Development and Implementation of Pediatric In-Hospital Antimicrobial Stewardship Policy Through Pediatric Clinical Pathways

Antimicrobial resistance has become a global problem. Italian pediatric antimicrobial prescription rates are among the highest in Europe (EU). As a first step for antimicrobial stewardship (AS) implementation, clinical pathways (CP) outlining standard of care for acute otitis media (AOM), and group A streptococcus (GAS) pharyngitis and community-acquired pneumonia (CAP) were developed and implemented in our pediatric emergency department (PED) in collaboration with Children’s Hospital of Philadelphia. Aims. The primary aim of this study was to assess changes in antibiotic prescription one year after the CP implementation for AOM, GAS pharyngitis and CAP; secondary aim was to compare treatment failure before and after CPs implementation. Methods. CPs were implemented at the Department for Woman and Child Health of Padua on October 1st 2015. The first before/after quasi-experimental study has been conducted between the Pre-intervention period (from 15/10/2014 to 15/04/2015), Post-intervention period (from 15/10/2015 to 15/04/2016) and 1-Year post intervention period (from 15/10/2016 to 15/04/2017). ITS was used to determine the effect of the intervention, chi squared test to define the treatment failure and Kruskal Wallis test to compare antibiotic dosages and durations. Results. AOM: after CP implementation there was an increase in “wait and see” (21.7% vs. 33.1% vs. 28.9%, p=0.08) and in the use of amoxicillin as first line therapy (25.1% vs. 34.5%, p<0.001), with a decrease from 53.2% to 32.4% (p<0.001) in overall prescription of broad-spectrum antibiotics. Amoxicillin prescriptions increased (32% Pre vs. 51.6% Post and 52.8% 1-Year Post, p<0,001) with a decrease in overall prescription of broad-spectrum antibiotics. Among fully immunized with no complicated OMA, broad-spectrum antibiotics were prescribed in only 4.7% of cases (29.8%, Pre vs. 7.2% Post, p<0.001). Pharyngitis: During 1-year Post intervention period 63.2% of patients received a diagnosis Goup A Steptococcus pharyngitis (50.7% Pre vs 45.4% Post), reflecting the increasing age of the population examined (more patients aged 3-15 years). Amoxicillin was the choice for 93.2% of patients (53.6% Pre and 93.4% Post). CAP: prescriptions/patients rate has decreased to 1.02 (1.3 Pre, 1.12 Post) reflecting an increase use of monotherapy. 82.5% of patients received amoxicillin (52.1% Pre vs. 69.9% Post, p<0.001) and macrolide prescriptions decreased to 2.1% (19.7 Pre vs. 6.5% Post). No statistically significant difference in treatment failure was seen for all the pathologies examined. Conclusions. A reduction in broad-spectrum antibiotic prescriptions for AOM. Gas pharyngitis and CAP without compromising clinical outcomes indicates effectiveness of CPs in this setting. Furthermore their effects after more than one year suggests CPs are useful and suitable tool

Breves consideraciones sobre la naturaleza jurídica de la República Social Italiana

El trabajo analiza la naturaleza jurídica de la República Social Italiana. El objetivo de la contribución es demostrar cómo la violación de prodottasi legalidad constitucional tras el "golpe de Estado" por el rey Vittorio Emanuele III 25 de julio de 1943, ha servido de base para el nacimiento del Estado republicano fascista en septiembre del mismo año, después de la liberación de Mussolini de su cautiverio en el Gran Sasso de Italia. Al igual que ocurrió el día de fiesta el poder tras el 25 de julio fue el título de la elegibilidad para el asentamiento del Gobierno Fascista Republicano, sin dua, un gobierno provisional, dada la inestabilidad causada por la situación de guerra, pero una vez que la vocación constituyente Italia fue liberado por los anglo-americanos. Se sirve el análisis de la situación jurídica adoptada por la República Social, además, también para reflexionar sobre el Reino del Sur y sus relaciones con los aliados

Effect of clinical pathways on antibiotic prescriptions in an emergency department: Italian pediatric antimicrobial stewardship starts here

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Antimicrobial Prophylaxis in Neonates and Children Undergoing Dental, Maxillo-Facial or Ear-Nose-Throat (ENT) Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication in surgical procedures, mainly because clean/contaminated surgery involves organs that are normally colonized by bacteria. Dental, maxillo-facial and ear-nose-throat (ENT) surgeries are among those that carry a risk of SSIs because the mouth and the first respiratory tracts are normally colonized by a bacterial flora. The aim of this consensus document was to provide clinicians with recommendations on surgical antimicrobial prophylaxis in neonates (&lt;28 days of chronological age) and pediatric patients (within the age range of 29 days-18 years) undergoing dental, maxillo-facial or ENT surgical procedures. These included: (1) dental surgery; (2) maxilla-facial surgery following trauma with fracture; (3) temporo-mandibular surgery; (4) cleft palate and cleft lip repair; (5) ear surgery; (6) endoscopic paranasal cavity surgery and septoplasty; (7) clean head and neck surgery; (8) clean/contaminated head and neck surgery and (9) tonsillectomy and adenoidectomy. Due to the lack of pediatric data for the majority of dental, maxillo-facial and ENT surgeries and the fact that the recommendations for adults are currently used, there is a need for ad hoc studies to be rapidly planned for the most deficient areas. This seems even more urgent for interventions such as those involving the first airways since the different composition of the respiratory microbiota in children compared to adults implies the possibility that surgical antibiotic prophylaxis schemes that are ideal for adults may not be equally effective in children

