We aimed to decrease the difference in first-line therapy (ΔFLT) for common acute respiratory infections (ARI) in pediatric urgent care clinics (PUCs) in relation to race, ethnicity, language, and insurance using quality improvement (QI) methodology.

Retrospective cohort study of 13-month pre-intervention (April 2022–April 2023) and 17-month (May 2023–September 2024) intervention data collection.

92 PUC sites from 9 organizations spanning 22 states.

Encounters of patients 6 months to 18 years of age with ARI diagnoses.

Sites created local multidisciplinary QI teams, cause-and-effect analyses, driver diagrams, and used Plan-Do-Study-Act (PDSA) cycles. We defined FLT per national guidelines. We measured ΔFLT between socioeconomic groups as our primary outcome. Balancing measure was overall rate of FLT. Logistic regression models evaluated the impact education-only PDSAs had on ΔFLT compared to PDSAs that used education plus another intervention modality (eg clinical decision support).

We included 895,604 encounters. Despite our QI efforts, we saw no change in ΔFLT between Spanish and English-speaking patients (3.1%), Hispanic and non-Hispanic patients (1.6%), or commercial and government-insured patients (1.6%). We saw an increase in ΔFLT between Black and White patients from 3.6% to 5.8%. We observed fluctuations in overall rates of FLT over time. The impact of PDSA cycle types was variable.

Despite local interventions to reduce differences in prescribing, we noted a widening of the ΔFLT by race. More work is needed to understand causes of these disparities and develop effective interventions that improve equitable antibiotic prescribing.

To describe the antimicrobial management of and examine the etiology of intracranial suppurative infections (ISIs) at a single pediatric institution.

Retrospective review.

We included children hospitalized at a 367-bed freestanding pediatric institution for treatment of an ISI (epidural or subdural empyema, brain abscess) between January 1, 2015, and September 30, 2023. ISIs were identified using international classification of diseases 9/10 discharge diagnosis codes.

We collected data regarding patient characteristics, infection etiology and complications, antimicrobial choice and route (empiric, definitive, and outpatient), microbiology results, treatment duration, and treatment-related outcomes from the electronic health record.

A total of 72 patients met inclusion criteria. Most patients received a third- or fourth-generation cephalosporin, metronidazole, and vancomycin empirically (69.4%), while a third- or fourth-generation cephalosporin in combination with metronidazole was the most common definitive regimen (63.9%). Almost half of patients (44%) were transitioned to an entirely oral antibiotic regimen, after a median of 27 days of intravenous therapy. The median duration of antimicrobial therapy was 45 days (interquartile range = 33,56). Organisms in the Streptococcus anginosus group were the most common pathogens identified (62.5%). Treatment-related complications occurred in 12 (16.7%) patients.

Empiric therapy targeting resistant gram-positive organisms was not required to treat ISIs at our institution. Further data are needed on timing and requirements for oral antibiotic transition and treatment duration. In the future, there is opportunity for multi-institutional collaboration and data-sharing to determine the most appropriate management of pediatric ISIs.

To determine whether differences exist in antibiotic prescribing for respiratory infections in pediatric urgent cares (PUCs) by patient race/ethnicity, insurance, and language.

Multi-center cohort study.

Nine organizations (92 locations) from 22 states and Washington, DC.

Patients ages 6 months–18 years evaluated April 2022–April 2023, with acute viral respiratory infections, otitis media with effusion (OME), acute otitis media (AOM), pharyngitis, community-acquired pneumonia (CAP), and sinusitis.

We compared the use of first-line (FL) therapy as defined by published guidelines. We used race/ethnicity, insurance, and language as exposures. Multivariable logistic regression models estimated the odds of FL therapy by group.

We evaluated 396,340 ARI encounters. Among all encounters, 351,930 (88.8%) received FL therapy (98% for viral respiratory infections, 85.4% for AOM, 96.0% for streptococcal pharyngitis, 83.6% for sinusitis). OME and CAP had the lowest rates of FL therapy (49.9% and 60.7%, respectively). Adjusted odds of receiving FL therapy were higher in Black Non-Hispanic (NH) (adjusted odds ratio [aOR] 1.53 [1.47, 1.59]), Asian NH (aOR 1.46 [1.40, 1.53], and Hispanic children (aOR 1.37 [1.33, 1.41]), compared to White NH. Additionally, odds of receiving FL therapy were higher in children with Medicaid/Medicare (aOR 1.21 [1.18–1.24]) and self-pay (aOR 1.18 [1.1–1.27]) compared to those with commercial insurance.

