Pediatric ASP Toolkit

Actions for Policy and Practice

Use Evidence-based Diagnostic Criteria and Treatment Recommendations

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.

Identification of Antibiotic Stewardship Targets

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 PharyngitisJAMA Internal Medicine 2016; 176:1870.)

  • Lipsett SC, Hall M, Ambroggio L et al. Antibiotic Choice and Clinical Outcomes in Ambulatory Children with Community-Acquired Pneumonia, The Journal of Pediatrics,Volume 229,2021,Pages 207-215.e1, ISSN 0022-3476, https://doi.org/10.1016/j.jpeds.2020.10.005.

Educational Interventions

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.

Communication Skills Training for Clinicians

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.

Providing Feedback to Prescribers

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:

Leveraging the Electronic Health Record (EHR)

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.

Delayed Prescribing Practices or Watchful Waiting

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.

Systematic Reviews of Outpatient Antibiotic Stewardship Strategies

Two recent in-depth reviews of outpatient antibiotic stewardship interventions have been performed:

Antibiotic Stewardship for the General Pediatrician

Outpatient Pediatric practices can implement antibiotic stewardship principles even if a formal program does not yet exist. 

Recommendations:

  1. Create awareness 
  • Zetts RM, Garcia AM, Doctor JN, Gerber JS, Linder JA, Hyun DY. Primary Care Physicians’ Attitudes and Perceptions Towards Antibiotic Resistance and Antibiotic Stewardship: A National Survey. Open Forum Infect Dis. 2020 Jun 20;7(7):ofaa244. doi: 10.1093/ofid/ofaa244. PMID: 32782909; PMCID: PMC7406830.

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. 

  • Opportunities Revealed for Antimicrobial Stewardship and Clinical Practice with Implementation of a Rapid Respiratory Multiplex Assay. Zoe F. Weiss, Cheston B. Cunha, Alison B. Chambers, Audrey V. Carr, Cleo Rochat, Mariska Raglow-Defranco, Diane M. Parente, Aimee Angus, Leonard A. Mermel, Latha Sivaprasad, Kimberle Chapin. Journal of Clinical Microbiology Sep 2019, 57 (10) e00861-19; DOI: 10.1128/JCM.00861-19
  • M. Echavarría, D.N. Marcone, M. Querci, A. Seoane, M. Ypas, C. Videla, C. O’Farrell, S. Vidaurreta, J. Ekstrom, G. Carballal. Clinical impact of rapid molecular detection of respiratory pathogens in patients with acute respiratory infection, Journal of Clinical Virology, Volume 108,2018, Pages 90-95, ISSN 1386-6532,https://doi.org/10.1016/j.jcv.2018.09.009.

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- 

  • Utilize graphics from the CDC Be Antibiotics Aware Campaign 

https://www.cdc.gov/antibiotic-use/community/materials-references/graphics.html

Additional references:

  • Hamdy RF and Katz SE. The Key to Antibiotic Stewardship Is Combining Interventions. Pediatrics. 2020;146(3):e2020012922 – Highlights best practices. 

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