1. Rangel QI 2012-2013: Antibiotic Stewardship in the Ambulatory Setting COS – May 15, 2013

2. Background Information Antibiotic prescribing in the ambulatory setting occurs >1 in 5 visits In study of pediatric office visits, antibiotics prescribed: 44% of visits for the common cold 75% of visits for bronchitis Estimate at least 40-50% of inappropriate antibiotic use While national antibiotic prescribing rates have decreased, more broad spectrum antibiotics are prescribed Inappropriate antibiotic use contributes to antibiotic resistance, side effects, and increased cost Pediatrics. 2012; 130: 23-31. JAMA 2002; 287(23): 3096-3102.

3. Background Information 3-24 months 24-48 months 48-<72 months

4. Background Information

5. Questions How well do we adhere to Clinical practice guidelines for promoting appropriate antimicrobial use? How can we improve our practice? How can we increase the Rangel Community’s understanding of viral/bacterial infections and the clinically accepted guidelines for therapy? Focusing on common pediatric respiratory illnesses: Upper Respiratory Infection (URI) Acute Otitis Media (AOM) Streptococcal pharyngitis

6. AIM Statement AOM 1a) for pt’s 3-17yo with uncertain diagnosis or non-severe illness, increase our observation rates from 60% to 80% 1b) for pt’s 3-17yo with certain diagnosis and severe illness, increase our prescription of appropriate antibiotic from 73% to 90% Streptococcal pharyngitis 2) Improve the correct prescription (antibiotic, dose, duration) from 55% to 75% Viral URIs 3) For patients who present for sick visits and leave without antibiotic prescription, decrease the number who feel antibiotics are necessary from 85% to 65%

7. Provider cycles/interventions

8. Pre-intervention provider survey Survey Monkey survey of providers assessing knowledge, perceptions and practice of AOM diagnosis & management For children < 2 years of age with suspected AOM, how often do you prescribe antibiotics at time of diagnosis? 67% providers respond that they would always prescribe abx For children > 2 years of age with suspected AOM, how often do you prescribe antibiotics at the time of diagnosis? 17% providers responded that they would always prescribe abx

9. Didactics Powerpoint presentation to all providers to review the clinical guidelines for both AOM and Strep pharyngitis

10. Clinic materials Created handout materials & posters that highlighted the clinical guidelines and listed antibiotic options with dose and timing

11. 2004 AAP/AAFP Clinical Practice Guideline: Diagnosis of Acute Otitis Media 3 major criteria for diagnosis of AOM: acute onset of symptoms signs of middle ear effusion limited or absent mobility bulging of TM air-fluid level otorrhea signs and symptoms of middle ear inflammation distinct erythema of TM distinct otalgia Pediatrics 2004; 113(5):1451-1465.

12. AGECertain diagnosisUncertain diagnosis Birth to <6 months Amoxicillin 80-90mg/kg, div BID x 10-days 6 months to < 2 years Amoxicillin 80-90mg/kg, div BID x 10-daysSEVERE illness: Mod to severe otalgia or fever > 102.2 in past 24hrs HD amoxicillin x 10-days Non-severe illness: mild otalgia or temp < 102.2 OBSERVE only > 2 yearsSEVERE illness: Mod to severe otalgia or fever > 102.2 in past 24hrs HD amoxicillin x 5-10 days* OBSERVE only Non-severe illness: mild otalgia or temp < 102.2 OBSERVE only Do you have a patient with AOM? **Certain diagnosis includes BOTH inflammation AND effusion *5-day treatment option if pt > 6 yo AND no h/o AOM in last 3-months

