A comparison of antibiotic prescribing trends for children with community-acquired pneumonia (CAP) who received care at a children’s hospitals vs those treated at non-children’s hospitals found that fewer children in non-children’s hospitals receive therapy in concordance with the national pediatric CAP guidelines, according to a letter published in JAMA Pediatrics.

In a retrospective analysis of inpatient discharges from January 1, 2009 to September 30, 2015 across the United States, researchers gathered data from 2 hospital billing databases: children’s hospitals only and all other hospital types (non-children’s hospitals). Data included admissions of children aged 1 to 17 years with a primary diagnosis of pneumonia (N=120,238), who received “a systemic antibiotic potentially prescribed for CAP (penicillins with or without β-lactamase inhibitors, cephalosporins, carbapenems, macrolides, doxycycline, fluoroquinolones, vancomycin, linezolid, clindamycin, or trimethoprim-sulfamethoxazole).” 

Exclusion criteria included:

  1. history of complex chronic conditions,
  2. severe and/or complicated CAP (defined as hospitalized >7 days; effusion, empyema, or lung abscess; 2 consecutive days of mechanical ventilatory assistance or vasopressor use, or extracorporeal membrane oxygenation),
  3. infection, colonization, or history of methicillin-resistant Staphylococcus aureus.

Researchers used a longitudinal piecewise logistic model with a knot at the time of guideline publication in October 2011, and modeled the linear trajectory of guideline-concordant prescribing (defined as receipt of any penicillin, amoxicillin, or ampicillin) before and after publication and stratified by hospital type (children’s vs non-children’s).

The modeled probability of guideline-concordant prescribing increased from 0.25 (95% CI, 0.15-0.34) to 0.61 (95% CI, 0.56-0.66) in children’s hospitals from before the guidelines were released to the end of the study. The study investigators noted that without the impetus of the publication of pediatric CAP guidelines, the trajectory demonstrated that the probability of guideline-concordant prescribing would have been 0.31 (95% CI, 0.15-0.47; P =.001) at children’s hospitals. In contrast, the probability of guideline-concordant prescribing in non-children’s hospitals increased from 0.06 (95% CI, 0.04-0.08) before guideline release to 0.27 (95% CI, 0.20-0.35) at study end. Again, study investigators noted that the trajectory of concordance without impetus of guideline publication would have demonstrated a probability of 0.08 (95% CI, 0.01-0.14; P =.004) in non-children’s hospitals. The difference in postguideline trajectories’ probability from beginning to end of final study year was a 0.08 absolute increase (95% CI, 0.05-0.10) at children’s hospitals vs 0.07 absolute increase (95% CI, 0.04-0.10) at non-children’s hospitals (P =.56). 

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This study is limited by the reliance on administrative data and the potential unknown discrepancies in reporting that may be present within.

The researchers concluded that “although guideline-concordant prescribing has increased in both children’s and nonchildren’s hospitals, non-children’s hospitals appear to be lagging markedly behind children’s hospitals. This discrepancy may represent an important target for antimicrobial stewardship efforts.”

Reference

Tribble AC, Ross RK, Gerber JS. Comparison of antibiotic prescribing for pediatric community-acquired pneumonia in children’s and non-children’s hospitals [published online December 10, 2018]. JAMA Pediatr. doi:10.1001/jamapediatrics.2018.4270