Intervention Improves Adherence to Antibiotic Prescribing Guidelines for Children: Study

by Rukmani Krishna on? June 15, 2013 at 12:30 AM Child Health News According to a study in the June 12 issue of JAMA, an intervention consisting of clinician education coupled with personalized audit and feedback about antibiotic prescribing improved adherence to prescribing guidelines for common pediatric bacterial acute respiratory tract infections, although the intervention did not affect antibiotic prescribing for viral infections.
"Antibiotics are the most common prescription drugs given to children. Although hospitalized children frequently receive antibiotics, the vast majority of antibiotic use occurs in the outpatient setting, roughly 75 percent of which is for acute respiratory tract infections (ARTIs). Unnecessary prescribing for viral ARTIs is well documented and has been declining. However, inappropriate prescribing also occurs for bacterial ARTIs, particularly when broad-spectrum antibiotics are used to treat infections for which narrow-spectrum antibiotics are indicated and recommended," according to background information in the article. "Antimicrobial stewardship programs have been effective for inpatients, often through prescribing audit and feedback. However, most antimicrobial use occurs in outpatients with acute respiratory tract infections.

Jeffrey S. Gerber, M.D., Ph.D., of The Children''s Hospital of Philadelphia, and colleagues conducted a study to evaluate the effect of an antimicrobial stewardship intervention on antibiotic prescribing for pediatric outpatients. The randomized trial of outpatient antimicrobial stewardship compared prescribing between intervention and control practices using a common electronic health record. After excluding children with chronic medical conditions, antibiotic allergies, and prior antibiotic use, the researchers estimated prescribing rates for targeted ARTIs standardized for age, sex, race, and insurance from 20 months before the intervention to 12 months afterward (October 2008-June 2011). The study included a network of 18 pediatric primary care practices in Pennsylvania and New Jersey (162 clinicians). Overall, there were 1,291,824 office visits by 185,212 unique patients.

The intervention consisted of one 1-hour on-site clinician education session followed by 1 year of personalized, quarterly audit and feedback of prescribing for bacterial and viral ARTIs or usual practice. The researchers measured rates of broad-spectrum (off-guideline) antibiotic prescribing for bacterial ARTIs and antibiotics for viral ARTIs for 1 year after the intervention.

The authors found that among children who were prescribed antibiotics for any indication, the overall proportion of antibiotic prescriptions that were broad-spectrum decreased from 26.8 percent to 14.3 percent in the intervention group and from 28.4 percent to 22.6 percent in control practices (difference of differences [DOD], 6.7 percent) during the 12-months following initiation of education/audit and feedback.

"When stratifying by the individual bacterial ARTIs targeted by the intervention, broad-spectrum (off-guideline) antibiotic prescribing for pneumonia decreased from 15.7 percent to 4.2 percent in the intervention group and from 17.1 percent to 16.3 percent in the control group (DOD, 10.7 percent). Broad-spectrum prescribing for acute sinusitis decreased from 38.9 percent to 18.8 percent in the intervention group and from 40.0 percent to 33.9 percent in the control practices (DOD, 14.0 percent). Broad-spectrum prescribing for streptococcal pharyngitis started and remained low for both the intervention group (from 4.4 percent to 3.4 percent) and the control group (from 5.6 percent to 3.5 percent) (DOD, -1.1 percent)," they write.

In addition, the baseline rate of any antibiotic prescribing for viral infections was low and did not change significantly after the intervention in either the intervention group (from 7.9 percent to 7.7 percent) or the control group (from 6.4 percent to 4.5 percent) (DOD, -1.7 percent).

"This intervention nearly halved prescribing of broad-spectrum antibiotics to children during acute primary care encounters and decreased use of off-guideline antibiotics for children with pneumonia by 75 percent by 1 year after the intervention," the researchers note.

"Our findings suggest that extending antimicrobial stewardship to the ambulatory setting, where such programs have generally not been implemented, may have important health benefits."

"This targeted application of antimicrobial stewardship principles to the ambulatory setting has the potential to affect the most common indications for antibiotic use. Future studies should examine the key drivers of these effects on antibiotic prescribing and the generalizability of findings to other health systems and measure the sustainability and clinical outcomes associated with differential prescribing patterns," the authors conclude.

