Rangel QI 2012-2013:Antibiotic Stewardship in the

Ambulatory Setting

COS – May 15, 2013

Background Information• Antibiotic prescribing in the ambulatory setting

occurs >1 in 5 visits• In study of pediatric office visits , antibiotics

prescribed: • 44% of visits for the common cold• 75% of visits for bronchitis• Estimate at least 40-50% of inappropriate antibiotic

use

• While national antibiotic prescribing rates have decreased, more broad spectrum antibiotics are prescribed

• Inappropriate antibiotic use contributes to antibiotic resistance, side effects, and increased cost

Pediatrics. 2012; 130: 23-31.

JAMA 2002; 287(23): 3096-3102.

Background Information

3-24 months

24-48 months

48-<72 months

Background Information

Questions• How well do we adhere to Clinical practice

guidelines for promoting appropriate antimicrobial use?

• How can we improve our practice?• How can we increase the Rangel Community’s

understanding of viral/bacterial infections and the clinically accepted guidelines for therapy?

• Focusing on common pediatric respiratory illnesses:

• Upper Respiratory Infection (URI)• Acute Otitis Media (AOM)• Streptococcal pharyngitis

AIM Statement• AOM

• 1a) for pt’s 3-17yo with uncertain diagnosis or non-severe illness, increase our observation rates from 60% to 80%

• 1b) for pt’s 3-17yo with certain diagnosis and severe illness, increase our prescription of appropriate antibiotic from 73% to 90%

• Streptococcal pharyngitis• 2) Improve the correct prescription (antibiotic, dose,

duration) from 55% to 75%

• Viral URIs• 3) For patients who present for sick visits and leave

without antibiotic prescription, decrease the number who feel antibiotics are necessary from 85% to 65%

Provider cycles/interventions

Pre-intervention provider survey

• Survey Monkey survey of providers assessing knowledge, perceptions and practice of AOM diagnosis & management

• For children < 2 years of age with suspected AOM, how often do you prescribe antibiotics at time of diagnosis?• 67% providers respond that they would always prescribe

abx

• For children > 2 years of age with suspected AOM, how often do you prescribe antibiotics at the time of diagnosis?• 17% providers responded that they would always

prescribe abx

Didactics• Powerpoint presentation to all providers to review

the clinical guidelines for both AOM and Strep pharyngitis

Clinic materials• Created handout materials & posters that

highlighted the clinical guidelines and listed antibiotic options with dose and timing

2004 AAP/AAFP Clinical Practice Guideline: Diagnosis of Acute

Otitis Media

• 3 major criteria for diagnosis of AOM:• acute onset of symptoms• signs of middle ear effusion

• limited or absent mobility• bulging of TM• air-fluid level• otorrhea

• signs and symptoms of middle ear inflammation• distinct erythema of TM• distinct otalgia

Pediatrics 2004; 113(5):1451-1465.

AGE Certain diagnosis Uncertain diagnosis

Birth to <6 months

Amoxicillin 80-90mg/kg, div BID x 10-days

Amoxicillin 80-90 mg/kg, div BID x 10-days

6 months to < 2 years

Amoxicillin 80-90mg/kg, div BID x 10-days

SEVERE illness: Mod to severe otalgia or fever > 102.2 in past 24hrs

HD amoxicillin x 10-days

Non-severe illness: mild otalgia or temp < 102.2

OBSERVE only

> 2 years SEVERE illness: Mod to severe otalgia or fever > 102.2 in past 24hrs

HD amoxicillin x 5-10 days*OBSERVE only

Non-severe illness: mild otalgia or temp < 102.2

OBSERVE onlyOBSERVE only

Do you have a patient with AOM?

