January 27, 2020
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Stewardship in the pediatrician’s office: It’s about time to get antibiotic smart with acute respiratory viral infections

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Asif Noor 
Asif Noor
Ulka Kothari 
Ulka Kothari

In this bimonthly column, pediatric infectious disease specialists Asif Noor, MD, FAAP, and Ulka Kothari, MD, share valuable insight on antimicrobial stewardship in pediatric outpatient settings and explain why it is important for your practice. Antimicrobial stewardship programs, or ASPs, have become a crucial intervention to spare patients and facilities from the burden of antibiotic-resistant pathogens, which are responsible for one death every 15 minutes, according to updated estimates from the CDC.  

As the winter cold continues to grip parts of the United States, the incidence of respiratory infections is on the rise. Annual winter outbreaks are mostly due to viral infections. Infants and young children are more susceptible to lower respiratory tract infections, such as bronchiolitis. Respiratory syncytial virus is the most common cause of bronchiolitis, accounting for 1.5 million outpatient visits. On the contrary, many older children and adolescents seeking care in the pediatrician’s office have influenza virus infection. The 2019-2020 influenza season is up and running, driven primarily by an elevated activity of the B (Victoria) strain, followed by the A(H1) strain.

Management of these viral infections in the pediatrician’s office essentially boils down to educating parents about supportive care paired with reassurance. Antivirals, such as oseltamivir, are indicated for influenza infection in high-risk children or those with severe disease. There is a limited role for antibiotics. The risk for secondary bacterial infection in RSV is 1.2% — UTI being the leading source. The rate of confirmed bacterial coinfection was 2% in a population-based surveillance study of hospitalized children with influenza.

1. Confronting the conundrum of appropriate antibiotic prescription

In a nationally representative analysis of antibiotic prescribing in ambulatory pediatric settings, Hersh and colleagues estimated that 23.4% of visits received antibiotics for acute respiratory tract infections without any clear indication for a bacterial infection. This means more than 10 million patients annually got unnecessary antibiotics during office visits. In the U.S. ED setting, Papenburg and colleagues reviewed antibiotic prescriptions for patients with acute bronchiolitis between 2007 and 2015. One-fourth of the patients received antibiotics, and 70% of these had no documented bacterial coinfection. Macrolides were prescribed in 38% of the cases.

Although the rate of antibiotic prescriptions has plateaued in recent years, there is a clear need for outpatient ASPs. Clinicians have these three main hurdles when faced with the dilemma of antibiotic indication in acute respiratory infection: diagnostic uncertainty, parental demands or perceived parental expectations, and time constraints, which are explained in detail below.

Diagnostic uncertainty

The clinical decision-making required to prescribe or not to prescribe an antibiotic is a daily occurrence in this cold weather season. This includes primarily confirming a viral infection and excluding a bacterial superinfection (see Chart). Stringent clinical diagnostic criteria for bacterial infections with some help from point-of-care testing can remove this ambiguity. Tools for clinicians in the form of decisions support systems and guidelines are already available. The Pediatric Infectious Diseases Society provides a toolkit for ASPs in the outpatient setting (https://www.pids.org/asp-toolkit.html). It includes guidelines on evidence-based diagnostic and treatment criteria.

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Confirming a viral infection: In acute respiratory viral infections, pediatricians can educate parents on signs and symptoms consistent with a viral infection (eg, rhinorrhea, cough, hoarseness, viral exanthema), as well as the clinical course (infection can last up to 10 days). In cases in which the natural history of infection coincides with viral upper respiratory infection (URI), influenza or bronchiolitis, there is no need for confirmatory testing. If there is uncertainty of a viral diagnosis, a point-of-care test such as a rapid influenza antigen test or an RSV antigen test could be performed in the office. Given the low-to-moderate sensitivities of these rapid assays (50% to 70%), one should consider PCR-based testing (multiplex PCR assays), if available.

Excluding bacterial superinfection: A physical exam finding, such as a bulging tympanic membrane, justifies a same-day or delayed antibiotic prescription.

If fevers persist into the second week or if new fevers occur, laboratory investigation to look for UTI in cases of bronchiolitis and chest X-ray studies in cases of influenza can assist in excluding a bacterial infection.