13. 1st line antibiotics: Amoxicillin80 mg/kg/d div BID5-10 days* Ceftriaxone50 mg/kg IM/IVSingle dose Type I hypersensitivity- PCN allergy Azithromycin10 mg/kg/d x 1d 5 mg/kg/d x 4 d 5 days Clindamycin30-40 mg/kg/d div TID 10 days 2nd line antibiotics: if mild PCN- reaction (no anaphylaxis or urticaria), or failure of 1st line Augmentin90 mg (of amox) /kg/d div BID 10 days Cefdinir14 mg/kg qday10 days Cefpodoxime10 mg/kg/d div BID10 days Ceftriaxone50 mg/kg IM/IV3 doses Antibiotic options for AOM *5-day treatment option if pt > 6 yo AND no h/o AOM in last 3-months

14. New 2013 AAP/AAFP AOM Guidelines <6 months6-23 months>24 months Severe AOM Defined as: *fever ≥39 or, *moderate or severe otalgia or, *otalgia for >48 hours Antibiotics Non-severe Bilateral AOM Defined as: *mild ear pain lasting less <48 hours or, * Temp <39 Antibiotics Observation w/ assured f/u Non-severe Unilateral AOM AntibioticsObservation w/ assured f/u Observation w/ assured f/u *moderate or severe bulging of TM or new onset otorrhea, or *mild bulging of TM and recent onset (<48 hours) otalgia, or *mild bulging of TM and intense erythema

15. Do you have a patient with throat pain? Consider the rapid Strep test, IF AGE > 3 years AND >=2 of the following: NO URI symptoms (cough, conjunctivitis, rhinitis) Sudden onset of sore throat Fever Headache Nausea, vomiting, abdominal pain Palatal petechiae Scarlatiniform rash Anterior cervical adenitis

16. Antibiotic options for GAS-pharyngitis: 1st line antibiotics: Pencillin VChildren: 250 mg BID Adol: 500 mg BID 10 days Amoxicillin50 mg/kg/d, max 1G10 days Bicillin IM600K if < 27 kg 1200K if > 27 kg Single dose 2nd line antibiotics: if PCN- allergic Azithromycin12 mg/kg qday5 days Cephalexin40 mg/kg/d div BID Max 500 mg/dose 10 days Cefadroxil30 mg/kg qday Max 1G 10 days Clindamycin21 mg/kg/d div TID10 days Clarithromycin15 mg/kg/d div BID10 days

17. QI “Tip of the Week” emails

18. EMR tools Acronym expander for both AOM and Strep pharyngitis for use in the EMR.aom

19. EMR tools Acronym expander for both AOM and Strep pharyngitis for use in the EMR.aom.pharyngitis

20. Provider Interventions: Results For children < 2 years of age with suspected AOM, how often do you prescribe antibiotics at time of diagnosis?

21. Provider Interventions: Results For children > 2 years of age with suspected AOM, how often do you prescribe antibiotics at the time of diagnosis?

22. Provider Interventions: Results AIM Goal 1a: To increase our observation in pts 3-17yo with uncertain diagnosis or nonsevere illness from 60% to 80%

23. Provider Interventions: Results AIM Goal 1b: To increase our prescription of appropriate antibiotic for pts 3-17yo with certain diagnosis and severe illness from 73% to 90%

24. Provider Interventions: Results AIM Goal 2: Improve the correct prescription (antibiotic, dose, duration) of strep pharyngitis from 55% to 75%

25. Provider Interventions: Results AIM Goal 2: Improve the correct prescription (antibiotic, dose, duration) of strep pharyngitis from 55% to 75%

26. Nurse/MA cycles/interventions

27. Nursing/MA interventions Posted handouts around clinic and reviewed with RNs, ex. “how to triage patient with ‘sore throat’”.

