Use Evidence-based Diagnostic Criteria and Treatment Recommendations
Most infections encountered in general pediatrics can be managed according to best-practice guidelines from the American Academy of Pediatrics or Infectious Diseases Society of America. These guidelines can help providers identify inappropriate antibiotic prescribing and offer a “gold standard” to serve as a target.
Antimicrobial stewardship starts with appropriate targets. Evidence suggests that certain conditions are more likely to be associated with inappropriate antibiotic prescribing (see “Antibiotic Use”). These can include conditions that do not require antibiotics, such as viral upper respiratory tract infections (URTIs), and conditions for which diagnosis or management frequently deviates from evidence-based guidelines, such as acute bacterial sinusitis.
Certain antibiotics are commonly used despite not being first-line for any common respiratory infection. Examples include oral third-generation cephalosporins, such as cefdinir, and azithromycin. (Hersh AL et al. Frequency of First-line Antibiotic Selection Among US Ambulatory Care Visits for Otitis Media, Sinusitis, and Pharyngitis. JAMA Internal Medicine 2016; 176:1870.)
Most of the studies cited here have included an educational intervention such as a one-hour in-person didactic lecture about improving antibiotic prescribing. In most cases, this was a component of a multifaceted intervention; in some cases, the educational session was provided to the control group. Educational interventions are probably necessary to inform clinicians about the need for improvement and the planned intervention but not sufficient to induce sustained improvement.
Patient education has also been a component of multiple studies, but there is very little evidence suggesting that patient education interventions can have a significant impact on antibiotic overuse. See Education section for more information.
Physicians’ expectation of a parent/caregiver wanting an antibiotic is the most important factor involved with antibiotic prescribing.
Communication training can help clinicians avoid conflict with patients and family members with a strong desire for antibiotics and reduce overuse of antibiotics.
Interventions involving peer comparisons for antibiotic prescribing have led to a decrease in inappropriate prescribing. Interventions of this type have been effective in improving professional practice in other areas (Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;(6): CD000259.). Examples include:
Several studies of outpatient antimicrobial stewardship interventions have used the shared EHR to encourage providers to be more thoughtful about prescribing and to provide just-in-time clinical decision support.
In some cases, such as in older children with acute otitis media, delaying antibiotic prescribing allows many infections to clear without antibiotics while providing a “safety net” for those that do not resolve spontaneously. In one trial (below), fewer than 40% of delayed prescriptions were filled.
Two recent in-depth reviews of outpatient antibiotic stewardship interventions have been performed:
Outpatient Pediatric practices can implement antibiotic stewardship principles even if a formal program does not yet exist.
2. Make guidelines for the common conditions that may elicit antibiotic prescriptions accessible. These include otitis media, pharyngitis, pneumonia and sinusitis. Practices can create cheat sheets or pocket guides for providers or incorporate the following links into the EMR.
3. Incorporate point of care diagnostic testing such as Rapid Influenza/RSV, Rapid Strep, Viral PCR panel including Rhinovirus (common cold virus), COVID testing (both rapid antigen and PCR available), and urine dipstick into daily outpatient care.
4. Audit and feedback- practices can utilize their IT and/or billing teams to audit charts with the ICD10 diagnosis of otitis media, pharyngitis, pneumonia and sinusitis to assess compliance with guideline recommended antibiotic choice, indication, dose, and duration.
5. Incorporate quality improvement methods to improve daily practice processes including antibiotic stewardship. These links include easy to use to tools such as driver diagrams, a primer on PDSA cycles, and examples of antibiotic stewardship QI.
6. Patient Education-