Pediatric Antibiotic Prescribing Research Articles

Optimal Pediatric Outpatient Antibiotic Prescribing

In the US, 50% of all pediatric outpatient antibiotics prescribed are unnecessary or inappropriate. Less is known about the appropriateness of pediatric outpatient antibiotic prescribing. To identify the overall percentage of outpatient antibiotic prescriptions that are optimal according to guideline recommendations for first-line antibiotic choice and duration. This cross-sectional study obtained data on any clinical encounter for a patient younger than 20 years with at least 1 outpatient oral antibiotic, intramuscular ceftriaxone, or penicillin prescription filled in the state of Tennessee from January 1 to December 31, 2022, from IQVIA's Longitudinal Prescription Claims and Medical Claims databases. Each clinical encounter was assigned a single diagnosis corresponding to the lowest applicable tier in a 3-tier antibiotic tier system. Antibiotics prescribed for tier 1 (nearly always required) or tier 2 (sometimes required) diagnoses were compared with published national guidelines. Antibiotics prescribed for tier 3 (rarely ever required) diagnoses were considered to be suboptimal for both choice and duration. Primary outcome was the percentage of optimal antibiotic prescriptions consistent with guideline recommendations for first-line antibiotic choice and duration. Secondary outcomes were the associations of optimal prescribing by diagnosis, suboptimal antibiotic choice, and patient- and clinician-level factors (ie, age and Social Vulnerability Index) with optimal antibiotic choice, which were measured by odds ratios (ORs) and 95% CIs calculated using a multivariable logistic regression model. A total of 506 633 antibiotics were prescribed in 488 818 clinical encounters (for 247 843 females [50.7%]; mean [SD] age, 8.36 [5.5] years). Of these antibiotics, 21 055 (4.2%) were for tier 1 diagnoses, 288 044 (56.9%) for tier 2 diagnoses, and 197 660 (39.0%) for tier 3 diagnoses. Additionally, 194 906 antibiotics (38.5%) were optimal for antibiotic choice, 259 786 (51.3%) for duration, and 159 050 (31.4%) for both choice and duration. Acute otitis media (AOM) and pharyngitis were the most common indications, with 85 635 of 127 312 (67.3%) clinical encounters for AOM and 42 969 of 76 865 (55.9%) clinical encounters for pharyngitis being optimal for antibiotic choice. Only 257 of 4472 (5.7%) antibiotics prescribed for community-acquired pneumonia had a 5-day duration. Optimal antibiotic choice was more likely in patients who were younger (OR, 0.98; 95% CI, 0.98-0.98) and were less socially vulnerable (OR, 0.84; 95% CI, 0.82-0.86). This cross-sectional study found that less than one-third of antibiotics prescribed to pediatric outpatients in Tennessee were optimal for choice and duration. Four stewardship interventions may be targeted: (1) reduce the number of prescriptions for tier 3 diagnoses, (2) increase optimal prescribing for AOM and pharyngitis, (3) provide clinician education on shorter antibiotic treatment courses for community-acquired pneumonia, and (4) promote optimal antibiotic prescribing in resource-limited settings.

Temporal trends in antibiotic prescribing and serious and nonserious infections in children presenting to general practice: a registry-based longitudinal cohort study of 162 507 individuals.

It is crucial to understand the trends in paediatric antibiotic prescribing and serious and nonserious infections to improve antibiotic prescribing practices for children in ambulatory care. Assessing trends in paediatric antibiotic prescribing and infection incidence in general practice from 2002 to 2022. In this retrospective cohort study using INTEGO network data from 162 507 patients in Flanders (Belgium), we calculated antibiotic prescribing rates and proportions alongside incidence rates of serious and nonserious infections, stratified by age (0-1, 2-6, 7-12 years) and municipality. We performed autoregressive moving average time-series analyses and seasonality analyses. From 2002 to 2022, antibiotic prescribing rate decreased significantly: 584/1000 person-years (PY) (95% CI 571-597) to 484/1000PY (95% CI 478-491); so did antibiotic overall prescribing proportion: 46.3% (95% CI 45.1-47.6) to 23.3% (95% CI 22.9-23.7) (59.3% amoxicillin and 17.8% broad spectrum). Prescribing proportions dropped significantly for nonserious (45.6% to 20.9%) and increased for serious infections (64.1% to 69.8%). Proportions significantly dropped for acute suppurative otitis media (74.7% to 64.1%), upper respiratory tract infections (44.9% to 16.6%), bronchitis/bronchiolitis (73.6% to 44.1%) and acute tonsillopharyngitis (59.5% to 21.7%), while significantly increasing for pneumonia (65.2% to 80.2%). Nonserious and serious infection incidence rates increased from 785/1000PY and 34.2/1000PY to 1223/1000PY and 64.1/1000PY, respectively. Blood and CRP testing proportions increased significantly. Antibiotic prescribing in general practice for children declined from 2002 to 2022. Further targeted antibiotic stewardship initiatives are needed to reduce the use of broad-spectrum antibiotics and antibiotic prescribing for conditions such as otitis media and bronchitis/bronchiolitis.

