pediatric-spesific antimicrobial suspectibility data and empiric antibiotic selection - cyntia meta

7/30/2019 Pediatric-spesific Antimicrobial Suspectibility Data and Empiric Antibiotic Selection - Cyntia Meta

1/10

DOI: 10.1542/peds.2012-0563; originally published online August 13, 2012;2012;130;e615Pediatrics

Joel C. Boggan, Ann Marie Navar-Boggan and Ravi Jhaveri

SelectionPediatric-Specific Antimicrobial Susceptibility Data and Empiric Antibiotic

http://pediatrics.aappublications.org/content/130/3/e615.full.html

located on the World Wide Web at:The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2012 by the American Academypublished, and trademarked by the American Academy of Pediatrics, 141 Northwest Point

publication, it has been published continuously since 1948. PEDIATRICS is owned,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on September 6, 2012pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/content/130/3/e615.full.htmlhttp://pediatrics.aappublications.org/content/130/3/e615.full.htmlhttp://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/content/130/3/e615.full.html


2/10

Pediatric-Specific Antimicrobial Susceptibility Data

and Empiric Antibiotic Selection

WHATS KNOWN ON THIS SUBJECT: Ideal empirical antibiotic

choices are based on local susceptibility data. These choices are

important for ensuring positive patient outcomes, but pediatric-

specific data may not be available.

WHAT THIS STUDY ADDS: Antibiotic susceptibilities differ by age

group within a tertiary-care hospital. Knowing these differences,

pediatricians chose empirical antibiotic therapy more likely to be

successful. Children with infectious diseases would benefit from

reporting of pediatric-specific susceptibility results.

abstractOBJECTIVE: Duke University Health System (DUHS) generates annual

antibiograms combining adult and pediatric data. We hypothesized

significant susceptibility differences exist for pediatric isolates and

that distributing these results would alter antibiotic choices.

METHODS: Susceptibility rates for Escherichia coliisolates from patients

aged #12 years between July 2009 and September 2010 were com-

pared with the 2009 DUHS antibiogram. Pediatric attending and resident

physicians answered case-based vignettes about children aged 3

months and 12 years with urinary tract infections. Each vignettecontained 3 identical scenarios with no antibiogram, the 2009 DUHS

antibiogram, and a pediatric-specific antibiogram provided. Effective

antibiotics exhibited .80% in vitro susceptibility. Frequency of

antibiotic selection was analyzed by using descriptive statistics.

RESULTS: Three hundred seventy-five pediatric isolates were identified.

Pediatric isolates were more resistant to ampicillin and trimethoprim-

sulfamethoxazole (TMP-SMX) and less resistant to amoxicillin-clavulanate

and ciprofloxacin (P, .0005 for all). Seventy-five resident and attending

physicians completed surveys. In infant vignettes, physicians selected

amoxicillin-clavulanate (P, .05) and nitrofurantoin (P, .01) more often

and TMP-SMX (P,

.01) less often with pediatric-specifi

c data. Effectiveantibiotic choices increased from 68.6% to 82.2% (P = .06) to 92.5% (P,

.01) across scenarios. In adolescent vignettes, providers reduced TMP-SMX

use from 66.2% to 42.6% to 19.0% (P, .01 for both). Effective antibiotic

choices increased from 32.4% to 57.4% to 79.4% (P, .01 and P = .01).

CONCLUSIONS: Pediatric E. coli isolates differ significantly in antimicrobial

susceptibility at our institution, particularly to frequently administered oral

antibiotics. Knowledge of pediatric-specific data altered empirical antibiotic

choices in case vignettes. Care of pediatric patients could be improved with

use of a pediatric-specific antibiogram. Pediatrics 2012;130:e615e622

AUTHORS: Joel C. Boggan, MD, MPH,

a

Ann MarieNavar-Boggan, MD, PhD,a and Ravi Jhaveri, MDb

aDepartments of Medicine and Pediatrics, and bDivision of

Infectious Diseases, Department of Pediatrics, Duke University

Medical Center, Durham, North Carolina

KEY WORDS

pediatric-specific antimicrobial susceptibility, antimicrobial

resistance, quality of care

ABBREVIATIONS

AMOX-CLAVamoxicillin-clavulanate

DUHSDuke University Health System

EDemergency department

TMP-SMXtrimethoprim-sulfamethoxazole

UTIurinary tract infection

Drs Boggan, Navar-Boggan, and Jhaveri designed the study and

wrote the manuscript; and Drs Boggan and Navar-Boggan

collected and analyzed the data.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-0563

doi:10.1542/peds.2012-0563

Accepted for publication Apr 27, 2012

Address correspondence to Ravi Jhaveri, MD, Division of Pediatric

Infectious Diseases, Duke University Medical Center, DUMC 3499,

Durham, NC 27710. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2012 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: No external funding.

