National collaborative improves antibiotic prescribing for common pediatric infections
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ANAHEIM, Calif. — An antimicrobial stewardship initiative involving more than 130 U.S. hospitals has shown promise — particularly when it comes to treating children for an appropriate duration, researchers reported here.
“What we demonstrated was that partnering across disciplines to improve antibiotic use is effective,” Russell McCulloh, MD, a professor of pediatric hospital medicine at the University of Nebraska Medical Center, told Healio.
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The Better Antibiotic Selection in Children (BASiC) project is a quality improvement program involving 133 hospitals, managed through the AAP’s Value in Inpatient Pediatrics (VIP) Network. Its goal is to increase the percentage of children who receive appropriate antibiotics for three common pediatric infections seen in the ED and hospital setting: community-acquired pneumonia (CAP), skin and soft tissue infections and UTIs.
According to McCulloh and colleagues, up to half of antibiotic prescriptions for children are inappropriate or unnecessary, putting them at risk for adverse events and increasing the likelihood of drug resistance. To gauge whether the BASiC project is working, they analyzed data from 126 participating hospitals, which reported on approximately 45,000 children who presented to EDs or were admitted as inpatients. The hospitals submitted 18 months of baseline data from July 2019 to December 2020, and an additional 12 months of data after the intervention was implemented, from March 2021 to February 2022.
The intervention included order sets, chart audits, educational webinars, academic detailing and a mobile app to help guide and improve antibiotic prescribing. With the exception of the app, which was developed specifically for the BASiC program, all of these components are used in other VIP Network programs, McCulloh noted. The metrics used to gauge the program’s successes were based largely on clinical guidance from the AAP and the Pediatric Infectious Diseases Society, and in some cases, expert consensus.
Results showed that the hospitals’ adherence to the recommended duration of antibiotic therapy for the three common infections increased on average by 1.05% month over month since the BASiC project was adopted. No such improvement was seen during the baseline period.
Although the researchers did not see any significant changes regarding empiric and definitive antibiotic selection from baseline overall, a subanalysis of children with CAP and UTIs did show improvements.
“When you look at all three infections combined, we didn't see changes in empiric therapy or definitive therapy, but when you split them out, we saw improvements” in antibiotic selection, McCulloh said.
McCulloh, who is chair of the VIP Network for the next 2 years, noted that the BASiC program was still able to improve antibiotic prescribing amid a pandemic. He is now “looking at how the project impacted institutional resources and policy to help in sustaining the changes that we saw over time.”
He suggested that hospital providers who want to improve prescribing practices should partner with their pharmacist and emergency and infectious disease colleagues.
“You can achieve big change,” he said.
Perspective
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I think it’s challenging to know who needs antibiotics and who doesn’t. In fact, the data suggest that approximately half of the antibiotics we prescribe are either the wrong ones, are unnecessary, or are given for the wrong length of time.
McCulloh and colleagues have deployed a multipronged, multisite approach to addressing this important issue. However, even with webinars, coaching, a mobile app and more, changes over time are modest, highlighting the clinical challenge of antibiotic prescribing.
Some of our challenges are at the level of diagnostics; we have laboratory assays that can detect viral infections, but we don’t always use them out of a desire for diagnostic stewardship. Sometimes, we prescribe antibiotics out of an abundance of caution for the child with fever and tachypnea who we convince ourselves has crackles on physical exam. And sometimes, we make the right diagnosis and select the right antibiotic but simply treat for longer than is recommended because the recommendations have recently changed. We would do well to acknowledge that the same interventions needed for improvements in selecting empiric therapy may not be the same for improving our standard lengths of therapy. McCulloh’s work will be particularly important for us to examine which interventions are most successful over time.
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McCulloh R, et al. Better Antibiotic Section in Children (BASiC): Results from a national quality improvement collaborative. Presented at: AAP National Conference & Exhibition; Oct. 7-11, 2022; Anaheim, Calif.
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