How to Improve Antibiotics Stewardship for Pediatric Patients

AdventHealth is launching an initiative to improve antibiotic stewardship for pediatric patients in the outpatient setting.

Antibiotic stewardship has several benefits, including lowering cost of care, reducing medication side effects, and addressing antimicrobial resistance. For pediatric patients, most antibiotics are prescribed in the outpatient setting.

“What makes what we are doing unique is the focus on ambulatory care,” says Jeffrey Kuhlman, MD, MPH, chief quality and safety officer at AdventHealth. “We have launched a program that is focused on patients such as a parent bringing a child in for an acute respiratory tract infection including sinus and throat. In the U.S. healthcare system, there is very little emphasis on antibiotic use in the ambulatory setting for pediatric patients.”

The initiative is being supported in part by $2.5 million from the Patient-Centered Outcomes Research Institute (PCORI).

The effort is centered on three clinical care settings: Hundreds of AdventHealth doctor’s offices such as pediatricians, family medicine doctors, and primary care physicians; AdventHealth’s Centra Care urgent care centers, which have more than 60 locations; and 70 emergency departments, which for the purposes of this initiative are considered outpatient locations because most ED pediatric patients are not admitted to a hospital.

A primary element of the initiative is addressing antibiotic use for acute respiratory infections, according to Kuhlman.

“Half of the time for those diagnoses, the illness is viral, which is not appropriate for antibiotics,” Kulman says. “Half of the time it is bacterial, and you need to start with a narrow-spectrum antibiotic such as amoxicillin instead of a broad-spectrum antibiotic, which is like using a bazooka to kill a mosquito.”

How the initiative works

Provider education is a key component of the initiative. PCORI funding will help AdventHealth to provide more organized and focused education for providers in all three outpatient settings, Kuhlman explains.

“We have online learning for providers through the AdventHealth Learning Network,” Kuhlman says. “We have assembled a list of providers in our outpatient settings along with their medical directors. We will engage with the medical directors to encourage the providers to take advantage of our educational offerings.”

The initiative is data driven, according to Kuhlman. Providers in all three outpatient settings will have access to dashboards that will have real-time data on the rate of prescribing antibiotics and the rate of prescribing narrow-spectrum versus broad-spectrum antibiotics.

“We have evidence-based literature from PCORI and Children’s Hospital of Philadelphia that pediatric patients with an acute respiratory tract infection need antibiotics only half of the time,” Kuhlman says. “The other half of the time, the illness is viral and not appropriate for antibiotics. A provider’s prescribing patterns for antibiotics should follow that evidence.”

Last year, AdventHealth prescribed narrow-spectrum antibiotics for pediatric patients with acute respiratory infections about two-thirds of the time. Now, the goal is to increase that prescription rate to more than 90% of the time, Kulman explains.

“If providers use amoxicillin instead of a powerful antibiotic such as azithromycin, the outcomes are the same and there are fewer side effects,” Kuhlman says. “In addition, the cost of care is significantly lower for the antibiotic.”

In addition to provider education and data management, the initiative is improving the health system’s electronic medical record, Epic. A highly skilled nurse is adjusting the order sets for pediatric patients with acute respiratory infections, according to Kuhlman.

“With these order sets, there are symptoms for acute respiratory tract infections in pediatric patients; the order sets remind clinicians about the differences between a viral infection versus a bacterial infection; and if clinicians go down the bacterial infection pathway, narrow-spectrum antibiotics are placed at the top of the treatment options,” Kuhlman says. “We are making it easy for clinicians to do the right thing in the electronic medical record.”

Initiatives such as AdventHealth’s pediatric antibiotics stewardship program are in the CMO’s wheelhouse, according to Kulman.

“CMOs basically have four jobs: professionalism, persuasion, performance, and patient safety,” Kuhlman says. “If you think about pediatric antibiotic stewardship, it touches on all four of those areas.”

In professionalism, part of integrity in being a clinician is doing the right thing. “Our initiative is helping clinicians to do the right thing,” Kuhlman says.

In terms of persuasion, the initiative is designed to persuade clinicians to change their practice of medicine and improve antibiotics stewardship, according to Kuhlman.

For performance, the initiative is striving to improve clinicians’ adherence to evidence-based guidelines. “Our initiative is changing the performance of clinicians,” Kulman says.

In patient safety, clinicians should not expose pediatric patients with acute respiratory infections to harmful side effects,” Kuhlman says. “We need to appropriately decide whether an antibiotic is necessary, then we need to pick the right antibiotic.”