PEDIATRICS Volume 130, Number 3, September 2012 e615

ARTICLE

mailto:[email protected]://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/mailto:[email protected]


3/10

Appropriate antibiotic prescribing is

essential to improve patient outcomes

and to help prevent the emergence of

resistant organisms. As has been noted

for many years, resistance rates con-

tinue to rise with continued use of

current antibiotics such that the even-tual obsolescence of many of these

agents is a major concern.1,2

A key aspect of successful outcomes in

bacterial infections is selection of the

appropriate empirical antibiotic based

on the likely organism and predicted

antimicrobial susceptibility. In adults,

following guidelines for pneumonia

improves antibiotic selection and thus

outcomes,3 and improved outcomes

have been shown for children withfaster administration of appropriate

antibiotics.4 Inappropriate antibiotics

are often broad spectrum, potentially

leading to increased selection of resis-

tant organisms.5,6Susceptibilitypatterns

may vary regionally and nationally,7 as

well as in different units within hospitals

and between hospitals within health

systems.8 Patterns of antibiotic resis-

tance also vary within specific units and

patient groups. Studies suggest thatadults and children often have dif-

ferences in resistance patterns for

Escherichia coli,9 group A streptococci,10

Candida,11 and community-acquired

methicillin-resistant Staphylococcus au-

reus.12 Access to the most accurate an-

timicrobial antibiogram for pediatric

patients therefore would likely improve

outcomes while limiting the risk of drug

resistance.

At our institution, Duke UniversityMedical Center, pediatric and adult

patients are cared for in the same

physical hospital structure(a hospital-

within-a-hospital) with a single, shared

microbiology laboratory. Annual antibi-

otic antibiograms are generated based

on combined data from both adult and

pediatric isolates. Given that these

reports represent a collection of iso-

lates that may not accurately represent

those found in pediatric patients with

commonly encountered infections, we

hypothesized that there may be signifi-

cant differences in resistance patterns

when pediatric isolates were analyzed

independently.

To test our hypothesis, we undertooka study ofE. coliresistance patterns in

the pediatric population at our insti-

tution to determine if resistance pat-

terns differed significantly from those

reported from hospital-wide isolates.

To demonstrate further that these po-

tential differences may affect the care

of pediatric patients, we developed a

case-based survey of pediatric providers

within the health system to determine if

the availability of pediatric-specific datawould alter antibiotic selection.

METHODS

This protocol was reviewed and ap-

proved by the Duke Institutional Review

Board (Pro00026893).

Comparison of Adult and Pediatric

Susceptibility

Electronic medical record data were

used to evaluate pediatric-specific cul-

ture dataforall isolates ofE. colicultured

in patients#12 years in the emergency

department (ED), hospital, and outpa-

tient settings between July 1, 2009,

through September 30, 2010, within the

Duke University Health System (DUHS).

This was performed by using an auto-

mated electronic record review tool de-

veloped at our institution that allows

for user-designed queries of electronic

medical information. All inpatient, ED,and outpatient microbiology data are

available via electronic medical record

and are therefore accessible via elec-

tronic review. First, the cohort of patients

aged#12 years who had a microbiolog-

ical isolate ofE. coliwere identified. Data

technicians at our institution were then

able to extract antibiotic susceptibility

results for these patients from the ele-

ctronic medical record.

E. coliwas chosen because it is the most

frequently isolated pathogen from pe-

diatric samples (predominantly urine).13

Twelve years of age was chosen as the

age cutoff in an attempt to limit urine

cultures from sexually active adoles-

cents because these may be moresimilar to adult isolates in the commu-

nity. For children with multiple positive

cultures during the same hospitaliza-

tion, only the first positive culture was

used. Susceptibility percentages were

then calculated for each antibiotic. The

antibiotics for which susceptibility rates

are reported are listed in Table 1. Third-

generation cephalosporins (ceftriax-

one) were reported only if the isolate

was resistant to thefi

rst-generation al-ternative (cefazolin).

The Duke University Medical Center

Clinical Microbiology Laboratory annu-

ally creates an antibiogram for multiple

bacteria, including E. coli. The antibiotics

for which susceptibilities were reported

from 2009 are shown in Table 1. Com-

parison of rates of resistance be-

tween these 4314 samples and those

obtained from database abstraction

for children#

12 years were derivedby using a comparison of proportions

assuming a binomial distribution.

