Impact analysis of an evidence-based guideline on diagnosis of urinary tract infection in infants and young children with unexplained fever

Geurts, Dorien; Vos, W.H. De; Moll, Henriëtte A.; Oostenbrink, Rianne

doi:10.1007/s00431-013-2182-5

Cited by 17 publications

(27 citation statements)

References 21 publications

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“…1 Flowchart of the study selection process 94-107, 110-114, 116-121, 123-135, 137, 138, 141-143, 147, 148]; sixty-one of these were studies with a single intervention, mainly with an audit and feedback strategy(19/61, 31.1%) [53, 56-58, 62, 64, 67-71, 74, 76, 82-86, 89, 91, 92, 94, 107, 110, 111, 113, 120, 121, 123, 127, 132, 134, 135, 138, 141, 142, 147]. Eighteen papers (18/113, 15.9%)[40-42, 51, 54, 60, 71, 85, 87, 91, 98, 105, 106, 125, 135, 136, 138, 142] showed an increase in compliance among prescribing physicians; half of the papers analysing this outcome were from USA and Canada (10/18, 55.5%), and the main ASPs adopted were guidelines (9/34, 26.5%)[40,42,54,60,85,87,91,106,125,142], doctors education (5/34, 14.7%)[54,91,98,138,142] and other not common ASPs such as antibiotic order set[42,51], and checklists[87,91]. Sixteen of the included studies[16/113, 14.2% in total; 7/16 (43.7%) from USA, 6/16 (37.5%) from Asia and the rest (18.7%) from Europe] quantified cost savings related to the intervention[39,49,52,64,66,69,73,86,89,92,97,101,102,[122][123][124].…”

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confidence: 99%

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Donà

Barbieri

Daverio

et al. 2020

Antimicrob Resist Infect Control

113

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Background: Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods: MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results: Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions: Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

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confidence: 99%

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Donà

Barbieri

Daverio

et al. 2020

Antimicrob Resist Infect Control

113

View full text Add to dashboard Cite

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“…This recommendation implied chest-radiography in children with estimated risk for pneumonia ≥15% and urine-dipstick and culture if estimated risk for other SBI was ≥30%. Following the local protocol [ 26 ] and international guidelines [ 27 ] urine-dipstick testing was also recommended in low-risk children without a clear focus for their febrile illness. Nurses and physicians were blinded for these cut-off values and for the contribution of predictors on risk scores.…”

Section: Methodsmentioning

confidence: 99%

Impact of a Clinical Decision Model for Febrile Children at Risk for Serious Bacterial Infections at the Emergency Department: A Randomized Controlled Trial

Vos-Kerkhof

Nijman

Vergouwe³

et al. 2015

PLoS ONE

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ObjectivesTo assess the impact of a clinical decision model for febrile children at risk for serious bacterial infections (SBI) attending the emergency department (ED).MethodsRandomized controlled trial with 439 febrile children, aged 1 month-16 years, attending the pediatric ED of a Dutch university hospital during 2010-2012. Febrile children were randomly assigned to the intervention (clinical decision model; n=219) or the control group (usual care; n=220). The clinical decision model included clinical symptoms, vital signs, and C-reactive protein and provided high/low-risks for “pneumonia” and “other SBI”. Nurses were guided by the intervention to initiate additional tests for high-risk children. The clinical decision model was evaluated by 1) area-under-the-receiver-operating-characteristic-curve (AUC) to indicate discriminative ability and 2) feasibility, to measure nurses’ compliance to model recommendations. Primary patient outcome was defined as correct SBI diagnoses. Secondary process outcomes were defined as length of stay; diagnostic tests; antibiotic treatment; hospital admission; revisits and medical costs.ResultsThe decision model had good discriminative ability for both pneumonia (n=33; AUC 0.83 (95% CI 0.75-0.90)) and other SBI (n=22; AUC 0.81 (95% CI 0.72-0.90)). Compliance to model recommendations was high (86%). No differences in correct SBI determination were observed. Application of the clinical decision model resulted in less full-blood-counts (14% vs. 22%, p-value<0.05) and more urine-dipstick testing (71% vs. 61%, p-value<0.05).ConclusionsIn contrast to our expectations no substantial impact on patient outcome was perceived. The clinical decision model preserved, however, good discriminatory ability to detect SBI, achieved good compliance among nurses and resulted in a more standardized diagnostic approach towards febrile children, with less full blood-counts and more rightfully urine-dipstick testing.Trial RegistrationNederlands Trial Register NTR2381

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“…Even when clinicians are aware of the evidence and are willing to change practice accordingly, altering well established care processes can be difficult without a thorough 'due diligence' phase (assessment of barriers and determinants prior to implementation) and a supportive environment conducive to quality improvement [24][25][26]. A multifaceted, organisationally relevant approach is necessary, with educational outreach, buy-in and support of both clinicians and executives, underpinned by a systemic, real-time capacity to prompt, monitor, evaluate and feedback on practice [27][28][29][30].…”

Section: Interventions That Improve Adherencementioning

confidence: 99%

Management of fever in Australian children: a population-based sample survey

et al. 2020

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Background: Fever in childhood is a common acute presentation requiring clinical triage to identify the few children who have serious underlying infection. Clinical practice guidelines (CPGs) have been developed to assist clinicians with this task. This study aimed to assess the proportion of care provided in accordance with CPG recommendations for the management of fever in Australian children. Methods: Clinical recommendations were extracted from five CPGs and formulated into 47 clinical indicators for use in auditing adherence. Indicators were categorised by phase of care: assessment, diagnosis and treatment. Patient records from children aged 0 to 15 years were sampled from general practices (GP), emergency departments (ED) and hospital admissions in randomly-selected health districts in Queensland, New South Wales and South Australia during 2012 and 2013. Paediatric nurses, trained to assess eligibility for indicator assessment and adherence, reviewed eligible medical records. Adherence was estimated by individual indicator, phase of care, age-group and setting. Results: The field team conducted 14,879 eligible indicator assessments for 708 visits by 550 children with fever in 58 GP, 34 ED and 28 hospital inpatient settings. For the 33 indicators with sufficient data, adherence ranged from 14.7 to 98.1%. Estimated adherence with assessment-related indicators was 51.3% (95% CI: 48.1-54.6), 77.5% (95% CI: 65.3-87.1) for diagnostic-related indicators and 72.7% (95% CI: 65.3-79.3) for treatment-related indicators. Adherence for children < 3 months of age was 73.4% (95% CI: 58.0-85.8) and 64.7% (95% CI: 57.0-71.9) for children 3-11 months of age, both significantly higher than for children aged 4-15 years (53.5%; 95% CI: 50.0-56.9). The proportion of adherent care for children attending an ED was 77.5% (95% CI: 74.2-80.6) and 76.7% (95% CI: 71.7-81.3) for children admitted to hospital, both significantly higher than for children attending a GP (40.3%; 95% CI: 34.6-46.1). Conclusions: This study reports a wide range of adherence by clinicians to 47 indicators of best practice for the management of febrile children, sampled from urban and rural regions containing 60% of the Australian paediatric population. Documented adherence was lowest for indicators related to patient assessment, for care provided in GP settings, and for children aged 4-15 years.

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Impact analysis of an evidence-based guideline on diagnosis of urinary tract infection in infants and young children with unexplained fever

Cited by 17 publications

References 21 publications

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Impact of a Clinical Decision Model for Febrile Children at Risk for Serious Bacterial Infections at the Emergency Department: A Randomized Controlled Trial

Management of fever in Australian children: a population-based sample survey

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