The Impact of an Infectious Diseases Consultation on Antimicrobial Prescribing : The Pediatric Infectious Disease Journal

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Letters to the Editor

The Impact of an Infectious Diseases Consultation on Antimicrobial Prescribing

Osowicki, Joshua MB BS; Gwee, Amanda MB BS; Noronha, Jesuina MB BS; Palasanthiran, Pamela MD; McMullan, Brendan MB BS; Britton, Philip N. MB BS; Isaacs, David MD; Lai, Tony B Pharm; Nourse, Clare MD; Avent, Minyon Pharm D; Moriarty, Paul MB BS; Clark, Julia MB BS; Francis, Joshua R. MB BS; Blyth, Christopher C. MB BS; Cooper, Celia M. BMBS; Bryant, Penelope A PhD

Author Information
The Pediatric Infectious Disease Journal: June 2014 - Volume 33 - Issue 6 - p 669-671
doi: 10.1097/INF.0000000000000285
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To the Editors:

The article published in the April issue by Gwee et al1 describes the activities of an infectious diseases (ID) consult service in children. Their study did not aim to compare patients who received a consult with those who did not. Using national Australian data, we have compared patients who received a consult with those who did not, to provide additional insight to the value of ID consultation in improving antimicrobial use.

In conjunction with the international Antimicrobial Resistance and Prescribing in European Children study,2 8 Australian pediatric hospitals participated in a single-day, hospital-wide point prevalence survey of antimicrobials. Deidentified data were collected about all antimicrobial prescriptions, including the appropriateness of the antimicrobial prescription using a standardized method of describing inappropriate prescribing (decision, choice and application) and whether there had been a concurrent ID consult.

Of 1373 patients, 631 (46%) were receiving 1174 antimicrobials. Of this group, 153 (27%) patients had had an ID consult involving 255 (22%) prescriptions. There were 919 (78%) prescriptions not subject to ID consultation and 3 (0.4%) were unknown. Of the 255 antimicrobial prescriptions where an ID consult had occurred, 99 (39%) were from high-intensity units, with consults accounting for 52/235 (22%) of antimicrobial prescriptions in hematology/oncology, 23/78 (28%) in pediatric intensive care unit and 26/222 (12%) in neonates. Gwee et al1 reported lower proportions of ID consults in these units, likely because that study included patients not receiving antimicrobials.

A comparison of antimicrobial prescriptions was made between patients who did and did not have an ID consult using a χ2 test (Table 1). Prescriptions guided by ID consultation were significantly more likely than those with no consult to be for treatment of community- or hospital-acquired infection. ID consultation was less likely to be associated with medical and surgical prophylaxis, which is often based on protocols. Targeted treatment for proven infection was significantly more likely to have been guided by an ID consult, and consultation was less likely for use of empiric therapy, reflecting that 7 of the 8 hospitals had guidelines for empiric antibiotics for common infections.3

T1-33
TABLE 1:
Comparison of Antimicrobial Prescriptions With and Without an ID Consult

For specific antibacterial agents, there was no universal association between spectrum of antibiotic activity and involvement of an ID consult. Antimicrobials least likely to have involved ID consultation were those incorporated in protocols for prophylaxis (eg, first-generation cephalosporins) or empiric treatment (eg, aminoglycosides). Antimicrobials most likely to have involved ID consultation were those restricted by antimicrobial stewardship programs (eg, carbapenems). Although some broader spectrum antibiotics were associated with ID consultation, a limitation of our data is the inability to determine confounders, for example, patient complexity. Antimicrobials subject to ID consultation were more likely to have a reason documented for their use.

Inappropriate prescribing was significantly more common where there was no ID consult, most frequently in relation to decision making concerning the need for antimicrobials at all. Inappropriate choice of agents and their application (dose, frequency, route) were also more common when there was no ID consult, although numbers were low, perhaps reflecting the impact of guidelines. In an era when antimicrobial stewardship is of critical importance, our data provide important evidence for the value of an ID consult in ensuring targeted and appropriate use of antibiotics.

We would like to acknowledge the physicians and pharmacists, including Maria Chan, Mona Mostaghim and James Newcombe, at every participating hospital who were involved in collecting the data.