Impact of Susceptibility Data on

Provider Prescribing Practices

A survey assessing clinical treatment of

acute urinary tract infections (UTIs)

was distributed electronically to pedi-

atric providers deemed most likely to

treat acute UTIs: ED physicians, pedi-

atric hospitalists and other pediatricfaculty that attend on the inpatient

wards, primary care outpatient pro-

vidersworkinginacutecareclinics,and

pediatric residents of all levels. Pro-

viders were asked their training level

and primary site of practice (inpatient

vs outpatient vs ED).

Thissurveypresented2clinicalvignettes

of children with probable UTIs, 1 in a

3-month-old child and 1 in a 12-year-old

e616 BOGGAN et alat Indonesia:AAP Sponsored on September 6, 2012pediatrics.aappublications.orgDownloaded from
http://-/?-http://-/?-http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://-/?-http://-/?-


4/10

child. Providers were asked to report

antibiotic choices within each vignette.

The survey text for these cases and

additionalinformation are shownin the

Appendix.

The 2 cases (3-month-old and 12 year-

old, both with UTIs) were presented 3

times on subsequent survey screens,

each time asking identical questions

regarding selection of antibiotics for

each scenario. All cases were answered

within the same survey administration.

In Scenario A (first screen), no antibiotic

resistance data were provided. In Sce-

nario B (second screen), a chart of the

hospital-wide2009Duke antibiogram for

E. coli, Klebsiella, Pseudomonas, and

Enterococcuswere presented alongside

the case. In Scenario C (final screen),

a chart of the Duke pediatric-specific

antibiogram obtained from our analy-

sis ofE. colipositive cultures in children

#12 years from 2009 was available. The

screens were in the same order for all

surveys administered, and participants

could not return to previous screensafter moving forward. Antibiotic se-

lections were entered as free-text by

providers. Effective antibiotics were

considered to be those with .80% in

vitro susceptibility rates because this is

the cut off for use of tri met hoprim-

sulfamethoxazole (TMP-SMX) as an

empirical therapy in the most recent

Infectious Disease Society of America

guidelines for uncomplicated cystitis.14

Descriptive statistics were used to

calculate frequency of response by

antibiotic or antibiotic group (ie, first-

generation cephalosporins) for each

scenario by subset of antibiogram (sce-

nario A vs B and A vs C) and by training

level. Differences in survey response

rates by antibiotic were assessed by

using Fishers exact test, with cutoff for

statistical significance at P , .05. All

analyses were performed by using Stata

v 9.2 (College Station, TX).

RESULTSComparison of Adult and Pediatric

Susceptibility

Three hundred and seventy-five pedi-

atric isolates were identified from 327

patients.Of these,most, butnotall,were

tested for each antibiotic. Demographic

data for patients providing these iso-

lates are shown in Table 2. Pediatric

and hospital-wide antibiotic antibio-

grams are shown in Table 1. Pediatric

isolates were more likely to be re-sistant to amoxicillin, amikacin, and

TMP-SMX and less likely to be resis-

tant to amoxicillin-clavulanate (AMOX-

CLAV) and ciprofloxacin than the iso-

lates generated from across age

groups (P, .0005 for all). Suscepti-

bility to nitrofurantoin was not re-

ported in the DUHS antibiogram though

these data were available for the pe-

diatric report.

Impact of Antibiograms on

Provider Prescribing Practices

To test for the potential utility of a

pediatric-specific antimicrobial anti-

biogram on clinical practice, 92 cate-

goricalpediatricsandcombinedinternal

medicine-pediatrics residents were sur-

veyed along with 43 attending pedia-

tricians. Surveys were completed by 49

residents (53%) and 26 attending physi-

cians (61%), for an overall response rate

of 56%.

Three-Month-Old Female With UTI

All but 1 provider initially chose to treat

the 3-month-old female after urinalysis

results were obtained. This provider

reported that he or she would treat the

patient on day 1 when culture results

were positive. Of 74 pediatricians who

chose to initiate antibiotics after the

urinalysis was obtained, 3 reported

they would change antibiotic therapy

once they knew the organism was E.

coli. Initial antibiotic choices for the 3

scenarios (no antibiogram, combined

adult/pediatric data, and a pediatric-

specific antibiogram) are presented

in Table 3.Comparing antibiotic choices between

scenario A (no data) and scenario B

(hospital-wide data), providers were

more likely to choose a first-generation

cephalosporin when presented with

hospital-wideor pediatric-specificdata.

However, when pediatric-specific data

were presented, providers were also

more likely to choose AMOX-CLAV and

less likely to choose TMP-SMX.

Physicians were more likely to chooseantibiotics only available in intravenous

formulations when antibiotic antibio-

grams were provided compared with

when no data were provided. In addi-

tion, 2 providers selected ciprofloxacin

(not US Food and Drug Administration

approved for treatment of uncompli-

cated UTI in infants) when antibiograms

were available, compared with no pro-

viders when data were not available.

