1746. Electronic medical record-embedded clinical decision support decreases inappropriate duration of antibiotics for outpatient pediatric skin and soft tissue infections

Abstract

Abstract Background Most antibiotics are prescribed outside of the hospital, and up to 50% are unnecessary or inappropriate. Studies of ambulatory stewardship interventions have primarily targeted respiratory infections. We investigated the impact of an electronic medical record (EMR)-embedded clinical decision support tool on antibiotic duration for outpatient pediatric skin and soft tissue infection (SSTI). Methods Institutional SSTI treatment guidelines for pediatric and adult patients were developed in 7/2019, followed in 5/2020 by dedicated education for primary care pediatricians. In 12/2020, a SmartSet (EMR-embedded tool with a templated progress note and antibiotic guidance) was created for pediatrics only. In this quasi-experimental pre-post study, we included adult and pediatric patients who were prescribed antibiotics for SSTI at a primary care or surgery clinic (in person, virtual, or phone) from 7/2019 to 12/2021. Inappropriate pediatric antibiotic duration ( >7 days) was compared pre- and post-intervention with interrupted time series (ITS) analysis of aggregate quarterly data. The trend in adult antibiotic duration was modeled with linear regression. Results We included 3,786 (948 pediatric and 2,838 adult) pre-intervention and 2,122 (469 pediatric and 1,653 adult) post-intervention visits. Pre-intervention, the percentage of inappropriate duration for pediatric patients was decreasing 1.6 percentage points per quarter (p < 0.01). After SmartSet implementation, there was an immediate decrease of 10.3 percentage points (p < 0.01), a relative decrease of 40% from the modeled percentage just prior to intervention (Figure 1). Inappropriate antibiotic duration for adults averaged 22.9% over the same period and did not change (p = 0.88). Figure 1Figure 1. Raw and modeled percentages of inappropriate antibiotic duration for skin and soft tissue infection before (quarters -6 to 0, encompassing Q3 2019 through Q4 2020) and after (quarters 0 to 4, encompassing Q1 2021 through Q4 2021) implementation of an EMR-embedded clinical decision support tool for pediatric patients. Time is represented in 3-month intervals, with quarter 0 being indicating the intervention at the end of December 2020. Conclusion Following guideline implementation and education, inappropriate antibiotic duration for ambulatory pediatric SSTI declined only modestly. An EMR-embedded clinical decision support tool was associated with an additional relative decrease of 40% in inappropriate antibiotic duration. In the same health system with comparable adult SSTI guidelines, the percentage of inappropriate antibiotic duration for adults was unchanged, suggesting timely EMR nudges can provide additional benefit over guidelines alone. Disclosures All Authors: No reported disclosures.