Variability in Antibiotic Prescribing for Community-Acquired Pneumonia.
Variability in Antibiotic Prescribing for Community-Acquired Pneumonia.
复制标题
DOI：
10.1542/peds.2016-2331
复制
发表时间：
2017-04
期刊：
影响因子：
8
通讯作者：
Feemster KA
中科院分区：
文献类型：
--
作者：
Handy LK;Bryan M;Gerber JS;Zaoutis T;Feemster KA
已发布的指南建议大多数患有社区获得性肺炎 (CAP) 的儿童使用阿莫西林，但更常见的是大环内酯类药物和广谱抗生素。我们的目的是确定与阿莫西林处方与大环内酯类药物或广谱抗生素治疗 CAP 相关的患者和临床医生特征。 2009 年 7 月 1 日至 2013 年 6 月 30 日在门诊儿科初级保健网络中进行的回顾性队列研究。纳入了服用阿莫西林、大环内酯类或广谱抗生素（阿莫西林克拉维酸、头孢菌素或氟喹诺酮）治疗 CAP 的患者。采用多变量逻辑回归模型，根据患者和临床医生的特征，控制实践，确定 CAP 抗生素选择的预测因素。在10414名儿童中，4239名（40.7%）接受阿莫西林治疗，4430名（42.5%）接受大环内酯类治疗，1745名（16.8%）接受广谱抗生素治疗。与阿莫西林相比，接受大环内酯类药物的几率增加的相关因素包括患者年龄≥5岁（aOR 6.18；95% CI：5.53，6.91）、既往接受过抗生素（aOR 1.79；95% CI：1.56、2.04）和私人保险（aOR 1.47；95% CI：1.28， 1.70）。在各个诊所中，儿童服用大环内酯类药物的预测概率在 0.22 到 0.83 之间显着变化。与阿莫西林相比，与接受广谱抗生素的几率增加相关的非临床特征包括郊区执业（aOR 7.50；95% CI：4.16，13.55）和私人保险（aOR 1.42；95% CI：1.18，1.71）。不同实践中 CAP 的抗生素选择差异很大。与 CAP 微生物学病因不太可能相关的因素是抗生素选择的重要驱动因素。了解超指南处方的驱动因素可以为有针对性的抗菌药物管理举措提供信息。
Published guidelines recommend amoxicillin for most children with community-acquired pneumonia (CAP), yet macrolides and broad-spectrum antibiotics are more commonly prescribed. We aimed to determine the patient and clinician characteristics associated with prescription of amoxicillin versus macrolide or broad-spectrum antibiotics for CAP. Retrospective cohort study in an outpatient pediatric primary care network from July 1, 2009, to June 30, 2013. Patients prescribed amoxicillin, macrolides, or a broad-spectrum antibiotic (amoxicillin-clavulanic acid, cephalosporin, or fluoroquinolone) for CAP were included. Multivariable logistic regression models were implemented to identify predictors of antibiotic choice for CAP based on patient- and clinician-level characteristics, controlling for practice. Of 10414 children, 4239 (40.7%) received amoxicillin, 4430 (42.5%) received macrolides, and 1745 (16.8%) received broad-spectrum antibiotics. Factors associated with an increased odds of receipt of macrolides compared with amoxicillin included patient age ≥ 5 years (aOR 6.18; 95% CI: 5.53, 6.91), prior antibiotic receipt (aOR 1.79; 95% CI: 1.56, 2.04), and private insurance (aOR 1.47; 95% CI: 1.28, 1.70). The predicted probability of a child being prescribed a macrolide ranged significantly between 0.22 and 0.83 across clinics. Nonclinical characteristics associated with an increased odds of receipt of broad-spectrum antibiotics compared with amoxicillin included suburban practice (aOR 7.50; 95% CI: 4.16, 13.55) and private insurance (aOR 1.42; 95% CI: 1.18, 1.71). Antibiotic choice for CAP varied widely across practices. Factors unlikely related to the microbiologic etiology of CAP were significant drivers of antibiotic choice. Understanding drivers of off-guideline prescribing can inform targeted antimicrobial stewardship initiatives.