Joshua Osowicki, MB BS

Amanda Gwee, MB BS

Infectious Diseases Unit

Department of General Medicine

The Royal Children’s Hospital Melbourne

Parkville

Jesuina Noronha, MB BS

Department of Paediatric Infectious

Diseases

Monash Children’s, Clayton

Pamela Palasanthiran, MD

Brendan McMullan, MB BS

Department of Immunology and Infectious

Diseases

Sydney Children’s Hospital, Randwick

School of Women’s and Children's Health

University of New South Wales

New South Wales

Philip N. Britton, MB BS

David Isaacs, MD

Department of Infectious Diseases and Microbiology

Tony Lai, B Pharm

Pharmacy Department

The Children’s Hospital at Westmead

Westmead, New South Wales

Clare Nourse, MD

Paediatric Infection Management Service

Mater Health Services

Department of Paediatrics

University of Queensland

Minyon Avent, Pharm D

Mater Pharmacy Services

Mater Health

University of Queensland

Centre for Clinical Research

South Brisbane

Paul Moriarty, MB BS

Paediatric Infection Management Service

Mater Health Services

South Brisbane

Julia Clark, MB BS

Infection Management and

Prevention Service

Royal Children’s

Hospital, Brisbane, Queensland

Joshua R. Francis, MB BS

Department of Paediatric and

Adolescent Medicine

Princess Margaret Hospital for Children

Subiaco

Christopher C. Blyth, MB BS

Department of Paediatric and

Adolescent Medicine

Princess Margaret Hospital

for Children, Subiaco

School of Paediatrics and Children’s Health

University of Western Australia

PathWest Laboratory Medicine WA

Princess Margaret

Hospital, Western Australia

Celia M. Cooper, BMBS

SA Pathology, Women’s and

Children’s Hospital

North Adelaide, South Australia

Penelope A Bryant, PhD

Infectious Diseases Unit

Department of General Medicine

The Royal Children’s Hospital Melbourne

Murdoch Children’s Research

Institute, Parkville

Department of Paediatric

Infectious Diseases

Monash Children’s

Clayton, Australia

on behalf of the ANZPID-ASAP Group

Australian and New Zealand Paediatric Infectious Diseases

Australasian Stewardship of Antimicrobials in Paediatrics

REFERENCES

1. Gwee A, Carapetis J, Buttery J, et al. Formal infectious diseases consultations at a tertiary paediatric hospital: a 14 year review. Pediatr Infect Dis J. 2014;33:411–413
2. Versporten A, Sharland M, Bielicki J, et al.ARPEC Project Group Members. The antibiotic resistance and prescribing in European Children project: a neonatal and pediatric antimicrobial web-based point prevalence survey in 73 hospitals worldwide. Pediatr Infect Dis J. 2013;32:e242–e253
3. Bryant PAon behalf of the ANZPID-ASAP group. . Antimicrobial stewardship resources and activities for children in hospitals in Australasia: a comprehensive survey. Poster presented at the World Congress of Paediatric Infectious Diseases 2013 Cape Town

APPENDIX

The members of the ANZPIDASAP group are: Penelope Bryant (Chair); David Andresen, St Vincents and Concord Hospitals Sydney; and University of Sydney, New South Wales, Australia; Minyon Avent, Mater Pharmacy Services, Mater Health; and University of Queensland Centre for Clinical Research, South Brisbane, Queensland, Australia; Sean Beggs, Department of Paediatrics, Royal Hobart Hospital; and School of Medicine, University of Tasmania, Hobart, Tasmania, Australia; Christopher C. Blyth, School of Paediatrics and Child Health, University of Western Australia; PathWest Laboratory Medicine WA and Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital for Children, Western Australia, Australia; Asha Bowen, Royal Darwin Hospital, Darwin, Northern Territory, Australia; Julia Clark, Infection Management and Prevention Service, Royal Children’s Hospital, Brisbane, Queensland, Australia; Celia M. Cooper, SA Pathology, Women’s and Children’s Hospital, North Adelaide, South Australia, Australia; Nigel Curtis, Infectious Diseases Unit, Department of General Medicine, The Royal Children’s Hospital Melbourne; Murdoch Children’s Research Institute; and Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia; Andrew Daley, Department of Microbiology, The Royal Children’s Hospital Melbourne, Parkville; and Department of Microbiology, Royal Women's Hospital, Parkville, Victoria, Australia; Jacky Dobson, Royal Canberra Hospital, Canberra, Australian Capital Territory, Australia; Gabrielle Haeusler, Department of Infectious Diseases, Monash Children’s Hospital, Monash Health; and Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Victoria, Australia; David Isaacs, Children’s Hospital at Westmead, Sydney, New South Wales, Australia; Brendan McMullan and Pamela Palasanthiran, Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, Randwick; and School of Women’s and Child Health, University of New South Wales, New South Wales, Australia; Thomas Snelling, Department of Paediatric and Adolescent Medicine, Princess Margaret Hospital for Children, Western Australia, Australia; Mike Starr, Infectious Diseases Unit, Department of General Medicine, The Royal Children’s Hospital Melbourne; Lesley Voss, Starship Children’s Hospital, Auckland, New Zealand.

© 2014 by Lippincott Williams & Wilkins, Inc.