Monthly Archives: September 2015

Antibiotic Stewardship

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Shah Lekha (2)

By Lekha Shah

lashah@emory.edu

Jenna Wade, a feisty 17-month-old toddler, presents the ER because her mom found a swollen, red, tender area on her right buttock today after she spiked a fever. On clinical exam, she has a soft tissue abscess. She will require Incision & Drainage (I&D) under procedural sedation. Her distraught mother asks, “How did this happen?” and “What can I do to prevent this next time?”

We are largely to blame for the current epidemic increase in MRSA. Abscesses and cellulitis from CA-MRSA (community acquired MRSA) are routine, rather than rare. Many pediatric providers have memorized the dose and concentration of Bactrim and Clindamycin suspensions. CA-MRSA is so widely prevalent in the US that the CDC’s Choosing Wisely campaign now recommends against the routine use of wound culture; instead soft tissue infection should be presumed be due to MRSA or S. pyogenes. Many CHOA PEM physicians sedate for I&D approximately once (or more) per shift per provider and treat MRSA-associated cellulitis on a daily basis.

What is the scope of the antibiotic overuse problem? The antibiotic prescribing rate for children under age 2 years exceeds that of elderly adults over 65 years! Acute viral respiratory infections (e.g., sinusitis, acute bronchitis, viral pharyngitis, and otitis media) account for 75% of antibiotic prescriptions written for children, mostly under 2 years of age. According to a large UK database analysis of 3.4 million respiratory infections (excluding pneumonia) treated with antibiotics, the number need to treat (NNT) to prevent 1 complication was > 4000 (Peterson).

Regarding more serious adverse events, a recent CDC analysis found 944 pediatric Clostridium difficile infections in the US in 2010-11. Of the community acquired C. difficile isolates, 71% occurred in infants. Horton, et als’ study in the May issue of Pediatrics, found a dose-dependent association between antibiotic exposure and onset of Juvenile Idiopathic Arthritis compared to age-matched controls.

From the ER perspective, adverse events attributable to antibiotics account for >142,000 ER visits/per year in the US. Allergic reactions account for four-fifths of these ER visits; the most common culprit drugs are penicillins and cephalosporins. These are bread-and-butter drugs in any pediatric practice.

Many of our patients, and perhaps some of us, believe that antibiotics are benign, but consider this statement in an opinion piece by Linder regarding antibiotics in acute URI treatment: “For your infection, there is ~1 in 4000 chance that an antibiotic will prevent a serious complications, a 5-25% chance that it will cause diarrhea, and an ~1 in 1000 chance that you will require a visit to the emergency department because of a bad reaction to the antibiotic.”

For further information, please visit the CDC Get Smart: Know When Antibiotics Work website at http://www.cdc.gov/getsmart/week/partners/partners.html.

Community Acquired Pneumonia Guidelines

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By Sam Spizman

samuel.spizman@emory.edu

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Recently, CHOA put together a task force to review the evaluation and treatment of pneumonia. Members included representatives from both inpatient and outpatient care areas. The goal was to provide a more consistent and evidence-based approach to treatment. Based on their review, CHOA implemented a guideline for simple pneumonia in December 2014. The guidelines are available on the new MD portal. The key points are discussed below:

There are some exclusion criteria. The guideline excludes neonates and complex patients with comorbidities. Examples include:

  • Infants <2 Months Of Age
  • Immunocompromised
  • Cystic Fibrosis
  • Nosocomially Acquired Pneumonia (>48 Hrs)
  • Moderate To Severe Effusion, Empyema/Abscess, Necrosis
  • Multilobar Pneumonia · Suspected Aspiration Pneumonia
  • Medically Complex Patients

This last criterion is clinically subjective.

The admission criteria are listed as the following:

  • Signs and Symptoms Of Respiratory Distress (note: pulse ox of 90% acceptable for outpatient management)
  • Vomiting/poor PO/dehydration
  • Inability To Manage Patient At Home
  • Failed Outpatient Therapy
  • Consider If ≤ 6 Months With Lobar Consolidation

These are not all inclusive and we welcome any phone conversation to better take care of your patient.

One of the main goals for the taskforce was to recommend antibiotic therapy for both outpatient and inpatient treatment. Literature reviews still show that the most common etiologic bacterial organism is pneumococcus (for simple lobar pneumonias without effusion or empyema). Staph aureus and Strep pyogenes are considerations, but are less prevalent.

