1474
Table 1. Urinary Tract Infection Antibiograms for Healthy, Complex, and All Children All Outpatients
Empiric Antibiotic
Amoxicillin/ Clavulanate Ampicillin Cefazolin
Ceftriaxone Trimethoprim/ Sulfamethoxazole aComparing healthy vs complex cohorts.
Susceptible Isolates/ Total
Isolates Tested 544/681 265/680 406/677 600/684 212/315
Susceptible Isolates/
%
Susceptible 79.88 38.97 59.97 87.72 67.3
Total Isolates Tested
324/376 160/375 245/372 345/375 129/170
%
Susceptible 86.2 42.7 65.9 92.0 75.9
Yusuf Y. Chao et al
Healthy Cohort
Complex Cohort Susceptible
Isolates/ Total Isolates Tested
220/305 105/305 161/305 255/309 83/146
%
Susceptible 72.1 34.4 52.8 82.5 56.9
<.001 .033 .001
<.001 <.001
P Valuea
Table 2. Urinary Tract Infection Antibiograms for Healthy Children Identified by Chart Review Versus EHR Method
Empiric Antibiotic
Amoxicillin/ Clavulanate Ampicillin Cefazolin
Ceftriaxone
Trimethoprim/ Sulfamethoxazole Note. EHR, electronic health record.
Results
Overall, 686 outpatient UTI specimens were included in the study. The most common organisms in the healthy cohort were Escherichia coli (269; 71.5%), Proteus mirabilis (31, 8.2%), and Klebsiella pneumoniae (23; 6.1%). The most common organisms in the complex cohort were E. coli (166, 53.6%) K. pneumoniae (32; 10.3%), and Pseudomonas aeruginosa (21; 6.8%). Compared to the cohort of complex patients, urinary isolates
from the EHR-derived healthy cohort had statistically sig- nificantly greater susceptibility rates (P<.05) for all study anti- biotics (Table 1). The greatest difference in susceptibility was seen for trimethoprim-sulfamethoxazole (56.9% vs 75.9%; P<.001), and the least was seen for ampicillin (34.4% vs 42.7%; P=.033). Compared to the WISA for all outpatient children, the WISA for the healthy cohort showed higher susceptibility for all antibiotics. This difference was statistically significant for amoxicillin (P=.012), ceftriaxone (P=.038), and trimethoprim/ sulfamethoxazole (P=.048). Compared to manual chart review, the EHR-based criteria
identified healthy children with a sensitivity of 85%, specificity of 81%, positive predictive value of 76%, and negative predictive value of 89%. Susceptibility rates for healthy children based on the EHR definition were similar to rates for previously healthy chil- dren confirmed by manual chart review (Table 2). For all study antibiotics, antibiotic susceptibilities were higher via direct chart review.
Chart Review-derived Healthy Cohort, % Susceptibility
89.6 45.4 68.1 95.7 77.8
EHR-derived Healthy Cohort, % Susceptibility
86.2 42.7 65.9 92.0 75.9
P Value .327 .571 .689 .140
1.000
Discussion
By defining a healthy cohort and comparing it to the remaining medically complex patients and the ambulatory patient popula- tion as a whole, we demonstrated differences in antibiotic sus- ceptibility for multiple antibiotics. While it is expected that healthy patients would have less frequent antibiotic resistance, our methodology utilized discrete data elements, including diag- nostic codes, to readily build these customized antibiograms from an EHR. We have previously described that 58% of pediatricians report that overly complex patient populations limit the gen- eralizability of their hospital antibiogram, and 95% of pediatri- cians would probably or definitely use an antibiogram that compiled antibiotic resistance data from healthy children with common infections.5 Thus, we surmise that using our proposed methodology to develop and disseminate healthy child anti- biograms would be well received by general pediatricians. Dahle et al6 had previously developed a pediatric ambulatory antibiogram for uropathogens and compared it to an existing hospital antibiogram, demonstrating increased susceptibility of E. coli to narrower-spectrum antibiotics. Simpao et al7 embedded an electronic antibiogram into the EHR that can provide customized reports based on inputs for body site, hospital/clinic location, and community versus hospital-acquired infection. Our EHR-derived healthy cohort demonstrated less frequent antibiotic resistance among urine isolates compared to medically complex patients. Furthermore, compared to manual chart review, EHR derivation
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