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BACKGROUND: One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program’s effectiveness for reducing outpatient antibiotic prescribing for ARTI visits. METHODS: In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to RESULTS: Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90–0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50–0.87) and sinusitis (aRR 0.59; 95% CI, 0.44–0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83–1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51–0.70). CONCLUSIONS: This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.

OBJECTIVES: To characterize and compare ambulatory antibiotic prescribing for children in US pediatric and nonpediatric emergency departments (EDs). METHODS: A cross-sectional retrospective study of patients aged 0 to 17 years discharged from EDs in the United States was conducted by using the 2009–2014 National Hospital Ambulatory Medical Care Survey ED data. We estimated the proportion of ED visits resulting in antibiotic prescriptions, stratified by antibiotic spectrum, class, diagnosis, and ED type (“pediatric” defined as >75% of visits by patients aged 0–17 years, versus “nonpediatric”). Multivariable logistic regression was used to determine factors independently associated with first-line, guideline-concordant prescribing for acute otitis media, pharyngitis, and sinusitis. RESULTS: In 2009–2014, of the 29 million mean annual ED visits by children, 14% (95% confidence interval [CI]: 10%–20%) occurred at pediatric EDs. Antibiotics overall were prescribed more frequently in nonpediatric than pediatric ED visits (24% vs 20%, P < .01). Antibiotic prescribing frequencies were stable over time. Of all antibiotics prescribed, 44% (95% CI: 42%–45%) were broad spectrum, and 32% (95% CI: 30%–34%, 2.1 million per year) were generally not indicated. Compared with pediatric EDs, nonpediatric EDs had a higher frequency of prescribing macrolides (18% vs 8%, P < .0001) and a lower frequency of first-line, guideline-concordant prescribing for the respiratory conditions studied (77% vs 87%, P < .001). CONCLUSIONS: Children are prescribed almost 7 million antibiotic prescriptions in EDs annually, primarily in nonpediatric EDs. Pediatric antibiotic stewardship efforts should expand to nonpediatric EDs nationwide, particularly regarding avoidance of antibiotic prescribing for conditions for which antibiotics are not indicated, reducing macrolide prescriptions, and increasing first-line, guideline-concordant prescribing.

* Abbreviation: CAP — : community-acquired pneumonia One way to characterize antibiotic stewardship is providing the right antibiotic to the right patient, in the right dose, at the right time, for the right duration, and by the right route. For children requiring hospitalization for uncomplicated infections, what, then, is the right route? Is it intravenous or oral? We pediatricians have grown accustomed to using intravenous antibiotics for children who are hospitalized with common but uncomplicated infections, such as community-acquired pneumonia (CAP), skin and soft tissue infection, or urinary tract infection. There certainly are circumstances in which the intravenous route for antibiotics may be preferable to the oral route, such as in the treatment of central nervous system infections, the use of antibiotics with limited oral bioavailability, and when faced with the inherent difficulty of getting children to take medications orally while sick. Lastly, some care team members report concerns that insurance carriers will not cover the cost of a hospitalization for infection if oral antibiotics are administered because that therapy could be given equally well at home. However, we should reevaluate our oral antibiotic aversion for common, uncomplicated infections. Preferentially using oral instead of intravenous therapy has a number of benefits for children who are hospitalized with common infections. If the use of peripheral and central intravenous catheters can be minimized or even completely eliminated, children can … Address correspondence to Matthew P. Kronman, MD, MSCE, Seattle Children’s Hospital, 4800 Sand Point Way NE, Mailstop MA.7.226, Seattle, WA 98105. E-mail: matthew.kronman{at}seattlechildrens.org