Strep pneumoniae continues to show susceptibility to penicillins. Because of this, Amoxicillin is the recommended first-line antibiotic of choice. The recommended daily dosing is that of high-dose Amoxicillin (90-100mg/kg/day) as in the treatment of otitis media. It is recommended to divide this into 3 doses, not 2. The literature to support this says that the required MIC (mean inhibitory concentration) for pneumococcus is 2mcg/ml. While both bid and tid dosing achieve adequate peaks, bid dosing achieves only a 65% cure rate while tid dosing achieves a 90% cure rate. The implication is that bid dosing results in the MIC falling below 2mcg/ml in some patients, resulting in treatment failures.

For inpatients, recommended IV therapy is Ampicillin until the patient meets discharge criteria.

In the case of true penicillin allergy, the recommended treatment is clindamycin for outpatients and ceftriaxone or levofloxacin for inpatients.

Lastly, treatment to cover atypical pneumonia (Mycoplasma) is not recommended unless the patient is failing outpatient therapy.

Take- home points:

– Amoxicillin and Ampicillin are the first-line recommendations for simple CAP

– High-dose Amoxicillin should be divided into tid dosing

– We all probably utilize too much Rocephin and Augmentin for CAP

Please refer to CHOA MD portal: md.choa.org to review this and other CHOA Guidelines

Bronchiolitis Update 2015

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By Maggie Kilgore and Javier Tejedor-Sojo

Margaret.Killgore@choa.org

javier.tejedor-sojo@choa.org

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As we move into bronchiolitis season, we wanted to remind you all of the new recommendations for inpatient and outpatient bronchiolitis treatment published by the AAP in 2014. These new recommendations were incorporated into Children’s Healthcare of Atlanta’s updated guidelines in the fall of 2014. Bronchiolitis is one of the top three admission diagnoses at Children’s. The 2014 Children’s guideline fosters patient-centered, value-based outcomes, more closely supports evidence-based therapies and interventions, and recommends that care providers deliver a consistent message to families.

Some of the key elements of the 2014 AAP guideline are that:

  • Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. Chest X-Rays or laboratory studies should not be obtained routinely
  • Clinicians should not routinely administer albuterol or epinephrine to patients with a diagnosis of bronchiolitis
  • Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one
  • In infants with bronchiolitis, clinicians may choose not to administer supplemental oxygen if the O2 saturation exceeds 90%

It can be difficult to explain to families that the best treatment for their child is supportive care. The evidence and the new recommendations support that supportive care is what patients benefit from the most. In regards to albuterol, current recommendations discouraging its use in bronchiolitis are derived from the 2010 Cochrane review which included 10 inpatient and 10 outpatient trials. There was no statistical difference in the rate of hospitalization, length of hospitalization, oximetry nor time to resolution of illness at home between albuterol and placebo treated children. Some brief improvement in clinical respiratory scores was noted among outpatient and hospitalized patients but the standard mean difference was very small and no impact on clinical care would be expected.

There may be a sub-group of children with an underlying predisposition to asthma who may exhibit a response to albuterol. These children are generally older (>12 months) and have either a previous history of wheezing or atopy or a strong family history of asthma in first degree relatives. In the bronchiolitis guideline, these children may receive a single trial of albuterol without other concurrent interventions to determine whether they exhibit a positive clinical response to it. If they indeed have a positive documented response to albuterol these children would be managed under the ED/Inpatient asthma pathway.

Families should be educated that bronchiolitis is a disease that may last for two to three weeks. Many parents present for care because they are concerned their child is not feeding as usual. During the acute illness it is common and expected that children will feed less than their baseline. We need to help parents understand that if their child can sustain their basic fluid needs (even if they take sometimes half of what they typically drink), they are not likely to get dehydrated. Patients who maintain saturations >90% on room air, are able to handle secretions, and can maintain acceptable hydration and activity can generally be treated at home with supportive therapy.

On October 1, 2014 Children’s implemented the guidelines in the ED, Urgent Care, and Inpatient Settings. During the Sept 2014—April 2015 season, we decreased albuterol usage in 1-12 month olds with bronchiolitis from 45% to 25% in the ED and from 40% to 11% for patients who were admitted. We were able to achieve these results without negatively impacting our length of stay or 7 day readmission rate. Reducing the use of therapies that have not demonstrated benefit to our patients and helping them return home sooner if medically stable, is an example of delivering value to them and their families.

If there are any questions about the guideline, feel free to contact :

Dr Shabnam Jain sjain@emory.edu

Dr Tejedor-Sojo  javier.tejedor-sojo@choa.org

Please see the link below to the clinical guideline page on the physician portal for access to our guidelines, link to the AAP 2014 recommendations, and see Children’s full evidence summary that is posted on the physician portal:

https://md.choa.org/clinical-excellence/clinical-practice-guidelines/bronchiolitis