TOP 17 - Enhancing Diagnostic Stewardship and Reducing Antibiotic Overuse in Pediatric Group A Strep Pharyngitis: A Quality Improvement Initiative

Publication Number: 3745.TOP 17

Daniel Hibbard-Lubow, Albert Einstein College of Medicine, New York, NY, United States; Marianna B. Castellanos, The Children's Hospital at Montefiore, Bronx, NY, United States; Mahmoud AA. Ali, The Children's Hospital at Montefiore, Bronx, NY, United States; Philip Lee, The Children's Hospital at Montefiore, Bronx, NY, United States; Musa G. Bolkent, Sanford Health, Bemidji, MN, United States; Daniel M. Fein, The Children's Hospital at Montefiore, Teaneck, NJ, United States; Brenda I.. Anosike, Albert Einstein College of Medicine, Bronx, NY, United States

Background: Group A Streptococcal (GAS) pharyngitis accounts for up to 30% of pediatric pharyngitis cases. Diagnostic overlap with viral infections limits the reliability of clinical assessment alone. Guidelines advise against testing in children < 3 years of age, as GAS pharyngitis and its sequelae are rare and no validated criteria exist for this age. Frequent GAS testing in children < 3 years was observed across Montefiore Health System (MHS) Emergency Departments (EDs), suggesting potential over testing and unnecessary antibiotic exposure. This quality improvement (QI) initiative aims to align testing with evidence-based guidelines and optimize resource utilization.

Objective: To reduce inappropriate GAS testing in patients < 3 years by 20% over 12 months (January 2025-December 2025) across all MHS EDs, with a secondary goal of decreasing unnecessary antibiotic prescriptions.

Design/Methods: This multisite QI project employs a quasi-experimental pre-post intervention design across four urban EDs in The Bronx, NY, beginning in January 2025. The multidisciplinary team includes pediatric emergency medicine, infectious disease, and resident physicians. The study population comprises children < 3 years for whom a GAS PCR test was ordered. The key drivers diagram outlines the project's aim (Figure 1), and the process map is shown in Figure 2.

Three strategies are being implemented: (1) Providers education through in-person sessions, lectures, and emails on disease epidemiology, diagnostic criteria, and guideline recommendations; iterative education guided by override feedback. (2) Implementation of an EHR "Soft Stop" alert prompting clinicians to reconsider testing in patients < 3 years; overrides require documented justification (e.g., known household exposure or prolonged fever). (3) Future removal of GAS tests from ED order sets is planned to minimize reflexive testing and promote clinical discretion.

Pre- and post-intervention data from matched seasonal periods (2024-2025) were collected across all sites. Variables included age, sex, provider type, test results, antibiotic prescriptions, and 7-day ED revisits with pharyngitis-related complications. The primary outcome was the proportion of cancelled GAS tests and overall reduction in testing post-intervention. The secondary outcome was the reduction in antibiotic prescriptions for pharyngitis. Balancing measures included 7-day ED revisits with pharyngitis-related complications. Data will be analyzed using statistical process control charts alongside descriptive and inferential statistics, with completion anticipated by January 31, 2026.

Key Drivers diagram
BPA, Best Practice Advisory; IDSA, Infectious Diseases Society of America; EMR, Electronic Medical Record

Process Map for GAS Testing in Children <3 Years in the Emergency Department
OPA, Our Practice Advisory