TABLE 1 Antibiotic Susceptibilities by Age Group

Antibiotic (Pediatric nTested) Pediatric Isolates (% Susc) Combined Isolates

(% Susc, n= 4314)

Amikacin (306) 97 100a

Ampicillin (374) 45 57a

AMOX-CLAV/ampicillin-sulbactam (374) 83 59a

Cefazolin (371) 90 90

Ciprofloxacin (297) 91 81aGentamicin (374) 93 92

Imipenem (299) 100 100

Nitrofurantoin (338) 99 Not reported

Piperacillin-tazobactam (370) 95 96

Tobramycin (306) 91 92

TMP-SMX (374) 68 77a

Susc, susceptible.a P, .0005 for difference between pediatric and combined, all other Pnonsignificant at ..05.

ARTICLE

PEDIATRICS Volume 130, Number 3, September 2012 e617at Indonesia:AAP Sponsored on September 6, 2012pediatrics.aappublications.orgDownloaded from
http://-/?-http://-/?-http://-/?-http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://-/?-http://-/?-http://-/?-


5/10

When antiobiograms were not pro-

vided, only 68.6% of pediatricians se-

lected an antibiotic with 80% or more

in vitro efficacy against E. colibased onour pediatric data. This increased to

82.2% (P = .08 compared with no anti-

biogram) when the combined antibio-

gram was included in the scenario, and

92.5% when the pediatric-specific anti-

biogram was available (P, .01 com-

pared with no antibiogram).

Twelve-Year-Old Female With UTI

Seventy-four providers responded to

this set of cases. Four (5.4%) chose notto treat the 12-year-old female after the

urinalysis result was obtained. Of 70

pediatricians who chose to initiate

antibiotics after the urinalysis was

obtained, only 3 reported they would

change antibiotic therapy once they

knew that the organism was E. coli.

Providers were significantly less likely

to choose TMP-SMX when presented

with the hospital-wide antibiogramthan when no data were available.

Physicianswere also significantly more

likely to choose ciprofloxacin or nitro-

furantoin than when no antibiogram

was available. Physicians were more

likely to input antibiotics only available

in intravenous or intramuscular formu-

lationswhen hospital-wideandpediatric-

specific antibiotic antibiograms were

available than when not presented with

susceptibility information (13.2% and9.5%, respectively, vs 0%; P, .01 for

both). Antibiotic choices for the 3 sce-

narios (no antibiogram, hospital-wide,

and pediatric-specific antibiograms) are

presented in Table 4.

When antibiograms were not included

in the scenario, only 32.4% of pedia-

tricians selected an antibiotic with 80%

or more in vitro efficacy against E. coli

based on our pediatric data. This in-

creased to 57.3% when the combinedantibiogram was included in the sce-

nario, a statistically significant in-

crease (P, .01). When the pediatric

antibiogram was presented, the rate of

provider selection of an effective anti-

biotic increased to 79.4%, a statistically

significant improvement (P = .01).

DISCUSSION

In this study, we demonstrated signifi-

cant differences in antimicrobial sus-

ceptibility in E. coli isolates obtained

from pediatric patients relative to

current hospital-wide published data at

our institution. We subsequently dem-

onstrated that presenting clinicians

with this pediatric-specific information

altered their clinical decision-making

when choosing empirical therapy for

children with UTI, with the more specific

data increasing the theoretical efficacy

of their empirical regimens. This 2-part

study highlights several points about

the need for and application of a pedi-

atric-specific antibiogram.

First, the finding of significant differ-

ences in antimicrobial susceptibility in

pediatric isolates is not entirely new. It

is known that susceptibility can vary by

age,9 point of care (inpatient vs out-

patient),15,16 and by inpatient ward.9

Our primary purpose in collecting thisinformation at our institution was to

gather data to support a change in our

local practices for reporting these

data. Currently, our clinical microbi-

ology laboratory reports aggregated

data for several thousand E. coli iso-

lates from all sites in the hospital. Our

hypothesis at the outset was that

these data may not accurately repre-

sent the isolates causing infections in

community-dwelling infants and ado-lescents. Accordingly, pediatric isolates

at our institution have significantly

lower rates of susceptibility to TMP-SMX

and significantly higher rates of sus-

ceptibility to AMOX-CLAV than reported

in aggregate data.

