Abstract Corresponding Author Rana E. El Feghaly, MD, MSCI, Division of Infectious Diseases, Department of Pediatrics, Children’s Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO 64108. Tel: 816-234-3061. E-mail: relfeghaly@cmh.edu Funding/Support This work was supported by the Heroes in Implementation Research Scholar Award from the Association for Professionals in Infection Control and Epidemiology. Conflict of Interest Disclosures (includes financial disclosures) REE receives funding from Merck for an investigator-initiated grant on reducing health inequity in antimicrobials prescribing for respiratory infections in pediatric urgent cares. REE received an honorarium for reviewing grants for Pfizer. All other authors report no conflict of interest. Background Although national agencies recommend specific antibiotic stewardship (AS) interventions e.g., commitment letters, reports, quality improvement (QI) to improve the appropriateness of outpatient prescribing, studies have not evaluated the efficacy of specific interventions. This study aimed to evaluate the impact of benchmarking and sharing reports on antibiotic use and identify AS strategies that improve pediatric outpatient antibiotic prescribing. Methods The Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS-Outpatient) Collaborative started sharing quarterly benchmarking reports with 22 institutions in November 2022. The antibiotic use metrics included in the report are: rate of antibiotic use for acute encounters, rate of antibiotic use for acute respiratory infection (ARI) encounters, percent of ARI encounters receiving amoxicillin (amoxicillin index) or azithromycin (azithromycin index), and percentage of acute encounters receiving short (≤ 7 days) antibiotic courses. All institutions submitted data from their primary care clinics (PCC), 18 from emergency departments (ED)s, and 16 from urgent care clinics (UC)s for the reports. Fifteen (68%) institutions submitted duration data. An AS leader from each institution completed an investigator-developed survey to assess AS implementation strategies and the impact of the benchmarking reports in January 2024. We compared baseline (January 2019-December 2022) to the benchmarking implementation period (January 2023-September 2024). We used logistic regression models to assess the impact of AS strategies on the different metrics. Results We included 32.4 million acute encounters (21.1 million baseline; 11.2 million benchmarking). Eighteen (81.8%) responders agreed or strongly agreed that the benchmarking reports were useful, and 9 (40.9%) reported additional AS initiatives implemented as a direct result of the benchmarking reports. Although variable among sites, the most common AS strategies implemented were toolkits, electronic medical record features, QI projects, and educational activities. Although antibiotic use for ARI encounters increased in the implementation period 34.6% (IQR 27.8%-43.5%) to 39.7% (35.4%-50.1%) p.001 in PCC; 27.4% (23.7%-32.9%) to 34.8% (32.2%-41.7%) p.001 in ED; and 40.1% (34.0%-44.9%) to 51.8% (46.6%-57.1%) p.001 in UC, we saw improvements in the amoxicillin and azithromycin indices as shown by an increase in amoxicillin index in ED 72.2% (66.1%-75.7%) to 73.5% (66.1%-78.9%) p=.039, and UC 68.1% (65.7%-72.9%) to 71.2% (69.5%-75.0%) p.001, and a decrease in azithromycin index in PCC 5.2% (2.1%-7.6%) to 3.8% (2.4%-5.5%) p=.012 and UC 3.0% (2.2%-4.8%) to 2.3% (1.7%-3.9%) p=.021. We also saw shorter antibiotic duration in PCC 24.9% (19.0%-40.4%) to 30.3% (23.3%-48.4) p=.07 and ED 48.4% (39.6%-62.0%) to 55.3% (49.2%-65.3%) p=.027. The odds of receiving antibiotics for ARI were variable across sites and AS strategies, although toolkits and QI projects appeared to be associated with lower odds of antibiotic use, higher amoxicillin index, and lower azithromycin index in most settings. Most AS strategies impacted antibiotic duration in UC, although impact in other locations were variable (Fig. 1). Conclusion Although antibiotic use for ARI increased after sharing benchmarking reports, we observed improvements for select antibiotics, specifically increased use of amoxicillin, decreased azithromycin use, and decreased antibiotic duration. Toolkits and QI appear to have the biggest impact, although there was substantial variation between sites and institutions.
Feghaly et al. (Mon,) studied this question.
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