Improving the Transition of Intravenous to Enteral Antibiotics in Pediatric Patients with Pneumonia or Skin and Soft Tissue Infections.

BACKGROUND: Despite national recommendations for early transition to enteral antimicrobials, practice variability has existed at our hospital. OBJECTIVE: The aim of this study was to increase the proportion of enterally administered antibiotic doses for Pediatric Hospital Medicine patients aged >60 days admitted for uncomplicated community-acquired pneumonia or skin and soft tissue infections from 44% to 75% in eight months. METHODS: This quality improvement study was conducted at a large, urban, academic children's hospital. The study population included Hospital Medicine patients aged >60 days with diagnoses of pneumonia or skin and soft tissue infections. Interventions included education on intravenous and enteral antibiotic charge differentials, documentation of transition plan, structured discussions of transition criteria, and real-time identification of failures with feedback. Our process measure was the total number of enteral antibiotic doses divided by all antibiotic doses in patients receiving enteral medications on the same day. An annotated statistical process control chart tracked the impact of interventions on the administration route of antibiotic doses over time. Additional outcome measures included antimicrobial costs per patient encounter using average wholesale prices and length of stay. RESULTS: The percentage of enterally administered antibiotic doses increased from 44% to 80% within eight months. Antimicrobial costs per patient encounter and the associated standard deviation of costs for our target diagnoses decreased by 70% and 84%, respectively. Average length of stay did not change. CONCLUSIONS: Standardized communication about criteria for transition from intravenous to enteral antibiotics can lead to earlier transitions for patients with pneumonia or skin and soft tissue infections, subsequently reducing costs and prescribing variability.

Dexmedetomidine for the Management of Postoperative Pain and Sedation in Newborns.

BACKGROUND: Opioids and benzodiazepines have been the mainstay of neonatal analgesia and sedation. However, based on evidence in neonatal animals, these drugs may be deleterious for the developing brain. Dexmedetomidine (DEX), a central alpha-2 agonist, has sedative and analgesic effects and has been shown to be neuroprotective in animal models. Despite increasing use of DEX in newborns, there is a paucity of data regarding its safety and efficacy in this population. OBJECTIVES: The impact of using DEX in postsurgical neonates, either alone or with opioid infusions, for sedation/analgesia was evaluated. The cumulative dose of opioids among patients who did or did not receive DEX was calculated to examine the hypothesis that the addition of DEX can reduce the patient exposure to opioids without significantly increasing side effects and providing adequate sedation and pain control. METHODOLOGY: This was a retrospective cohort study in which patients were matched by postnatal age and surgical procedure into 2 groups. One group received DEX in the regimen for treatment of pain or sedation after a surgical procedure, and the other group received no DEX. Episodes of bradycardia, respiratory depression and hypotension, and the cumulative dose of opioids and number of supplemental doses administered in both groups were documented. RESULTS: Although there was no difference in gestational age or weight at birth between the DEX and no-DEX groups, the DEX group's median postconceptional date was older at the time of surgery (39.6 vs 37.4 weeks; p = 0.003). Patients in the DEX group experienced more episodes of bradycardia (12.8% vs 5.1%; p = 0.01). There was no difference between groups in episodes of hypotension or respiratory depression. The cumulative dose of opioids was significantly lower in the DEX group compared with the no-DEX group (1155 mcg/kg vs 1841 mcg/kg; p = 0.01). There was no difference in the number of supplemental doses of opioids given between the groups. CONCLUSIONS: The addition of DEX to opioid infusions resulted in a significant decrease in the cumulative dose of opioids but was associated with more episodes of bradycardia than opioids alone.