In our opinion, the rationale for not

providing a pediatric-specific antibio-

gram is weak. All the data required are

already collected as part of database

TABLE 2 Description of Patients ProvidingPediatric Isolates

Number of isolates 375

Number of patientsa 327

Gender (female %) 292 (78)

Average age, y 7.6, range 0.210.2

Source (%)

Urine 339 (90.4)

Endotracheal 10 (2.7)

Blood 7 (1.9)

Otherb 18 (4.8)

a Repeat cultures from the same hospitalization were not

included.b Includes cerebrospinal fluid (4), skin/abscess (3), peri-

toneal (2), abdominal (3), ear (1), eye (2), back (1), hand

(1), and other (1).

TABLE 3 Antibiotic Selection for a 3-Month-Old Febrile Infant With UTI, by Scenario

Antibiotic Scenario A: No

Data (n= 70)

Scenario B: Hospital-

wide Data (n= 73)

Scenario C: Pediatric-

Specific Data (n= 67)

Aminoglycoside, (%) 1(1.4) 6 (8.2) 4 (6.0)

Amoxicillin, (%) 4 (5.7) 1 (1.4) 1 (1.5)

AMOX-CLAV, (%) 1 (1.4) 1 (1.3) 7 (10.4)a

Ciprofloxacin, (%) 0 2 (2.7) 2 (3.0)

Nitrofurantoin, (%) 2 (2.9) 0 7 (10.4)

Piperacillin/tazobactam 0 1 0

TMP-SMX, (%) 18 (25.7) 12 (16.4) 4 (5.8)b

Firs t-generation cephalosporin, (%) 10 (14. 2) 26 (35.6)c 19 (28.4)a

Second-generation cephalosporin, (%) 1 (1.4) 0 0

Third-generation cephalosporin, (%) 31 (44.2) 22 (30.1) 22 (32.8)

Cephalosporin, NOS 1 (1.4) 1 (1.4) 1 (1.5)

Antibiotic with$80% effectiveness, (%) 48 (68.6) 60 (82.2) 62 (92.5)b

Intravenous only, (%) 3 (4.3) 16 (21.9)d 22 (32.8)b

NOS, not otherwise specified.a P, .05.b P, .01 for comparison between scenario A (no data) and scenario C (pediatric-speci fic data).c P, .05.d P, .01 for comparison between scenario A (no data) and scenario B (adult/pediatric combined data).

http://-/?-http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://-/?-


6/10

tracking within our institution. Only an

incremental extra effort to report the

data for certain organisms or units is

necessary. To better understand how

our institution compares with peer

institutions nationwide with regard to

reporting antibiotic susceptibility pat-

terns, we randomly contacted 10 pedi-

atric hospitals-within-hospitals. These

were selected by contacting every third

institution sequentially from the list of

78 provided by the National Associationof Childrens Hospitals and Research

Institutions (10 responded). Overall,

these institutions have a variety of

practices: completely separating pedi-

atric and adult data for internal dis-

semination (2 hospitals), separating

only certain organisms (1 hospital),

separating data only for the intensive

care nursery (1 hospital), or reporting

data together regardless of age or

ward (6 hospitals). Proponents of pe-diatric quality of care initiatives and

also of antimicrobial resistance con-

trol should advocate for the simple

step of universal pediatric reporting in

their efforts toward improvement. Lack

of pediatric representation in clinical

microbiology leadership, lack of spe-

cific data documenting the utility of of-

fering pediatric specific antimicrobial

susceptibility, potential cost increases,

and lack of advocacy on the part of pe-

diatric practitioners demanding these

data are likely reasons for such reports

not being offered more widely.

When examining the results of provider

choices of empirical antibiotic therapy

in the UTI vignettes in our survey, a few

key points are highlighted. First, anti-

biotic choices differed less with the

addition of DUHS antibiogram data to

the scenario than with a change from

DUHS antibiogram data to our pediatricdata. We think this is largely because

our practitioners had been conditioned

with hospital-wide data and therefore

were already incorporating these

results into their practices and man-

agement. When practitionerswere then

provided with pediatric-specific data,

their choices reflected the more spe-

cific data.

Additionally, with the increased rates of

resistance to TMP-SMX and AMOX,practitioners shifted their choices to

alternative agents. For the infant case

vignette, smaller trends in antibiotic

changes were evidenced because most

providersinitially chose afirst- or third-

generation cephalosporin, to which

the isolates were largely susceptible.

For the 12-year-old patient vignette,

the changes were more magnified as

pediatric-specific data shifted the

choices from TMP-SMX to other agents

with increased susceptibility. Although

some individual antibiotic switch rates,

even if statistically significant, may not

be clinically meaningful, the overall

trend to reduce TMP-SMX use is both

statistically significant and clinicallymeaningful. In our study population,

TMP-SMX was a common choice of ini-

tial empirical antibiotic in the infant

vignette (26%) and the most commonly

chosen initial empirical antibiotic (66%)

in our adolescent vignette. Although

TMP-SMX remains the most prescribed

antibiotic for pediatric UTIs nationally,17

its use declined by 78% in infants and

73% in adolescents as increasingly spe-

cific antibiograms were provided. Thisshift in prescriptions led to a theoreti-

cal improvement in potential outcomes

because the number of prescriptions

for antibiotics with .80% in vitro

susceptible isolates increased signifi-

cantly in both vignettes.

