Stewardship / Resistance Scan for Aug 17, 2022

News brief

Long antibiotic durations noted for kids with pneumonia, urinary infections

Prescribing data from a children's hospital network in Chicago showed considerable variation in antibiotic durations for children treated for community-acquired pneumonia (CAP) and urinary tract infections (UTIs) in ambulatory settings, with the variability largely unrelated to the severity of symptoms, researchers reported late last week in the Journal of the Pediatric Infectious Diseases Society.

The retrospective study used outpatient prescribing data from 2016 through 2019 to determine antibiotic durations for CAP and UTIs in pediatric populations and the influence of non-clinical predictors of long antibiotic duration. While some medical society guidelines suggest 10 days of antibiotics for pediatric CAP, and 7 to 14 days of antibiotics for UTIs in children ages 2 to 24 months, recent studies have suggested shorter antibiotic durations for both conditions may be just as effective in children. Guidelines at the hospital and its 14 outpatient centers recommend 7 days of antibiotics for treatment of both CAP and UTIs in children.

Overall, 2,124 prescriptions for CAP and 1,116 prescriptions for UTI were included in the study. Prescriptions were longer than 10 days in 59.9% and 47.6% of children treated for CAP and UTI, respectively. Long durations were more common in the emergency department (ED) than in clinics for UTIs, and more common in convenient care for CAP. Younger children had greater odds of long antibiotic duration for both diagnoses, with children younger than 1 year old having much higher odds of a longer antibiotic duration for CAP (odds ratio [OR], 8.64; 95% confidence interval [CI], 5.01 to 14.89) and for UTIs (OR, 4.24; 95% CI, 2.33 to 7.72) compared with older children.

Medicaid insurance was also associated with long therapy for UTI (OR, 1.66; 95% CI, 1.17 to 2.35) and CAP (OR, 1.43; 95% CI, 1.o9 to 1.86). Residents and fellows were less likely to give long durations than attending physicians, while advanced practice nurses were more likely to administer long therapies in CAP. Subsequent hospitalizations were uncommon for UTI (n = 10) and CAP (n = 20).

"Future stewardship interventions should address non-clinical predictors of antibiotic duration including addressing potential provider biases that can influence the decision-making process," the study authors concluded. "Reducing the unnecessarily long duration of therapy is an important quality intervention to reduce the risk of antimicrobial resistance and adverse events."
Aug 14 J Pediatric Infect Dis Soc abstract

Higher antibiotic use found in young, White, rural children in Kentucky

In another study published late last week in the same journal, an analysis of statewide Medicaid data in Kentucky showed that antibiotic fills were higher among young, White children in rural areas and those with chronic conditions.

To evaluate patient-level antibiotic use among children in Kentucky, which consistently ranks as one of the highest prescribing states for antibiotic use in adults and children, researchers from the University of Tennessee, the University of Louisville, and Duke University examined pharmacy data from a cohort of children enrolled in Medicaid from 2012 through 2017. The cohort followed the same children, who were ages 0 to 14 in 2012, over the 6-year study period, looking at outpatient antibiotic prescriptions, age, sex, race, zip code, and chronic conditions.

A total of 169,724 children were included in the study, and they received 1,478,484 antibiotic prescriptions over the study period. Of these children, there were 10,804 (6.4%) children with no antibiotic prescription claims during the study period; 43, 473 (25.6%) had 1 to 3 antibiotic prescriptions; 34,318 (20.2%) had 4 to 6 antibiotic prescriptions; 30, 994 (18.3%) had 7 to 10; 35, 018 (20.6%) had 11 to 20; and 15, 117 (8.9%) children had more than 20 antibiotic prescriptions.

Overall, the population had a median total of six antibiotic prescriptions during the study period, but use was higher in children ages 0 to 5 (median of 8 antibiotic fills, compared with 5 for older children), White children (median of 7 antibiotic fills, compared with 3 for Black children), children in rural settings (median of 9 antibiotic fills, compared with 7 for suburban children and 4 for urban children), and children with chronic conditions (median of 8 antibiotic fills, compared with 6 for children without chronic conditions).

The study authors say the findings support studies in other states that have found racial and urban-rural disparities in antibiotic prescribing for children, and that further research is needed to better understand whether these disparities reflect variations in family expectations, care-seeking behavior, and/or clinician bias.

