By Marie Rosenthal, MS
Including preset treatment orders in the electronic health records (EHRs) improved compliance with treatment guidelines and shortened antibiotic use in children with acute otitis media (AOM) who were treated in emergency and urgent care settings, according to new findings presented at IDWeek 2024, held in Los Angeles (abstract 176).
The bundled intervention included an order set across the health-system network that preselected a five-day course of antibiotics for children 24 months of age and older, and created a local clinical care pathway for AOM, which encouraged observation and pain management for children with unilateral AOM that was not severe.
“We noticed at our institution that children were being prescribed a lot of antibiotics for ear infections and that the duration of antibiotics was longer than we thought necessary,” explained Joana Dimo, DO, a doctoral fellow at the University of Colorado Anschutz Medical Campus, in Aurora, and presenting author, during a press briefing before IDWeek. “In response to this, we implemented a new electronic health record order set across our network, at emergency departments, urgent care centers, which preselected a five-day antibiotic course for children over 2. We also developed a guideline on managing ear infections for clinicians to use.”
Dr. Dimo and her team analyzed the medical records of 34,324 patients at the University of Colorado/Children’s Hospital Colorado, from 61 days to 18 years of age who visited emergency or urgent care centers for AOM between January 2019 and September 2023. If AOM was confirmed, the researchers looked at the type and duration of antibiotics prescribed and the change in duration of antibiotics in children 24 months of age and older—from seven or 10 days to five days—after the preset intervention was implemented.
The outcomes were the rates of antibiotic prescribing in patients 61 days to 18 years of age, treatment duration of five or fewer days (excluding azithromycin) in patients 24 months to 18 years, and first-line antibiotic choice (amoxicillin) in patients 61 days to 18 years.
The study found that compliance with antibiotic recommendations for children 24 months of age and older increased from 3% to 83% when preset interventions were integrated into the EHRs of children with AOM.
“In this initiative, we were able to show a dramatic 80% improvement in prescribing five-day durations of antibiotics for children over 2, with a simple and cost-effective strategy that did not lead to increased treatment failures or complications,” Dr. Dimo said. “The biggest takeaway from our study is that we were able to effectively cut antibiotic use in half by shortening the duration of treatment.”
Five out of six children have at least one ear infection before they are 36 months old, according to the National Institutes of Health. Even though most cases—up to 75%—resolve without antibiotics, many still receive unnecessary prescriptions, often for inappropriately long periods. Those prescriptions have consequences in addition to developing resistance; 1 in 4 children prescribed amoxicillin will have an adverse drug event such as diarrhea, vomiting or a rash.
“We know antibiotics cause a lot of side effects such as diarrhea and rashes, and each additional day of antibiotics that are not needed leads to more risks for side effects,” Dr. Dimo added, “and research supports that 75% of children get better on their own without antibiotics. Courses of five days are as safe and effective as traditional longer courses.”
The researchers said practical steps to improve antibiotic prescribing to combat resistance and prevent adverse drug events from antibiotics were effective.
“One of the great things about our project is that it utilizes the EHR ordering system, which is present in every institution to implement these changes in antibiotic prescribing that we saw. And I think that makes it very reproducible in a wide variety of settings. The benefit of this sort of strategy to other institutions is that it is not labor-intensive. It is cost-effective and it can result in dramatic changes in antibiotic use,” Dr. Dimo said.
Nicole M. Poole, MD, MPH, who was also part of the study, said the order set was also helpful to the physicians. “We chose a population of clinicians that work in a really fast-paced environment—emergency care and urgent care. Utilizing something like an order set helps their flow of patient care as well. So, the goal is help make the right thing the easy thing for our clinicians,” Dr. Poole said, reducing the burden the fast-paced environment provides. Dr. Poole is an assistant professor of pediatric infectious diseases and epidemiology at the University of Colorado.
Implementing changes in the EHR can be a quick way to implement change within an institution, Dr. Poole added. “When it comes to durations of antibiotic therapy, we know in academic medicine it takes some time for evidence to be put into practice. We see that across the board. What previous work has found is shorter durations of therapy are very well accepted with clinicians and parents. Parents trust clinicians that the shorter course is just as effective, and safer is best.
“So, it actually has a really great acceptance rate, when you bring up that we now know that shorter is better for these sorts of conditions. That is good news that parents accept this, and it is probably a lot easier for their lives as well, and it is just as impactful for their [children’s] care,” said Dr. Poole, who is also a practicing pediatric infectious disease specialists at Children’s Hospital Colorado.
