Guideline-concordant antibiotic prescribing for pediatric outpatients with otitis media, community-acquired pneumonia, and skin and soft tissue infections in a large multispecialty healthcare system

Abstract

Antibiotics are commonly prescribed in pediatric outpatient settings; however, efforts to decrease inappropriate use have largely focused on inpatients. We obtained baseline metrics to identify conditions that may benefit from establishment of outpatient antimicrobial stewardship interventions (ASP). We evaluated rates and appropriateness of antibiotic prescribing for children with acute otitis media (AOM), community acquired pneumonia (CAP), and skin and soft tissue infections (SSTI) in ambulatory settings within a large healthcare system in the US Midwest. We retrospectively reviewed 77,821 visits and associated diagnostic codes for children less than 17 years seen in ambulatory settings within our health system from August 1, 2009 to July 31, 2010. We measured rates of antibiotic prescribing by location, provider type, patient age, and diagnosis, and assessed concordance with treatment guidelines for AOM, CAP, and SSTI. AOM, CAP, and SSTI comprised about 1/3 of all infections in the study population. Antibiotics were prescribed in 14,543 (18.7%) visits. Antibiotic prescribing rates were 1.1 to 1.2 times higher among Emergency Room (ER) providers compared to Pediatricians and Family Physicians. Antibiotics prescribed for AOM and SSTI were concordant with guidelines in approximately 97% of cases. In contrast, 47% of antibiotics prescribed for treatment of CAP in children < 5 years old were macrolides, which are not recommended first line therapy for CAP in this age group. Antibiotic prescribing for pediatric outpatients within our health system is not guideline-concordant for treatment of CAP.

Keywords: Antimicrobial stewardship; Otitis Media; Pediatrics; Pneumonia; Skin and soft tissue infections.

Figure 1. Antibiotic prescriptions by infection type in pediatric outpatients at FH-MCHS August 2009–July 2010

Number of prescriptions per diagnosis: N = 5928 for AOM; N=563 for CAP; N=693 for SSTI. FH-MCHS= Franciscan Healthcare-Mayo Clinic Health System, AOM= Acute otitis media, CAP= community acquired pneumonia, SSTI= skin and soft tissue infections.

Figure 2. Proportion of guideline-concordant antibiotics prescribed for children by type of infection at FH-MCHS August 2009–July 2010

AOM: first line treatment, Amoxicillin or amoxicillin-clavulanate; second line treatment, cefdinir, ceftriaxone and clindamycin; not recommended, sulfonamides. CAP: first line treatment penicillin or amoxicillin, macrolides (for >5 to 17 years); second line/alternative treatment, amoxicillin-clavulanate, second or third generation cephalosporins; not recommended, macrolides (for children < 5 years). SSTI: first line treatment, penicillin, amoxicillin, cephalexin, trimethoprim-sulfamethoxazole, clindamycin, doxycycline and minocycline; second line treatment, amoxicillin-clavulanate; not recommended, second/third generation cephalosporins. Number of prescriptions per diagnosis: N=5844 for AOM, N= 551 for CAP, N= 681 for SSTI. Patients receiving multiple concurrent antibiotics were excluded (N=84 for AOM; N=12 for CAP, and N=12 for SSTI).