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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).
Each practice site had a QI team including, at a minimum, a physician practice champion, an office administrator, and a nurse or medical assistant; required attendance at educational sessions; development and execution of monthly PDSA cycles; submission of monthly provider-level data; and completion of surveys. In total, 27 PDSA (plan-do-study-act) cycles were completed by the 8-practice teams.
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.
Some of our prior columns on antibiotic stewardship:
Frost, HM, Monti JD, Andersen LM, et al. Improving Delayed Antibiotic Prescribing for Acute Otitis Media. Pediatrics 2021; 147(6): e2020026062
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