Paediatric antibiotic prescribing in a nationwide direct-to-consumer telemedicine platform in France, 2018-2021.

Recent regulatory and reimbursement changes facilitated the development of teleconsultation within primary care. French guidance advises against antibiotic prescribing in children in teleconsultation. We assessed paediatric antibiotic prescribing on a French teleconsultation platform. This cross-sectional observational study analysed paediatric (0-14 years) visits on a national direct-to-consumer teleconsultation platform between January 2018 and December 2021. Teleconsultations with complete information regarding diagnosis (ICD-10 coding) and prescriptions were included. We assessed antibiotic prescription rates per 100 visits across diagnoses and used logistic regression to identify factors associated with antibiotic prescribing. In the 37 587 included paediatric teleconsultations (median age 3 years) performed by 713 general practitioners (GPs) and 89 paediatricians, antibiotics were prescribed for 12.1%. Respiratory tract infections (RTIs) accounted for 49.5% of antibiotic prescriptions. Antibiotic prescription rates per 100 visits were: sinusitis, 69.5%; urinary tract infections, 62.2%; pharyngitis, 59.0%; pneumonia, 45.5%; otitis, 46.6%; bronchitis, 19.6%; rhinitis, 11.6%; bronchiolitis 6.6%. Antibiotic prescription rates were higher in GPs than paediatricians [OR 2.21 (IC95% 2.07-2.35)], among physicians aged 45-54 and over 65 [OR 1.66 (1.48-1.85) and 1.48 (1.32-1.66), respectively], in female practitioners [OR 1.13 (1.05-1.21)], in children 3-6 years old [OR 1.41 (1.28-1.56)] and over 6 [OR 1.50 (1.35-1.66)], during winter [OR 1.28 (1.21-1.37)] and for RTIs [OR 1.99 (1.87-2.10)]. Antibiotic prescription rates were lower in doctors with extensive experience in teleconsultation [OR 0.92 (0.86-0.98)]. Despite current recommendations, paediatric patients were frequently prescribed antibiotics during acute care teleconsultations. Specific antibiotic stewardship campaigns should target paediatric teleconsultations.

Variations in antibiotic prescribing among children enrolled in North Carolina Medicaid, 2013-2019.

The majority of pediatric antibiotic prescribing occurs in the outpatient setting and inappropriate use contributes to antimicrobial resistance. There are regional variations in outpatient antibiotic use with the highest rates occurring in the Southern states, including in Appalachia. The purpose of this study was to describe the rates and risk factors for inappropriate antibiotic prescription among pediatric patients enrolled in North Carolina (NC) Medicaid. We used Medicaid prescription claims data from 2013 to 2019 to describe patterns of pediatric antibiotic prescription in NC. We assessed patient and provider factors to identify variations in prescribing. Children who were less than 2 years of age, non-Hispanic White, and living in a rural area had the highest overall rates of antibiotic prescription. Compared to pediatricians, the risk of inappropriate antibiotic prescription was highest among other specialists and general practioners and lowest among nurse practitioners. Rural areas of NC had the highest rates of inappropriate antibiotic prescribing, and the risk for non-Hispanic Black children compared to children of other races/ethnicities was compounded by rurality. Prescribing practices in NC differ compared to neighboring states with a lower overall risk of inappropriate prescription in Appalachian regions; however, disparities by race and rurality exist. Outpatient stewardship efforts in NC should focus on ensuring health equity by appreciating racial and geographic variations in prescribing patterns and providing education to all health care providers.