Our results also highlight a potential

downside to antibiograms, which is

that more data may not always lead to

better choices. Several respondents

selected highly potent IV antibiotics forthese case vignettes (eg, amikacin)

when other more appropriate agents

were available. Others selected nitro-

furantoin for the treatment of young

infants when this drug is not recom-

mended because of poor serum con-

centrationsto treatpotentiallyassociated

bacteremia. We attribute these findings

to the relative inexperience of the

practitioners taking the survey, several

of whom were pediatric interns. How-ever, although no attending physicians

choseaminoglycosidesor nitrofurantoin,

similar proportions of attending phy-

sicians and residents chose intrave-

nous or intramuscular antibiotics for

the 3-month-oldpatient,and 1 attending

chose ciprofloxacin. These issues can

be counteracted by adjusting reporting

to reflect inpatient versus outpatient

collection of the isolate, age of the

TABLE 4 Antibiotic Selection for a 12-Year-Old Female With UTI, by Scenario

Antibiotic Scenario A: No

Data (n= 68)

Scenario B: Hospital-

wide Data (n= 68)

Scenario C: Pediatric-

Specific Data (n= 63)

Aminoglycoside, (%) 0 3 (4.4) 2 (3.2)

Amoxicillin, (%) 1 (1.5) 0 1 (1.6)

AMOX-CLAV, (%) 0 0 2 (3.2)

Ciprofloxacin, (%) 1 (1.5) 6 (8.8) 8 (12.7)a

Nitrofurantoin, (%) 1 (1.5) 0 12 (19.0)aPiperacillin/Tazobactam, (%) 0 1 (1.5) 0

TMP-SMX, (%) 45 (66.2) 29 (42.6)b 12 (19.0)c

First-generation cephalosporin, (%) 10 (14.7) 19 (27.9) 15 (23.8)

Third-generation cephalosporin, (%) 10 (14.7) 9 (13.2) 9 (14.3)

Cephalosporin, NOS, (%) 0 1 (1.5) 0

Antibiotic with$80% effectiveness, (%) 22 (32.4) 39 (57.3)d 50 (79.4)c

Intravenous only 0 9 (13.2)d 6 (9.5)c

NOS, not otherwise specified.a P, .05.b P, .05.c P, .01 for comparison between scenario A (no data) and scenario C (pediatric-specific data).d P, .01 for comparison between scenario A (no data) and scenario B (adult/pediatric combined data).

ARTICLE

http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/


7/10

patient, or purposefully reporting only

oral options if they are susceptible (hi-

erarchical reporting), for example. Re-

porting of antimicrobial susceptibility

for several organisms (eg, Streptococ-

cus pneumoniae intermediate suscep-

tibility in blood versus cerebrospinalfluid) already takes these issues into

account, so these adjustments could

also be made in pediatric cases. Addi-

tionally, with the increasing use of

electronic ordering protocols, choices

can be offered that direct providers to

preferred agents for particular age

groups and oral alternatives, as well as

reminding providers of the most fre-

quent causative agents. In the case

offi

rst-generation cephalosporins, forwhich susceptibility to a popular in-

travenous formulation, cefazolin, may

not translate into similar susceptibility

of oral formulations,18 additional sus-

ceptibility testing in the microbiology

laboratory could be undertaken.

Ourresults must be examined in light of

certain limitations. We performed an

analysis of 1 years worth of data for 1

organism in pediatric patients at our

institution, which may have skewed ourresults. Broader studies of pediatric

specific antimicrobial susceptibility

should be conducted examining multi-

ple organisms over multiple years.

Additionally, we performed a survey of

practitioners at our own institution.

This is a small number of physicians,

and although our response rate was

good, our sample size is small. Also,this survey evaluated preferences as

stated in a survey, not actual pre-

scribing patterns, which may differ.

Finally, 2 scenarios within each vi-

gnette involved presentation of anti-

biograms with specific antibiotics

listed, which may have led to different

choices (such as nitrofurantoin in

infants or more frequent intravenous

therapies) given this visual prompt. It

is possible that we may have biasedthe selections made by practitioners

based on the presentation of the data.

Finally, E. coli was chosen as the most

frequently isolated pediatric pathogen.

