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Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Pharyngitis

Published online by Cambridge University Press:  02 November 2020

Jeffrey Gerber
Affiliation:
University of Pennsylvania School of Medicine
Robert Grundmeier
Affiliation:
Childrenld
Keith Hamilton
Affiliation:
Hospital of the University of Pennsylvania
Lauri Hicks
Affiliation:
Centers for Disease Control and Prevention
Melinda Neuhauser
Affiliation:
CDC DHQP
Nicole Frager
Affiliation:
Children’s Hospital of Philadelphia
Muida Menon
Affiliation:
University of Pennsylvania
Ellen Kratz
Affiliation:
Children’s Hospital of Philadelphia
Anne Jaskowiak
Affiliation:
University of Pennsylvania
Leigh Cressman
Affiliation:
University of Pennsylvania
Tony James
Affiliation:
University of Pennsylvania
Jacqueline Omorogbe
Affiliation:
University of Pennsylvania
Ebbing Lautenbach
Affiliation:
Perelman School of Medicine, University of Pennsylvania
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Abstract

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Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.

Funding: None

Disclosures: None

Type
Poster Presentations
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.