1654. Impact of a Daily Web-Based Educational Quiz on Appropriateness of Pediatric Outpatient Antibiotic Prescribing

Abstract Background Nearly ⅓ of outpatient antibiotic prescriptions are unnecessary or inappropriate. QuizTime is a web-based application based on Test-Enhanced Learning Theory that delivers daily case-based questions to a learner’s email or cell phone. We performed a prospective cohort study to evaluate the impact of a QuizTime module on appropriateness of pediatric outpatient antibiotic prescriptions. Methods Participants received one question daily for 10 days starting in July 2022. Quiz topics included age-appropriate antibiotic duration for acute otitis media (AOM), empiric antibiotics for uncomplicated urinary tract infections (UTI), and empiric antibiotics and duration for community-acquired pneumonia (CAP) (Table 1). Participants were pediatric prescribers (physician, resident, physician assistant, nurse practitioner) in a primary care, urgent care, retail health, or emergency department setting. Antibiotic prescription data were collected during the “baseline” period (Jul 1, 2021 – Jun 30, 2022) though 3 months after QuizTime participation (Jul 15 – Oct 15 2022) defined as the “post-quiz” period. Pre- and post-intervention data were analyzed in aggregate (not at the provider-level). Significance was determined by calculating a 95% confidence interval (CI) for the difference of proportions. Outcome measures are listed in Table 1.Figure 1.Prisma diagram showing providers and oral antibiotics prescribed in each cohort. Results Eighty clinicians participated in QuizTime totaling 13,478 antibiotic prescriptions [AOM 5,613 (41.6%), UTI 668 (5.0%), CAP 225 (1.7%)] compared to 776 non-QuizTime clinicians totaling 43,321 antibiotic prescriptions [AOM 15,258 (35.2 %), UTI 2,528 (5.8%), CAP 849 (2.0%)] (Figure 1). AOM guideline-concordant antibiotic duration was significantly higher among participants than non-participants (Table 2). There were encouraging trends towards improvement in secondary outcomes (Table 3, 4). Conclusion Clinicians who participated in a QuizTime module on pediatric outpatient antibiotic prescribing showed improvement in antibiotic appropriateness suggesting web-based microlearning modules are an effective tool for disseminating antibiotic stewardship education. Creation, dissemination, and evaluation of additional QuizTime modules is ongoing. Disclosures Ritu Banerjee, MD, Ph.D, bioMerieux: Grant/Research Support|bioMerieux: company is providing partial support for an ongoing trial unrelated to submitted abstract Sophie E. Katz, MD MPH, Dolly Parton Pediatric Infectious Diseases Research Funds: Grant/Research Support|Optum: Advisor/Consultant|Pfizer: Grant/Research Support

Benchmarking of Outpatient Pediatric Antibiotic Prescribing: Results of a Multicenter Collaborative.

Most antibiotic use occurs in ambulatory settings. No benchmarks exist for pediatric institutions to assess their outpatient antibiotic use and compare prescribing rates to peers. We aimed to share pediatric outpatient antibiotic use reports and benchmarking metrics nationally. We invited institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient (SHARPS-OP) Collaborative to contribute quarterly aggregate reports on antibiotic use from January 2019 to June 2022. Outpatient settings included emergency departments (ED), urgent care centers (UCC), primary care clinics (PCC) and telehealth encounters. Benchmarking metrics included the percentage of: (1) all acute encounters resulting in antibiotic prescriptions; (2) acute respiratory infection (ARI) encounters resulting in antibiotic prescriptions; and among ARI encounters receiving antibiotics, (3) the percentage receiving amoxicillin ("Amoxicillin index"); and (4) the percentage receiving azithromycin ("Azithromycin index"). We collected rates of antibiotic prescriptions with durations ≤7 days and >10 days from institutions able to provide validated duration data. Twenty-one institutions submitted aggregate reports. Percent ARI encounters receiving antibiotics were highest in the UCC (40.2%), and lowest in telehealth (19.1%). Amoxicillin index was highest for the ED (76.2%), and lowest for telehealth (55.8%), while the azithromycin index was similar for ED, UCC, and PCC (3.8%, 3.7%, and 5.0% respectively). Antibiotic duration of ≤7 days varied substantially (46.4% for ED, 27.8% UCC, 23.7% telehealth, and 16.4% PCC). We developed a benchmarking platform for key pediatric outpatient antibiotic use metrics drawing data from multiple pediatric institutions nationally. These data may serve as a baseline measurement for future improvement work.

