Amanda Nedved

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.

Background: National guidelines provide recommendations for first-line therapy (FLT) for acute respiratory infections (ARIs). Sociodemographic differences in FLT for ARIs have been described. This study identified and categorized reasons for non–FLT for ARIs in pediatric urgent care (PUC) and evaluated whether these reasons differ across sociodemographic groups. Methods: We conducted a retrospective chart review of PUC encounters for patients ages 6 months to 19 years diagnosed with acute otitis media, pharyngitis, community-acquired pneumonia, or acute bacterial rhinosinusitis between April 2023 and March 2024 who received an oral antibiotic. We categorized reasons for non–FLT using predefined groups: penicillin allergy label (PAL), treatment failure, new adverse effect of FLT, recent antibiotic exposure, other clinical rationale such as additional diagnoses or concern for atypical infections, family request, or no documented reason. Sociodemographic characteristics were compared across categories. Results: Among 18 507 ARI encounters, 1506 (8.1%) received non–FLT. PALs accounted for 58.8% (n = 886) of non–FLT prescribing. Recent antibiotic exposure was the second most common reason (n = 265, 17.6%); however, only 9.8% of therapy escalations were guideline-concordant. Family requests accounted for 4.3% of non–FLT use. Non–FLT were more common in White children, those on Commercial insurance, and children who speak English as their primary language compared to their socioeconomic counterparts. No differences in reasons for non–FLT were observed by race, insurance type, or preferred language. Hispanic patients had a higher proportion of PAL-related non–FLT (71.4%) compared with non-Hispanic patients (58.3%). Conclusion: PALs and escalation of therapy were the predominant drivers of non–FLT prescribing in PUC. Family requests played a minimal role. Although we observed differences of non–FLT by race, language, and insurance as described previously, we did not observe differences in reasons for non–FLT between the different socioeconomic groups. Interventions aimed at improving PAL accuracy and guideline-concordant escalation practices may enhance appropriate FLT use.

Objective: To evaluate the impact of nurse-led visits on in-person referrals for clinical evaluation from pediatric urgent care telehealth. Methods: We conducted this quality improvement study within our 3 freestanding in-person pediatric urgent care clinics and telehealth service. In May 2022, we implemented nurse-led visits to offer diagnostic and therapeutic interventions including rapid group A streptococcal testing, urinalysis, respiratory viral testing, and intramuscular antibiotic injections without requiring an additional clinical evaluation following a telehealth encounter. We measured the percentage of telehealth encounters with in-person referrals as the primary outcome. We tracked the percentage of encounters with nurse-led visits and return visits within 72 hours as process and balancing measures, respectively. We used control charts to identify special cause variation over time. Results: In-person referrals following telehealth visits decreased from 23.0% to 12.3% after implementing nurse-led visits. The use of nurse-led visits increased over time from 4.0% to 6.8%. Rapid group A streptococcal testing accounted for most nurse-led visits (64.0%). Only 2.8% of nurse-led visits resulted in return visits within 72 hours. Nurse-led visits were associated with shorter length of stays (32 min) compared with in-person clinical evaluations (69 min) and had an average cost-savings of $135 compared with visits of similar medical complexity. Conclusion: Integrating nurse-led visits into urgent care telehealth encounters provides a safe and effective option for diagnostic and therapeutic interventions in the virtual setting. The results support the use of nurse-led visits to expand access to high-quality acute care, reduce unnecessary referrals, and promote evidence-based practice.

Backgrounds/Objectives: Acute otitis media (AOM) is the leading reason antibiotics are prescribed to children. Despite guidelines advocating for watchful waiting and shorter antibiotic durations, overprescribing remains a concern. This meta-analysis aims to quantify potential reduction in antibiotic days of therapy (DOT) for AOM if prescribers adhered to guidelines. Methods: Cochrane databases were sourced for studies on ear infections, diagnostic accuracy, antibiotic duration, and watchful waiting. Randomized clinical trials, observational studies, and quality improvement reports of children aged 6 months–17 years with uncomplicated AOM published between 2000 and 2024 from the U.S., Canada, and Europe. Of 4187 studies, 425 met selection criteria. PRISMA guidelines were adhered to for independent extraction by multiple reviewers. Pooled prevalence of AOM outcomes and odds ratios (OR) for effectiveness interventions were calculated using the DerSimonian-Laird random effects model. A simulation study compared current practice to national guidelines. Results: Eighty-six studies found an estimated 107 million DOT prescribed to children in the U.S. annually for AOM. Following the American Academy of Pediatrics’ guidelines could reduce DOT by 57.9 million days (54%). Adherence to NICE guidelines could reduce DOT by 74.1 million days (70%). Watchful waiting and short-course antibiotic interventions had pooled Ors of 4.35 and 7.12, respectively, for decreasing DOT. Conclusions: Adherence to guidelines for AOM management could avert millions of antibiotic DOT. Watchful waiting and short-duration interventions are most impactful on antibiotic overprescribing.

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.