Less frequently encountered organ-

isms would generate less precise es-

timates given smaller denominators

and may need to be combined with

adult data to achieve sufficient num-

bers to report. Also, care must be

taken in using antibiograms because

in vitro sensitivity data do not account

for drug concentration in the urine and

therefore do not always accurately

predict in vivo response.

CONCLUSIONS

We demonstrated significant differ-

ences in pediatric isolates ofE. coliat

our institution with regard to antimi-

crobial susceptibility. By using these

data, we found that knowledge of

pediatric-specific data altered the

prescribing choices of empirical an-

tibiotic treatment in 2 UTI patient case

vignettes. Our results suggest that

care of pediatric patients could be

improved by more widespread use of

pediatric specific antibiograms. Given

the lack of additional resources re-

quired of clinical microbiology labo-

ratories, pediatric providers should

urge their own laboratories to make

this data available.

ACKNOWLEDGMENTS

We thank the pediatric house staff and

faculty at Duke University Medical Cen-

ter for their participation in this pro-

ject. We also thank Tara McKellar for

assistance in preparing clinical re-

search documents and Pat Seed andMichael Cohen-Wolkowiez for critical

review of the manuscript.

REFERENCES

1. Cohen ML. Epidemiology of drug resistance:

implications for a post-antimicrobial era.

Science. 1992;257(5073):10501055

2. Tenover FC, Hughes JM. The challenges of

emerging infectious diseases. Development

and spread of multiply-resistant bacterialpathogens. JAMA. 1996;275(4):300304

3. Grenier C, Ppin J, Nault V, et al. Impact of

guideline-consistent therapy on outcome of

patients with healthcare-associated and

community-acquired pneumonia. J Anti-

microb Chemother. 2011;66(7):16171624

4. Muszynski JA, Knatz NL, Sargel CL, Fernandez

SA, Marquardt DJ, Hall MW. Timing of cor-

rect parenteral antibiotic initiation and

outcomes from severe bacterial community-

acquired pneumonia in children. Pediatr

Infect Dis J. 2011;30(4):295301

5. Goossens H, Ferech M, Vander Stichele R,

Elseviers M; ESAC Project Group. Outpatient

antibiotic use in Europe and association

with resistance: a cross-national database

study. Lancet. 2005;365(9459):579587

6. Hsueh PR, Chen WH, Luh KT. Relationshipsbetween antimicrobial use and antimi-

crobial resistance in Gram-negative bac-

teria causing nosocomial infections from

1991-2003 at a university hospital in Taiwan.

Int J Antimicrob Agents. 2005;26(6):463

472

7. Bertrand X, Dowzicky MJ. Antimicrobial

susceptibility among gram-negative iso-

lates collected from intensive care units in

North America, Europe, the Asia-Pacific

Rim, Latin America, the Middle East, and

Africa between 2004 and 2009 as part of

the Tigecycline Evaluation and Surveillance

Trial. Clin Ther. 2012;34(1):124137

8. Lubowski TJ, Woon JL, Hogan P, Hwang CC.

Differences in antimicrobial susceptibility

among hospitals in an integrated health

system. Infect Control Hosp Epidemiol. 2001;22(6):379382

9. Tonkic M, Goic-Barisic I, Punda-Polic V.

Prevalence and antimicrobial resistance of

extended-spectrum beta-lactamases-producing

Escherichia coli and Klebsiella pneumoniae

strains isolated in a university hospital in

Split, Croatia. Int Microbiol. 2005;8(2):119124

10. Seppl H, Klaukka T, Lehtonen R, Nenonen

E, Huovinen P. Erythromycin resistance of

group A streptococci from throat samples

is related to age. Pediatr Infect Dis J. 1997;

16(7):651656

http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/


8/10

11. Blyth CC, Chen SC, Slavin MA, et al ;

Australian Candidemia Study. Not just

little adults: candidemia epidemiology,

molecular characterization, and antifun-

gal susceptibility in neonatal and pedi-

atric patients. Pediatrics. 2009;123(5):1360

1368

12. David MZ, Crawford SE, Boyle-Vavra S,

Hostetler MA, Kim DC, Daum RS. Contrast-

ing pediatric and adult methicillin-resistant

Staphylococcus aureus isolates. Emerg In-

fect Dis. 2006;12(4):631637

13. Watt K, Waddle E, Jhaveri R. Changing epi-

demiology of serious bacterial infections in

febrile infants without localizing signs.