Pediatric Antibiotic Prescribing and Utilization Practices for RTIs at Private Urgent Care Centers.

Data on pediatric antibiotic prescribing and utilization practices at urgent care centers (UCC) remain limited. In this study, an electronic medical record-based review of UCC encounters for respiratory tract infections (RTI) of patients belonging to one mid-sized pediatric practice was performed. Antibiotic prescribing and guideline adherence were compared between UCCs that were staffed exclusively by pediatric-trained providers to those staffed otherwise. Of a total of 457 RTI visits, 330 (72%) occurred at the pediatric UCC. Across all bacterial RTIs, 82% of encounters at the pediatric UCC were guideline-adherent versus 59% at nonpediatric UCCs (P < .001). At nonpediatric UCCs, pharyngitis was the most common RTI encounter diagnosis (40%), and full streptococcal management guideline adherence was 41%. While 93% of RTI-UCC encounters for <2 years were at pediatric UCCs, the majority of children >10 presented to nonpediatric UCCs. RTI guideline education to UCCs should be a focus of ambulatory stewardship efforts.

Yonder: International medical graduates, genetics at end-of-life, climate change, and paediatric antibiotic prescribing in China.

Yonder: International medical graduates, genetics at end-of-life, climate change, and paediatric antibiotic prescribing in China.

Quality of antibiotic prescribing to children through the coronavirus disease 2019 (COVID-19) pandemic.

To describe pediatric outpatient visits and antibiotic prescribing during the coronavirus disease 2019 (COVID-19) pandemic. An observational, retrospective control study from January 2019 to October 2021. Outpatient clinics, including 27 family medicine clinics, 27 pediatric clinics, and 26 urgent or prompt care clinics. Children aged 0-19 years receiving care in an outpatient setting. Data were extracted from the electronic health record. The COVID-19 era was defined as April 1, 2020, to October 31, 2021. Virtual visits were identified by coded encounter or visit type variables. Visit diagnoses were assigned using a 3-tier classification system based on appropriateness of antibiotic prescribing and a subanalysis of respiratory visits was performed to compare changes in the COVID-19 era compared to baseline. Through October 2021, we detected an overall sustained reduction of 18.2% in antibiotic prescribing to children. Disproportionate changes occurred in the percentages of antibiotic visits in respiratory visits for children by age, race or ethnicity, practice setting, and prescriber type. Virtual visits were minimal during the study period but did not result in higher rates of antibiotic visits or in-person follow-up visits. These findings suggest that reductions in antibiotic prescribing have been sustained despite increases in outpatient visits. However, additional studies are warranted to better understand disproportionate rates of antibiotic visits.

A qualitative assessment of nonclinical drivers of pediatric outpatient antibiotic prescribing: The importance of continuity.

Antibiotic overuse is common in outpatient pediatrics and varies across clinical setting and clinician type. We sought to identify social, behavioral, and environmental drivers of outpatient antibiotic prescribing for pediatric patients. We conducted semistructured interviews with physicians and advanced practice providers (APPs) across diverse outpatient settings including pediatric primary, urgent, and retail care. We used the grounded theory constant comparative method and a thematic approach to analysis. We developed a conceptual model, building on domains of continuity to map common themes and their relationships within the healthcare system. We interviewed 55 physicians and APPs. Clinicians across all settings prioritized provision of guideline-concordant care but implemented these guidelines with varying degrees of success. The provision of guideline-concordant care was influenced by the patient-clinician relationship and patient or parent expectations (relational continuity); the clinician's access to patient clinical history (informational continuity); and the consistency of care delivered (management continuity). No difference in described themes was determined by setting or clinician type; however, clinicians in primary care described having more reliable relational and informational continuity. Clinicians described the absence of long-term relationships (relational continuity) and lack of availability of prior clinical history (informational continuity) as factors that may influence outpatient antibiotic prescribing. Guideline-concordant outpatient antibiotic prescribing was facilitated by consistent practice across settings (management continuity) and the presence of relational and informational continuity, which are common only in primary care. Management continuity may be more modifiable than informational and relational continuity and thus a focus for outpatient stewardship programs.