Source-Newswise

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WHO Issues New Guidelines To Pave Way for Achieving AIDS-free Generation

"Implementing these new guidelines will require thoughtful leadership and planning" said R.J. Simonds, M.D., vice president of program innovation and policy at EGPAF. "We must listen to the local communities and involve them in the rollout efforts. These guidelines have the opportunity to provide unprecedented access to treatment and prevention measures and reduce HIV/AIDS transmission rates worldwide."

The new guidelines include recommendations to provide lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, also known as Option B+, which are expected to improve prevention of mother-to-child transmission (PMTCT) services and increase the likelihood that infants born to HIV-positive mothers will be born and remain HIV-negative. In addition, lifelong ART has the potential to improve the health and livelihood of HIV-positive mothers and reduce the spread of infection to uninfected partners.

The guidelines also call for expanded pediatric treatment, including immediate initiation of ART for all HIV-positive children younger than five years of age. This new recommendation shines a light on efforts to treat new and existing pediatric HIV infections, a component that is often overlooked in the global HIV/AIDS response.

"Currently, only one in three eligible children living with HIV receives the medicines they need. We hope the new guidelines will focus increased attention and efforts to eliminate this gap," said Laura Guay, M.D., vice president of research at EGPAF.

"In addition, because of the many novel aspects of the guidelines, studying its translation into practice is essential for achieving its potential."

Globally, an estimated 26 million people living with HIV in low-and middle-income countries will be eligible for ART under the new guidelines, compared with the previous 17 million eligible recipients in accordance with the WHO's 2010 guidelines. Full implementation could avert as many as 3 million AIDS-related deaths and 3.5 million new HIV infections between 2013 and 2025.

"The new recommendations embody the continuing evolution of the global HIV/AIDs response," said EGPAF President and CEO Charles Lyons. "As we work to combat this epidemic, we must be willing to change and expand upon current treatment and prevention efforts to reach as many HIV-positive people as possible. The Foundation supports efforts to implement these guidelines as we continue our mission to eliminate pediatric HIV and create a world free of HIV/AIDS."

Source-ANI

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Scientists Set Guidelines for Stem Cell Transplants in Older Patients With MDS

MDS is the most common blood disorders in people over 60 years of age, and frequently a precursor for leukemia.

The new study was led by an international team of Dana-Farber Cancer Institute.

Using mathematical models to analyze hundreds of MDS cases from around the world, the researchers found reduced intensity transplants of donor stem cells are advisable for patients aged 60-70 who have higher-risk forms of MDS that are likely to turn into leukemia in the near future. For patients with lower-risk MDS, non-transplant treatments are preferable, the model indicates.

The research was reported online today in the Journal of Clinical Oncology.

"Our study helps inform older MDS patients and their doctors whether a stem cell transplant is preferred or whether it makes more sense to pursue other options," says John Koreth, MBBS, DPhil, medical oncologist in the Division of Hematologic Malignancies at Dana-Farber, who is the study's lead author and co-principal investigator (with Joseph Pidala, MD, MS, of the H. Lee Moffitt Cancer & Research Institute, and senior author Corey Cutler, MD, MPH, of the Division of Hematologic Malignancies at Dana-Farber). "Until now, there haven't been statistically-quantified guidelines for making these decisions for older patients, who are most impacted by the disease."

MDS arises in the blood-forming cells of the bone marrow, causing a drop in the number of healthy white and red blood cells and of platelets needed for blood clotting. Depending on which type of cells are in short supply, the result can be fatigue, shortness of breath, easy bruising and bleeding, or infection and fever. An estimated 12,000 people in the United States are diagnosed with MDS each year, and more than 80 percent of whom are over age 60. (Some researchers believe MDS to be widely under-diagnosed, so the number of people affected may be much larger.)

