A Quality Improvement Initiative to Decrease Intravenous Antibiotic Use in Febrile Young Infants

The American Academy of Pediatrics (AAP) published guidelines in 2021 recommending the use of inflammatory markers (IMs), including procalcitonin (PCT), to evaluate febrile infants and identify those at low risk for bacterial infection for whom clinicians may forego antibiotics. This quality improvement (QI) project aimed to safely decrease antibiotic administration in febrile infants 22 to 56 days old presenting to the emergency department from a baseline of 46% to 36% within 1 year, inclusive of race and ethnicity and preferred language.

A multidisciplinary team identified interventions including clinical pathway updates, clinical decision support (CDS), and education, which were implemented in 4 Plan-Do-Study-Act cycles. Statistical process control methodology was used to analyze the primary outcome measure (percentage of patients receiving antibiotics) and the process measure (percentage of infants with PCT result). The balancing measure was missed bacteremia or bacterial meningitis.

Antibiotic use decreased from 46% to 33%, with the greatest decrease in infants 22 to 28 days old (from 86% to 43%). We decreased antibiotic use in non-Hispanic white infants but not non-Hispanic Black infants. PCT use increased from 4% to 97%, and there were no disparities in obtaining IMs. There were no missed cases of bacteremia or bacterial meningitis during the intervention.

Using a QI framework, we aligned clinical pathway updates, CDS, and education with AAP guidelines to safely reduce unnecessary antibiotic exposure in febrile infants as young as 22 days old. Future work should focus on ensuring equitable decreases in antibiotic exposure.