**Certain diagnosis includes BOTH inflammation AND effusion

*5-day treatment option if pt > 6 yo AND no h/o AOM in last 3-months

1st line antibiotics:

Amoxicillin 80 mg/kg/d div BID

5-10 days*

Ceftriaxone 50 mg/kg IM/IV Single dose

Type I hypersensitivity- PCN allergy

Azithromycin

10 mg/kg/d x 1d

5 mg/kg/d x 4 d

5 days

Clindamycin 30-40 mg/kg/d

div TID

10 days

2nd line antibiotics: if mild PCN- reaction (no anaphylaxis or urticaria), or failure of 1st line

Augmentin 90 mg (of amox) /kg/d div

BID

10 days

Cefdinir 14 mg/kg qday 10 days

Cefpodoxime

10 mg/kg/d div BID

10 days

Ceftriaxone 50 mg/kg IM/IV 3 doses

Antibiotic options for AOM

*5-day treatment option if pt > 6 yo AND no h/o AOM in last 3-months

New 2013 AAP/AAFP AOM Guidelines

<6 months 6-23 months >24 months

Severe AOMDefined as: *fever ≥39 or,

*moderate or severe otalgia or,

*otalgia for >48 hours

Antibiotics

Non-severe Bilateral AOMDefined as: *mild ear pain lasting less <48 hours or,

* Temp <39

Antibiotics Antibiotics

Observationw/ assured f/u

Non-severe Unilateral AOM Antibiotics Observation

w/ assured f/u

Observationw/ assured f/u

*moderate or severe bulging of TM or new onset otorrhea, or*mild bulging of TM and recent onset (<48 hours) otalgia, or*mild bulging of TM and intense erythema

Do you have a patient with throat pain?

Consider the rapid Strep test, IF AGE > 3 years

AND >=2 of the following:

NO URI symptoms

(cough, conjunctivitis, rhinitis)

Sudden onset of sore throat

Fever

Headache

Nausea, vomiting, abdominal pain

Palatal petechiae

Scarlatiniform rash

Anterior cervical adenitis

Antibiotic options for GAS-pharyngitis:

1st line antibiotics:

Pencillin V Children: 250 mg BID

Adol: 500 mg BID

10 days

Amoxicillin 50 mg/kg/d, max 1G

10 days

Bicillin IM 600K if < 27 kg

1200K if > 27 kg

Single dose

2nd line antibiotics: if PCN- allergic

Azithromycin

12 mg/kg qday 5 days

Cephalexin 40 mg/kg/d div BID

Max 500 mg/dose

10 days

Cefadroxil 30 mg/kg qday

Max 1G

10 days

Clindamycin 21 mg/kg/d div TID 10 days

Clarithromycin

15 mg/kg/d div BID 10 days

QI “Tip of the Week” emails

EMR tools• Acronym expander for both AOM and Strep

pharyngitis for use in the EMR• .aom

EMR tools• Acronym expander for both AOM and Strep

pharyngitis for use in the EMR• .aom• .pharyngitis

Provider Interventions: Results•For children < 2 years of age with suspected AOM, how often do you prescribe antibiotics at time of diagnosis?

Provider Interventions: Results• For children > 2 years of age with suspected AOM,

how often do you prescribe antibiotics at the time of diagnosis?

Provider Interventions: Results• AIM Goal 1a: To increase our observation in pts 3-17yo

with uncertain diagnosis or nonsevere illness from 60% to 80%

Provider Interventions: Results• AIM Goal 1b: To increase our prescription of

appropriate antibiotic for pts 3-17yo with certain diagnosis and severe illness from 73% to 90%

Provider Interventions: Results• AIM Goal 2: Improve the correct prescription

(antibiotic, dose, duration) of strep pharyngitis from 55% to 75%

Provider Interventions: Results• AIM Goal 2: Improve the correct prescription

(antibiotic, dose, duration) of strep pharyngitis from 55% to 75%

Nurse/MA cycles/interventions

Nursing/MA interventions• Posted handouts around clinic and reviewed with

RNs, ex. “how to triage patient with ‘sore throat’”.

Nursing/MA interventions• Didactics on Rapid Strep testing• Change in Rapid Strep testing workflow

Nursing/MA interventions• Didactics on Rapid Strep testing• Change in Rapid Strep testing workflow

Nurse Interventions: Results

Patient cycles/interventions

Pre-intervention Patient Questionnaire: • Paper/pen survey of random group of parents

presenting for visits during a given block• 85% of patients believed that antibiotics are

appropriate for one of the following: ANY FEVER, ANY INFECTION, or ONLY VIRAL INFECTIONS.

