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Broad-Spectrum antibiotic prescriptions forUncomplicated AOM

AOM CP Implementation

Background

Daniele Dona1,2, Maura Baraldi3, Giulia Brigadoi3, Silvia Zingarella3, Rebecca Lundin4, Rana F. Hamdy1, Theoklis Zaoutis1, Liviana Da Dalt3 & Carlo Giaquinto2,4

(1)Department of Pediatrics, Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA,

(2)Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Padua, Italy,

(3)Pediatric Emergency Department, Department for Woman and Child Health, University of Padua, Padua, Italy,

(4)PENTA Foundation, Padua, Italy

• Italian pediatric antimicrobial prescription rates are among the highest in Europe. Identifying effective

stewardship activities is essential [1].

• Where resources are limited for establishment of a robust Antimicrobial Stewardship Program (ASP),

clinical pathways (CPs) represent a reasonable and feasible first step for implementation [2]

• Objective: To evaluate the impact of CPs on antibiotic prescriptions, including drug (narrow vs broad

spectrum) and duration of therapy for acute otitis media (AOM), pharyngitis and community-acquired

pneumonia (CAP)

Effect of clinical pathways on antibiotic prescriptions in an emergency department:

Italian pediatric antimicrobial stewardship starts here

Methods• Intervention: On 1 October 2015 CPs for the management of AOM, Pharyngitis and CAP were

implemented at the Pediatric Emergency Department of the University Hospital of Padua. Three

educational lectures were presented and CPs were distributed as a laminated pocket card.

• Quasi experimental study: Baseline period (10/15/2014 – 04/15/2015) and post intervention period

(10/15/2015 – 04/15/2016)

• Outcomes: Proportion provided prescriptions following “wait and see” approach (AOM only), proportion

provided prescriptions by drug, days of therapy (DOT) and Length of Therapy (LOT) for combination

therapy.

• Data Analysis: process control p-charts were created using QI macros p-chart software. Chi-square,

Fisher’s exact test and Wilcoxon rank sum test were used to evaluate differences from baseline to post-

intervention.

• Definitions:

• Broad-spectrum antibiotics: Amoxicillin-clavulanate, cephalosporins and macrolides were

considered broad-spectrum antibiotics

• Treatment failure: 1)change in antibiotic regimen for persistence of symptoms; 2 ) change in

antibiotic regimen for adverse drug events; 3) relapse of symptoms within 30 days from discharge

date with new antibiotic prescription; 4) new antibiotic prescription in case “wait and see” was the

first line therapeutic choice (only for AOM).

Conclusions

1899

Results

• Evidence-based CPs supported by adequate provider education can

effectively influence prescribing practices for AOM, pharyngitis and

CAP reducing overall and broad spectrum antibiotic prescription

without compromising clinical outcomes.

• CPs represent a promising, resource efficient antimicrobial stewardship

tool especially in an ED setting.

AOM

Pharyngitis

Figure 1. Process control p-charts of broad-spectrum antibiotic

prescriptions for AOM at the ED. An immediate and stable decrease in

broad-spectrum antibiotic use is indicated after CP implementation,

especially for uncomplicated AOM (AOM without otorrea).

CAP

Figure 4. Process Control P-charts of Broad-spectrum antibiotic prescriptions

for CAP at the ED. A stable decrease in broad-spectrum antibiotic use for CAP

is indicated after CP implementation.

Figure 7. Process Control P-charts of Broad-spectrum antibiotic prescriptions for GAS

Pharyngitis at the ED. A dramatic decrease in broad-spectrum antibiotic use is

indicated after pharyngitis CP implementation.

