In the United States, there are approximately 2 million outpatient visits related to community-acquired pneumonia (CAP) in the pediatric population as well as approximately 124,000 hospitalizations for children, annually.1 And CAP continues to be one of the most common reasons for hospitalizations in this patient group.1
With concerns around CAP hospitalizations, investigators from the Children's Hospital of Philadelphia (CHOP) studied an intervention utilizing clinician feedback reports to evaluate the appropriate usage for antibiotics for CAP inpatients.
Typically, in the outpatient pediatric setting, these feedback reports have been used as a stewardship tool looking at individual performance says, study first author Kathleen Chiotos, MD, MSCE, assistant professor of Anesthesiology, Critical Care, and Pediatrics at the University of Pennsylvania Perelman School of Medicine and an attending physician in Critical Care Medicine and Infectious Diseases at CHOP. She explained using these reports in the inpatient setting and including group-level performances were novel concepts.
Chiotos said audit and feedback reports were generated monthly using a previously validated algorithm to both identify patients with CAP and discuss the antibiotic use.
“We delivered the reports both by email as well as during a monthly quality improvement meeting with our hospital medicine clinicians, which allowed for discussion around the report and recommendations for optimal management of CAP,” Chiotos said in an interview with Contagion.
The intervention showed increased improvement in clinician adherence to antibiotic recommendations. “Preintervention, 213 of 413 (52%) encounters received the appropriate antibiotic choice and duration, which increased to 308 of 387 (80%) postintervention,” the investigators wrote.2
The investigators’ analysis demonstrated an 18% increase in adherence without any significant changes over time. Although there were no differences in the length of stay or hospital revisits, Chiotos points out the importance of the overall study.
"We showed that there was no difference in the rate of revisits or readmissions and that there was a slightly shorter length of stay during the post-intervention period, when antibiotic durations were shorter,” Chiotos said. “While not better outcomes per se, the fact that kids do just as well with a shorter duration and are at less risk of side effects is an important finding and a win for our patients.”
What You Need to Know
The intervention using clinician feedback reports significantly increased adherence to recommended antibiotic choices and durations for pediatric CAP inpatients.
This study introduced a novel application of audit and feedback reports in the inpatient setting, including group-level performance metrics.
The study showed that shorter antibiotic durations did not compromise clinical outcomes. There were no differences in hospital revisit rates or length of stay, suggesting that children with CAP can achieve the same recovery outcomes with fewer side effects from shorter antibiotic courses.
The investigators conducted a “quasi-experimental study” between December 2021 and November 2023 within CHOP. They used an “interrupted time series analysis (ITSA) to estimate the immediate change and change over time in the proportion of CAP encounters adherent to validated metrics of antibiotic choice and duration, then used Poisson regression to estimate intervention effect as a rate ratio (RR).” 2
The investigators determined the specific antibiotic and duration using only data from the electronic health record (EHR). "Appropriate antibiotic choice was defined as administration of amoxicillin or ampicillin within the first 48 hours. If the patient was admitted to the PICU or had a concurrent diagnosis code for empyema or lung abscess, ceftriaxone was also considered appropriate. If the patient had a history of methicillin-resistant Staphylococcus aureus (MRSA) infection or colonization within the preceding one year, any anti-MRSA antibiotic was also considered appropriate. For patients with reported beta-lactam allergy or beta-lactam antibiotic use within the preceding 28 days, any antibiotic was considered appropriate," the investigators wrote.
In addition to determining the right antibiotic and duration, Chiotos believes this novel application could be utilized further. “Because we were able to derive definitions for CAP as well as for appropriate antibiotic use using only data from the electronic health record—as opposed to manually reviewing charts—utilizing feedback reports such as these may be more feasible for stewardship programs.”
References
1. Katz SE, Williams DJ. Pediatric Community-Acquired Pneumonia in the United States: Changing Epidemiology, Diagnostic and Therapeutic Challenges, and Areas for Future Research. Infect Dis Clin North Am. 2018;32(1):47-63. doi:10.1016/j.idc.2017.11.002
2. Chiotos K, Dutcher L, Grundmeier RW, et al. Impact of clinician feedback reports on antibiotic use in children hospitalized with community-acquired pneumonia. Clin Infect Dis. Published online December 3, 2024. doi:10.1093/cid/ciae593