• 45% of parents treat their children at home when sick• 45% of parents take their children to the ED when sick

• Parents opt for the ED principally based on severity of illness, but also because they feel they are more likely to be seen by a doctor (rather than an allied health professional) and for convenience.

• 15% of parents call the clinic or walk-in when their child is sick, with 1/3 of these patients opting occasionally to take their children to the ED instead

Patient Interventions• For patients discharged

with viral diagnoses, providers were instructed to supply a viral prescription with written recommendations for care at home.

Patient Interventions• Providers instructed to have patients read back

the most important instructions in the viral prescription to maximize retention and ensure understanding• In a study of critical laboratory values relayed by

telephone to medical providers, physicians had an error rate of 5%, caught and corrected by a program of mandatory read back to laboratory technicians.

Am J Clin Pathol 2004; 121:801-803.

Post-intervention Patient Questionnaire• AIM Goal 3: For patients who present for sick visits and

leave without antibiotic prescription, decrease the number who feel antibiotics are necessary from 85% to 65%

Post-intervention Patient Questionnaire• AIM Goal 3: For patients who present for sick visits and

leave without antibiotic prescription, decrease the number who feel antibiotics are necessary from 85% to 65%

Sustainability within our ACN clinics• Include lecture(s) on diagnosis of, and antibiotic

prescription for, common outpatient presentations: AOM, Strep pharyngitis, CAP, bacterial sinusitis.

• Handout materials above provider offices and RN/MA stations.

• Acronym expander for AOM and Pharyngitis guidelines and other common outpatient walk-in visits.

• Use of viral prescriptions with read back method.

• Ensure availability of pneumatic otoscopy to increase accuracy of AOM diagnosis.

QI as a tool for improvement in Antibiotic Stewardship

Thanks to the entire Rangel Team!• Residents: ElShadey Bekeley, Sandhya Brachio,

Karen Lee-Bride, Alicia Chang, Wee Chua, Kenny McKinley, Laura Perretta, Pelton Phinizy, Lauren Sanlorenzo, Andrew Wherman, Ronny Zviti

• Preceptors: Evelyn Berger-Jenkins, Hetty Cunningham, Christine Krause, Tawana Winkfield-Royster

• NP: Marcia Clarke• MAs: Wendy, Amarilys, Luisa• Nurses: Clara, Michelle, Cindy, Sharman• PFAs: Taina, Betty, Liz• Rangel Parents

References• Hersh, AL, et al.. “Antibiotic Prescribing in Ambulatory Pediatrics in the United States”. Pediatrics

2011; 129(6): 1053-1061.• Di Pentima MC, et al. “Benefits of a Pediatric Antimicrobial Stewardship Program at a Children’s

Hospital”. Pediatrics 2011: 128(6): 1062-1070.• Coco, A, et al. “Management of acute otitis media after publication of the 2004 AAP and AAFP

clinical practice guideline. Pediatrics 2010; 125:214.• Greene SK, et al. “Trends in antibiotic use in Massochusetts children, 2000-2009.” Pediatrics

2012: 3137.• McCaig LF, et al. “Trends in antimicrobial prescribing rates for children and adolescents.” JAMA

2002; 287(23): 3096-3102.• American Academy of Pediatrics and American Academy of Family Physicians – Subcommittee on

Management of Acute Otitis Media. “Diagnosis and Management of Acute Otitis Media”. Pediatrics 2004; 113(5):1451-1465.

• Shulman ST, et al. Infectious Diseases Society of America. “Clinical practice guidelines for the diagnosis and maangement of Group A Streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.” Clinical infectious diseases 2012; : doi: 10.1093/cid/cis629

• Chai, G, et al. “ Trends of outpatient prescription drug utilization in US children, 2002-2010.” Pediatrics 2012; 130(1): 23-31

• Barenfanger J, et al. “Improving patient safety by repeating (Read-Back) telephone reports of critical information.” Am J Clin Pathol 2004; 121:801-803.