Clinical Pathway Revision Increases Amoxicillin Monotherapy and 5-Day Durations of Therapy for Pediatric Community-Acquired Pneumonia in the Emergency Department and Urgent Care: A Quality Improvement Initiative.

Abstract

The American Academy of Pediatrics recommends 5-day amoxicillin monotherapy as first-line treatment for pediatric uncomplicated community-acquired pneumonia. We aimed to use local quality improvement interventions to increase first-line amoxicillin use, reduce azithromycin use, and increase 5-day therapy durations for uncomplicated community-acquired pneumonia. A quality improvement initiative took place at a pediatric hospital network, including 4 emergency departments (EDs) and 5 urgent care centers. Children discharged between July 2018 and July 2022 with a community-acquired pneumonia diagnosis and an antibiotic prescribed were included. A 2-part intervention was implemented: (1) an electronic health record order set that preselected 5-day antibiotic therapy (August 2020) and (2) a revised community-acquired pneumonia pathway newly integrated into the electronic health record (April 2021). Proportions of antibiotic encounters receiving amoxicillin, azithromycin, and antibiotic durations of 5 days or fewer were analyzed using statistical process control charts to identify special cause variation. Order set implementation had no effect on pediatric community-acquired pneumonia prescribing. After pathway revision, amoxicillin prescribing increased from 60.6% to 70.9%, azithromycin prescribing decreased from 12.5% to 3.7%, and durations for 5 days or fewer increased from 2.0% to 66.1%. A revised, electronic health record-integrated community-acquired pneumonia pathway was associated with improving already high adherence to guideline-recommended antibiotic choice and reducing antibiotic durations for pediatric community-acquired pneumonia in ED and urgent care settings. Local quality improvement efforts, when adapted to institutional workflows and culture, can effectively implement clinical pathways to support evidence-based prescribing for uncomplicated community-acquired pneumonia across diverse health care settings.