Improving antibiotic prescribing in the emergency department for uncomplicated community-acquired pneumonia

doi:10.5847/wjem.j.1920-8642.2020.04.001

Abstract

Abstract:

BACKGROUND: The Pediatric Infectious Disease Society (PIDS) and Infectious Disease Society of America (IDSA) published an evidence-based guideline for the treatment of uncomplicated community-acquired pneumonia (CAP) in children, recommending aminopenicillins as the first-line therapy. Poor guideline compliance with 10%-50% of patients admitted to the hospital receiving narrow-spectrum antibiotics has been reported. A new clinical practice guideline (CPG) was implemented in our emergency department (ED) for uncomplicated CAP. The aim of this study was to examine baseline knowledge and ED provider prescribing patterns pre- and post-CPG implementation.

METHODS: Prior to CPG-implementation, an anonymous case-based survey was distributed to evaluate knowledge of the current PIDS/IDSA guideline. A retrospective chart review of patients treated in the ED for CAP from January 2015 to February 2017 was performed to assess prescribing patterns for intravenous (IV) antibiotics in the ED at Children’s National Health System pre- and post-CPG implementation.

RESULTS: ED providers were aware of the PIDS/IDSA guideline recommendations, with 86.4% of survey responders selecting ampicillin as the initial antibiotic of choice. However, only 41.2% of patients admitted to the hospital with uncomplicated CAP pre-CPG received ampicillin (P<0.01). There was no statistically significant increase in ampicillin prescribing post-CPG (P=0.40).

CONCLUSIONS: Providers in the ED are aware of the PIDS/IDSA guideline regarding the first-line therapy for uncomplicated CAP; however, this knowledge does not translate into clinical practice. Implementation of a CPG in isolation did not significantly change prescribing patterns for uncomplicated CAP.

Key words: Antibiotics, Community-acquired pneumonia, Emergency department, Pediatrics

Rebekah Shaw, Erica Popovsky, Alyssa Abo, Marni Jacobs, Nicole Herrera, James Chamberlain, Andrea Hahn. Improving antibiotic prescribing in the emergency department for uncomplicated community-acquired pneumonia[J]. World Journal of Emergency Medicine, 2020, 11(4): 199-205.

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Variables	Pre-implementation (n=94)	Post-implementation (n=184)
Age (months) (mean)	21.5	36.3
3 - <13	37 (39.4)	44 (23.9)
13 - <61	55 (58.5)	111 (60.3)
≥61	2 (2.1)	29 (15.8)

Variables	Ampicillin (n=84)	Ceftriaxone (n=97)	Odds ratio (OR), ampicillin prescribed, 95% CI
Age, n (%)
3 - <13 months	16 (19.1)	28 (28.9)	0.58 (0.29-1.17)
13 - <61 months	55 (65.5)	54 (55.7)	1.51 (0.83-2.76)
≥61 months	13 (15.5)	15 (15.5)	1.00 (0.45-2.25)
Vitals at presentation, n (%)
Fever (temperature ≥38 ^oC); missing	36 (43.4); 1	47 (49.5); 2	0.78 (0.43-1.41)
Tachycardia^a; missing	77 (91.7); 0	80 (83.3); 1	2.20 (0.86-5.64)
Tachypnea^a	65 (77.4)	68 (70.8)	1.41 (0.72-2.77)
Hypoxia (SaO₂ <90% and/or FiO₂ >21%)	18 (21.4)	16 (16.5)	1.38 (0.65-2.92)
Laboratory results, n (%)
Elevated WBC count^a; missing	13 (30.2); 41	18 (26.1); 28	1.23 (0.53-2.86)
Positive blood cultures^b; missing	0 (0); 69	2 (4.1); 48	NA
Positive urine cultures^b; missing	0 (0); 76	2 (8.3); 73	NA
pH <7.32^b; missing	2 (22.2); 75	2 (10.5); 78	NA
PCO₂ >50 mmHg^b; missing	2 (22.2); 75	1 (5.3); 78	NA
Seasons of admission, n (%) (n=181)
Spring (March - May)	26 (31.0)	24 (25.0)	1.36 (0.71-2.62)
Summer (June - August)	14 (16.7)	15 (15.6)	1.09 (0.49-2.42)
Fall (September - November)	15 (17.9)	21 (21.9)	0.79 (0.38-1.65)
Winter (December - February)	29 (34.5)	37 (38.1)	0.86 (0.47-1.57)

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