Abstract
Background
Most antibiotics prescribed to children are provided in the outpatient and emergency department (ED) settings, yet these prescribers are seldom engaged by antibiotic stewardship programs. We reviewed ED antibiotic prescriptions for three common infections to describe current prescribing practices.
Methods
Prescription data between 2018 and 2021 were extracted from the electronic records of children discharged from the Children’s Hospital of Eastern Ontario ED with urinary tract infection (UTI), community acquired pneumonia (CAP), and acute otitis media ≥2 years of age (AOM). Antibiotic choice, duration, as well as the provider’s time in practice and training background were collected. Antibiotic durations were compared with Canadian guideline recommendations to assess concordance. Provider-level prescribing practices were analyzed using k-means cluster analysis.
Results
10,609 prescriptions were included: 2868 for UTI, 2958 for CAP, and 4783 for AOM. Guideline-concordant durations prescribed was generally high (UTI 84.9%, CAP 94.0%, AOM 52.8%), a large proportion of antibiotic-days prescribed were in excess of the minimally recommended duration for each infection (UTI 16.8%, 19.3%, AOM 25.5%). Cluster analysis yielded two clusters of prescribers, with those in one cluster more commonly prescribing durations at the lower end of recommended interval, and the others more commonly prescribing longer durations for all three infections reviewed. No statistically significant differences were found between clusters by career stage or training background.
Conclusions
While guideline-concordant antibiotic prescribing was generally high, auditing antibiotic prescriptions identified shifting prescribing towards the minimally recommended duration as a potential opportunity to reduce antibiotic use among children for these infections.
1
Background
Overuse of antibiotics poses twin threats to human health: firstly, significant infection-related morbidity and mortality attributable to increasing antimicrobial resistance [ ], and secondly, adverse events [ , ] including increasingly recognized long term health impacts of antibiotic use such as obesity [ ], asthma [ ], and inflammatory bowel disease [ ]. Although antimicrobial stewardship programs (ASPs) have been operationalized in inpatient settings, they are nascent in the ambulatory care setting, with a recent American study revealing that no surveyed pediatric hospitals actively monitored antibiotic prescribing in the emergency department (ED) [ ].
This is particularly concerning because the majority (59–90%) of antibiotic prescriptions in North America are given in the outpatient and ED settings [ ], and at least 30% of all antibiotic prescriptions are thought to be inappropriate [ ].
The Canadian Pediatric Society (CPS) and the Association of Medical Microbiology and Infectious Disease have published practice points [ ] to guide the duration of antibiotics prescribed for many common bacterial infections; however, the suggested durations permit prescribing over a wide interval (e.g. 7–10 days). They also fail to encourage clinicians to take infection severity into consideration by explicitly recommending durations at the lower end of the interval for more mild infections. Previous authors have demonstrated significant provider-level variability in the proportion of ambulatory care visits for respiratory illness resulting in an antibiotic prescription [ , ], and it is likely that the duration prescribed also varies as a function of the child’s illness severity and provider-related factors. Given the large numbers of outpatient prescriptions provided, reducing unwarranted variability in treatment duration by more frequently choosing the minimally recommended treatment duration for outpatients could have a large impact on the total community-level antibiotic consumption by children.
The primary objectives of this study were to 1) describe antibiotic prescribing practices in the ED at departmental- and provider-levels for three common pediatric infections: urinary tract infection (UTI), community acquired pneumonia (CAP), and acute otitis media (AOM), and 2) assess concordance of antibiotic prescribing with CPS practice points.
2
Methods
We conducted a retrospective observational study using data extracted from the electronic records of all children less than 18 years of age who were prescribed antibiotics after being seen at the Children’s Hospital of Eastern Ontario (CHEO) ED and discharged with an International Classification of Diseases, 10th Revision, Canada (ICD-10-CA) diagnosis of UTI (N39.0), CAP (J15.9 or J18.9), or AOM (H66.0 or H66.9). CHEO is a free-standing tertiary care children’s hospital with an ED that has approximately 70,000 visits annually. Children with a visit diagnosis of AOM who were <2 years old at the time of the visit were excluded, consistent with previous studies evaluating outpatient antibiotic use [ ]. Only prescriptions given by ED providers between 1st January 2018 and 31th December 2021 were included, and encounters with incomplete prescription data were excluded. Prescribers with fewer than 5 prescriptions for any of the three infections were excluded. The study received institutional research ethics board approval, and followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines [ ]. Most variables of interest, including age at visit, prescriber name, diagnosis, and prescription information (antibiotic choice and duration) were extracted directly from the electronic medical record (EMR), Epic (Verona, WI) by author ML using a structured query language (SQL) query. A physician (CK) reviewed the data output for accuracy and rectified discrepancies (i.e. where the EPIC-calculated duration field and the free-text prescription instruction duration differed, the latter was taken as correct). Prescriber’s years in practice and their area of expertise were gathered from the publicly available College of Physicians and Surgeons of Ontario ( https://doctors.cpso.on.ca/ ) and College of Nurses of Ontario ( https://registry.cno.org/ ) websites, while full- or part-time employment status was obtained from ED administrative records. Years in practice were categorized into early career (<11 years), mid-career (11–24 years), and late career (≥25 years). Prescribers were grouped as follows: a) Royal College of Physicians and Surgeons of Canada specialty certification in pediatric emergency medicine or full-time employment in the ED with specialty certification in pediatrics, or b) Royal College of Physicians and Surgeons of Canada Certified pediatricians with part-time employment in the ED, or other full- or part time ED providers (i.e. family physicians and nurse practitioners).
