多中心协作对儿科急诊中急性呼吸道感染抗生素疗程的影响

文献信息

中文摘要

背景： 针对常见急性呼吸道感染（ARIs）的最新指南推荐更短的抗生素疗程。尽管抗菌药物管理努力通常侧重于合适的抗生素选择，但针对一线药物选择的干预措施是否也会影响疗程仍不清楚。
设计/方法： 我们对一个全国性质量改进协作进行了二次分析，该协作包括来自22个州和华盛顿特区9个组织的92个儿科急诊护理点（2022年4月至2024年9月）。该协作强调公平的一线抗生素选择；疗程并非明确目标。我们纳入了年龄6个月至18岁、具有ARI国际疾病分类第10版（ICD-10）诊断并导致抗生素处方的就诊，排除了阿奇霉素。2023年10月至2024年4月被定义为积极计划-执行-研究-行动（Plan-Do-Study-Act）周期期间的干预期。主要结局是短疗程处方（≤7天）。多变量、多水平logistic回归模型估计了不同时间段（协作前、干预期、协作后）和社会人口学组别中≤7天疗程的比值比。
结果： 在257,879次就诊中，急性中耳炎最常见（160,292；62.2%）。我们看到≤7天疗程处方的比例从协作前的33.4%增加到干预期间的35.9%和协作后的37.8%。这一增加在鼻窦炎中最为显著（从协作前的11.2%到协作后的33.9%）。与协作前时期相比，干预期间（aOR 1.22，95% CI 1.18，1.25，p < 0.001）和协作后时期（aOR 1.31，95% CI 1.27，1.35，p < 0.001）≤7天疗程的比值比更高。按种族、语言和支付方类型观察到疗程差异。
结论： 在一个专注于公平一线抗生素选择的协作中，短疗程处方增加，表明在更广泛的长期趋势之外，可能对疗程产生了溢出效应。持续存在的社会人口学差异突出表明，需要在门诊抗菌药物管理工作中明确纳入公平性，而不仅仅关注抗生素选择。

英文摘要

BACKGROUND: Updated guidance for common acute respiratory infections (ARIs) recommends shorter antibiotic durations. While stewardship efforts often focus on appropriate antibiotic selection, it remains unclear whether initiatives targeting first-line choice also influence duration.
DESIGN/METHODS: We conducted a secondary analysis of a national quality improvement collaborative including 92 pediatric urgent care sites across 9 organizations in 22 states and Washington, D.C. (April 2022-September 2024). The collaborative emphasized equitable first-line antibiotic selection; duration was not an explicit target. We included encounters for patients aged 6 months-18 years with ARI International Classification of Diseases-10 (ICD-10) diagnoses resulting in an antibiotic prescription and excluded azithromycin. October 2023-April 2024 was defined as the intervention period during active Plan-Do-Study-Act cycles. The primary outcome was short-course prescribing (≤7 days). Multivariable, multilevel logistic regression models estimated odds of ≤7-day duration across time periods (pre-collaborative, intervention, post-collaborative) and sociodemographic groups.
RESULTS: Among 257 879 encounters, acute otitis media was most common (160 292; 62.2%). We saw an increase in ≤7-day duration prescribing from 33.4% pre-collaborative to 35.9% during the intervention and 37.8% post-collaborative. This increase was most notable for sinusitis (11.2% pre-collaborative to 33.9% post-collaborative). Compared with the pre-collaborative period, odds of ≤7-day duration were higher during intervention (aOR 1.22, 95% CI 1.18, 1.25, p < 0.001) and post-collaborative periods (aOR 1.31, 95% CI 1.27, 1.35, p < 0.001). Differences in duration were observed by race, language, and payor type.
CONCLUSIONS: During a collaborative focused on equitable first-line antibiotic selection, short-course prescribing increased, suggesting potential spillover to duration alongside broader secular trends. Persistent sociodemographic differences highlight the need to explicitly incorporate equity into outpatient stewardship efforts beyond antibiotic choice.