This multicenter collaborative showed lower rates of FL therapy for children of the White NH race and those with commercial insurance compared to other groups. Exploring these differences through a health equity lens is important for developing mitigating strategies.

To investigate differences in the rate of firstline antibiotic prescribing for common pediatric infections in relation to different socioeconomic statuses and the impact of an antimicrobial stewardship program (ASP) in pediatric urgent-care clinics (PUCs).

Quasi-experimental.

Three PUCs within a Midwestern pediatric academic center.

Patients aged >60 days and <18 years with acute otitis media, group A streptococcal pharyngitis, community-acquired pneumonia, urinary tract infection, or skin and soft-tissue infections who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis requiring systemic antibiotics.

We used national guidelines to determine the appropriateness of antibiotic choice in 2 periods: prior to (July 2017–July 2018) and following ASP implementation (August 2018–December 2020). We used multivariable regression analysis to determine the odds ratios of appropriate firstline agent by age, sex, race and ethnicity, language, and insurance type.

The study included 34,603 encounters. Prior to ASP implementation in August 2018, female patients, Black non-Hispanic children, those >2 years of age, and those who self-paid had higher odds of receiving recommended firstline antibiotics for all diagnoses compared to male patients, children of other races and ethnicities, other ages, and other insurance types, respectively. Although improvements in prescribing occurred after implementation of our ASP, the difference within the socioeconomic subsets persisted.

We observed socioeconomic differences in firstline antibiotic prescribing for common pediatric infections in the PUCs setting despite implementation of an ASP. Antimicrobial stewardship leaders should consider drivers of these differences when developing improvement initiatives.

Penicillin (PCN) allergy labels affect antimicrobial selection for surgical prophylaxis. We aimed to increase the percentage of cefazolin usage in patients with PCN allergy labels undergoing orthopedic surgery from 50% to 80%.

Quality improvement initiative.

Children’s Mercy Kansas City (CMKC), a freestanding children’s hospital.

Children scheduled for an orthopedic surgery (excluding spinal surgery) at CMKC who had a PCN allergy label and received a perioperative antibiotic.

No standardized process existed to identify and clarify PCN-allergic–labeled patients preoperatively. We developed a process for patient identification combined with a pharmacist phone interview for PCN allergy clarification. In plan–do–study–act (PDSA) part 1, we implemented a computer-generated patient list. In PDSA part 2, we combined automated identification with a phone interview. In PDSA part 3, we enhanced the patient list, making it timely and concise. In PDSA part 4, we included a PCN allergy clarification electronic survey to caregivers via the electronic medical record.

Cefazolin use in PCN-allergic surgical patients increased from 50% to 74% following interventions. Patients who had their PCN allergy label clarified were 4 times more likely to receive cefazolin compared to those whose allergy labels were not clarified (OR, 4.21; 95% CI, 1.68–11.61; P = 0.003). Moreover, 90% of patients received cefazolin when their PCN allergy was clarified and cefazolin was recommended. When a PCN allergy label was not clarified, only 59% of patients received cefazolin.

Appropriate clarification and documentation of PCN allergy labels increases the use of cefazolin for surgical prophylaxis.

To assess current resources, interventions, and obstacles of pediatric outpatient antimicrobial stewardship programs (ASP).

Cross-sectional study.

Institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient collaborative (SHARPS-OP).

Antimicrobial stewardship leaders from the above institutions.

An investigator-developed survey was deployed online in September 2020 to antimicrobial stewardship leaders in SHARPS-OP institutions. The survey was divided into 4 sections: (1) basic information, (2) status of pediatric outpatient ASP in the institutions including financial support, (3) outpatient ASP interventions undertaken by the institutions, and (4) needs and SHARPS-OP collaborative goals.

Of 56 invited institutions, 45 participated, achieving an 80% response rate. Only 5 sites (11%) had allocated financial support for an outpatient ASP, compared to 42 (95.6%) for their inpatient ASP. The most widely used outpatient ASP interventions included antimicrobial guidance (57.8%), education (46.7%), and quality improvement projects (37.8%). Time was identified as the biggest barrier to expanding outpatient ASPs (91.1%), followed by financial support (53.3%), development of meaningful reports (51.1%), and administrative support (44.4%). Important goals of the collaborative included seeking learning opportunities and developing clear metrics for pediatric outpatient ASP benchmarking. Program needs included securing operational support (35.8%) and strengthening data analysis (31.6%).

Very few pediatric institutions with robust inpatient ASPs have devoted time and financial support to advance outpatient efforts. To promote appropriate antibiotic prescribing in the outpatient arena, time and resource funding by administrative leaders are necessary to develop a robust, sustainable stewardship infrastructure.