602 - A Quality Improvement Initiative to Increase Appropriate Antibiotic Selection for Hospitalized Children with Community Acquired Pneumonia

Publication Number: 2587.602

Heriberto Martinez, Phoenix Children's Hospital, Scottsdale, AZ, United States; Lindsay Podraza, Phoenix Children's Hospital, Scottsdale, AZ, United States; Nina Gupta, Phoenix Children's Hospital, Phoenix, AZ, United States; Sandra Gage, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States; Richard Engel, Phoenix Children's Hospital, Phoenix, AZ, United States; Christian L. Armstrong, Phoenix Children's Hospital, Phoenix, AZ, United States; Katherine Dyer, Phoenix Children's Hospital, Phoenix, AZ, United States; Nehal Thakkar, Phoenix Children's Hospital, Phoenix, AZ, United States; Reina Patel, Phoenix Children's Hospital, Phoenix, AZ, United States; Cherisse Mecham, Phoenix Children's Hospital, Phoenix, AZ, United States; Matthew W. Smith, Phoenix Children's Hospital, Phoenix, AZ, United States

Background: Guidelines from the Infectious Diseases Society of America and Pediatric Infectious Disease Society recommend ampicillin/amoxicillin as first-line therapy for uncomplicated community acquired pneumonia (CAP) in children older than 3 months given its high efficacy against Streptococcus pneumoniae. However, while inpatient use of ampicillin/amoxicillin has increased nationally to 61%, at our institution, inpatients with CAP received ampicillin/amoxicillin for approximately 45.5% of hospital days from July-December 2024. We sought to improve adherence to recommended guidelines for children admitted with CAP.

Objective: Increase the percentage of hospital days that admitted patients with CAP receive ampicillin/amoxicillin to 65% over 12 months.

Design/Methods: Project members included providers from outpatient clinics, hospital medicine, emergency medicine, infectious diseases, pharmacy, and antibiotic stewardship. Data was collected using the institution's CAP dashboard, and sample chart review was performed to ensure data accuracy. To evaluate the problem, identify metrics and inform interventions, process mapping (Figure 1) and key driver diagram (KDD) (Figure 2) development were undertaken. Team consensus and the literature aided in forming additional interventions. QI methodology was applied; data was plotted on SPC P-charts.

Our primary outcome was the percentage of hospital days CAP inpatients received ampicillin/amoxicillin (goal: 65%). Process measures included CAP order set use (goal: 50%) and therapy narrowing (goal: 10%). Balancing measures included antibiotic broadening, readmission rates, and length of stay (goal: no change).

Phase I interventions focused on education for outpatient pediatric primary care, residents, hospital medicine, and emergency medicine providers. Phase II interventions focused on revising CAP order sets and direct provider feedback. Refer to the KDD for details (Figure 2).

Results: Ampicillin/amoxicillin usage increased from 45.5% to 66% of hospital days over 6 months (Figure 3), meeting criteria for a median shift. Order set usage and antibiotic narrowing remained unchanged. There was no change in length of stay, broadening of antibiotics, or transfer to the PICU.

Conclusion(s): We successfully increased the percentage of hospital days that inpatients with CAP receive ampicillin/amoxicillin. This advances patient safety and improves quality of care by encouraging adherence to national guidelines and limiting the exposure of children to unnecessary broad-spectrum antibiotics. Ongoing interventions aim to expand the improvements seen thus far and sustain changes.

Figure 1. Process Map


Figure 2. Key Driver Diagram


Figure 3. P-chart
Percentage of hospital days in which patients with CAP received ampicillin/amoxicillin. Numerals "1" through "4" refer to the interventions noted in the Interventions Key.

Interventions Key:
1. January 2025: ​Resident, Hospitalist, PEM provider education​
2. February 2025: ​Resident, PEM fellow education; Flyers; Order set revisions​
3. May 2025: ​Antibiotic stewardship provider feedback; PCP education​
4. June 2025: ​New intern education​