O2133: A Multi-center Collaborative to Improve Prescribing for Antibiotic Choice in Pediatric Urgent Care

Purpose/Objectives: Clinicians in pediatric urgent care centers (UCCs) prescribe antibiotics at a high rate to patients with acute otitis media (AOM) and acute pharyngitis. The American Academy of Pediatrics (AAP) Section on Urgent Care Medicine and Pediatric Acute and Critical Care (PACC) Network developed a multi-center quality improvement (QI) collaborative to improve the rate of first-line antibiotic agent in AOM to 80% and group A streptococcal (GAS) pharyngitis 90%, diagnostic stewardship for strep pharyngitis to 95%, and the use of delayed antibiotics for low-risk AOM to 50% of encounters by the end of the study period.

Design/Methods: We used national guidelines to determine first-line antibiotic treatment for AOM and GAS and criteria for low-risk AOM. Participating sites committed at least 3 UCC clinicians to submit 10 encounters for each diagnosis (AOM and GAS pharyngitis) per month via the AAP’s Quality Improvement Data Aggregator (QIDA). In addition to collecting rates of first-line antibiotic use for each diagnosis and rates of offering delayed antibiotics to low-risk AOM as our outcome measure, we collected rates of documentation of eligibility for delayed antibiotics in AOM as a process measure. We monitored the rates of amoxicillin allergy for encounters and refusal of delayed antibiotics as balancing measures. During the intervention period (October 2022-June 2023) participants signed commitment letters, attended monthly webinars, developed interventions, and participated in virtual roundtable discussions to share “lessons learned and next steps” with other sites around the United States. This project is funded by Pfizer.

Results: 58 clinicians from 14 pediatric UCCs participated. Use of first-line antibiotics for AOM and GAS pharyngitis remained stable, with monthly rates ranging from 68.0-80.2% and 76.7-85.9% respectively. Use of first-line antibiotics for AOM decreased in November and December which coincided with a national amoxicillin shortage (Figure 1). As documentation of eligibility for delayed antibiotics for AOM increased (Figure 2A), use of delayed antibiotics increased from a baseline range of 34.8-38.8% to 75.5% in January 2023 and then remained >70% during the intervention period (Figure 2B). Families agreed to delayed antibiotics >66% of encounters (Figure 2C). Practices maintained high rates of testing before treating GAS pharyngitis (>90%) throughout the baseline and intervention periods.

Conclusion/Discussion: This multi-center QI collaborative provided education and networking opportunities to improve antibiotic prescribing behaviors for AOM and GAS pharyngitis in pediatric UCCs. During the intervention period, we experienced unexpected challenges of a post-pandemic viral surge (October-December), antibiotic shortages, (November-February) and high rates of GAS infections (January-April). Despite these challenges, UCC clinicians remained dedicated to improving prescribing behaviors as evidenced by their increase in the use of discussing the option of delayed antibiotics for AOM. The AAP SOUCM plans to continue to provide collaborative opportunities to support local champions in their QI efforts.