Clinical Decision Support and Prescribing Analytics to Improve Empiric Antibiotic Selection for Pediatric Urinary...

BACKGROUND: Outpatient antibiotic prescribing often deviates from local guidelines despite the availability of institutional pathways and antibiograms. Limited integration of these resources into clinical workflow may reduce their effect on point-of-care decision-making.

OBJECTIVE: This study aimed to evaluate whether a multicomponent intervention integrating electronic health record (EHR)-embedded clinical decision support (CDS), provider education, and practice-level prescribing analytics could increase use of the recommended first-line empiric antibiotic selection for pediatric urinary tract infections (UTIs).

METHODS: We conducted a 12-month quality improvement initiative across pediatric outpatient clinics within a large academic health system using iterative Plan-Do-Study-Act cycles. Empiric therapy was defined as antibiotic prescribing at the initial visit before culture results. Encounters were identified using the International Classification of Diseases, Tenth Revision (ICD-10) codes with concurrent antibiotic prescribing. The intervention combined sequential components: provider education, passive CDS embedded within urinalysis results linking to institutional guidance, practice-level prescribing reports with audit and feedback, and targeted case-based emails discouraging broader-spectrum cephalosporin use. Prescribing trends were evaluated using run charts.

RESULTS: Among 3312 eligible encounters, empiric prescribing of the recommended first-line increased from 13.9% at baseline to 41.9% within 12 months. A shift in prescribing patterns followed the deployment of the EHR-embedded CDS and dissemination of practice-level prescribing reports. Concurrently, the use of broad-spectrum second- and third-generation cephalosporins declined.

CONCLUSION: This initiative brought stewardship guidance into the EHR workflow and reinforced it with provider education, prescribing analytics, and audit and feedback. We observed improved empiric antibiotic selection for outpatient pediatric UTIs after implementation. These findings suggest that informatics strategies may support outpatient antimicrobial stewardship when they fit naturally into clinical decision-making and make prescribing patterns visible over time.