Pre-intervention period Post-intervention period P value

295 278

Treatment N % N %

Wait and see 64 21.7 92 33.1 <0.01

Antibiotic therapy 231 78.3 186 66.9 <0.01

Amoxicillin 74 25.1 96 34.5 <0.05

Broad spectrum (amoxi-

clavulanate

+cephalosporins+

macrolides)

157 53.2 90 32.4 <0.001

Amoxicillin-clavulanate 106 35.9 70 25.2 <0.01

Cephalosporins 47 15.9 16 5.8 <0.001

Macrolides 4 1.4 4 1.4 0.79

Pre intervention Period

298

Post intervention Period

366p-value

Patients not treated with abx 147 49.3 200 54.6 0.17

Pharyngitis treated with abx (Strept

group A (GAS) Pharyngitis)

151 50.7 166 45.4 0.17

Antibiotic option for Pharyngitis

Amoxicillin 81 54 155 93 <0.001

Broad-spectrum

(amoxi-clav + cephalosporins +

macrolides)

70 46 11 7 <0.001

Amoxicillin-clavulanate 60 40 5 3 <0.001

Cephalosporin 10 7 6 4 0.28

Table 1 Treatment options and treatment failure analysis for AOM

Pre-intervention

period

Post-intervention

period

p valueNumber of outpatients 56 41

Total DOT 620 342

N % of DOT N % of DOT

Amoxicillin 338 54.5 243 71.1 <0.0001

Cephalosporins 60 9.7 29 8.5 0.5

Macrolides 132 21.3 22 6.4 <0.0001

Amoxicillin-clavulanate 90 14.5 48 14.0 0.8

References

1 - European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2013. Annual report of the European Antimicrobial

Resistance Surveillance Network (EARS-Net). Stockholm: The Centre; 2014.

2 - Samore MH, Bateman K, Alder SC, et al. Clinical decision support and appropriateness of antimicrobial prescribing: a randomized trial. JAMA. 2005 Nov

9;294(18):2305–2314.

Table 3 Treatment options and treatment failure analysis for PharyngitisTable 2 Treatment options for CAP

Figure 5. Days of therapy pre and post-implementation

Figure 6. Length of therapy pre and post implementation

Figure 2. Duration of therapy in median days of therapy (DOT)

each month in pre- and post-intervention by age and diagnosis.

Among children >2 years old with uncomplicated AOM, duration

of therapy changed from exceeding guidelines pre-intervention to

meeting guidelines afterwards.

Therapy Duration for Children < 2 YO with

AOM

Fig.1

Fig.7

Fig.8

Fig.4 Broad-spectrum antibiotic prescriptions for CAP

DOT pre and post implementation

LOT pre and post implementation

Figure 8. Duration of therapy in median days of therapy

(DOT) each month in pre- and post-intervention

Broad-spectrum antibiotic prescriptions for Pharyngitis

Treatment Duration for Children with Pharyngitis

Treatment Failure Pre-intervention Period Post-intervention Period p-value

Children available for follow-up 214 (72.5% of total AOM) 206 (74.1% of total AOM)

Treatment failures 26 12.1 23 11.2 0.75

Changed abx for

persistence of symptoms12 5.6 5 2.4 0.10

Changed abx for side

effects 3 1.4 4 1.9 0.96

Ab prescription after

“wait and see”7 3.3 13 6.3 0.14

Ab prescriptions for new

episode within 30 days4 1.9 1 0.5 0.39

Treatment failures Pre-intervention period Post-intervention period P value

Patients available for follow up98 (64.9% of tretaed

pharyngitis)

118 (71.1% of treated

pharyngitis)

Treatment failure 6 6 8 7 0.93

Changed abx for persistence of

symptoms2 2 3 3 0.83

Changed abx for side effects 2 2 2 2 0.75

Ab prescriptions for new

episode within 30 days2 2 3 2.5 0.83

Treatment failures Pre-intervention period Post-intervention period

p valueNumber of outpatients

available for follow-up44 34

N % N %

Changed abx for

persistence of

symptoms

1 2.3 4 11.8 0.3

Changed abx for

side effects 0 0 0 0

Ab prescriptions for

new episode within

30 days

0 0 0 0

AOM CP ImplementationAOM CP Implementation AOM CP ImplementationAOM CP Implementation

Therapy Duration for Children > 2 YO with

uncomplicated AOM

Therapy Duration for Children > 2 YO with

complicated AOM

AOM CP ImplementationAOM CP Implementation

Fig.2