A multifaceted approach to decrease inappropriate antibiotic use in a pediatric outpatient clinic.

BACKGROUND: Inappropriate use of antimicrobial agents is the major cause for the development of resistance. Thus, it is important to include outpatient clinics in the development of antibiotic stewardship program.
METHODS: We report a multifaceted approach to decrease inappropriate antibiotic use in upper respiratory tract infections (URTIs) in an outpatient pediatric clinic. The interventions included educational grand round, academic detailing, and prospective audit and feedback and peer comparison.
RESULTS: During the study period, a total of 3677 outpatient clinic visits for URTIs were evaluated. Of all the included patients, 12% were <1 year of age, 42% were 1-5 years, and 46% were >5 years of age. Of the total patients, 684 (17.6%) received appropriate antibiotics, 2812 (76.4%) appropriately did not receive antibiotics, and 217 (6%) inappropriately received antibiotics. The monthly rate of prescription of inappropriate antibiotics significantly decreased from 12.3% at the beginning of the study to 3.8% at the end of the study (P < 0.0001). Antibiotic prescription among those who had rapid streptococcal antigen test (RSAT) was 40% compared with 78% among those who did not have RSAT (P < 0.0001).
CONCLUSIONS: The combination of education and academic detailing is important to improve antibiotic use.

Use, misuse, and abuse of antimicrobial agents are the major causes for the development of resistance. Antimicrobial resistance is a major concern due to the limited availability of newer antibiotics.[1] One area for antimicrobial misuse is upper respiratory tract infections (URTIs).[2345678] There is a global concern of emerging resistance among respiratory pathogens. In Saudi Arabia, Haemophilus influenzae resistance to ampicillin was 13.2%.[9] In addition, Streptococcus pneumoniae showed 59% resistance to penicillin, of which 15% were highly resistant.[10] The resistance rate was higher in children <10 years of age.[10] In a study, S. pneumoniae from pediatric patients showed 28.8% intermediate susceptibility and 13.7% high resistance rates to penicillin.[11]

Different methodologies were used to limit the use of antibiotics in children with URTIs, including delayed antibiotic prescribing, education, and the use of laboratory tests.[1213141516] Delayed prescription may result in >50% reduction in antibiotic use.[12] However, adding education to delayed prescribing strategy resulted in a significant reduction in antibiotic use.[171819]

Recently, there had been a call to include outpatients in the development of antibiotic stewardship program.[20] In this study, we report our experience with a multifaceted approach to decrease inappropriate antibiotic usage in an outpatient pediatric clinic targeting patients with URTIs.

Methods

During the study period of December 2012–December 2013, we collected all the charts for pediatric patients <13 years of age who presented to the outpatient clinic at Dhahran health center with a chief complaint of any respiratory symptom (cough, cold, congestion, sore throat, or sneezing). Paper and electronic medical records were reviewed by an experienced physician and used the Centers for Disease Control and Prevention Pediatric Treatment Recommendations of Upper Respiratory Tract infection.[21] The following information were recorded: The date, age, gender, chief complaint, diagnosis, rapid streptococcal antigen test (RSAT), and treatment choice. For treatment choice, we recorded whether antibiotics were given or not, the type of the antibiotic, and whether the treatment choice was appropriate or not [Table 1].

Table 1

A summary of data collection in relation to antibiotics

The multifaceted interventions included an initial grand round about judicious antibiotic use, followed by multiple other interventions as summarized in Table 2. Academic detailing is a concept of adult learning and behavior change. This principle relies on probing baseline knowledge of an individual physician, using evidence-based resources highlighting essential messages on appropriate antibiotic use and providing positive feedback.[22]

Table 2

A summary of multifaceted approach to reduce inappropriate antibiotic use in children with upper respiratory tract infections

The use of RSAT was also introduced to help in the differentiation of streptococcal pharyngitis. RSAT was introduced for testing in children with a streptococcal score of ≥5 as described previously.[2324]

The study was approved by the Institutional Review Board and informed consent was not required.

Results

During the study period, a total of 3677 outpatient clinic visits for URTI were evaluated. Of all the included patients, 441 (12%) were <1 year of age, 1544 (42%) were 1–5 years, and 1692 (46%) were >5 years of age. Of the total patients, 56% were male. The initial diagnosis of the patients is summarized in Figure 1.

Figure 1

Initial diagnosis in the included pediatric patients, numbers represent percentage of the total patients. URTI=Upper respiratory tract infections

Of the included patients, 684 (17.6%) received appropriate antibiotic, 2812 (76.4%) appropriately did not receive antibiotic, and 217 (6%) received antibiotic inappropriately. Of those who received antibiotic appropriately, 42 patients (6.5%) had streptococcal pharyngitis. The most frequently prescribed antibiotics were amoxicillin (42%) and azithromycin (25%) [Figure 2]. The monthly inappropriate antibiotic prescription decreased from 12.3% at the beginning of the study to 3.8% at the end of the study (P < 0.0001) [Figure 3].

Figure 2

Most frequently prescribed antibiotics (numbers represent percentage of the total prescribed antibiotics)

Figure 3

A scattered diagram showing monthly inappropriate antibiotic usage as a percentage

Among 317 patients with a diagnosis of pharyngitis, 162 (51%) patients had RSAT was antibiotic prescription among those who had RSAT was 65 (40%) compared with 121 (78%) among those who did not have RSAT (P < 0.0001).

Discussion

This study showed that a multifaceted approach is useful for the reduction of antibiotic use in pediatric patients with URTIs. Education and academic detailing were important parts of the interventions as well as the use of RSAT.

One important finding of this study is the lower rate of antibiotic prescribing for pediatric patients with URTIs and the achievement of even a lower rate with a multifaceted approach. In Saudi Arabia, antibiotics were prescribed for 87% of URTI patients[25] and account for 43.8% of all prescriptions.[26] In the United States of America, 75% of the antibiotic prescriptions in the outpatient settings are for acute URTIs.[27]

In this study, we utilized multiple interventions to improve antibiotic use focused on physicians. A multifaceted approach was cited as the best intervention to reduce antibiotic usage in patients with URTIs.[282930]

Individual prescriber and small group education play a role in the reduction of inappropriate antibiotic use.[2231323334] We specifically included academic detailing in the intervention. Academic detailing is an important component of an individual educational perspective.[223536] In one study, academic detailing showed better compliance in relation to the choice of antibiotics but did not result in reduction in total prescription rates.[37] One method to facilitate academic detailing is the use of clinical vignette.[3839]

Although Group A beta-hemolytic Streptococcus accounts for 15%-30% of acute pharyngitis in children, this condition is overdiagnosed and overtreated.[40] In the current study, the use of RSAT resulted in 50% reduction in antibiotic use (40% vs. 78%). Similarly in previous studies, RSAT was associated with 22.4% antibiotic prescription for children with pharyngitis compared to 41.4% for those who did not have RSAT.[4041] RSAT is an easy and sensitive test that is available at the point-of-care testing and could be utilized to decrease inappropriate antibiotic use.[4243]

Conclusions

The combination of education, academic detailing, and focus education of physicians is an important intervention to improve antibiotic utilization.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.