Surgical Antimicrobial Prophylaxis in Patients of Neonatal and Pediatric Age Undergoing Orthopedic and Hand Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication in any type of surgery and can occur up to one year after the procedure in the case of implant placement. In the field of orthopedic and hand surgery, the rate of SSIs is a relevant issue, considering the need for the placement of synthesis devices and the type of some interventions (e.g., exposed fractures). This work aims to provide guidance on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing orthopedic and hand surgery in order to standardize the management of patients and to reduce, on the one hand, the risk of SSI and, on the other, the development of antimicrobial resistance. The following scenarios were considered: (1) bloodless fracture reduction; (2) reduction of unexposed fracture and grade I and II exposed fracture; (3) reduction of grade III exposed fracture or traumatic amputation; (4) cruel fracture reduction with percutaneous synthesis; (5) non-traumatic amputation; (6) emergency intact skin trauma surgery and elective surgery without synthetic media placement; (7) elective orthopedic surgery with prosthetic and/or synthetic media placement and spinal surgery; (8) clean elective hand surgery with and without bone involvement, without use of synthetic means; (9) surgery of the hand on an elective basis with bone involvement and/or with use of synthetic means. This manuscript has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies and represents, in our opinion, the most complete and up-to-date collection of recommendations regarding the behavior to be adopted in the peri-operative setting in neonatal and pediatric orthopedic and hand surgery. The specific scenarios developed are aimed at guiding the healthcare professional in practice to ensure the better and standardized management of neonatal and pediatric patients, together with an easy consultation

Surgical Antimicrobial Prophylaxis in Neonates and Children Undergoing Neurosurgery: A RAND/UCLA Appropriateness Method Consensus Study

Pediatric neurosurgery is a highly specialized branch of surgery in which surgical site infections (SSIs) are potentially serious complications that can also adversely affect a good surgical outcome, compromising functional recovery and, in some cases, even putting the patient's life at risk. The main aim of this consensus document is to provide clinicians with a series of recommendations on antimicrobial prophylaxis for neonates and children undergoing neurosurgery. The following scenarios were considered: (1) craniotomy or cranial/cranio-facial approach to craniosynostosis; (2) neurosurgery with a trans-nasal-trans-sphenoidal approach; (3) non-penetrating head injuries; (4) penetrating head fracture; (5) spinal surgery (extradural and intradural); (6) shunt surgery or neuroendoscopy; (7) neuroendovascular procedures. Patients undergoing neurosurgery often undergo peri-operative antibiotic prophylaxis, with different schedules, not always supported by scientific evidence. This consensus provides clear and shared indications, based on the most updated literature. This work has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies, and represents, in our opinion, the most complete and up-to-date collection of recommendations on the behavior to be held in the peri-operative setting in this type of intervention, in order to guide physicians in the management of the patient, standardize approaches and avoid abuse and misuse of antibiotics

Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse

Peri-Operative Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Cardiac and Thoracic Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication of surgical procedures, with a significant impact on mortality, morbidity, and healthcare costs. Patients undergoing cardiac surgery and thoracic surgery are often considered patients at high risk of developing SSIs. This consensus document aims to provide information on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing cardiac and non-cardiac thoracic surgery. The following scenarios were considered: (1) cardiac surgery for the correction of congenital heart disease and/or valve surgery; (2) cardiac catheterization without the placement of prosthetic material; (3) cardiac catheterization with the placement of prosthetic material; (4) implantable cardiac defibrillator or epicardial pacemaker placement; (5) patients undergoing ExtraCorporal Membrane Oxygenation; (6) cardiac tumors and heart transplantation; (7) non-cardiac thoracic surgery with thoracotomy; (8) non-cardiac thoracic surgery using video-assisted thoracoscopy; (9) elective chest drain placement in the pediatric patient; (10) elective chest drain placement in the newborn; (11) thoracic drain placement in the trauma setting. This consensus provides clear and shared indications, representing the most complete and up-to-date collection of practice recommendations in pediatric cardiac and thoracic surgery, in order to guide physicians in the management of the patient, standardizing approaches and avoiding the abuse and misuse of antibiotics