Use of the Child Opportunity Index to Examine Racial Variations in Outpatient Antibiotic Prescribing to Children.

To examine further racial and ethnic variations in antibiotic prescribing to children, we used the Child Opportunity Index. Black children were less likely to be prescribed an antibiotic. Low- and moderate-opportunity areas were associated with greater rates of antibiotic prescribing, after adjusting for race and other factors.

Quality of antibiotic prescribing to children through the coronavirus disease 2019 (COVID-19) pandemic.

Objective: To describe pediatric outpatient visits and antibiotic prescribing during the coronavirus disease 2019 (COVID-19) pandemic. Design: An observational, retrospective control study from January 2019 to October 2021. Setting: Outpatient clinics, including 27 family medicine clinics, 27 pediatric clinics, and 26 urgent or prompt care clinics. Patients: Children aged 0-19 years receiving care in an outpatient setting. Methods: Data were extracted from the electronic health record. The COVID-19 era was defined as April 1, 2020, to October 31, 2021. Virtual visits were identified by coded encounter or visit type variables. Visit diagnoses were assigned using a 3-tier classification system based on appropriateness of antibiotic prescribing and a subanalysis of respiratory visits was performed to compare changes in the COVID-19 era compared to baseline. Results: Through October 2021, we detected an overall sustained reduction of 18.2% in antibiotic prescribing to children. Disproportionate changes occurred in the percentages of antibiotic visits in respiratory visits for children by age, race or ethnicity, practice setting, and prescriber type. Virtual visits were minimal during the study period but did not result in higher rates of antibiotic visits or in-person follow-up visits. Conclusions: These findings suggest that reductions in antibiotic prescribing have been sustained despite increases in outpatient visits. However, additional studies are warranted to better understand disproportionate rates of antibiotic visits.

Inappropriate outpatient antibiotic use in children insured by Kentucky Medicaid.

OBJECTIVE: To describe risk factors associated with inappropriate antibiotic prescribing to children. DESIGN: Cross-sectional, retrospective analysis of antibiotic prescribing to children, using Kentucky Medicaid medical and pharmacy claims data, 2017. PARTICIPANTS: Population-based sample of pediatric Medicaid patients and providers. METHODS: Antibiotic prescriptions were identified from pharmacy claims and used to describe patient and provider characteristics. Associated medical claims were identified and linked to assign diagnoses. An existing classification scheme was applied to determine appropriateness of antibiotic prescriptions. RESULTS: Overall, 10,787 providers wrote 779,813 antibiotic prescriptions for 328,515 children insured by Kentucky Medicaid in 2017. Moreover, 154,546 (19.8%) of these antibiotic prescriptions were appropriate, 358,026 (45.9%) were potentially appropriate, 163,654 (21.0%) were inappropriate, and 103,587 (13.3%) were not associated with a diagnosis. Half of all providers wrote 12 prescriptions or less to Medicaid children. The following child characteristics were associated with inappropriate antibiotic prescribing: residence in a rural area (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07-1.1), having a visit with an inappropriate prescriber (OR, 4.15; 95% CI, 4.1-4.2), age 0-2 years (OR, 1.39; 95% CI, 1.37-1.41), and presence of a chronic condition (OR, 1.31; 95% CI, 1.28-1.33). CONCLUSIONS: Inappropriate antibiotic prescribing to Kentucky Medicaid children is common. Provider and patient characteristics associated with inappropriate prescribing differ from those associated with higher volume. Claims data are useful to describe inappropriate use and could be a valuable metric for provider feedback reports. Policies are needed to support analysis and dissemination of antibiotic prescribing reports and should include all provider types and geographic areas.

Antibiotic prescribing to Kentucky Medicaid children, 2012-2017: Prescribing is higher in rural areas.

PURPOSE: Antibiotic resistance is a major public health threat. Antibiotic use is the main driver of resistance, with children and the state of Kentucky having particularly high rates of outpatient antibiotic prescribing. The purpose of this study was to describe patient and provider characteristics associated with pediatric antibiotic use in Kentucky Medicaid children. METHODS: We used Medicaid prescription claims data from 2012 to 2017 to describe patterns of pediatric antibiotic receipt in Kentucky. Patient and provider variables were analyzed to identify variations in prescribing. FINDINGS: Children who were female, less than 2 years old, White, and living in a rural area had consistently higher rates of antibiotic prescriptions. There was significant geographic variability in prescribing, with children in Eastern Kentucky receiving more than 3 courses of antibiotics a year. Most antibiotic prescriptions for children were written by general practitioners and nurse practitioners rather than pediatricians. CONCLUSION: These findings support the need for extensive antibiotic stewardship efforts inclusive of rural outpatient practices.

Multisystem Inflammatory Syndrome in Children: Survey of Protocols for Early Hospital Evaluation and Management.

