Reducing Ophthalmic Antibiotic Use for Non-severe Conjunctivitis in Children

Abstract

Background: Antibiotics are often overprescribed for pediatric conjunctivitis. We implemented a system-level quality improvement (QI) intervention to reduce unnecessary ophthalmic antibiotic use.

Methods: The multi-faceted intervention in Denver, CO comprised a clinical care pathway, nurse protocol modifications, electronic health record (EHR) changes, parent education materials, and clinician education. We evaluated children aged 6 months-17 years with conjunctivitis seen between November 2018 and December 2022. A multi-interrupted time series model evaluated the effectiveness of the intervention over three time periods: Pre-COVID, Pre-Intervention (November 2018-February 2020), COVID, Pre-Intervention (March 2020-March 2021), and Post-Intervention (April 2021-December 2022). Fisher's exact tests compared treatment failure and healthcare utilization rates between time periods and among children receiving or not receiving ophthalmic antibiotics.

Results: Among 6960 eligible encounters, ophthalmic antibiotic use was reduced by 18.8% (95% CI: 16.3, 21.3) from Pre-COVID, Pre-Intervention to Post-Intervention. During the Pre-Intervention period following the onset of COVID, a reduction of 16.1% (95% CI: 12.9, 19.3) was observed. Implementation of the intervention resulted in an additional 2.7% (95% CI: -0.4, 5.7) reduction in antibiotic prescribing, primarily in younger children (ages 6 months-5 years). The greatest reduction in prescribing occurred for nurse triage encounters with an 82.1% (95% CI: 76.8, 87.5) reduction in prescribing rates (92.6%-10.5%). Treatment failure occurred in 1301 (18.7%) children and was more common among children that received an ophthalmic antibiotic than those that did not (20.0 vs 17.9%; P = .03).

Conclusion: The QI intervention significantly reduced ophthalmic antibiotic prescribing for pediatric conjunctivitis without increasing treatment failure rates or health care utilization.

Keywords: antibiotic stewardship; conjunctivitis; pediatrics; quality improvement.

Figure 1.

Change in ophthalmic antibiotic prescribing by time-period. There is no significant difference in slope between the Pre-COVID, Pre-Intervention and Post-Intervention period (slope = 0.26, 1.07, respectively; P = .24). Level change between Pre-COVID, Pre-Intervention and the Post-Intervention period was significant (−32.7, P < .01). See Supplementary Table for more details.