Objective: To increase the percentage of first-line antibiotics prescribed for acute otitis media (AOM) and pharyngitis, the percentage of treated pharyngitis with a positive group A streptococcus (GAS) test, and the percentage of nonsevere AOM patients prescribed delayed antibiotics in pediatric urgent care clinics (UCCs). Methods: The American Academy of Pediatrics Section on Urgent Care Medicine and Pediatric Acute and Critical Care Quality Network developed a multicenter quality improvement collaborative. We used national guidelines to determine criteria for nonsevere AOM and first-line antibiotics for AOM and pharyngitis. Participating UCCs committed at least 3 clinicians to submit 10 encounters for each diagnosis per month during the intervention period (October 2022 to June 2023). Clinicians signed commitment letters, participated in monthly learning sessions, and tested UCC-selected interventions. Results: We recruited 84 participants from 13 UCCs. Participants submitted 5017 AOM encounters and 3762 pharyngitis encounters. The use of first-line antibiotics for AOM and GAS pharyngitis remained stable at 75.7% and 79.9%, respectively, throughout the project. The documentation of delayed antibiotic criteria increased from a range of 26%-27% at baseline to 83% [5.42% per month (95% CI: 4.03-6.81)]. This corresponded to an increase in use of delayed antibiotics for AOM from a range of 32%-42% at baseline to 70% by the end of the intervention period [2.53% per month (95% CI: 0.57-4.48)]. Rates of GAS testing before treating pharyngitis increased during baseline and remained high (>96%) throughout the intervention period. Conclusions: This multicenter collaborative provided education and networking to increase the use of delayed antibiotics for AOM in pediatric UCCs.

Background/Objective: Penicillin allergy labels (PALs) contribute to broad-spectrum antibiotic use. Thorough documentation can help prescribers identify and remove unnecessary PALs. We aimed to improve documentation of PALs in three pediatric urgent care (PUC) clinics, using a nurse-initiated quality improvement (QI) approach. Methods: QI interventions included a survey to assess prescriber and nurse confidence, an online educational module, and an algorithm to aid in clarifying PALs. We measured the percentage of PALs with a clarified reaction severity as our primary outcome using annotated control charts. Descriptive and inferential statistics evaluated survey responses between nurses and prescribers. Results: Clarified PAL reaction severity had a sustained upward shift from 58.5% to 63.3% following implementation of our interventions. Of 129 nurses and prescribers, 87 (67.4%) respondents completed the survey. Prescribers and nurses reported feeling knowledgeable about PALs but experienced different challenges to clarifying PAL documentation. Prescribers reported time pressures as a barrier to PAL clarification more often than nurses (IQR [3, 4], p = 0.001). Nurses reported higher confidence in ability to document a PAL compared to prescribers (IQR [3.25, 5], p = 0.010). Respondents requested family education and practice guidance to aid PAL clarification. No consistent differences were noted in PAL documentation by sociodemographic characteristics. Conclusions: The nurse-initiated QI approach demonstrated improved PAL documentation in PUCs. Engaging nurses in antibiotic stewardship initiatives can provide new perspectives and broaden the approach to intervention design and implementation. Future efforts should focus on improving electronic health record and interprofessional workflow processes to build on these improvements.

Objective: To evaluate the impact of a croup clinical pathway (CP) on transfer rates from our urgent cares (UCs). Methods: We revised our croup CP in November 2022 to recommend giving additional doses of racemic epinephrine (RE) in UC before transferring a patient and using shared decision-making with families on post-RE observation of their child at home or in a clinical setting. We conducted a retrospective cohort study of patients with croup in 3 UCs who received RE in the pre-CP revision (November 2021 to October 2022) and post-CP revision (November 2022 to October 2023) periods. Interrupted time series analysis evaluated trends over time. Results: We reviewed encounters of 1575 patients diagnosed with croup in the pre-CP revision and 1530 patients in the post-CP revision. In the pre-CP revision period, 77 patients (4.9%) received RE, and 94 patients (6.1%) received RE in the post-CP revision (P=0.09). We saw a decrease in patients who received RE that were transferred from 32.5% in the pre-CP revision period (32.5%) to 10.6% in the post-CP revision period (odds ratio, 0.25; 95% CI, 0.11-0.56; PP=0.008). We did not see a change in return visits at 24 or 72 hours. Conclusion: Although we saw a downward trend in the percentage of patients with croup transferred after receiving RE in our UCs post-CP revision, we did not see a significant decrease over time. However, this study demonstrates that providing additional RE doses for croup in UC and using shared decision-making with families in the setting for observation did not increase length of stay or return visits.

Objective: To determine whether differences exist in antibiotic prescribing for respiratory infections in pediatric urgent cares (PUCs) by patient race/ethnicity, insurance, and language.Design: Multi-center cohort study.Setting: Nine organizations (92 locations) from 22 states and Washington, DC.Participants: Patients ages 6 months–18 years evaluated April 2022–April 2023, with acute viral respiratory infections, otitis media with effusion (OME), acute otitis media (AOM), pharyngitis, community-acquired pneumonia (CAP), and sinusitis.Methods: We compared the use of first-line (FL) therapy as defined by published guidelines. We used race/ethnicity, insurance, and language as exposures. Multivariable logistic regression models estimated the odds of FL therapy by group.Results: We evaluated 396,340 ARI encounters. Among all encounters, 351,930 (88.8%) received FL therapy (98% for viral respiratory infections, 85.4% for AOM, 96.0% for streptococcal pharyngitis, 83.6% for sinusitis). OME and CAP had the lowest rates of FL therapy (49.9% and 60.7%, respectively). Adjusted odds of receiving FL therapy were higher in Black Non-Hispanic (NH) (adjusted odds ratio [aOR] 1.53 [1.47, 1.59]), Asian NH (aOR 1.46 [1.40, 1.53], and Hispanic children (aOR 1.37 [1.33, 1.41]), compared to White NH. Additionally, odds of receiving FL therapy were higher in children with Medicaid/Medicare (aOR 1.21 [1.18–1.24]) and self-pay (aOR 1.18 [1.1–1.27]) compared to those with commercial insurance.Conclusions: This multicenter collaborative showed lower rates of FL therapy for children of the White NH race and those with commercial insurance compared to other groups. Exploring these differences through a health equity lens is important for developing mitigating strategies.