Methods Study Design: Retrospective chart review Patient Population: Pediatric patients admitted to the 5 th floor of UAMC Diamond Children’s Medical Center between January 22, 2013 and April 4, 2013. Inclusion Criteria: o Positive chest x-ray for pneumonia o Inpatient order for antibiotic therapy o Age > 3 months and < 18 years Exclusion Criteria: o Aspiration pneumonia o History of antibiotics for the treatment of pneumonia within the previous month o Cystic fibrosis o Viral pneumonia Procedures: Data Collection: o Electronic medical records of patients admitted to the 5 th floor of UAMC Diamond Children’s Medical Center were evaluated. o For patients who met the inclusion criteria, the following information was collected: sex, allergies, weight, age, antibiotic prescribed (date and dose), history of lung disease, chest x-ray results, and history of readmission due to pneumonia. o Pre-intervention data collection was conducted January 22, 2013 to February 14, 2013. o Post-intervention data collection was conducted March 7, 2013 to April 4, 2013. Intervention: o A brief presentation on the pre-intervention results and the IDSA pediatric CAP guidelines (accounting for local resistance patterns and hospital formulary) was given to pediatric medical residents at teaching day on March 6, 2013. o Pediatric residents were provided with a laminated reference card containing guideline recommendations on antibiotic selection and dosing to attach to their lanyards [Figure 1]. Statistical Methods: Chi-square test, a priori alpha < 0.05 Figure 1. Pediatric Pneumonia Guidelines Reference Card Intervention Background and Introduction Objectives Background: o In 2011, the Infectious Diseases Society of America (IDSA) released clinical practice guidelines for the treatment of Community-Acquired Pneumonia (CAP) in pediatric patients. 1 These guidelines recommend ampicillin as the preferred parenteral therapy and amoxicillin as the preferred oral therapy for the treatment of non-complicated pneumonia due to Streptococcus pneumoniae. o Adherence to evidence-based guidelines has been shown to decrease morbidity and mortality. 2 o This project focuses on the prescribing portion of the medication use process at The University of Arizona Medical Center (UAMC)-Diamond Children’s. UAMC is a teaching hospital in Tucson, Arizona and Diamond Children’s Medical Center treats pediatric patients with a variety of conditions. Supportive Research: o Newman et al. found that implementation of clinical practice guidelines and an antimicrobial stewardship program in a children’s hospital led to a significant increase in use of ampicillin for the treatment of uncomplicated CAP and speculated that this has the potential to minimize the development of resistant strains of bacteria. 3 o Smith et al. analyzed the importance of education and the use of guidelines for CAP in a pediatric setting and found significant changes in the prescription patterns after the creation of an antimicrobial stewardship task force and the release of the guidelines. 4 o McCabe et al. examined the use of CAP guidelines in adults and discovered that the implementation resulted in a decrease in length of stay, duration of parenteral treatment, and in-hospital deaths. 5 o Dean et al. discovered an association between 30 day mortality, length of hospital stay, and readmission rate in CAP inpatient treatments when guidelines were appropriately used. 2 Goal: o It is important to investigate prescribing patterns and assess adherence to guideline recommendations because this could improve patient outcomes and decrease antibiotic resistance. o Examine prescribing patterns for the treatment of CAP in pediatric patients in comparison to the IDSA treatment guidelines. o Assess the effect of a brief educational intervention on prescribing practices. o The pneumonia season time frame limited the total number of collected cases. o The lack of patient outcomes measurements in comparison to antibiotic prescribed. o The inability to measure the effects of antibiotic resistance in relation to guideline adherence. o The ability to distinguish between antibiotics prescribed in the emergency department versus the pediatric floor based on electronic medical records. Evaluation of Appropriate Antibiotic Usage in Community-Acquired Pneumonia in Hospitalized Pediatric Patients: A Quality Improvement Project Sarah Deitering 1 , Emily Kilber 1 , Amy Nguyen 1 , Elaine Truong 1 , and Megan Brandon, PharmD 2 1. University of Arizona College of Pharmacy, 2. University of Arizona Medical Center-Diamond Children’s Conclusion and Discussion Recommendations & Future Research References Results Limitations o Expand this quality improvement project to other locations in the hospital, including the emergency department. o Examine the relationship between patient outcomes (e.g. length of stay and/or length of infusion therapy) and antibiotic prescribed. 1. Bradley JS, Byington CL, Shah SS et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the pediatric infectious diseases society and the infectious diseases society of america. Clin Infect Dis. 2011;53(7):e25-76. 2. Dean NC, Bateman KA, Donnelly SM et al. Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest. 2006;130(3):794-9. 3. Newman RE, Hedican EB, Herigon JC et al. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics. 2012;129(3):e597-604. 4. Smith MJ, Kong M, Cambon A et al. Effectiveness of antimicrobial guidelines for community-acquired pneumonia in children. Pediatrics. 2012;129(5):e1326-33. 5. McCabe C, Kirchner C, Zhang H et al. Guideline-concordant therapy and reduced mortality and length of stay in adults with community- acquired pneumonia: Playing by the rules. Arch Intern Med. 2009;169(16):1525-31. 6. Preacher, KJ. Calculation for the chi-square test: An interactive calculation tool for chi-square tests of goodness of fit and independence [Computer software]. Retrieved at http://quantpsy.org. Accessed 15 Apr 2013. Table 1. Patient Characteristics (n=45) Pre-Intervention Post-Intervention Age Range 6 months – 10 years 5 months – 15 years Mean Age 3.3 years 4.0 years Median Age 3.0 years 1.8 years Number of Males 18 12 Number of Females 6 9 Total Number of Patients 24 21 Table 2. Antibiotic Usage in Pediatric Pneumonia Patients (n=81) Antibiotic Pre-Intervention Post-Intervention n (%) n (%) amoxicillin 18 (41) 14 (38) ceftriaxone 10 (23) 3 (8) azithromycin 5 (11) 7 (19) other 5 (11) 0 (0) ampicillin 3 (7) 12 (32)* Augmentin 2 (5) 0 (0) cefdinir 1 (2) 1 (3) Total 44 (100) 37 (100) * ampicillin P value = 0.015 41% 23% 11% 11% 7% 5% 2% 38% 8% 19% 0% 32% 0% 3% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% PERCENTAGE OF ANTIBIOTIC PRESCRIBED ANTIBIOTIC PRE-INTERVENTION POST-INTERVENTION Figure 2. Antibiotic Usage in Pediatric Pneumonia Patients (n=81) For more information, please contact: Sarah Deitering: [email protected] Emily Kilber: [email protected] Amy Nguyen: [email protected] Elaine Truong: [email protected] Megan Brandon: [email protected] Results o Over a time period of 72 days, the medical records of 45 pediatric pneumonia patients between the ages of 5 months and 15 years were analyzed [Table 1]. o Forty-four antibiotic treatments were recorded during the pre-intervention period and 37 were recorded during the post-intervention period [Table 2]. o There was a statistically significant difference between pre- and post- intervention ampicillin prescribing (P=0.015) [Table 2]. o Adherence to the IDSA pediatric CAP guidelines for parenteral therapy improved. • After the intervention, there was a statistically significant 5-fold increase in ampicillin prescribing. • Additionally, there was a 3-fold decrease in ceftriaxone prescribing. o Adherence to the IDSA CAP guidelines for amoxicillin was appropriate prior to the intervention and remained similar during the post-intervention period. o Educational interventions improve adherence and may improve outcomes.