Response to “Building the Future of Infectious Diseases: A Call to Action for Quality Improvement Research and Measurement”

To the  Editor—We appreciated the article published by Madaline et al [1] discussing the importance of quality measures specific to infectious diseases (ID). We agree with and applaud their proposal, but we encourage broadening the goal to include children. This protected population faces many barriers to optimal health outcomes, including obstacles to research and physician workforce shortages [2], underscoring the need to systematically track the quality of care that they receive and respond to deficiencies. Additionally, the majority of pediatric hospitalizations take place at general hospitals rather than freestanding children's hospitals, so the widespread use of measures that include children, even outside of dedicated pediatric settings, is important [3]. At the national level, pediatric populations are more racially and ethnically diverse than adult populations. Thus, quality improvement metrics inclusive of children are oriented toward the needs of a diversifying US population [4].

The authors’ proposed guidelines thoughtfully center on antimicrobial stewardship. The critical importance of judicious use of antibiotics is well established, and many of the known risks of antimicrobial overuse in older patients also affect children, such as the development of antimicrobial resistance and the risk of Clostridiodes difficile infection. Young patients are further disproportionately affected by other antibiotic-related adverse events: almost half of emergency department visits for adverse drug events in children are due to complications from antibiotics [5], and exposure to antibiotics in childhood has been associated with development of a variety of illnesses, including inflammatory bowel disease and asthma [6, 7].

While the authors used the adult population to define denominators for their proposed measures, their suggestions translate smoothly to the pediatric population. For example, the use of β-lactam antibiotics for methicillin-susceptible Staphylococcus aureus is a well-established standard of care for children [8], and surgical prophylaxis recommendations in those aged <18 years reflect the recommendations in adults [9]. Expanding the denominators to include patients of all ages would be an elegant strategy to include children without limiting the validity of the proposed measures.

If ID-focused quality measures expand further, it is possible that some measures designed with adult outcomes in mind may not apply to younger patients. Similarly, hospitals could benefit from the development of key pediatric-focused goals. For example, even hospitals without dedicated pediatric inpatient units frequently manage the care of newborns in well-baby nurseries and neonatal intensive care units. Measures such as rates of antibiotic use in the first 24 hours of life for suspected sepsis are well supported by current standards of care and could reflect quality within those units [10]. For hospitals that care for children beyond the neonatal period, the management of acute hematogenous osteomyelitis (AHO) in children is another clinical scenario that could be tracked to ensure that hospitals are following best practices. The conversion from intravenous to oral antibiotics for pediatric AHO to complete therapy is well established and strongly recommended in a guideline jointly published by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America [11]. Measuring the proportion of patients aged <18 years with AHO who are discharged with oral antibiotics would be a helpful incentive to promote adoption of this practice and reduce risks associated with unnecessary outpatient parenteral antimicrobial therapy (Table 1).

Adult and pediatric ID physicians share similar goals, including a dedication to optimizing patient outcomes while minimizing harms. Both patient cohorts would benefit from measures designed with input from ID experts, and through collaboration our specialties can improve health across the life span.

Notes

Financial support. No financial support was received for this work.

References

Author notes