BACKGROUND AND OBJECTIVE: Single-center evaluations of pediatric antimicrobial stewardship programs (ASPs) suggest that ASPs are effective in reducing and improving antibiotic prescribing, but studies are limited. Our objective was to compare antibiotic prescribing rates in a group of pediatric hospitals with formalized ASPs (ASP+) to a group of concurrent control hospitals without formalized stewardship programs (ASP−). METHODS: We evaluated the impact of ASPs on antibiotic prescribing over time measured by days of therapy/1000 patient-days in a group of 31 freestanding children’s hospitals (9 ASP+, 22 ASP−). We compared differences in average antibiotic use for all ASP+ and ASP− hospitals from 2004 to 2012 before and after release of 2007 Infectious Diseases Society of America guidelines for developing ASPs. Antibiotic use was compared for both all antibacterials and for a select subset (vancomycin, carbapenems, linezolid). For each ASP+ hospital, we determined differences in the average monthly changes in antibiotic use before and after the program was started by using interrupted time series via dynamic regression. RESULTS: In aggregate, as compared with those years preceding the guidelines, there was a larger decline in average antibiotic use in ASP+ hospitals than in ASP− hospitals from 2007 to 2012, the years after the release of Infectious Diseases Society of America guidelines (11% vs 8%, P = .04). When examined individually, relative to preimplementation trends, 8 of 9 ASP+ hospitals revealed declines in antibiotic use, with an average monthly decline in days of therapy/1000 patient-days of 5.7%. For the select subset of antibiotics, the average monthly decline was 8.2%. CONCLUSIONS: Formalized ASPs in children’s hospitals are effective in reducing antibiotic prescribing.

OBJECTIVES: To assess trends in the duration of intravenous (IV) antibiotics for urinary tract infections (UTIs) in infants ≤60 days old between 2005 and 2015 and determine if the duration of IV antibiotic treatment is associated with readmission. METHODS: Retrospective analysis of infants ≤60 days old diagnosed with a UTI who were admitted to a children’s hospital and received IV antibiotics. Infants were excluded if they had a previous surgery or comorbidities, bacteremia, or admission to the ICU. Data were analyzed from the Pediatric Health Information System database from 2005 through 2015. The primary outcome was readmission within 30 days for a UTI. RESULTS: The proportion of infants ≤60 days old receiving 4 or more days of IV antibiotics (long IV treatment) decreased from 50% in 2005 to 19% in 2015. The proportion of infants ≤60 days old receiving long IV treatment at 46 children’s hospitals varied between 3% and 59% and did not correlate with readmission (correlation coefficient 0.13; P = .37). In multivariable analysis, readmission for a UTI was associated with younger age and female sex but not duration of IV antibiotic therapy (adjusted odds ratio for long IV treatment: 0.93 [95% confidence interval 0.52–1.67]). CONCLUSIONS: The proportion of infants ≤60 days old receiving long IV treatment decreased substantially from 2005 to 2015 without an increase in hospital readmissions. These findings support the safety of short-course IV antibiotic therapy for appropriately selected neonates.

Despite long-standing recognition by clinicians and the public, the problem of inappropriate antibiotic prescribing is, unfortunately, persistent. Inappropriate antibiotic prescribing not only harms our communities by contributing to the spread of antibiotic-resistant infections, but it also directly harms patients by leading to adverse drug events, unnecessary costs, and serious complications, such as Clostridium difficile colitis. Inappropriate antibiotic prescribing encompasses several domains (Table 1). The most important is unnecessary antibiotic prescribing (or overuse), which refers to prescribing an antibiotic when it is not indicated (eg, for a viral infection). At least 30% of all antibiotics prescribed in outpatient settings in the United States are considered unnecessary; this estimate rises to 50% for respiratory tract infections, which collectively are responsible for the largest number of antibiotic prescriptions overall.1 But there are several other important types of inappropriate antibiotic prescribing, including prescribing for an unnecessarily prolonged duration, selecting an unnecessarily broad-spectrum antibiotic, … Address correspondence to Adam L. Hersh, MD, PhD, Division of Infectious Diseases, Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108. E-mail: adam.hersh{at}hsc.utah.edu

