CL 0.3521 UCL 0.6053 LCL 0.0988 0.000 0.100 0.200 0.300 0.400 0.500 0.600 0.700 Prevalence of Broad-Spectrum Antibiotic Prescriptions Period Broad-Spectrum antibiotic prescriptions for Uncomplicated AOM AOM CP Implementation Background Daniele Dona 1,2 , Maura Baraldi 3 , Giulia Brigadoi 3 , Silvia Zingarella 3 , Rebecca Lundin 4 , Rana F. Hamdy 1 , Theoklis Zaoutis 1 , Liviana Da Dalt 3 & Carlo Giaquinto 2,4 (1)Department of Pediatrics, Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, (2)Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Padua, Italy, (3)Pediatric Emergency Department, Department for Woman and Child Health, University of Padua, Padua, Italy, (4)PENTA Foundation, Padua, Italy • Italian pediatric antimicrobial prescription rates are among the highest in Europe. Identifying effective stewardship activities is essential [1]. • Where resources are limited for establishment of a robust Antimicrobial Stewardship Program (ASP), clinical pathways (CPs) represent a reasonable and feasible first step for implementation [2] • Objective : To evaluate the impact of CPs on antibiotic prescriptions, including drug (narrow vs broad spectrum) and duration of therapy for acute otitis media (AOM), pharyngitis and community-acquired pneumonia (CAP) Effect of clinical pathways on antibiotic prescriptions in an emergency department: Italian pediatric antimicrobial stewardship starts here Methods • Intervention: On 1 October 2015 CPs for the management of AOM, Pharyngitis and CAP were implemented at the Pediatric Emergency Department of the University Hospital of Padua. Three educational lectures were presented and CPs were distributed as a laminated pocket card. • Quasi experimental study: Baseline period (10/15/2014 – 04/15/2015) and post intervention period (10/15/2015 – 04/15/2016) • Outcomes: Proportion provided prescriptions following “wait and see” approach (AOM only), proportion provided prescriptions by drug, days of therapy (DOT) and Length of Therapy (LOT) for combination therapy. • Data Analysis: process control p-charts were created using QI macros p-chart software. Chi-square, Fisher ’ s exact test and Wilcoxon rank sum test were used to evaluate differences from baseline to post- intervention. • Definitions: • Broad-spectrum antibiotics: Amoxicillin-clavulanate, cephalosporins and macrolides were considered broad-spectrum antibiotics • Treatment failure: 1)change in antibiotic regimen for persistence of symptoms; 2 ) change in antibiotic regimen for adverse drug events; 3) relapse of symptoms within 30 days from discharge date with new antibiotic prescription; 4) new antibiotic prescription in case “wait and see” was the first line therapeutic choice (only for AOM). Conclusions 1899 Results • Evidence-based CPs supported by adequate provider education can effectively influence prescribing practices for AOM, pharyngitis and CAP reducing overall and broad spectrum antibiotic prescription without compromising clinical outcomes. • CPs represent a promising, resource efficient antimicrobial stewardship tool especially in an ED setting. AOM Pharyngitis Figure 1. Process control p-charts of broad-spectrum antibiotic prescriptions for AOM at the ED. An immediate and stable decrease in broad-spectrum antibiotic use is indicated after CP implementation, especially for uncomplicated AOM (AOM without otorrea). CAP Figure 4. Process Control P-charts of Broad-spectrum antibiotic prescriptions for CAP at the ED. A stable decrease in broad-spectrum antibiotic use for CAP is indicated after CP implementation. Figure 7. Process Control P-charts of Broad-spectrum antibiotic prescriptions for GAS Pharyngitis at the ED. A dramatic decrease in broad-spectrum