), which indicates the possibility of their use to confirm inflammation of the lung parenchyma. Herewith the number of rod neutrophils in the hemogram ≤5% is characterized by a high specificity (Sp=84%), which allows to use this marker in confirming the diagnosis of acute obstructive bronchitis and, as well as, an indication for antibiotic therapy cancellation. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: community-acquired pneumoniae; obstructive bronchitis; children; markers of a blood inflammatory response; diagnostical value.

Development and Use of a Calculator to Measure Pediatric Low-Value Care Delivered in US Children’s Hospitals

The scope of low-value care in children's hospitals is poorly understood. To develop and apply a calculator of hospital-based pediatric low-value care to estimate prevalence and cost of low-value services. This cross-sectional study developed and applied a calculator of hospital-based pediatric low-value care to estimate the prevalence and cost of low-value services among 1 011 950 encounters reported in 49 US children's hospitals contributing to the Pediatric Health Information System (PHIS) database. To develop the calculator, a multidisciplinary stakeholder group searched existing pediatric low-value care measures and used an iterative process to identify and operationalize relevant hospital-based measures in the PHIS database. Children with an eligible encounter in 2019 were included in the calculator-applied analysis. Two cohorts were analyzed: an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort. Eligible condition-specific hospital encounters. The proportion and volume of encounters in which low-value services were delivered and their associated standardized costs. Measures were ranked by those outcomes. There were 1 011 950 encounters eligible for 1 or more of 30 calculator-included measures in 2019; encounters were incurred by 816 098 unique patients with a median age of 3 years (IQR, 1-8 years). In the emergency department cohort, low-value services delivered in the greatest percentage of encounters were Group A streptococcal testing among children younger than 3 years with pharyngitis (3679 of 9785 [37.6%]), computed tomography scan for minor head injury (7541 of 42 602 [17.7%]), and bronchodilators for treatment of bronchiolitis (8899 of 55 616 [16.0%]). In the hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics in the treatment of community-acquired pneumonia (3406 of 5658 [60.2%]), acid suppression therapy for infants with esophageal reflux (3814 of 7507 of [50.8%]), and blood cultures for uncomplicated community-acquired pneumonia (2277 of 5823 [39.1%]). Measured low-value services generated nearly $17 million in total standardized cost. The costliest services in the emergency department cohort were computed tomography scan for abdominal pain (approximately $1.8 million) and minor head injury (approximately $1.5 million) and chest radiography for asthma (approximately $1.1 million). The costliest services in the hospitalized cohort were receipt of 2 or more concurrent antipsychotics (approximately $2.4 million), and chest radiography for bronchiolitis ($801 680) and asthma ($625 866). This cross-sectional analysis found that low-value care for some pediatric services was prevalent and costly. Measuring receipt of low-value services across conditions informs prioritization of deimplementation efforts. Continued use of this calculator may establish trends in low-value care delivery.