Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America.
Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Padua, Italy.
PLoS One. 2018 Feb 28;13(2):e0193581. doi: 10.1371/journal.pone.0193581. eCollection 2018.
Italian pediatric antimicrobial prescription rates are among the highest in Europe. As a first step in an Antimicrobial Stewardship Program, we implemented a Clinical Pathway (CP) for Community Acquired Pneumonia with the aim of decreasing overall prescription of antibiotics, especially broad-spectrum.
The CP was implemented on 10/01/2015. We collected antibiotic prescribing and outcomes data from children aged 3 months-15 years diagnosed with CAP from 10/15/2014 to 04/15/2015 (pre-intervention period) and from 10/15/2015 to 04/15/2016 (post-intervention period). We assessed antibiotic prescription differences pre- and post-CP, including rates, breadth of spectrum, and duration of therapy. We also compared length of hospital stay for inpatients and treatment failure for inpatients and outpatients. Chi-square and Fisher's exact test were used to compare categorical variables and Wilcoxon rank sum test was used to compare quantitative outcomes.
120 pre- and 86 post-intervention clinic visits were identified with a diagnosis of CAP. In outpatients, we observed a decrease in broad-spectrum regimens (50% pre-CP vs. 26.8% post-CP, p = 0.02), in particular macrolides, and an increase in narrow-spectrum (amoxicillin) post-CP. Post-CP children received fewer antibiotic courses (median DOT from 10 pre-CP to 8 post-CP, p<0.0001) for fewer days (median LOT from 10 pre-CP to 8 post-CP, p<0.0001) than their pre-CP counterparts. Physicians prescribed narrow-spectrum monotherapy more frequently than broad-spectrum combination therapy (DOT/LOT ratio 1.157 pre-CP vs. 1.065 post-CP). No difference in treatment failure was reported before and after implementation (2.3% pre-CP vs. 11.8% post-CP, p = 0.29). Among inpatients we also noted a decrease in broad-spectrum regimens (100% pre-CP vs. 66.7% post-CP, p = 0.02) and the introduction of narrow-spectrum regimens (0% pre-CP vs. 33.3% post-CP, p = 0.02) post-CP. Hospitalized patients received fewer antibiotic courses post-CP (median DOT from 18.5 pre-CP to 10 post-CP, p = 0.004), while there was no statistical difference in length of therapy (median LOT from 11 pre-CP to 10 post-CP, p = 0.06). Days of broad spectrum therapy were notably lower post-CP (median bsDOT from 17 pre-CP to 4.5 post-CP, p <0.0001). No difference in treatment failure was reported before and after CP implementation (16.7% pre-CP vs. 15.4% post-CP, p = 1).
Introduction of a CP for CAP in a Pediatric Emergency Department led to reduction of broad-spectrum antibiotic prescriptions, of combination therapy and of duration of treatment both for outpatients and inpatients.
意大利儿科抗生素处方率在欧洲处于较高水平。作为抗生素管理计划的第一步，我们实施了社区获得性肺炎的临床路径（CP），旨在减少抗生素的总体处方，特别是广谱抗生素。
CP 于 2015 年 1 月 10 日实施。我们收集了 2014 年 10 月 15 日至 2015 年 4 月 15 日（干预前）和 2015 年 10 月 15 日至 2016 年 4 月 15 日（干预后）期间被诊断为 CAP 的 3 个月至 15 岁儿童的抗生素处方和结果数据。我们评估了 CP 实施前后抗生素处方的差异，包括使用率、谱宽和治疗持续时间。我们还比较了住院患者的住院时间和住院患者和门诊患者的治疗失败率。使用卡方和 Fisher 精确检验比较分类变量，使用 Wilcoxon 秩和检验比较定量结果。
共确定了 120 例干预前和 86 例干预后诊所就诊的 CAP 诊断。在门诊患者中，我们观察到广谱方案（50%的干预前 vs. 26.8%的干预后，p = 0.02）减少，特别是大环内酯类药物，窄谱（阿莫西林）方案增加。CP 后儿童接受的抗生素疗程（从 10 个 CP 前到 8 个 CP 后的中位数 DOT，p<0.0001）和治疗天数（从 10 个 CP 前到 8 个 CP 后的中位数 LOT，p<0.0001）均减少。与 CP 前相比，医生更频繁地开具窄谱单药治疗而不是广谱联合治疗（DOT/LOT 比 CP 前为 1.157，CP 后为 1.065）。CP 实施前后治疗失败率无差异（CP 前为 2.3%，CP 后为 11.8%，p = 0.29）。在住院患者中，我们还观察到广谱方案减少（CP 前为 100%，CP 后为 66.7%，p = 0.02）和引入窄谱方案（CP 前为 0%，CP 后为 33.3%，p = 0.02）。CP 后住院患者接受的抗生素疗程较少（CP 前的中位数 DOT 为 18.5，CP 后的中位数 DOT 为 10，p = 0.004），而治疗时间无统计学差异（CP 前的中位数 LOT 为 11，CP 后的中位数 LOT 为 10，p = 0.06）。CP 后广谱治疗天数明显减少（CP 前的中位数 bsDOT 为 17，CP 后的中位数 bsDOT 为 4.5，p<0.0001）。CP 实施前后治疗失败率无差异（CP 前为 16.7%，CP 后为 15.4%，p = 1）。
在儿科急诊室实施 CAP 的 CP 可减少广谱抗生素处方，减少联合治疗和门诊及住院患者的治疗持续时间。
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