The Antibiotic Likelihood Index: A New Measure of Antimicrobial Stewardship for Pediatric Primary Care Based on Reason for Visit.

Quality metrics for antibiotic prescribing by pediatricians are limited. We sought to define a novel measure that assesses clinicians' overall antibiotic prescribing. Using electronic health record (EHR) data from 2018 to 2019 for children 3 months to 17 years of age from 53 practices within a large pediatric network, we grouped encounters into Reason for Visit categories using the classification system of the National Ambulatory Medical Care Survey and analyzed the proportion of encounters with an antibiotic prescription. Categories were sorted according to the attributable proportion of encounters with an antibiotic prescribed. The proposed metric-the Antibiotic Likelihood Index (ALI)-was defined as the proportion of encounters with an antibiotic prescribed among categories that accounted for >80% of all encounters with an antibiotic prescribed. The ALI was calculated for the entire network and for individual prescribers, and the distribution among prescribers was described. Six Reason for Visit categories-cough, ear complaints, fever, sore throat, rash, and congestion/upper respiratory infection-accounted for 82.4% of all antibiotics prescribed. Among the 222 682 encounters for the top 6 categories combined, 67 368 (30.3%) had an antibiotic prescribed, defined as the ALI for the entire sample. The index among individual prescribers ranged from 7.5% to 57.2% (interquartile range 24.3% to 34.9%). The correlation for individual prescribers between 2018 and 2019 was high (R2 = 0.80). The ALI, a proposed new metric of pediatric antibiotic prescribing, can be readily calculated from EHR data and captures the range of antibiotic prescribing among pediatricians for common clinical scenarios.

Proposed metrics to benchmark antibiotic prescribing in pediatric outpatient settings

Metrics to track and compare outpatient pediatric antibiotic prescribing are needed to improve antibiotic use and prevent unwanted consequences of antibiotic overuse. We have considered the impact and feasibility of available metrics and propose select high-priority measures for electronic reporting of pediatric outpatient antibiotic use. Streamlined use of antibiotic prescribing metrics will allow for national benchmarking, monitoring and identification of targets and goals for improvement.

Antibiotic prescribing patterns for childhood infections in ambulatory settings in Jordan

Antibiotics' rational prescribing is a major goal of the World Health Organization's (WHO) global action plan to tackle antimicrobial resistance. Evaluation of antibiotic prescribing patterns is necessary to guide simple, globally applicable stewardship interventions. The impact of antimicrobial resistance is devastating, especially in low-income countries. We aimed to introduce ambulatory data on patterns of paediatric antibiotic prescribing in Jordan, which could be used to guide local stewardship interventions. A cross-sectional retrospective study was conducted by selecting a random sample of paediatric patients, who attended ambulatory settings in 2018. Records of outpatients (age ≤18years) receiving at least one antibiotic were included. The WHO's model of drug utilisation was applied, and all prescribing indicators were included. Multiple linear regression was performed to examine factors influencing the ratio of prescribed antibiotics to overall medications per encounter. A total of 20494 prescriptions, containing 45241 prescribed drugs, were obtained. The average number of prescribed drugs per prescription was (2.21±0.98). Approximately 77.5% of overall ambulatory prescriptions accounted for antimicrobials. Only 0.6% of total prescriptions were for injectables. All antimicrobials (100%) were prescribed by generic names and from the essential drug list. Antibiotics were most commonly prescribed for respiratory tract infections. Age, gender, season and facility type were significant predictors of prescribed antibiotics to overall medications ratio. This is the first study of antibiotic prescribing patterns among outpatient paediatrics that covers wide regions in Jordan. Results indicate high rates of antibiotics use among outpatient paediatrics. Such findings necessitate more focussed efforts and regulations that support rational utilisation of drugs.