BACKGROUND AND OBJECTIVES:Appendicitis guidelines recommend either narrower- or extended-spectrum antibiotics for treatment of complicated appendicitis. The goal of this study was to compare the effectiveness of extended-spectrum versus narrower-spectrum antibiotics for children with appendicitis.METHODS:We performed a retrospective cohort study of children aged 3 to 18 years discharged between 2011 and 2013 from 23 freestanding children’s hospitals with an appendicitis diagnosis and appendectomy performed. Subjects were classified as having complicated appendicitis if they had a postoperative length of stay ≥3 days, a central venous catheter placed, major or severe illness classification, or ICU admission. The exposure of interest was receipt of systemic extended-spectrum antibiotics (piperacillin ± tazobactam, ticarcillin ± clavulanate, ceftazidime, cefepime, or a carbapenem) on the day of appendectomy or the day after. The primary outcome was 30-day readmission for wound infection or repeat abdominal surgery. Multivariable logistic regression, propensity score weighting, and subgroup analyses were used to control for confounding by indication.RESULTS:Of 24 984 patients, 17 654 (70.7%) had uncomplicated appendicitis and 7330 (29.3%) had complicated appendicitis. Overall, 664 (2.7%) patients experienced the primary outcome, 1.1% among uncomplicated cases and 6.4% among complicated cases (P < .001). Extended-spectrum antibiotic exposure was significantly associated with the primary outcome in complicated (adjusted odds ratio, 1.43 [95% confidence interval, 1.06 to 1.93]), but not uncomplicated, (adjusted odds ratio, 1.32 [95% confidence interval, 0.88 to 1.98]) appendicitis. These odds ratios remained consistent across additional analyses.CONCLUSIONS:Extended-spectrum antibiotics seem to offer no advantage over narrower-spectrum agents for children with surgically managed acute uncomplicated or complicated appendicitis.

* Abbreviations: MV — : measles vaccine NME — : nonmedical exemption VPD — : vaccine-preventable disease Efforts to restrict parents’ ability to exempt children from receiving vaccinations required for school entry have recently reached a pinnacle. The American Medical Association voiced support for eliminating nonmedical exemptions (NMEs) from school vaccine requirements,1 and California enacted legislation doing so.2 Although laudable in their objective, policies eliminating NMEs from all vaccines are scientifically and ethically problematic. In the present article, we argue for an exemption policy that eliminates NMEs just for the measles vaccine (MV) and is pursued only after other less restrictive approaches have been implemented and deemed unsuccessful. A policy to eliminate NMEs just from MV is based on the premise that the nature and scope of the immediate threat to public health posed by measles and the ability to avert that threat with MV is distinct among vaccine-preventable diseases (VPDs). There are 3 features that, when considered in combination, support this premise. First, measles virus is extraordinarily contagious. Its basic reproduction number is 12 to 18.3 Only 1 other vaccine-preventable infectious agent is as contagious ( Bordetella pertussis ); all others have a basic reproduction number that ranges from 4 to 7. Due to this contagiousness, a very high rate of community immunity (∼92%–94%) must be achieved and sustained to prevent spread of the disease.4 Second, measles remains an important public health burden.5 Although other VPDs may be more common (eg, pertussis6) or have more severe typical cases (eg, invasive Haemophilus influenzae type b disease7), measles disease is severe enough,8,9 outbreaks common enough,10 … Address correspondence to Douglas J. Opel, MD, MPH, Seattle Children’s Research Institute, 1900 Ninth Ave, M/S: JMB-6, Seattle, WA 98101. E-mail: douglas.opel{at}seattlechildrens.org

OBJECTIVE: To determine whether childhood antianaerobic antibiotic exposure is associated with the development of inflammatory bowel disease (IBD). METHODS: This retrospective cohort study employed data from 464 UK ambulatory practices participating in The Health Improvement Network. All children with ≥2 years of follow-up from 1994 to 2009 were followed between practice enrollment and IBD development, practice deregistration, 19 years of age, or death; those with previous IBD were excluded. All antibiotic prescriptions were captured. Antianaerobic antibiotic agents were defined as penicillin, amoxicillin, ampicillin, penicillin/β-lactamase inhibitor combinations, tetracyclines, clindamycin, metronidazole, cefoxitin, carbapenems, and oral vancomycin. RESULTS: A total of 1 072 426 subjects contributed 6.6 million person-years of follow-up; 748 developed IBD. IBD incidence rates among antianaerobic antibiotic unexposed and exposed subjects were 0.83 and 1.52/10 000 person-years, respectively, for an 84% relative risk increase. Exposure throughout childhood was associated with developing IBD, but this relationship decreased with increasing age at exposure. Exposure before 1 year of age had an adjusted hazard ratio of 5.51 (95% confidence interval [CI]: 1.66–18.28) but decreased to 2.62 (95% CI: 1.61–4.25) and 1.57 (95% CI: 1.35–1.84) by 5 and 15 years, respectively. Each antibiotic course increased the IBD hazard by 6% (4%–8%). A dose-response effect existed, with receipt of >2 antibiotic courses more highly associated with IBD development than receipt of 1 to 2 courses, with adjusted hazard ratios of 4.77 (95% CI: 2.13–10.68) versus 3.33 (95% CI: 1.69–6.58). CONCLUSIONS: Childhood antianaerobic antibiotic exposure is associated with IBD development.

