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What’s New in the
Patient Safety World
August 2021
Antibiotic
Stewardship in Pediatrics
Inappropriate use of antibiotics is a problem for all
patient populations, but it has long been a particular problem in pediatrics.
One condition for which antibiotics are overprescribed is acute otitis media
(AOM), the most-common indication for antibiotics in children. Delayed
antibiotic prescribing for AOM can significantly reduce unnecessary antibiotic
use and is recommended by the American Academy of Pediatrics for select
children. A delayed antibiotic prescription is a prescription given to the
caregiver to fill in the event that the child’s symptoms
worsen or fail to improve after 48 to 72 hours.
A recent study sought to improve delayed prescribing for AOM
across 8 outpatient pediatric practices in Colorado. Frost et al. (Frost
2021), through a collaborative initiative with American Academy of
Pediatrics and the Centers for Disease Control and Prevention, implemented a
low-cost 6-month antimicrobial stewardship intervention that included
education, audit and feedback, online resources, and content expertise.
Practices varied by size (range: 6–37 providers), payer
type, and geographic setting. Overall, 69 clinicians at 8 practice sites
implemented the project.
The rate of delayed antibiotic prescribing increased from 2%
at baseline to 21% at intervention end (RRR 8.96). Five practices submitted
postintervention data. The rate of delayed prescribing at 3 months and 6 months
postintervention remained significantly higher than baseline (RRR 3 months
postintervention 8.46; 6 months postintervention 6.69.
So what, exactly, did the
intervention entail? There were 3 educational sessions (a full day in-person learning
session and two 90-minute virtual sessions covering the CDC Core Elements of
Outpatient Antibiotic Stewardship and the Institute for Health Improvement Model
of Improvement QI frameworks). There were also 4 monthly 60-minute webinars to
review data and discuss PDSA cycles. There was also subject matter expert
support and access to an online community collaborative Web site. CME credits
and maintenance of certification (MOC) credits were also provided. Education
included content on effective communication to reduce antibiotic use by using the
Dialogue Around Respiratory Treatment method. All practices were provided templates
for delayed prescribing-focused patient education material (handouts and
posters).
We’ve often said that education and training seldom result in sustained
behavioral improvement. But in this collaborative the intervention was more
than just an educational one. Adoption of good QI techniques, including PDSA
cycles with audit and feedback likely played a pivotal role. And, undoubtedly,
the collaborative had a beneficial impact on team building and safety culture
at the practice sites.
Will the results be sustainable beyond a year? Only time
will tell. But we’d expect that, once parents and
other caregivers have been exposed to the concept of delayed prescribing, they
will look to delayed prescribing the next time their child has a bout of AOM,
thus further sustaining the improvement.
Good work!
Some of our prior
columns on antibiotic stewardship:
- October 14, 2014 “Antibiotic Stewardship”
- November 2015 “Medications Most Likely to Harm the Elderly Are…”
- July 2016 “NQF/CDC Guideline on
Antibiotic Stewardship”
- August 2016 “Some Reassurance on
Antibiotic Stewardship”
- November 2016 “C. Diff and Your
Predecessor’s Room”
- December 2016 “Update on Ambulatory
Antibiotic Stewardship”
- July 2017 “Antibiotics and Adverse
Events”
- July 2019 “Dental Prescribing
Called Into Question”
- July 21, 2020 “Is This Patient
Allergic to Penicillin?”
- March 30, 2021 “Need for Better
Antibiotic Stewardship”
References:
Frost, HM, Monti JD, Andersen LM, et al. Improving Delayed
Antibiotic Prescribing for Acute Otitis Media. Pediatrics 2021; 147(6):
e2020026062
https://pediatrics.aappublications.org/content/147/6/e2020026062
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