28. Nursing/MA interventions Didactics on Rapid Strep testing Change in Rapid Strep testing workflow

29. Nursing/MA interventions Didactics on Rapid Strep testing Change in Rapid Strep testing workflow

30. Nurse Interventions: Results

31. Patient cycles/interventions

32. Pre-intervention Patient Questionnaire: Paper/pen survey of random group of parents presenting for visits during a given block 85% of patients believed that antibiotics are appropriate for one of the following: ANY FEVER, ANY INFECTION, or ONLY VIRAL INFECTIONS. 45% of parents treat their children at home when sick 45% of parents take their children to the ED when sick Parents opt for the ED principally based on severity of illness, but also because they feel they are more likely to be seen by a doctor (rather than an allied health professional) and for convenience. 15% of parents call the clinic or walk-in when their child is sick, with 1/3 of these patients opting occasionally to take their children to the ED instead

33. Patient Interventions For patients discharged with viral diagnoses, providers were instructed to supply a viral prescription with written recommendations for care at home.

34. Patient Interventions Providers instructed to have patients read back the most important instructions in the viral prescription to maximize retention and ensure understanding In a study of critical laboratory values relayed by telephone to medical providers, physicians had an error rate of 5%, caught and corrected by a program of mandatory read back to laboratory technicians. Am J Clin Pathol 2004; 121:801-803.

35. Post-intervention Patient Questionnaire AIM Goal 3: For patients who present for sick visits and leave without antibiotic prescription, decrease the number who feel antibiotics are necessary from 85% to 65%

36. Post-intervention Patient Questionnaire AIM Goal 3: For patients who present for sick visits and leave without antibiotic prescription, decrease the number who feel antibiotics are necessary from 85% to 65%

37. Sustainability within our ACN clinics Include lecture(s) on diagnosis of, and antibiotic prescription for, common outpatient presentations: AOM, Strep pharyngitis, CAP, bacterial sinusitis. Handout materials above provider offices and RN/MA stations. Acronym expander for AOM and Pharyngitis guidelines and other common outpatient walk-in visits. Use of viral prescriptions with read back method. Ensure availability of pneumatic otoscopy to increase accuracy of AOM diagnosis.

38. QI as a tool for improvement in Antibiotic Stewardship

39. Thanks to the entire Rangel Team! Residents: ElShadey Bekeley, Sandhya Brachio, Karen Lee- Bride, Alicia Chang, Wee Chua, Kenny McKinley, Laura Perretta, Pelton Phinizy, Lauren Sanlorenzo, Andrew Wherman, Ronny Zviti Preceptors: Evelyn Berger-Jenkins, Hetty Cunningham, Christine Krause, Tawana Winkfield-Royster NP: Marcia Clarke MAs: Wendy, Amarilys, Luisa Nurses: Clara, Michelle, Cindy, Sharman PFAs: Taina, Betty, Liz Rangel Parents

40. References Hersh, AL, et al.. “Antibiotic Prescribing in Ambulatory Pediatrics in the United States”. Pediatrics 2011; 129(6): 1053- 1061. Di Pentima MC, et al. “Benefits of a Pediatric Antimicrobial Stewardship Program at a Children’s Hospital”. Pediatrics 2011: 128(6): 1062-1070. Coco, A, et al. “Management of acute otitis media after publication of the 2004 AAP and AAFP clinical practice guideline. Pediatrics 2010; 125:214. Greene SK, et al. “Trends in antibiotic use in Massochusetts children, 2000-2009.” Pediatrics 2012: 3137. McCaig LF, et al. “Trends in antimicrobial prescribing rates for children and adolescents.” JAMA 2002; 287(23): 3096-3102. American Academy of Pediatrics and American Academy of Family Physicians – Subcommittee on Management of Acute Otitis Media. “Diagnosis and Management of Acute Otitis Media”. Pediatrics 2004; 113(5):1451-1465. Shulman ST, et al. Infectious Diseases Society of America. “Clinical practice guidelines for the diagnosis and maangement of Group A Streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.” Clinical infectious diseases 2012; : doi: 10.1093/cid/cis629 Chai, G, et al. “ Trends of outpatient prescription drug utilization in US children, 2002-2010.” Pediatrics 2012; 130(1): 23-31 Barenfanger J, et al. “Improving patient safety by repeating (Read-Back) telephone reports of critical information.” Am J Clin Pathol 2004; 121:801-803.