Going shopping or consulting in medical visits: Caregivers’ roles in pediatric antibiotic prescribing in China

Antimicrobial Resistance (AMR) is one of the gravest global public health crises today. Over-prescription in clinical settings is a primary driver. Despite its magnitude and scale, the problem of antibiotic over-prescription in China has not been understood adequately nor addressed effectively. Based on a corpus of 183 video-recorded medical conversations in the Chinese pediatric setting, we show that patient caregivers frequently challenge the physician's medical authority by resisting treatment recommendations, displaying a high level of entitlement to influence the treatment decision. As a result, even when the physicians do not recommend antibiotics based on their professional judgment, they prescribe in response to caregiver pressure. We argue that the relatively low level of medical authority is a significant contributor to the problem. Under this consumerist model of doctor-patient relationship, antibiotics are oriented to by the caregivers as a negotiable commodity and physicians are unable to fulfill their role as gatekeepers. Educational campaigns are needed to promote rational use of antibiotics among patients and caregivers, and serious efforts are called for to protect physicians' professional authority in China.

1345. Impact of the COVID-19 Pandemic on Pediatric Ambulatory Antibiotic Use in an Academic Health System

BackgroundIt is unclear how the COVID-19 pandemic has impacted outpatient pediatric antibiotic prescribing.MethodsWe compared diagnoses and antibiotic prescription rates for children pre- vs post-COVID-19 in 5 ambulatory settings affiliated with Vanderbilt University Medical Center: emergency department (ED), urgent care clinics (including pediatric-only after-hours clinics [AHC]s and walk-in clinics [WIC] for all ages), primary care clinics (PCC), and retail health clinics (RHC). Time periods were pre-COVID-19 3/1/19 – 5/15/19 (P1); and post-COVID-19 3/1/20 – 5/15/20 (P2). Diagnoses and percent of encounters with an antibiotic prescription were analyzed by encounter (in-person vs telemedicine [TMed]), clinic and provider type. We also interviewed 16 providers about perceived COVID-19 impact on pediatric ambulatory antibiotic prescribing. Student’s T and χ 2 tests were used as appropriate.ResultsThe number of pediatric ambulatory visits was 16671 in P1 and 7010 in P2. There were no TMed visits in P1 vs 188 in P2 (2.7% of total P2 visits); 186 (99% of TMed visits) were in PCC (Table). In all settings, the number of encounters was lower in P2 vs P1 (p< 0.001). The percent of encounters with an antibiotic prescription was lower in P2 (32%) than in P1 (38.2%) (p< 0.001) (Table) overall and in all settings except RHCs. Only 14 (7.4%) TMed visits resulted in an antibiotic prescription. There were no differences in antibiotic prescribing rates by provider type. Diagnoses varied significantly between periods in all clinic types except the ED, with noninfectious diagnoses being higher in P2 vs P1 (Figure 1). Providers felt that COVID-19 led to fewer but sicker patients presenting for care, and variable impact on antibiotic prescribing (Figure 2).Table. Percent of Encounters with an Antibiotic by Clinic Type, Pre- and Post-COVID-19 Figure 1. Diagnosis Rates by Clinic Type, Pre- and Post-COVID-19 Figure 2. Themes from Provider Interviews about perceived Impact of COVID-19 on Clinician Practice ConclusionThe proportion of encounters with non-infectious diagnoses increased and antibiotic prescribing rates decreased significantly in all pediatric ambulatory settings post-COVID-19 except RHCs. Almost all TMed encounters occurred in the primary care setting, and few resulted in an antibiotic prescription. Providers felt they saw fewer patients and higher acuity of illness post COVID-19.DisclosuresHillary Spencer, MD, MPH, NIH (T32 grant support) (Grant/Research Support)