antibiotic use is indicated after pharyngitis CP implementation. Pre-intervention period Post-intervention period P value 295 278 Treatment N % N % Wait and see 64 21.7 92 33.1 <0.01 Antibiotic therapy 231 78.3 186 66.9 <0.01 Amoxicillin 74 25.1 96 34.5 <0.05 Broad spectrum (amoxi- clavulanate +cephalosporins+ macrolides) 157 53.2 90 32.4 <0.001 Amoxicillin-clavulanate 106 35.9 70 25.2 <0.01 Cephalosporins 47 15.9 16 5.8 <0.001 Macrolides 4 1.4 4 1.4 0.79 Pre intervention Period 298 Post intervention Period 366 p-value Patients not treated with abx 147 49.3 200 54.6 0.17 Pharyngitis treated with abx (Strept group A (GAS) Pharyngitis) 151 50.7 166 45.4 0.17 Antibiotic option for Pharyngitis Amoxicillin 81 54 155 93 <0.001 Broad-spectrum (amoxi-clav + cephalosporins + macrolides) 70 46 11 7 <0.001 Amoxicillin-clavulanate 60 40 5 3 <0.001 Cephalosporin 10 7 6 4 0.28 Table 1 Treatment options and treatment failure analysis for AOM Pre-intervention period Post-intervention period p value Number of outpatients 56 41 Total DOT 620 342 N % of DOT N % of DOT Amoxicillin 338 54.5 243 71.1 <0.0001 Cephalosporins 60 9.7 29 8.5 0.5 Macrolides 132 21.3 22 6.4 <0.0001 Amoxicillin-clavulanate 90 14.5 48 14.0 0.8 References 1 - European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2013. Annual report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). Stockholm: The Centre; 2014. 2 - Samore MH, Bateman K, Alder SC, et al. Clinical decision support and appropriateness of antimicrobial prescribing: a randomized trial. JAMA. 2005 Nov 9;294(18):2305–2314. Table 3 Treatment options and treatment failure analysis for Pharyngitis Table 2 Treatment options for CAP Figure 5. Days of therapy pre and post-implementation Figure 6. Length of therapy pre and post implementation Figure 2. Duration of therapy in median days of therapy (DOT) each month in pre- and post-intervention by age and diagnosis. Among children >2 years old with uncomplicated AOM, duration of therapy changed from exceeding guidelines pre-intervention to meeting guidelines afterwards. Therapy Duration for Children < 2 YO with AOM Fig.1 Fig.7 Fig.8 Fig.4 Broad-spectrum antibiotic prescriptions for CAP DOT pre and post implementation LOT pre and post implementation Figure 8. Duration of therapy in median days of therapy (DOT) each month in pre- and post-intervention Broad-spectrum antibiotic prescriptions for Pharyngitis Treatment Duration for Children with Pharyngitis Treatment Failure Pre-intervention Period Post-intervention Period p-value Children available for follow-up 214 (72.5% of total AOM) 206 (74.1% of total AOM) Treatment failures 26 12.1 23 11.2 0.75 Changed abx for persistence of symptoms 12 5.6 5 2.4 0.10 Changed abx for side effects 3 1.4 4 1.9 0.96 Ab prescription after “wait and see” 7 3.3 13 6.3 0.14 Ab prescriptions for new episode within 30 days 4 1.9 1 0.5 0.39 Treatment failures Pre-intervention period Post-intervention period P value Patients available for follow up 98 (64.9% of tretaed pharyngitis) 118 (71.1% of treated pharyngitis) Treatment failure 6 6 8 7 0.93 Changed abx for persistence of symptoms 2 2 3 3 0.83 Changed abx for side effects 2 2 2 2 0.75 Ab prescriptions for new episode within 30 days 2 2 3 2.5 0.83 Treatment failures Pre-intervention period Post-intervention period p value Number of outpatients available for follow-up 44 34 N % N % Changed abx for persistence of symptoms 1 2.3 4 11.8 0.3 Changed abx for side effects 0 0 0 0 Ab prescriptions for new episode within 30 days 0 0 0 0 AOM CP Implementation Therapy Duration for Children > 2 YO with uncomplicated AOM Therapy Duration for Children > 2 YO with complicated AOM AOM CP Implementation AOM CP Implementation Fig.2