In some cases, MDS produces only mild symptoms that don't worsen for years. In others, the symptoms can be severe, leading to the development of a fast-growing form of leukemia. The most common tool for predicting the course of MDS is the International Prognostic Scoring System (IPSS), which is based on a patient''s blood counts, percentage of immature "blast" cells in the blood or bone marrow, and occurrence of chromosomal abnormalities in these cells. Based on IPSS scores, the disease is classified as low risk, intermediate-1 or -2 risk, or high risk.

Patients in the first two categories, with lower-risk disease, usually receive treatments such as antibiotics, transfusions, blood cell growth-promoting agents, or other supportive therapies to alleviate their specific symptoms. Patients in the latter two categories, with higher-risk disease, often receive chemotherapy.

While these treatments are often helpful, they cannot cure the disease. The only potentially curative treatment is a donor stem cell transplant, which can, in principle, be used for patients with any stage of MDS. But because even reduced-intensity transplants are fatal in a significant minority of cases, there has been some uncertainty over the use of transplantation for older patients with MDS.

"It hasn't been clear for which older patient groups the benefits of transplant outweigh the risks," Koreth says. To find out, researchers collected data on 514 patients, age 60-70, who were newly diagnosed with MDS. For both lower- and higher-risk groups, they built separate mathematical models to compare treatment outcomes in patients who received reduced-intensity donor stem cell transplants with outcomes in patients who received non-transplant therapies. They analyzed not only length of survival but also the quality of life of patients in those groups.

Patients in the lower-risk groups who underwent transplant lived an average of 38 months after treatment, less than the 77 months for those who were treated without transplant. For patients in the higher-risk groups, by contrast, average life expectancy was 36 months for those receiving transplants, better than the 28 months for those receiving non-transplant therapies. Adjusting for patients' quality of life did not change the conclusions regarding the relative merits of the treatments.

"The clear result is that, on balance, reduced-intensity stem cell transplantation offers a survival benefit for patients with higher-risk MDS, but not for those with lower-risk disease," Koreth says. "The findings should offer useful guidance for older patients with MDS on deciding the best course of treatment."

Study co-authors include Waleska Perez, MPH, and Mary Horowitz, MD, CIBMTR Statistical Center; H. Joachim Deeg, MD, and Stephanie Lee, MD, Fred Hutchinson Cancer Research Center; Guillermo Garcia-Manero, MD, M.D. Anderson Cancer Center; Luca Malcovati, MD, and Mario Cazzola, MD, University of Pavia Medical School, Italy; Sophie Park, MD, PhD, Universite Paris V, France; Raphael Itzykson, MD, Lionel Ades, MD, and Pierre Fenaux, MD, Universite Paris 13, France; Martin Jadersten, MD, PhD, and Eva Hellstrom-Lindberg, MD, PhD, Karolinska Institutet, Sweden; C. L. Beach, PharmD, Celgene Corp.; Robert Peter Gale, MD, PhD, Celgene Corp. and Imperial College, London, U.K.; Peter Greenberg, MD, Stanford University School of Medicine; Martin Tallman, MD, Memorial Sloan-Kettering Cancer Center; John DiPersio, MD, PhD, Washington University School of Medicine, St. Louis; Donald Bunjes, MD, of University Hospital Ulm, Germany; and Daniel Weisdorf, MD, University of Minnesota.

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Stroke patients perform better in Get with the guidelines (Regd) - racing program

"Previous studies have shown get with the guidelines hospitals improved the manner in which they have taken in charge for people, but it is the first to show how the recovery tempeature patient.".The researchers compared 366 hospitals that joined the programme of the American Heart Association/American Stroke Association get with lines guidelines-race in April 2004-December 2007 with 366 that did not.

They correspond to installations of size, geographical location, State of education, number of treated strokes and patients characteristics.Comparing the periods before and after hospitals joined to get with the guidelines, researchers found that participating hospitals improved their mortality rate 30 days and one year and a rate of readmission 30 days and one year. During the same time, only improved non-participating hospitals 30-day mortality rates.

Hospitals get with the guidelines-Stroke lines also had higher rates of discharge patients directly at home rather than in a care facility.More than 2,000 hospitals participate in several programmes to get with the guidelines of the association, which provide resources and tools to help care teams to follow the most recent treatment guidelines based on research.

Source-Eurekalert

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