OBJECTIVE: To determine current rates of and trends in hospitalizations for community-acquired pneumonia (CAP) and CAP-associated complications among children. METHODS: We performed a cross-sectional, retrospective, cohort study by using the 1997, 2000, 2003, and 2006 Kids' Inpatient Database. National estimates for CAP and CAP-associated local and systemic complication rates were calculated for children ≤18 years of age. Patients with comorbid conditions or in-hospital birth status were excluded. Percentage changes were calculated by using 1997 (before heptavalent pneumococcal conjugate vaccine [PCV7]) and 2006 (after PCV7) data. RESULTS: There were a total of 619 102 CAP discharges for 1997, 2000, 2003, and 2006, after application of inclusion and exclusion criteria. Overall rates of CAP discharges did not change substantially between 1997 and 2006, but stratification according to age revealed a 22% decrease for children CONCLUSIONS: After the introduction of PCV7 in 2000, rates of CAP-associated systemic complications decreased only for children

OBJECTIVE. The purpose of this work was to determine the excess charges, both overall and according to category, and lengths of stay attributable to adverse patient-care events during pediatric hospitalization.METHODS. Agency for Healthcare Research and Quality pediatric-specific quality indicators were used to identify adverse events in 431524 discharges from 38 freestanding, academic, not-for-profit, tertiary care pediatric hospitals in the United States participating in the Pediatric Health Information System database in 2006. All of the discharges from any of the 38 hospitals participating in the Pediatric Health Information System between January 1 and December 31, 2006, were eligible for inclusion. The primary outcomes were excess lengths of stay and charges (both overall and according to pharmacy, laboratory, imaging, clinical, supply, and other categories) were attributable to adverse patient-safety events as determined by 12 pediatric-specific quality indicators.RESULTS. Statistically significant excess lengths of stay attributable to pediatric-specific quality indicator events ranged from 2.8 days for accidental puncture and laceration to 23.5 days for postoperative sepsis, and statistically significant excess overall charges ranged from $34884 for accidental puncture and laceration to $337226 for in-hospital mortality after pediatric heart surgery. Each charge category had significant charge increases caused by pediatric-specific quality indicator events, with the largest being laboratory and other charges, ranging from $7622 to $78048 and $11094 to $97805, respectively.CONCLUSIONS. Some adverse events experienced during pediatric hospitalization have the potential to increase lengths of stay and charges considerably, and pediatric-specific quality indicators are useful in calculating these effects.

BACKGROUND AND OBJECTIVES: Antimicrobials are frequently prescribed for acute respiratory tract infections (ARTI), although many are viral. We aimed to determine bacterial prevalence rates for 5 common childhood ARTI - acute otitis media (AOM), sinusitis, bronchitis, upper respiratory tract infection, and pharyngitis- and to compare these rates to nationally representative antimicrobial prescription rates for these ARTI. METHODS: We performed (1) a meta-analysis of English language pediatric studies published between 2000 and 2011 in Medline, Embase, and the Cochrane library to determine ARTI bacterial prevalence rates; and (2) a retrospective cohort analysis of children age RESULTS: From the meta-analysis, the AOM bacterial prevalence was 64.7% (95% confidence interval [CI], 50.5%–77.7%); Streptococcus pyogenes prevalence during pharyngitis was 20.2% (95% CI, 15.9%–25.2%). No URI or bronchitis studies met inclusion criteria, and 1 sinusitis study met inclusion criteria, identifying bacteria in 78% of subjects. Based on these condition-specific bacterial prevalence rates, the expected antimicrobial rescribing rate for ARTI overall was 27.4% (95% CI, 26.5%–28.3%). However, antimicrobial agents were prescribed in NAMCS during 56.9% (95% CI, 50.8%–63.1%) of ARTI encounters, representing an estimated 11.4 million potentially preventable antimicrobial prescriptions annually. CONCLUSIONS: An estimated 27.4% of US children who have ARTI have bacterial illness in the post-pneumococcal conjugate vaccine era. Antimicrobials are prescribed almost twice as often as expected during outpatient ARTI visits, representing an important target for ongoing antimicrobial stewardship interventions.

