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Improved patient care may result with use of pediatric-specific antibiograms
Pediatric-specific antibiograms, with updated information on emerging resistant patterns and percentage susceptibilities may be of use in hospitals, according to study results published online.
Joel C. Boggan, MD, MPH, associate professor of pediatrics at the University of North Carolina in Chapel Hill, and colleagues examined data collected between July 2009 and September 2010 on 375 pediatric Escherichia coli isolates.
The researchers posed “case-based vignettes” to hospital residents and faculty, first with no antibiogram, another with a hospital-wide antibiogram, and the final with a pediatric-specific antibiogram.
The researchers said those providers who had the pediatric antibiogram were more likely to have suitable antibiotic choices across scenarios. “Effective antibiotic choices increased from 32.4% to 57.4% to 79.4%,” the researchers said.
Because antibiotic susceptibilities typically vary by age group, it is important to have specific knowledge to help guide antibiotic choices for specific wards, they said.
Boggan and colleagues concluded that given the lack of additional resources required of clinical microbiology laboratories, pediatric providers may want to urge their own laboratories to make this data available to physicians.
“With the increasing emphasis on improving both clinical outcomes and overall quality of care, reporting pediatric-specific susceptibility data contributes to both goals,” Boggan told Infectious Diseases in Children. “Considering that this data is already routinely collected by laboratories, we should be using the most up-to-date and relevant information to improve the care of our pediatric patients”
The researchers also called for broader studies that look at antimicrobial susceptibility patterns in an array of organisms, and also involving a larger number of clinicians, to confirm their findings.
Disclosure: Dr. Boggan and colleagues report no relevant financial disclosures.
Perspective
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Antibiotic resistance is a major public health problem. Infections caused by resistant bacteria generally lead to worse clinical outcomes than infections caused by susceptible bacteria. Unfortunately, the increase in antibiotic resistance has limited the availability of effective therapies for even the most common types of infections. This emerging threat of antibiotic resistance has prompted many organizations, including the National Institute of Allergy and Infectious Diseases, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society, to focus on improving antibiotic prescribing.
Boggan and colleagues used clinical vignettes to examine the impact of distributing antibiograms, which report bacteria-specific antibiotic susceptibility profiles, on antibiotic prescribing. Their goal was to determine whether clinicians would alter their prescribing behavior in a commonly encountered clinical scenario, children with urinary tract infections caused by Escherichia coli, when given access to hospital-wide (adults and children) and pediatric-specific antibiograms. When no antibiogram was provided, physicians selected an antibiotic with 80% or more in vitro effectiveness against E. coli (based on pediatric data) approximately 69% of the time in the scenario of a 3-month-old child with UTI. The proportion of patients receiving appropriate therapy in this scenario increased to 82% with hospital-wide antibiograms and 92% with pediatric-specific antibiograms. Perhaps more worrisome, the proportion of patients receiving appropriate antibiotics in the scenario of a 12-year-old girl with E. coli UTI increased from 32% without access to an antibiogram to 57% when a hospital-wide antibiogram was used, and to 79% when a pediatric-specific antibiogram was used. The authors concluded that the care of pediatric patients could be improved with use of a pediatric-specific antibiogram.
This study highlights several important issues. First, there were important differences in the antibiotic susceptibility patterns in E. coli isolated from adults compared with children. E. coli isolates from children were more likely to be resistant to amoxicillin and trimethoprim-sulfamethoxazole and less likely to be resistant to amoxicillin-clavulanate and ciprofloxacin than E. coli isolates generated from across all age groups. Second, rates of E. coli resistance to TMP-SMX and amoxicillin are increasing. Physicians should reconsider whether these drugs should be used in empiric therapy for children with suspected UTI. Finally, antibiograms can have a meaningful impact on antibiotic prescribing. Therefore, institutions ought to create antibiograms that most accurately reflect the population of interest. Hospitals caring for adults and children should consider creating separate antibiograms for these two distinct populations.
An important limitation of the study is that the authors used clinical vignettes to obtain treatment preferences; it is not known whether actual prescribing practices in the clinical setting would yield similar findings. Even if actual prescribing practices mirror the survey responses, additional challenges remain. For example, antibiotic susceptibility classifications (sensitive, intermediate and resistant) are based on achievable antibiotic serum concentrations. However, most antibiotics used to treat UTIs are cleared by the kidney. The end result is that antibiotic concentrations in the kidney and bladder far exceed the drug concentrations in the serum. Therefore, some antibiotics to which a bacterium is classified as “resistant” may still be clinically effective. We don’t yet fully understand the consequences of discordant antibiotic therapy, initial antibiotic therapy to which the causative bacterium is not susceptible, in children with UTI.
