The Impact of an Antimicrobial and Laboratory Stewardship Clinical Pathway on Outpatient Management of Pediatric Pharyngitis

From the 2023 HVPA National Conference

Diana Nguyen DO (University of Texas Medical Branch), Elizabeth Rodriguez Lien MD, Peter McCaffrey MD, Christy Cao BS, Gulshan Sharma MD, Stephen Williams MD, Janak Patel MD

Objective:
Our objective was to improve appropriate testing and treatment of pharyngitis in children < 3 years old in our health system’s ambulatory clinics through clinical pathway dissemination and provider education.

Methods:
A quality initiative was undertaken by our Lab and Antimicrobial Stewardship Programs from December 2021 through November 2022. An evidence-based pediatric pharyngitis pathway was created using the McIsaac criteria, a validated scoring system as well as recommendations from the 2012 Clinical Practice Guideline from the Infectious Diseases Society of America to guide providers in diagnosis and management of pharyngitis. An informational handout was created for caregivers. The tools were distributed to primary care and urgent care clinics, followed by a live, virtual educational session for providers and nursing staff, emphasizing GAS diagnostic criteria and treatment options. Primary outcomes included reduction of GAS rapid tests performed on children < 3 years of age and reduction of antibiotic prescriptions for pharyngitis when there was either a negative GAS test or no test performed by 10% within 1 year of implementing the pharyngitis clinical pathway. Outcomes were tracked monthly compared to the baseline period of December 2020 through November 2021.

Results:
There were 856 visits for pharyngitis in children < 3 years old during the implementation period. The percentage of GAS tests performed decreased from a baseline of 37.0% to 33.2% (p < 0.0001). The percentage of visits with an antibiotic prescription for pharyngitis when the GAS test was negative or when no test was done decreased from 66.3% to 42.0% (p = 0.007). Results were analyzed using a paired two-tailed t-test.

Conclusion:
Implementation of a pharyngitis clinical pathway and provider education can reduce unnecessary testing and antibiotic prescriptions. This method can be used for other common pediatric infections to expand laboratory and antimicrobial stewardship in the outpatient setting.

Clinical Implications:
This project reduced the number of unnecessary tests and antibiotic prescriptions in relation to management of pediatric pharyngitis. This leads to both health and cost benefits to patients and the health system. 

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