215 - Appropriateness and Accuracy of Antimicrobial Prescriptions at Pediatric Emergency Department Discharge

Background: Up to 20% of pediatric emergency department visits result in an antimicrobial prescription. The objective of this study was to evaluate the appropriateness and dosing accuracy of antimicrobial prescriptions given at discharge from an ED of a freestanding children’s hospital.

Methods: Electronic medical records of patients seen in the ED at Oishei Children’s Hospital from 12 dates (3 in each of 4 seasons) were screened. All patients discharged from the ED with a prescription for an antimicrobial were included. Diagnosis, provider type, antibiotic dose per weight, duration and frequency were recorded. Appropriateness of antibiotic choice and dosing accuracy were assessed using major medical society guidelines, pharmacy references and hospital antibiograms. Antibiotic doses were considered inaccurate if >10% outside of recommended weight-based dose ranges.

Results: Of a total of 1733 screened patients, 12% (207) were discharged with a systemic antimicrobial prescription. The percentage of visits resulting in an antimicrobial prescription varied by season, and was highest during the winter at 19%. Amoxicillin (33% of all) and oseltamivir (15%) were most frequently prescribed. Overall, 98% of patients were prescribed the appropriate antimicrobial, but only 65% of systemic antimicrobial prescriptions had accurate dosing. Amoxicillin was dosed incorrectly in 32% of prescriptions, Figure 1, specifically being below the high-dose recommended range in 28% of otitis media (OM) and 29% of pneumonia cases. Despite being the most common diagnosis, OM was treated with accurate dosing only 57% of the time, Figure 2.  Also, more than 40% of patients with UTI or pneumonia had inaccurate drug dosing. Nurse practitioners (NP) prescribed the most antibiotics. Appropriate prescribing did not vary by provider, but accuracy of dosing did; for example, NP dosing accuracy was 58%, vs. 73% for residents (p < 0.04), Figure 3.Dosing Accuracy of Antimicrobials
Dosing Accuracy by Diagnosis
Appropriateness and Accuracy by Prescriber Group


Conclusion: An eighth of pediatric ED visits resulted in an antimicrobial prescription. Inaccurate dosing occurred regularly for common infections; most notably underdosing of amoxicillin for OM and pneumonia. Education and audit related to specific drugs and providers promises to be of high stewardship impact in pediatric EDs.