 

Parental pressure or perceived parental antibiotic expectation

Most pediatricians are cognizant of the clinical practice guidelines. The commonly cited reasons for over-prescription by clinicians are A) parental pressure/perception of parental expectations; B) patient satisfaction; and C) meeting individual relative value unit goals.

Time constraints

The need to see more and more patients in the outpatient setting means less time for pediatricians to educate parents. In addition, decision fatigue plays a role in inappropriate antibiotic prescriptions. As the physicians’ work piles on, they are more likely to prescribe antibiotics, according to a 2014 study of primary care physicians. Using one or more of the effective communications strategies described in the Table can assist in informed decision-making.

 

2. Practice guidelines for outpatient settings

In recent years, several updated clinical practice guidelines offer advice on antibiotic use in URIs and bronchiolitis. The two leading resources are the AAP’s clinical practice guidelines on the management of bronchiolitis, which do not recommend routine use of antibiotics in cases in which the clinical course fits bronchiolitis irrespective of the patient’s age or severity of illness, and a clinical report of judicious use of antibiotics by the AAP, which establishes principles on assessing the likelihood of bacterial infection, balancing the risk for antibiotic side effects and having strategies for judicious antibiotic use.

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3. Operationalizing an ASP in your office through quality improvement and electronic health records

To operationalize ASP efforts in one's clinic, it is important to create a multidisciplinary team, including a designated facility leader or champion who will lead these efforts. Dr. W. Edwards Deming was quoted as saying, “In God we trust. All others must bring data.” An initial step in any improvement initiative is to conduct a gap analysis of current ASP practices. Creating an ASP prescription profile of providers (appropriate or inappropriate antibiotic prescriptions) and comparing their data with top performers may drive them to change behavior. A good measure for viral URI is the 2019 MIPS Measure #065, which measures all children aged 3 months to 18 years without a prescription for an antibiotic on or 3 days after the outpatient visit who had a diagnosis of URI (see detailed definition for exclusions). Implement at least one policy or practice to improve antibiotic prescribing. Some suggested solutions that have been proven to work in various studies include: clinic-based education of patients, parents and providers, including the use of posters, educational handouts and posted commitment letters for appropriate antibiotic prescribing; enhanced communication training (see example below); and clearly documenting the reason for prescribing an antibiotic in the EHR.

Clinicians often cite patient demand for antibiotics as a reason they prescribe inappropriately. In fact, clinicians are more likely to prescribe antibiotics when they think that the caregiver of the patient wants them. Patients and caregivers can be satisfied without antibiotics, even if they expect them, with effective communication. Enhanced communication training as an antibiotic stewardship intervention can improve antibiotic prescribing for respiratory infections at all ages, and the effect appears to be sustained over time. A training module called Dialogue Around Respiratory illness Treatment (DART), developed by Rita M. Mangione-Smith, MD, MPH, from Seattle Children's Hospital, is a great resource for structuring your communication strategy.

A simple change in the way we communicate with our patients is a positive step toward improving antibiotic prescribing in the outpatient setting.

References:

Dawood FS, et al. J Infect Dis. 2014;doi:10.1093/infdis/jit473.

Hall CB, et al. J Pediatr. 1988;113:266-271.

Hersh AL, et al. Pediatrics. 2013;doi:10.1542/peds.2013-3260.

Hersh AL, et al. Pediatrics. 2011;doi:10.1542/peds.2011-1337.

Linder JA, et al. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2014.5225.

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Mangione-Smith R. Dialogue around respiratory illness treatment: Optimizing communication with parents. https://www.hhs.gov/sites/default/files/mangione-smith-91317.pdf. Accessed January 17, 2020.

Papenburg J, et al. J Pediatric Infect Dis Soc. 2019;doi:10.1093/jpids/piy131.

Shawn LR., et al. Pediatrics. 2014;doi10.1542/peds.2014-2742.

For more information:

Ulka Kothari, MD, is a general pediatrician, physician informaticist and director of pediatric ambulatory quality at NYU Winthrop Hospital. She can be reached at ulka.kothari@nyulangone.org.

Asif Noor, MD, FAAP, is an assistant professor of pediatrics at NYU Long Island School of Medicine. He can be reached at asif.noor@nyulangone.org.

Disclosures: Kothari and Noor report no relevant financial disclosures.