Intermittent Education and Audit and Feedback Reduce Inappropriate Prescribing of Oral Third-Generation Cephalosporins for Pediatric Upper Respiratory Tract Infections

Published:December 14, 2020DOI:


      In June 2017, leaders within a pediatric ambulatory care network in Houston approached the antimicrobial stewardship team at Texas Children's Hospital with concerns for high oral third-generation cephalosporin (oTGC) use in their clinics. An outpatient quality improvement (QI) team was formed. The specific aim was to reduce inappropriate oTGC prescribing at one clinic (“Clinic A”) by 15% in one year.


      Following a benchmark analysis of oTGC use at Clinic A, Plan-Do-Study-Act (PDSA) cycles were designed and conducted over one year: one educational session, three individual audit and feedback sessions, and one group feedback session. The primary outcome was the percentage of oTGCs not aligning with American Academy of Pediatrics (AAP) guidelines for bacterial upper respiratory tract infections. Monthly oTGC prescribing at Clinic A was also compared to four control clinics.


      In June 2017, 72% (231/322) of oTGCs prescriptions at Clinic A did not align with AAP guidelines. The most common diagnosis was primary/nonrecurrent acute otitis media. Following interventions, the mean percentage inappropriate oTGCs decreased from 72% to 45% (absolute reduction 27%, p < 0.001), which was sustained the year following the last PDSA cycle (absolute reduction 26%, p < 0.001). Total monthly oTGC prescribing at Clinic A decreased over time, but not in four control clinics. Provider active participation in stewardship activities decreased over time.


      Intermittent education and audit and feedback were associated with reduced oTGC misuse at Clinic A but not at four control clinics. Improvements were maintained despite decreased participation in stewardship activities, suggesting that perceptions of ongoing antibiotic audits can help sustain prescribing improvements.
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