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Implementation of a clinical pathway for shortened antibiotic therapy in children with complicated appendicitis
Monica M Milovancev1, Parker T Evans2, Yasmeen Z Qwaider3
1Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
Insights
A clinical practice guideline reduced oral antibiotic use in children with complicated appendicitis. This antimicrobial stewardship initiative decreased antibiotic discharge rates without negatively impacting patient outcomes.
Area of Science:
- Pediatric Surgery
- Infectious Diseases
- Quality Improvement
Background:
- Complicated appendicitis management often involves prolonged antibiotic use.
- Previous institutional practices showed high rates of oral antibiotic discharge, exceeding peer hospital averages.
- Antimicrobial stewardship principles are crucial for optimizing antibiotic therapy.
Purpose of the Study:
- To implement a clinical practice guideline (CPG) for complicated appendicitis.
- To decrease the rate of oral antibiotic discharge to 35% by the end of 2024.
- To monitor key outcomes and balancing measures during the intervention.
Main Methods:
- A multidisciplinary team developed a CPG focusing on antibiotic use, discharge criteria, and imaging.
- Implementation involved provider education and an electronic health record order set.
- P-charts were used to analyze outcomes across pre-implementation, transition, post-implementation, and maintenance periods.
Main Results:
- The baseline rate of oral antibiotic discharge was 90.7%.
- Following CPG implementation, oral antibiotic duration decreased.
- No significant changes were observed in length of stay, organ-space surgical site infection rates, ED return visits, or readmissions.
Conclusions:
- Implementing a CPG effectively promotes antimicrobial stewardship in pediatric complicated appendicitis.
- Reduced antibiotic utilization was achieved without compromising patient safety or clinical outcomes.
- This initiative demonstrates a successful quality improvement strategy for antibiotic management.
Purpose:
We implemented a clinical practice guideline (CPG) for complicated appendicitis guided by antimicrobial stewardship principles. Previously, our institution had a 95.7 % rate of discharge on oral antibiotics and was an outlier compared to NSQIP-P peer hospitals. We aimed to decrease oral antibiotics at discharge to 35 % by the end of 2024 while monitoring balancing measures and outcomes.
Methods:
A multidisciplinary quality improvement team developed a CPG directing postoperative antibiotic utilization, clinically based discharge parameters, and indications for postoperative diagnostic imaging. Implementation began in April 2024 with provider education and an electronic health record order set. The primary outcome was the proportion of patients receiving oral antibiotics at discharge. Balancing measures were length of stay (LOS), organ-space surgical site infection (OSI), ED return and readmissions within 30 days. Data were analyzed using p-charts to detect special cause variation over the pre-implementation (01/2024-03/2024), transition (04/2024-06/2024), post-implementation (07/2024-09/2024) and maintenance (10/2024-12/2024) periods.
Results:
90.7 % of patients received oral antibiotics at discharge in the 3-month baseline pre-implementation period (n=43), with a mean LOS of 4 days (SD ± 2.2), OSI rate 7 %, 12 % return ED visit rate, and 7 % readmission rate. After quality improvement interventions, oral antibiotic duration decreased over time, without impacting LOS, ED visits, Readmissions, or OSI rates.
Conclusions:
Implementation of a clinical practice guideline to promote antimicrobial stewardship in children with complicated appendicitis led to decreased antibiotic utilization without worsened clinical outcomes.
Level Of Evidence:
III.
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