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Physician compliance with IDSA CAP guidelines varies across care settings
SAN DIEGO — Data presented here at the 2014 AAP National Conference and Exhibition indicate compliance with IDSA guidelines for community-acquired pneumonia is less than ideal and varies among different points of care.
Tiffany L. Milner, MD, of Dartmouth Hitchcock Medical Center in Lebanon, N.H., and colleagues assessed antibiotic prescribing trends among 609 children hospitalized with community-acquired pneumonia (CAP) in an outpatient setting prior to hospitalization, the ED, an inpatient setting, and at discharge across four children’s hospitals. Patients with complex chronic conditions, complicated pneumonia, unimmunized and ICU patients were excluded from the study.
Tiffany L. Milner
“One of the wonderful things about this particular project, where we looked at antibiotics across the continuum of care, is that we looked at four distinct hospitals in addition to where antibiotics were given both before patients presented to the ED, in the ED, while they were admitted and upon discharge,” study researcher Michael Koster, MD, FAAP, told Infectious Diseases in Children.
Michael Koster
In the outpatient setting, usage of narrow-spectrum antibiotics was 28% (95% CI, 23%-24%), compared with 28% (95% CI, 24%-32%) in the ED setting, 35% (95% CI, 31%-39%) in the inpatient setting and 56% (95% CI, 51%-60%) at discharge.
Outpatient and ED physicians prescribed narrow-spectrum antibiotics less often than the mean prescribing pattern of the cohort, according to researchers, while physicians at discharge prescribed narrow-spectrum antibiotics above the mean prescribing pattern.
When analyzing mean differences in compliance rates between the inpatient setting and at discharge, compliance with usage of narrow-spectrum antibiotics increased across the continuum of care (P<0.01).
Across all sites of care, third and fourth generation cephalosporins were the most frequently prescribed antibiotics not recommended by the guidelines; and were less prescribed in the preadmission setting and at discharge but more frequently prescribed in the ED.
“The study findings show there are a lot of different things happening in different settings. If we’re going to provide good quality care and safe care we need to be doing the same thing across the continuum of care. We’d like to see similar usage of narrow-spectrum guidelines across the continuum of care,” Koster told Infectious Diseases in Children.
To achieve similar compliance with IDSA CAP guidelines across the continuum of care, physicians in different care settings need to start collaborating, according to Koster. Educating ED doctors may also be necessary, as prescription of narrow-spectrum antibiotics was lowest in that setting.
For more information:
Milner TL. Abstract 18. Presented at: 2014 AAP National Conference and Exhibition; Oct. 11-14; San Diego.
Disclosure: Koster and Milner report no relevant financial disclosures.
Perspective
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The 2011 National Childhood Pneumonia Guidelines jointly published by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America recommend narrow-spectrum beta-lactam antibiotics such as amoxicillin and ampicillin as first-line treatment for children suspected of having uncomplicated bacterial pneumonia. While several hospital systems have implemented strategies to improve adherence to these national guideline recommendations, broad-spectrum antibiotic prescribing remains common.
The findings by Koster and colleagues indicate that despite the higher prevalence of narrow-spectrum antibiotic prescribing at discharge, broad-spectrum prescribing was distressingly common across all settings. Furthermore, broad-spectrum antibiotic prescribing in their study was especially common in the office and emergency department settings where most of the 1.5 million children with pneumonia each year receive treatment. While stewardship in the hospital setting is important, efforts to optimize antibiotic prescribing in outpatient settings are a critical component to reduce community-level antibiotic resistance and adverse drug events.
In this new era where hospitals and health systems are increasingly accountable for population-level health, hospital-based physicians must partner with providers across the spectrum of care to spearhead improvement effort. The publicly-available guidelines can be accessed at http://cid.oxfordjournals.org/content/53/7/e25.long.