Abstract
BACKGROUND: Ceftriaxone has many features which make it an attractive choice in the ambulatory paediatric setting. However, the ramifications of a broad-spectrum intravenous antibiotic, including the promotion of antibiotic resistance and daily visits to a Medical Day Hospital (MDH) should not be ignored. A prior analysis at our tertiary care center revealed a 57% rate of inappropriate ceftriaxone use among patients referred from the Emergency Department (ED) to the MDH. Following a brainstorming session with ED physicians, we identified the drivers of ceftriaxone overuse and developed interventions to reduce inappropriate prescribing. Interventions included: education sessions with physicians; revision of MDH inclusion criteria; and implementation of a standardized referral form to the MDH. OBJECTIVES: Our objective was to reduce the inappropriate use of ceftriaxone according to centre-specific first-line indications in children ages 3 months to 18 years in the MDH. DESIGN/METHODS: Data were collected retrospectively in each of the pre- and post-intervention periods for one summer and one winter season to capture diagnostic variations. The pre-intervention period was from November 2019 to January 2020 and June to September 2020; the post-intervention period was from November 2023 to January 2024 and May to July 2024. Included patients were between the ages of 3 months to 18 years and had received ceftriaxone in the MDH after referral from ED. Immunocompromised patients were excluded. We calculated the proportion of inappropriate ceftriaxone use pre-intervention and post-intervention as well as the frequency of MDH referral form use post-intervention. Ceftriaxone appropriateness was assessed based on our institution’s empiric antimicrobial guide. When the indications for ceftriaxone were unclear, a detailed chart review was performed by two parties including a staff trained in paediatric infectious diseases. RESULTS: There were 196 eligible patients in the pre-intervention and 107 in the post-intervention periods. Ceftriaxone use was inappropriate in 113 (58%) patients pre-intervention compared to 24 (22%) post-intervention (p<0.001). Inappropriate use was more common in the summer than the winter. The most frequent inappropriate indications were pneumonia (33%) and skin and soft tissue infections (29%). The use of the standardized MDH referral form was over 90% in both post-intervention seasons. CONCLUSION: Team brainstorming, educational sessions, guideline review and referral standardization were effective in our institution at reducing the rate of inappropriate ceftriaxone use in the MDH. This highlights the positive impact that antibiotic stewardship initiatives can have in the outpatient setting and further initiatives may include direct audit-and-feedback to physicians; however, this is more challenging in the ED setting.