PLoS ONE. 2010;5(8):e12448

14. Warren JW, Abrutyn E, Hebel JR, Johnson

JR, Schaeffer AJ, Stamm WE; Infectious

Diseases Society of America (IDSA). Guide-

lines for antimicrobial treatment of un-

complicated acute bacterial cystitis and

acute pyelonephritis in women. Clin Infect

Dis. 1999;29(4):745758

15. Fridkin SK, Steward CD, Edwards JR, et al.

Surveillance of antimicrobial use and an-

timicrobial resistance in United States

hospitals: project ICARE phase 2. Project

Intensive Care Antimicrobial Resistance

Epidemiology (ICARE) hospitals. Clin Infect

Dis. 1999;29(2):245252

16. Khanfar HS, Bindayna KM, Senok AC, Botta

GA. Extended spectrum beta-lactamases

(ESBL) in Escherichia coli and Klebsiella

pneumoniae: trends in the hospital and

community settings. J Infect Dev Ctries.

2009;3(4):295299

17. Copp HL, Shapiro DJ, Hersh AL. National

ambulatory antibiotic prescribing patterns

for pediatric urinary tract infection, 1998

2007. Pediatrics. 2011;127(6):10271033

18. Zhang SX, Parisian F, Yau Y, Fuller JD, Poutanen

SM, Richardson SE. Narrow-spectrum ceph-

alosporin susceptibility testing of Escher-

ichia coli with the BD Phoenix automated

system: questionable utility of cephalo-

thin as a predictor of cephalexin sus-

ceptibility. J Clin Microbiol. 2007;45(11):

37623763

ARTICLE

http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/


9/10

APPENDIX Survey Questions for Each Case

1. You are seeing a 3-month-old female infant in same day clinic with fever (101.0F). She is well-

appearing. Urinalysis obtained from straight cath shows:1+ Leukocyte esterase

2+ Nitrites

12 White Blood Cells

.50 bacteria

Your laboratorywill automatically culture the results and provide susceptibilities in 2 days. Would

you give this child antibiotics?

Yes

No

If yes, WHICH ANTIBIOTIC (please list only 1)?

2. Urine grows out.100 000 colonies ofE. colion day 1. Does this change your initial management?

Yes

No

If yes, HOW?

3. Your next patient is a 12 y-old female with dysuria. She is well-appearing.

Urinalysis obtained form clean catch shows:

1+ Leukocyte esterase

2+ Nitrites

12 White blood cells

.50 bacteria

Your laboratorywill automatically culture the results and provide susceptibilities in 2 days. Do you

give this child antibiotics?

Yes

No

If yes, WHICH ANTIBIOTIC (please list only 1)?

4. Urine grows out.100 000 colonies ofE. colion day 1. Does this change your initial management?

Yes

No

If yes, HOW?

http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/


10/10

DOI: 10.1542/peds.2012-0563

; originally published online August 13, 2012;2012;130;e615PediatricsJoel C. Boggan, Ann Marie Navar-Boggan and Ravi Jhaveri

SelectionPediatric-Specific Antimicrobial Susceptibility Data and Empiric Antibiotic

ServicesUpdated Information &

tmlhttp://pediatrics.aappublications.org/content/130/3/e615.full.hincluding high resolution figures, can be found at:

References

tml#ref-list-1http://pediatrics.aappublications.org/content/130/3/e615.full.hat:This article cites 18 articles, 7 of which can be accessed free

Subspecialty Collections

cs_and_toxicologyhttp://pediatrics.aappublications.org/cgi/collection/therapeutiTherapeutics & Toxicologythe following collection(s):This article, along with others on similar topics, appears in

Permissions & Licensing

tmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtables) or in its entirety can be found online at:Information about reproducing this article in parts (figures,

Reprintshttp://pediatrics.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright 2012 by the American Academy of Pediatrics. Alland trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elkpublication, it has been published continuously since 1948. PEDIATRICS is owned, published,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

http://pediatrics.aappublications.org/content/130/3/e615.full.htmlhttp://pediatrics.aappublications.org/content/130/3/e615.full.htmlhttp://pediatrics.aappublications.org/content/130/3/e615.full.htmlhttp://pediatrics.aappublications.org/content/130/3/e615.full.html#ref-list-1http://pediatrics.aappublications.org/content/130/3/e615.full.html#ref-list-1http://pediatrics.aappublications.org/content/130/3/e615.full.html#ref-list-1http://pediatrics.aappublications.org/cgi/collection/therapeutics_and_toxicologyhttp://pediatrics.aappublications.org/cgi/collection/therapeutics_and_toxicologyhttp://pediatrics.aappublications.org/cgi/collection/therapeutics_and_toxicologyhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/cgi/collection/therapeutics_and_toxicologyhttp://pediatrics.aappublications.org/content/130/3/e615.full.html#ref-list-1http://pediatrics.aappublications.org/content/130/3/e615.full.html

pediatric-spesific antimicrobial suspectibility data and empiric antibiotic selection - cyntia meta

Documents