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Hospital program improves antibiotic prescribing

By Kerry Grens

NEW YORK (Reuters Health) - A quality improvement program at a single children's hospital succeeded in cutting back inappropriate antibiotic prescribing, in a new study.

Researchers found within six months of introducing new electronic and educational tools, doctors were meeting national guidelines for treatment of childhood pneumonia in 100 percent of patients.

"It's quite truthfully astounding," said Dr. Thomas Brogan, a pediatrician at the University of Washington School of Medicine in Seattle who wasn't involved in the new study.

"They did an incredible job."

Brogan said the program, instituted by Cincinnati Children's Hospital Medical Center, can serve as a model for other institutions looking to get their antibiotic prescribing practices up to speed with current recommendations.

In mid-2011, the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America issued guidelines for treating kids who develop pneumonia outside of the hospital, called community-acquired pneumonia.

The recommendations state that doctors should prescribe the antibiotic ampicillin as a first line of therapy unless other circumstances - such as a child's underlying medical conditions - require a different approach.

Choosing this drug could help prevent antibiotic resistance, in which bacteria become immune to certain antibiotics because they are used inappropriately, said Brogan.

Ampicillin is considered a "narrow spectrum" antibiotic, meaning it only affects a select type of bacteria.

On the other hand, "broad spectrum" antibiotics, which are often used to treat pneumonia, can wipe out a wide range of bacteria.

If bacteria become resistant to ampicillin, there are still plenty of other antibiotics that could work on the organisms that ampicillin doesn't affect. But resistance to broad spectrum drugs leaves doctors with fewer options to treat those resistant bugs, Brogan said.

Lilliam Ambroggio, a research fellow at the University of Cincinnati College of Medicine and the lead author of the study, said previous research showed significant variation in how doctors treat pneumonia in children.

In an effort to get Cincinnati Children's up to date with the 2011 guidelines, she and her colleagues initiated a quality improvement program.

The team educated senior-level physicians on the new antibiotic prescribing rules and created a quick reference guide for doctors-in-training.

The researchers also updated the hospital's electronic medical records so they defaulted to the recommended antibiotics when a patient was diagnosed with pneumonia. Before this change, the default antibiotic that doctors would see pop up in the chart was a broad spectrum drug.

Ambroggio's team tracked patients' treatment starting six months prior to introducing the prescribing program and for nine months after. A total of 217 kids with pneumonia were treated during that span.

During the six months prior to the changes, doctors were rarely in line with the national guidelines, which were issued mid-way through this period.

In the emergency room, physicians' prescribing practices were virtually never consistent with the recommendations, and on the hospital floors, doctors were adherent about 30 percent of the time.

Ambroggio pointed out that children were still being treated with antibiotics, just not the ones that the professional organizations would consider appropriate.

Immediately after she and her colleagues began educating doctors, adherence jumped to 80 to 90 percent and ultimately reached 100 percent within a few months, according to findings published Monday in Pediatrics.

"It was better than anticipated," Ambroggio told Reuters Health.

She could not estimate how much the program would cost to set up at other institutions. The study also could not prove adhering to the national guidelines makes a difference to children's health or to antibiotic resistance.

An earlier study at Children's Mercy Hospital in Kansas City found that switching from regularly using a broad spectrum antibiotic to ampicillin did not result in any additional cases of the antibiotic not working (see Reuters Health report of February 21, 2012 here: http://reut.rs/yDrJUx).

Ambroggio said her group is following up on its study to see whether adhering to the guidelines does improve outcomes.

SOURCE: http://bit.ly/10Ygt6n Pediatrics, online April 15, 2013.

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