1333. A Cross-Sectional Analysis of Inappropriate Outpatient Antibiotic Use in Children Insured by Kentucky Medicaid

BackgroundKentucky (KY) consistently has one of the highest rates of outpatient pediatric antibiotic prescribing in the nation. Previous analyses identified significant variation in volume of antibiotic prescribing by geographic location, patient demographics, and provider type, but less is known about the appropriateness of this prescribing. We describe appropriateness of outpatient antibiotic prescribing in children insured by KY Medicaid.MethodsWe utilized KY Medicaid pharmacy and medical claims from 2017 for children < 20 years. Patient demographic variables were abstracted from Medicaid enrollment data. Antibiotic prescriptions were identified by NDC and matched to medical claims within 3 days prior to fill date to identify corresponding diagnoses via ICD-10 codes. A previously published appropriateness classification scheme (Chua, BMJ 2019) was applied to categorize antibiotic prescriptions as “appropriate”, “potentially appropriate”, “inappropriate” or “not associated with indication”.ResultsOf the 779,751 antibiotic prescriptions included, 19.5% were appropriate, 45.3% were potentially appropriate, 20.8% were inappropriate, and 14.4% were not associated with an indication (Table 1). Inappropriate prescriptions were more common among children 0-2 years (24.4%) and those living in non-metro areas (22.2%). Antibiotics prescribed by general practitioners were also more likely to be inappropriate (22.2%). The most common diagnoses for each category are summarized in Table 2. Amoxicillin was the most commonly prescribed antibiotic in all categories. Azithromycin was more frequently prescribed for inappropriate indications or those not associated with a diagnosis code. Cefdinir was more common for appropriate and potentially appropriate indications.Table 1: Antibiotic Prescription Characteristics, 2017 Table 2: Top Diagnoses for Antibiotic Prescriptions by Category ConclusionInappropriate antibiotic prescribing is more common among young children living in non-metro areas seen by general practitioners. Outpatient antibiotic stewardship interventions should target these patient demographics and provider types. This classification scheme to describe inappropriate prescribing is feasible for use in pediatric Medicaid patients and could serve as a valuable metric for provider feedback reports on antibiotic use.Disclosures Bethany A. Wattles, PharmD, Kentucky Medicaid (Grant/Research Support)Merck (Grant/Research Support) Michael J. Smith, MD, MSC.E, Kentucky Medicaid (Grant/Research Support)Merck (Grant/Research Support)

Increasing paediatric prescribing rates in British Columbian children: cause for concern?

Antibiotic prescribing in paediatric care is highly prevalent, and quite often, children are prescribed for conditions, like upper respiratory tract infections, which are self-limiting and viral in aetiology. The purpose of this study was to identify potential new targets for provincial antimicrobial stewardship efforts. Antibiotic prescription data for children were extracted from a provincial prescription database, linked to physician billing data in order to obtain diagnostic information, and then combined with demographic data in order to obtain patient age, sex and geographic location. Prescription rates were calculated, and trends were examined by major anatomical therapeutic chemical (ATC) classification. Our cohort included an average of 271,134 children per year and 1,767,652 antibiotic prescriptions. Antibiotic utilization increased 4.5% (from 453 to 474 prescriptions per 1000 population). The greatest increases in prescribing were seen in children aged 0-2years. Increased indication-specific rates of prescribing were observed in children aged 0-2years, across every category. Although antibiotic use for upper respiratory tract infections decreased, prescribing rates remain as high as 5 times more than other indications. Past studies have widely illustrated decreasing or static rates of prescribing in British Columbia. However, these results signal a potential problem in the sphere of paediatric antibiotic prescribing, wherein rates have been increasing since 2013. Despite the success of provincial efforts in reducing the use of broad-spectrum penicillins, marked surges in the use of classes like tetracyclines, quinolones and other antibacterials identify a new potential target for provincial stewardship.

Pediatric Antibiotic Prescribing in China According to the 2019 World Health Organization Access, Watch, and Reserve (AWaRe) Antibiotic Categories

To assess clinical indication-specific antibiotic prescribing in pediatric practice in China based on the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) metrics and to detect potential problem areas. Pediatric prescription records on the 16th of each month during 2018 were sampled for all encounters at outpatient and emergency departments of 16 tertiary care hospitals via hospital information systems. Antibiotic prescribing patterns were analyzed across and within diagnostic conditions according to WHO AWaRe metrics and Anatomical Therapeutic Chemical (ATC) classification. A total of 260 001 pediatric encounters were assessed, and antibiotics were prescribed in 94 453 (36.3%). In 35 167 encounters (37.2%), at least 1 intravenous antibiotic was administered. WHO Watch group antibiotics accounted for 82.2% (n=84 176) of all antibiotic therapies. Azithromycin (n=15 791; 15.4%) was the most commonly prescribed antibiotic, and third-generation cephalosporins (n=44 387; 43.3%) were the most commonly prescribed antibiotic class. In at least 66 098 encounters (70.0%), antibiotics were prescribed for respiratory tract conditions, mainly for bronchitis/bronchiolitis (n=25 815; 27.3%), upper respiratory tract infection (n=25 184; 26.7%), and pneumonia (n=13 392; 14.2%). Overuse and misuse of WHO Watch group antibiotics for respiratory tract conditions and viral infectious diseases is common in pediatric outpatients in China. Pediatric antimicrobial stewardship should be strengthened using WHO AWaRe metrics.