"Eliminating racial and rural differences in antibiotic prescribing should be a priority for outpatient antibiotic stewardship," they wrote.
Aug 14 J Pediatric Infect Dis Soc study

News Scan for Aug 17, 2022

News brief

Study suggests test-to-stay COVID-19 strategy in schools was effective

Using a test-to-stay (TTS) strategy in K-12 schools during the winter of 2021-22 resulted in substantial reduction in missed school days, according to a study yesterday in Pediatrics.

The study, led by researchers from Duke University, looked at the impact of TTS on North Carolina schools where masking was considered optional and the Omicron variant became the dominant strain in the United States.

The study enrolled 1,675 participants. Students and staff who were eligible for enrollment had a non-household exposure to SARS-CoV-2 within or outside of school from Nov 29, 2021, to Jan 28, 2022, as identified through the school contact-tracing program, and were not experiencing symptoms at the time of enrollment. Those enrolled were required to test using rapid antigen tests on the day they were notified of exposure, on day 3, and on day 5.

Researchers identified 201 positive cases and a tertiary attack rate of 10% (95% confidence interval, 6% to 19%). A total of 7,272 (89%) of potentially missed days were saved through the TTS strategy.

"We estimated one additional school-acquired case for every 21 TTS participants remaining in school buildings during the entire study period," the authors concluded. "Based on our data, a TTS approach allows more students and staff to remain in the classroom, with a modest increase in subsequent infections in optionally masked settings, even during the circulation of a highly transmissible variant."
Aug 16 Pediatrics study

Universal healthcare coverage tied to COVID-19 childhood vaccine uptake

Countries with more progress toward universal healthcare coverage (UHC) saw smaller decreases in childhood vaccination amid the health service delivery disruptions of the COVID-19 pandemic, suggests preliminary research published yesterday in PLOS Medicine.

Using a difference-in-difference design, New York University researchers quantified the relationship between UHC and childhood vaccination rates among 195 countries and their ability to provide 12 of 14 vaccines from 2010 to 2020.

A total of 20,230 country-year observations were included, 1,658 of which occurred after the emergence of SARS-CoV-2 in 2020. The data were derived from the World Health Organization/UNICEF Joint Estimates of National Immunization Coverage, and the 2019 UHC Service Coverage Index was used to classify countries' progress toward UHC.

The team found that, after adjustment, countries with a UHC index score of 80 or higher observed a 2.7% smaller drop in childhood vaccination in 2020 than those with lower scores. Before the pandemic, countries with a high UHC index had an average childhood vaccination uptake of 92.7%, compared with 86.2% in lower-UHC countries. In the first year of the pandemic, countries with a high UHC index realized a coverage rate of 91.9%, versus 81.7% in lower-UHC countries.

"Countries' health system resilience against public health emergencies has been studied almost exclusively under the framework of global health security (GHS), with no role of UHC discussed," the researchers wrote. "This clear separation of investigations has precluded the opportunity to examine the potential contribution of UHC in strengthening health system resilience against external shocks."

In a PLOS news release, senior author Yesim Tozan, PhD, noted that the COVID-19 pandemic has affected the delivery of essential health services worldwide. "This study provided the much-needed quantitative evidence of the protective effects of universal health coverage in times of public health crises, underpinning the policy recommendations for sustained political commitment and investments for universal health coverage to build resilient health systems," she said.
Aug 16 PLOS Med study
Aug 16 PLOS news release

Measles outbreak in Zimbabwe kills 157 children

A new measles outbreak in Zimbabwe has killed at least 157 children, virtually all of them unvaccinated, according to an Associated Press (AP) story today.

Officials have reported at least 2,056 infections. The outbreak was first reported in Manicaland province in the east in early April and has since spread nationwide. The government has initiated a mass immunization campaign targeting children from 6 months to 15 years of age. Authorities are also enlisting the help of traditional and faith leaders to encourage vaccination.

Zimbabwe continued vaccinating children against measles even during the height of COVID-19, but efforts have been hampered by Christian groups that preach against vaccines, the story said.

Church gatherings that have resumed following the easing of pandemic restrictions have led to measles spread to previously unaffected areas, the health ministry said.
Aug 17 AP story