Non-children's Hospitals Fall Short on CAP Prescribing

Troy Brown, RN

December 12, 2018

Most children admitted to non-children's hospitals with community-acquired pneumonia (CAP) fail to receive antibiotics in accordance with guidelines, a study has found.

"Four years after publication of national pediatric CAP guidelines, only 27% of children admitted to non-children's hospitals received guideline-concordant therapy compared with 61% in children's hospitals. This gap is concerning because approximately 70% of children hospitalized with pneumonia receive care in non-children's hospitals," the researchers write.

National guidelines for CAP call for penicillin, amoxicillin, and ampicillin to be given as first-line agents for children admitted to the hospital with CAP.

Alison C. Tribble, MD, from the Division of Pediatric Infectious Diseases, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, and colleagues published their findings online December 10 in JAMA Pediatrics.

The researchers compared antibiotic prescribing for CAP between children's hospitals and non-children's hospitals before the publication of clinical guidelines in 2011. They defined guideline-concordant prescribing as "receipt of any penicillin, amoxicillin, or ampicillin during Admission."

They analyzed data from two hospital billing databases on patients ages 1 to 17 years who were admitted for CAP and discharged between January 1, 2009 and September 30, 2015. Their analysis included children who received a systemic antibiotic potentially prescribed for CAP and who stayed overnight in the hospital. They excluded children with complex chronic conditions; severe and/or complicated CAP; and infection, colonization, or history of methicillin-resistant Staphylococcus aureus

Study Details

Overall, they identified 120,238 children with CAP and a median age of 3 years (interquartile range, 1–6 years) who were discharged from 51 children's hospitals (54.2%; 65,209 children) and 471 non-children's hospitals (45.8%; 55,029 children).

The trajectory of guideline-concordant prescribing changed after guideline publication at both pediatric and nonpediatric hospitals.

In pediatric hospitals, the modeled probability of prescribing according to guidelines rose from 0.25 (95% confidence interval [CI], 0.15 - 0.34) just before guideline publication to 0.61 (95% CI, 0.56 - 0.66) at the study's conclusion. If the prescribing trajectory before guideline publication had continued after publication, the probability of guideline-concordant prescribing would have been 0.31 (95% CI, 0.15 - 0.47; P = .001) in 2015.

In nonpediatric hospitals, the probability of prescribing according to guidelines rose from 0.06 (95% CI, 0.04 - 0.08) right before guideline publication to 0.27 (95% CI, 0.20 - 0.35) in 2015. If the preguideline trajectory had persisted, guideline-concordant prescribing would have been 0.08 (95% CI, 0.01 - 0.14; P = .004) at the study's conclusion.

The reason for these discrepancies in guideline-concordant prescribing is not known, the authors write. "It is unlikely attributable to differences in patient populations because we included only healthy children with uncomplicated CAP and adjusted for potential confounders. Studies in children's hospitals have suggested that local implementation efforts may be important in facilitating guideline uptake. Non-children's hospitals likely have fewer resources to lead pediatric-specific efforts, and care may be influenced by adult CAP guidelines," they explain.

Postguideline trajectories were similar between children's and non-children's hospitals (probability difference from start to end of final study year: 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).

Limitations of the study include the use of administrative data, and the possibility that there are unknown discrepancies between the two databases. However, the researchers used a validated algorithm, and their findings "were consistent with prior work in both databases," they write.

"Although guideline-concordant prescribing has increased in both children's and non-children'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," the authors conclude.

The authors have disclosed no relevant financial relationships.

JAMA Pediatrics. Published online December 10, 2018. Full text

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