OBJECTIVE: To describe the similarities and differences in the evaluation and treatment of multisystem inflammatory syndrome in children (MIS-C) at hospitals in the US. STUDY DESIGN: We conducted a cross-sectional survey from June 16 to July 16, 2020, of US children's hospitals regarding protocols for management of patients with MIS-C. Elements included characteristics of the hospital, clinical definition of MIS-C, evaluation, treatment, and follow-up. We summarized key findings and compared results from centers in which >5 patients had been treated vs those in which ≤5 patients had been treated. RESULTS: In all, 40 centers of varying size and experience with MIS-C participated in this protocol survey. Overall, 21 of 40 centers required only 1 day of fever for MIS-C to be considered. In the evaluation of patients, there was often a tiered approach. Intravenous immunoglobulin was the most widely recommended medication to treat MIS-C (98% of centers). Corticosteroids were listed in 93% of protocols primarily for moderate or severe cases. Aspirin was commonly recommended for mild cases, whereas heparin or low molecular weight heparin were to be used primarily in severe cases. In severe cases, anakinra and vasopressors frequently were recommended; 39 of 40 centers recommended follow-up with cardiology. There were similar findings between centers in which >5 patients vs ≤5 patients had been managed. Supplemental materials containing hospital protocols are provided. CONCLUSIONS: There are many similarities yet key differences between hospital protocols for MIS-C. These findings can help healthcare providers learn from others regarding options for managing MIS-C.

Medical Students' Views and Knowledge of the Affordable Care Act: A Survey of Eight U.S. Medical Schools.

BACKGROUND: It is not known whether medical students support the Affordable Care Act (ACA) or possess the knowledge or will to engage in its implementation as part of their professional obligations. OBJECTIVE: To characterize medical students' views and knowledge of the ACA and to assess correlates of these views. DESIGN: Cross-sectional email survey. PARTICIPANTS: All 5,340 medical students enrolled at eight geographically diverse U.S. medical schools (overall response rate 52% [2,761/5,340]). MAIN MEASURES: Level of agreement with four questions regarding views of the ACA and responses to nine knowledge-based questions. KEY RESULTS: The majority of respondents indicated an understanding of (75.3%) and support for (62.8%) the ACA and a professional obligation to assist with its implementation (56.1%). The mean knowledge score from nine knowledge-based questions was 6.9 ± 1.3. Students anticipating a surgical specialty or procedural specialty compared to those anticipating a medical specialty were less likely to support the legislation (OR = 0.6 [0.4-0.7], OR = 0.4 [0.3-0.6], respectively), less likely to indicate a professional obligation to implement the ACA (OR = 0.7 [0.6-0.9], OR = 0.7 [0.5-0.96], respectively), and more likely to have negative expectations (OR = 1.9 [1.5-2.6], OR = 2.3 [1.6-3.5], respectively). Moderates, liberals, and those with an above-average knowledge score were more likely to indicate support for the ACA (OR = 5.7 [4.1-7.9], OR = 35.1 [25.4-48.5], OR = 1.7 [1.4-2.1], respectively) and a professional obligation toward its implementation (OR = 1.9 [1.4-2.5], OR = 4.7 [3.6-6.0], OR = 1.2 [1.02-1.5], respectively). CONCLUSIONS: The majority of students in our sample support the ACA. Support was highest among students who anticipate a medical specialty, self-identify as political moderates or liberals, and have an above-average knowledge score. Support of the ACA by future physicians suggests that they are willing to engage with health care reform measures that increase access to care.

Low prevalence of Chlamydia trachomatis infection in non-urban pregnant women in Vellore, S. India.

OBJECTIVE: To determine the prevalence and risk factors for Chlamydia trachomatis (CT) infection in pregnant women and the rate of transmission of CT to infants. METHODS: Pregnant women (≥28 weeks gestation) in Vellore, South India were approached for enrollment from April 2009 to January 2010. After informed consent was obtained, women completed a socio-demographic, prenatal, and sexual history questionnaire. Endocervical samples collected at delivery were examined for CT by a rapid enzyme test and nucleic acid amplification test (NAAT). Neonatal nasopharyngeal and conjunctival swabs were collected for NAAT testing. RESULTS: Overall, 1198 women were enrolled and 799 (67%) endocervical samples were collected at birth. Analyses were completed on 784 participants with available rapid and NAAT results. The mean age of women was 25.8 years (range 18-39 yrs) and 22% (95% CI: 19.7-24.4%) were primigravida. All women enrolled were married; one reported >one sexual partner; and six reported prior STI. We found 71 positive rapid CT tests and 1/784 (0.1%; 95% CI: 0-0.38%) true positive CT infection using NAAT. CONCLUSIONS: To our knowledge, this is the largest study on CT prevalence amongst healthy pregnant mothers in southern India, and it documents a very low prevalence with NAAT. Many false positive results were noted using the rapid test. These data suggest that universal CT screening is not indicated in this population.

Common childhood bacterial infections.

Children with infectious diseases are commonly encountered in primary care settings. Identification of the subset of patients with bacterial infections is key in guiding the best possible management. Clinicians frequently care for children with infections of the upper respiratory tract, including acute otitis media, otitis externa, sinusitis, and pharyngitis. Conjunctivitis is not an uncommon reason for office visits. Bacterial pneumonia, urinary tract infections, and gastroenteritis are regularly seen. Over the last decade, a growing number of children have had infections of the skin and soft tissue, driven by the increased prevalence of infections caused by methicillin-resistant Staphylococcus aureus. The following review addresses the epidemiology and risk factors for specific infections and examines the clinical presentation and selection of appropriate diagnostic methods in such conditions. Methods to prevent these bacterial infections and recommendations for follow-up are suggested. Management of these infections requires that antimicrobial agents be used in a judicious manner in the outpatient setting. Such antibiotic therapy is recommended using both available clinical evidence and review of disease-specific treatment guidelines.