Development and Implementation of Pediatric In-Hospital Antimicrobial Stewardship Policy Through Pediatric Clinical Pathways

Antimicrobial resistance has become a global problem. Italian pediatric antimicrobial prescription rates are among the highest in Europe (EU). As a first step for antimicrobial stewardship (AS) implementation, clinical pathways (CP) outlining standard of care for acute otitis media (AOM), and group A streptococcus (GAS) pharyngitis and community-acquired pneumonia (CAP) were developed and implemented in our pediatric emergency department (PED) in collaboration with Children’s Hospital of Philadelphia. Aims. The primary aim of this study was to assess changes in antibiotic prescription one year after the CP implementation for AOM, GAS pharyngitis and CAP; secondary aim was to compare treatment failure before and after CPs implementation. Methods. CPs were implemented at the Department for Woman and Child Health of Padua on October 1st 2015. The first before/after quasi-experimental study has been conducted between the Pre-intervention period (from 15/10/2014 to 15/04/2015), Post-intervention period (from 15/10/2015 to 15/04/2016) and 1-Year post intervention period (from 15/10/2016 to 15/04/2017). ITS was used to determine the effect of the intervention, chi squared test to define the treatment failure and Kruskal Wallis test to compare antibiotic dosages and durations. Results. AOM: after CP implementation there was an increase in “wait and see” (21.7% vs. 33.1% vs. 28.9%, p=0.08) and in the use of amoxicillin as first line therapy (25.1% vs. 34.5%, p<0.001), with a decrease from 53.2% to 32.4% (p<0.001) in overall prescription of broad-spectrum antibiotics. Amoxicillin prescriptions increased (32% Pre vs. 51.6% Post and 52.8% 1-Year Post, p<0,001) with a decrease in overall prescription of broad-spectrum antibiotics. Among fully immunized with no complicated OMA, broad-spectrum antibiotics were prescribed in only 4.7% of cases (29.8%, Pre vs. 7.2% Post, p<0.001). Pharyngitis: During 1-year Post intervention period 63.2% of patients received a diagnosis Goup A Steptococcus pharyngitis (50.7% Pre vs 45.4% Post), reflecting the increasing age of the population examined (more patients aged 3-15 years). Amoxicillin was the choice for 93.2% of patients (53.6% Pre and 93.4% Post). CAP: prescriptions/patients rate has decreased to 1.02 (1.3 Pre, 1.12 Post) reflecting an increase use of monotherapy. 82.5% of patients received amoxicillin (52.1% Pre vs. 69.9% Post, p<0.001) and macrolide prescriptions decreased to 2.1% (19.7 Pre vs. 6.5% Post). No statistically significant difference in treatment failure was seen for all the pathologies examined. Conclusions. A reduction in broad-spectrum antibiotic prescriptions for AOM. Gas pharyngitis and CAP without compromising clinical outcomes indicates effectiveness of CPs in this setting. Furthermore their effects after more than one year suggests CPs are useful and suitable tool.