1117. A Retrospective Analysis of Paediatric Prescribing in British Columbia from 2013 to 2016

BackgroundAntibiotic prescribing in pediatric care is highly prevalent. Often children are prescribed antibiotics for conditions that are commonly self-limiting and viral in etiology such as upper respiratory tract infections. The purpose of this study was to examine the scope of pediatric antibiotic prescribing in British Columbia from 2013 to 2016 and identify potential new provincial antimicrobial stewardship targets.MethodsAntibiotic prescription data for children were extracted from a provincial prescription database, and linked to demographic files in order to obtain patient age, sex and geographic location. Prescription rates were then calculated, and trends were examined by major anatomical therapeutic chemical (ATC) classification.ResultsOur cohort included an average of 271,134 children per year and 1,767,652 antibiotic prescriptions. Over the 4 years, rates of antibiotic prescribing increased 4.5% (from 453 to 474 prescriptions per 1,000 population per year). The greatest increase, across all classes of antibiotics, was seen in children aged 0–2 years of age. By 2016, the greatest increase in prescribing, by class, was observed in J01X (e.g., nitrofurantoin, fosfomycin) with a 1360% increase for children aged 3–9. Across all ages, quinolones (J01M) increased 98%. Remaining classes, including β lactams (J01C), and macrolides (J01F), experienced modest reductions in the older age groups.ConclusionPast studies have illustrated decreasing or static rates of antibiotic prescribing in British Columbia. However, we have identified a paradoxical (4.5%) increase in pediatric antibiotic prescribing since 2013. Although it appears that provincial efforts have been successful in reducing the use of broad-spectrum penicillins (J01C), marked surges in the use of classes like tetracylines (J01A), quinolones (J01M), and other antibacterials (J01X) identify a new potential target for provincial stewardship.Disclosures All authors: No reported disclosures.

1118. Trends of Paediatric Prescribing for Common Infections in British Columbia

BackgroundAntibiotic prescribing in pediatric care is highly prevalent, and quite often children are prescribed for conditions which are commonly self-limiting and viral in etiology. The purpose of this study was to examine the scope of pediatric antibiotic prescribing by indication, from 2013 to 2016, and identify potential new targets for provincial antimicrobial stewardship efforts.MethodsAntibiotic prescription data for children were extracted from a provincial prescription database, and linked to physician billing data in order to obtain diagnostic information. Prescription rates were then calculated, and trends were examined by indication. Major categories included: upper respiratory tract infection, acute otitis media, lower respiratory tract, skin and soft tissue, and urinary tract infections.ResultsOur database included an average of 244,763 children per year, and 5,896,173 total antibiotic prescriptions. Increased indication-specific rates of prescribing were observed in children aged 0–2 years, for every category. Children aged 3–18 years experienced decreased prescribing across all indications, with the exception of urinary tract infections for those aged between 10–18 years. Urinary tract infections increased by 134% for children aged 0–2 years, and 75% for those aged 10–18 years, from 2013 to 2016. Although antibiotic use for upper respiratory tract infections decreased by 11% for all ages, these diagnoses continue to be prescribed for at rates 2 – 5 times higher than other conditions.ConclusionAlthough this study found a decrease in prescribing over time across all indications, antibiotic use continues to be a concern for upper respiratory tract infections in pediatric care. These diagnoses generally do not require antibiotics, and inappropriate prescribing is a major factor in antimicrobial resistance. The increased prescribing rates in the youngest age group (0–2 years) offers a new target for provincial stewardship efforts.Disclosures All authors: No reported disclosures.