Clinical diagnoses and antimicrobials predictive of pediatric antimicrobial stewardship recommendations: a program evaluation

Abstract

Background: The number of pediatric antimicrobial stewardship programs (ASPs) is increasing and program evaluation is a key component to improve efficiency and enhance stewardship strategies.

Objective: To determine the antimicrobials and diagnoses most strongly associated with a recommendation provided by a well-established pediatric ASP.

Design and setting: Retrospective cohort study from March 3, 2008, to March 2, 2013, of all ASP reviews performed at a free-standing pediatric hospital.

Methods: ASP recommendations were classified as follows: stop therapy, modify therapy, optimize therapy, or consult infectious diseases. A multinomial distribution model to determine the probability of each ASP recommendation category was performed on the basis of the specific antimicrobial agent or disease category. A logistic model was used to determine the odds of recommendation disagreement by the prescribing clinician.

Results: The ASP made 2,317 recommendations: stop therapy (45%), modify therapy (26%), optimize therapy (19%), or consult infectious diseases (10%). Third-generation cephalosporins (0.20) were the antimicrobials with the highest predictive probability of an ASP recommendation whereas linezolid (0.05) had the lowest probability. Community-acquired pneumonia (0.26) was the diagnosis with the highest predictive probability of an ASP recommendation whereas fever/neutropenia (0.04) had the lowest probability. Disagreement with ASP recommendations by the prescribing clinician occurred 22% of the time, most commonly involving community-acquired pneumonia and ear/nose/throat infections.

Conclusions: Evaluation of our pediatric ASP identified specific clinical diagnoses and antimicrobials associated with an increased likelihood of an ASP recommendation. Focused interventions targeting these high-yield areas may result in increased program efficiency and efficacy.

FIGURE 1

Number of total reviews performed by antimicrobial stewardship program (ASP) and the probability of an ASP recommendation based on antimicrobial (A) and diagnosis (B). Fluoro = fluoroquinolones; Clinda = clindamcyin; Metro = metronidazole; CNS = central nervous system; SSTI = skin and soft-tissue infections; ENT = ear, nose, and throat; CAP = community-acquired pneumonia; BSI = bloodstream infection.

FIGURE 2

Adjusted predictive probability of an antimicrobial stewardship program (ASP) recommendation by antimicrobial (A) and diagnosis (B). Fluoro = fluoroquinolones; Clinda = clindamcyin; Metro = metronidazole; CNS = central nervous system; SSTI = skin and soft-tissue infections; ENT = ear, nose, and throat; CAP = community-acquired pneumonia; BSI = bloodstream infection.