518 - Appropriate Treatment for Community Acquired Pneumonia

Publication Number: 2503.518

Morgan E. Leighton, UCSF Benioff Children's Hospital Oakland, Castro Valley, CA, United States; Monica Charpentier, George Washington University School of Medicine and Health Sciences, Washington DC, DC, United States; Rachael Herriman, UCSF, San Francisco, CA, United States; Daniel Shapiro, University of California, San Francisco, School of Medicine, San Francisco, CA, United States; Emily CZ. Roben, University of California, San Francisco, School of Medicine, San Jose, CA, United States; Israel Green-Hopkins, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA, United States

Background: Up to a quarter of antibiotics prescribed in pediatric patients are unnecessary, and this leads to adverse effects and increased rates of antibiotic resistance. Community-acquired pneumonia (CAP) is a common cause for prescription of antibiotics for pediatric patients treated in the Emergency Department, though antibiotic choices and course duration can often be too broad and too long. Short course (5 day), narrow spectrum antibiotic therapy is now the acceptable standard for uncomplicated CAP.

Objective: Our goal was to increase the percentage of antibiotic prescriptions of correct 5 day duration for children discharged from the ED with a diagnosis of community-acquired pneumonia from 46% to 75% within12 months and to sustain this improvement through the following year.

Design/Methods: We conducted a quality improvement initiative across two pediatric emergency departments in academic, urban children's hospitals. We collected 26 months of baseline data and 12 months of post-intervention data. Patients age 6 months to 18 years with a discharge diagnosis of pneumonia (ICD-10 codes J18.9, J18.1, and J15.9) were included. Our primary outcome was receipt of correct duration of antibiotic prescription, in line with short course therapy and our secondary outcome was receipt of correct duration, dose, and correct narrow spectrum therapy. Interventions included quarterly audits, educational sessions with staff and residents, a pediatric pneumonia pathway resource and implementation of electronic clinical decision support. Patients with no documented allergy to penicillins or cephalosporins who received isolated azithromycin prescriptions were excluded from the analysis. We monitored balancing measures of revisit and readmission to the hospital within 7 days.

Results: During the baseline period, 46% of patients received 5 day antibiotic courses while 34% of subjects had correct spectrum, dose and correct short-course duration. During the implementation phase, the rate of patients receiving short-course therapy improved to 76% and met criteria for shifting on SPC, while 60% received correct spectrum, dose and duration. We did not find significant increased rates of revisit or readmission during the implementation phase.

Conclusion(s): Through quality improvement methodology we successfully reduced antibiotic overexposure through standardizing short-course antibiotic therapy for patients discharged with community acquired pneumonia.

ATCAP Fishbone Diagram
ATCAP fishbone diagram.pdfA diagram identifying common barriers to correct discharge antibiotic prescriptions for community acquired pneumonia.

ATCAP SPC Chart: Correct Duration
A statistical process chart demonstrating improvement and reduced variability in discharge prescription of short-course antibiotics for community acquired pneumonia.

ATCAP SPC Chart: Correct Duration, Dose, and Narrow Spectrum
A statistical process chart demonstrating improvement in discharge prescription of appropriate duration, dose, and narrow-spectrum antibiotics for community acquired pneumonia.