The selection of antibiotic and duration of treatment prescribed for UTI, CAP, and AOM was compared descriptively. Antibiotic-days prescribed longer than minimally recommended (LMR) by the CPS practice points (i.e. over 7 days for UTI and CAP, and over 5 days for AOM) [ ], were determined for each infection as a percentage of the total antibiotic-days prescribed, and normalized per 1000 infection-specific visits during which antibiotics were prescribed (i.e. antibiotic-visits). This was to estimate the maximum possible reduction in antibiotic consumption that could be yielded from future duration-focused stewardship interventions. The percentage of prescriptions given that were concordant with CPS practice point recommendations was also assessed for each infection.
To identify groups of providers with similar prescribing practices, a k-means cluster analysis of prescriptions for UTI, CAP, and AOM with LMR durations was performed. The number of clusters was selected based on the greatest reduction in within-cluster sum of squares, a measure of heterogeneity, achieved before the rate of reduction fell substantially (i.e. the “elbow point”) with the addition of one cluster. The percentage of prescriptions with LMR durations was summarized for each infection and between-cluster testing was performed using the Wilcoxon rank sum test, with p -values adjusted for multiple testing using Holm’s method. Associations between provider’s cluster and career stage as well as between cluster and specialty were also tested using Fisher’s exact test.
3
Results
A total of 10,609 antibiotic-visits were identified: 2868 with UTI, 2958 with CAP, and 4783 with AOM in children over ≥2 years of age, provided by 51 prescribers. The antibiotic durations prescribed for each infection were plotted with histograms ( Fig. 1 ).
3.1
Urinary tract infection
The 2868 visits for UTI amounted to 23,022 antibiotic-days prescribed. The choices of antibiotics prescribed are seen in Table 1 with 1428 (49.8%) of children received cephalexin. CPS concordant duration prescribing (i.e. 7–10 days assuming that each case represented febrile UTI), was noted in 84.9% of cases, with 41.1% receiving a 7-day duration and 40.7% receiving 10 days. Of the total antibiotic-days prescribed, 3876 (16.8%) days were in excess of the LMR duration. Normalized, the LMR antibiotic-days were 1351 per 1000 ED antibiotic-visits for UTI.
| Drug | UTI [ ] | CAP [ ] | AOM [ ] |
|---|---|---|---|
| n = 2868 | n = 2958 | n = 4783 | |
| Antibiotic selected, n (%) | |||
| Amoxicillin | 44 (1.5) | 2427 (82.0) | 4026 (84.2) |
| Amoxicillin-Clavulanate | 29 (1.0) | 168 (5.7) | 393 (8.2) |
| Azithromycin | 0 (0.0) | 46 (1.6) | 13 (0.3) |
| Cefixime | 1053 (36.7) | 1 (0.0) | 3 (0.1) |
| Cefprozil | 2 (0.1) | 19 (0.6) | 86 (1.8) |
| Cefuroxime | 4 (0.1) | 62 (2.1) | 97 (2.0) |
| Cephalexin | 1428 (49.8) | 5 (0.2) | 16 (0.3) |
| Ciprofloxacin | 28 (1.0) | 1 (0.0) | 3 (0.1) |
| Clarithromycin | 0 (0.0) | 222 (7.5) | 139 (2.9) |
| Nitrofurantoin | 97 (3.4) | 0 (0.0) | 0 (0.0) |
| SMX-TMP | 163 (5.7) | 1 (0.0) | 0 (0.0) |
| Other ( n < 15) | 20 (0.7) | 6 (0.2) | 7 (0.1) |
| Duration Prescribed in Days, n (%) | |||
| <5 | 73 (2.5) | 27 (0.9) | 21 (0.4) |
| 5 | 301 (10.5) | 132 (4.5) | 2527 (52.8) |
| 6 | 29 (1.0) | 9 (0.3) | 7 (0.1) |
| 7 | 1180 (41.1) | 1179 (39.9) | 991 (20.7) |
| 8 | 9 (0.3) | 4 (0.1) | 1 (0.0) |
| 9 | 78 (2.7) | 4 (0.1) | 1 (0.0) |
| 10 | 1168 (40.7) | 1593 (53.9) | 1231 (25.7) |
| >10 | 30 (1.0) | 10 (0.3) | 4 (0.1) |
| Guideline Concordance, n (%) | 2435 (84.9) | 2780 (94.0) | 2527 (52.8) |
| Prescriptions given with durations longer than minimally recommended, n (%) | 1285 (44.8) | 1611 (54.5) | 2235 (46.7) |
| Proportion of total antibiotic-days given longer than minimally recommended, % | 16.8 | 19.3 | 25.5 |
| Antibiotic days given longer than minimally recommended, normalized per 1000 visits | 1351 | 1646 | 1712 |
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