BACKGROUND: The incidence of pediatric hospitalizations for community-acquired pneumonia (CAP) has declined after the widespread use of the heptavalent pneumococcal conjugate vaccine. The national incidence of outpatient visits for CAP, however, is not well established. Although no pediatric CAP treatment guidelines are available, current data support narrow-spectrum antibiotics as the first-line treatment for most patients with CAP. OBJECTIVE: To estimate the incidence rates of outpatient CAP, examine time trends in antibiotics prescribed for CAP, and determine factors associated with broad-spectrum antibiotic prescribing for CAP. PATIENTS AND METHODS: The National Ambulatory and National Hospital Ambulatory Medical Care Surveys (1994–2007) were used to identify children aged 1 to 18 years with CAP using a validated algorithm. We determined age group–specific rates of outpatient CAP and examined trends in antibiotic prescribing for CAP. Data from 2006–2007 were used to study factors associated with broad-spectrum antibiotic prescribing. RESULTS: Overall, annual CAP visit rates ranged from 16.9 to 22.4 per 1000 population, with the highest rates occurring in children aged 1 to 5 years (range: 32.3–49.6 per 1000). Ambulatory CAP visit rates did not change between 1994 and 2007. Antibiotics commonly prescribed for CAP included macrolides (34% of patients overall), cephalosporins (22% overall), and penicillins (14% overall). Cephalosporin use increased significantly between 2000 and 2007 (P = .002). Increasing age, a visit to a nonemergency department office, and obtaining a radiograph or complete blood count were associated with broad-spectrum antibiotic prescribing. CONCLUSIONS: The incidence of pediatric ambulatory CAP visits has not changed significantly between 1994 and 2007, despite the introduction of heptavalent pneumococcal conjugate vaccine in 2000. Broad-spectrum antibiotics, particularly macrolides, were frequently prescribed despite evidence that they provide little benefit over penicillins.

OBJECTIVE: To determine if systemic corticosteroid therapy is associated with improved outcomes for children hospitalized with community-acquired pneumonia (CAP). METHODS: In this multicenter, retrospective cohort study we used data from 36 children's hospitals for children aged 1 to 18 years with CAP. Main outcome measures were length of stay (LOS), readmission, and total hospitalization cost. The primary exposure was the use of adjunct systemic corticosteroids. Multivariable regression models and propensity scores were used to adjust for confounders. RESULTS: The 20 703 patients whose data were included had a median age of 4 years. Adjunct corticosteroid therapy was administered to 7234 patients (35%). The median LOS was 3 days, and 245 patients (1.2%) required readmission. Systemic corticosteroid therapy was associated with shorter LOS overall (adjusted hazard ratio [HR]: 1.24 [95% confidence interval (CI): 1.18–1.30]). Among children who received treatment with β-agonists, the LOS was shorter for children who had received corticosteroids compared with children who had not (adjusted HR: 1.36 [95% CI: 1.28–1.45]). Among children who did not receive β-agonists, the LOS was longer for those who received corticosteroids compared with those who did not (adjusted HR: 0.85 [95% CI: 0.75–0.96]). Corticosteroids were associated with readmission of patients who did not receive concomitant β-agonist therapy (adjusted odds ratio: 1.97 [95% CI: 1.09–3.57]). CONCLUSIONS: For children hospitalized with CAP, adjunct corticosteroids were associated with a shorter hospital LOS among patients who received concomitant β-agonist therapy. Among patients who did not receive this therapy, systemic corticosteroids were associated with a longer LOS and a greater odds of readmission. If β-agonist therapy is considered a proxy for wheezing, our findings suggest that among patients admitted to the hospital with a diagnosis of CAP, only those with acute wheezing benefit from adjunct systemic corticosteroid therapy.