Matthew P. Kronman

We implemented an institutional guideline to facilitate extended-interval amikacin dosing for multidrug-resistant urinary tract infections. Amikacin was recommended as a single dose for uncomplicated cystitis and as three once-daily doses for pyelonephritis. After policy implementation, use of extended-interval amikacin became routine, and approximately one-quarter of amikacin-treated patients avoided admission.

Background: Updated guidance for common acute respiratory infections (ARIs) recommends shorter antibiotic durations. While stewardship efforts often focus on appropriate antibiotic selection, it remains unclear whether initiatives targeting first-line choice also influence duration. Design/Methods: We conducted a secondary analysis of a national quality improvement collaborative including 92 pediatric urgent care sites across 9 organizations in 22 states and Washington, D.C. (April 2022–September 2024). The collaborative emphasized equitable first-line antibiotic selection; duration was not an explicit target. We included encounters for patients aged 6 months–18 years with ARI International Classification of Diseases-10 (ICD-10) diagnoses resulting in an antibiotic prescription and excluded azithromycin. October 2023–April 2024 was defined as the intervention period during active Plan-Do-Study-Act cycles. The primary outcome was short-course prescribing (≤7 days). Multivariable, multilevel logistic regression models estimated odds of ≤7-day duration across time periods (pre-collaborative, intervention, post-collaborative) and sociodemographic groups. Results: Among 257 879 encounters, acute otitis media was most common (160 292; 62.2%). We saw an increase in ≤7-day duration prescribing from 33.4% pre-collaborative to 35.9% during the intervention and 37.8% post-collaborative. This increase was most notable for sinusitis (11.2% pre-collaborative to 33.9% post-collaborative). Compared with the pre-collaborative period, odds of ≤7-day duration were higher during intervention (aOR 1.22, 95% CI 1.18, 1.25, p < 0.001) and post-collaborative periods (aOR 1.31, 95% CI 1.27, 1.35, p < 0.001). Differences in duration were observed by race, language, and payor type. Conclusions: During a collaborative focused on equitable first-line antibiotic selection, short-course prescribing increased, suggesting potential spillover to duration alongside broader secular trends. Persistent sociodemographic differences highlight the need to explicitly incorporate equity into outpatient stewardship efforts beyond antibiotic choice.

Introduction: Maintenance of Certification (MOC) projects have previously been shown to improve diagnostic accuracy and infection treatment in inpatient settings. Methods: We developed and delivered an MOC project in our ambulatory care network in 2023 to increase the use of American Academy of Pediatrics guideline-concordant antibiotic selection and duration for the treatment of acute otitis media (AOM), including amoxicillin for most patients, and the use of shorter (5–7 d) antibiotic durations in children over 2 years with nonsevere symptoms. We evaluated the use of guideline-concordant antibiotics across the network from January 2021 to September 2025, including periods before, during, and after the MOC intervention. We compared the use of guideline-concordant antibiotics between clinics that participated in the MOC intervention and those that did not. Results: The study period included 40,329 AOM episodes. By the end of the study period, 64.7% of children with AOM across the network received guideline-concordant antibiotic selection and duration, up from 46.6% at baseline. After the intervention, MOC-participating clinics had increased use of guideline-concordant antibiotic selection and duration compared to nonparticipating clinics (70.1% versus 54.5%). The frequency of patients returning within 7 days for a repeat AOM visit did not differ between the baseline period (124/12,735; 1.0%) and the postintervention period (303/27,594; 1.1%) ( P = 0.3). Conclusions: An MOC program was effective in increasing guideline-concordant antibiotic prescriptions for pediatric AOM across an outpatient network. This effect persisted over time and was stronger in MOC-participating clinics. MOC participation has the potential to improve antibiotic stewardship in ambulatory settings.

Lay Summary: Vancomycin is the first line antibiotic for resistant gram-positive infections, but can cause nephrotoxicity, ototoxicity, increased cost and healthcare utilization. We present an honorable memorial to this agent given the availability of similarly effective and less toxic alternatives.

Lay Summary: Although the overall average annual number of pediatric antibiotic-associated adverse events decreased during 2019-2023, the COVID-19 pandemic affected this outcome. Antibiotic-associated adverse events in 2023 alone were similar to historical numbers, suggesting the need for ongoing outpatient antimicrobial stewardship efforts.

Objective: 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. Design: Retrospective cohort study of 13-month pre-intervention (April 2022–April 2023) and 17-month (May 2023–September 2024) intervention data collection. Setting: 92 PUC sites from 9 organizations spanning 22 states. Patients: Encounters of patients 6 months to 18 years of age with ARI diagnoses. Methods: 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). Results: 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. Conclusions: 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.

We assessed implementation of a local intravenous-to-enteral antimicrobial transition protocol for pediatric hematology/oncology and bone marrow transplant patients with bacterial or candidal bloodstream infection and central line removal. Among 76 cases, 57 met protocol criteria. Enteral antimicrobials were used in 29 (50.8%) cases meeting eligibility criteria for conversion.