# Impact of implementing repeated clinical audits and feedback on outpatient antibiotic prescribing in the pediatric emergency department of a French university hospital

Mariem Ben Yaghlane, Arnaud Florentin, Ouarda Pereira, Anne Borsa-Dorion, Cyril Schweitzer, Alexandre Charmillon

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Mariem Ben Yaghlane, Arnaud Florentin, Ouarda Pereira, Anne Borsa-Dorion, Cyril Schweitzer, et al.. Impact of implementing repeated clinical audits and feedback on outpatient antibiotic prescribing in the pediatric emergency department of a French university hospital. Archives de Pédiatrie, 2026, 10.1016/j.arcped.2026.01.002. hal-05491237

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Research paper

# Impact of implementing repeated clinical audits and feedback on outpatient antibiotic prescribing in the pediatric emergency department of a French university hospital

Mariem Ben Yaghlane<sup>a, *, ID</sup>, Arnaud Florentin<sup>b, c ID</sup>, Ouarda Pereira<sup>d</sup>, Anne Borsa-Dorion<sup>a</sup>, Cyril Schweitzer<sup>e, f ID</sup>, Alexandre Charmillon<sup>g, h</sup>

## ARTICLE INFO

### Keywords:

Antimicrobial stewardship

Audit and feedback

Emergency department

Implementation

Pediatric outpatients

## ABSTRACT

**Background:** The burden of antimicrobial resistance is a significant public health challenge, especially in young children, driven by antibiotic misuse.

**Objective:** This study aimed to assess the impact of repeated prospective clinical audits, with a systematic feedback design, on enhancing antibiotic prescribing practices among outpatients visiting the Pediatric Emergency Department of a teaching hospital located in the north-eastern region of France.

**Methods and Setting:** We conducted a before-and-after study design over 13 months (2021–2023), performing clinical audits to assess antibiotic prescribing practices. The standards were based on guidelines from French scientific societies. We implemented a multimodal improvement plan, including regular meetings with prescribers. After each educational session, we reassessed antibiotic prescription patterns and provided rapid feedback to encourage timely adjustments.

**Results:** Outpatients accounted for 79% of emergency visits. Over 13 months, we retained 1477 prescriptions. The distribution of diseases remained consistent throughout periods. The overall guideline adherence rate was 75% during the preintervention period and remained stable throughout the study. In situations where antibiotics were recommended, this rate was 51.6% at baseline and 50% in the postintervention period. Nonetheless, adherence to treatment initiation guidelines increased significantly, from 88.9% to 96.6%. Furthermore, the proportion of appropriate antibiotic selections increased from 82.2% to 93.2% (p = 0.001). Additional analysis indicated a reduction in antibiotic consumption among pediatric outpatients during the study period.

**Conclusion:** These results show that implementing an antibiotic stewardship program in pediatric emergency departments can improve adherence to antibiotic guidelines. These findings support the need to expand antimicrobial stewardship programs in pediatric settings.

## 1. Introduction

In 2014, the World Health Organization (WHO) declared antibiotic resistance a significant public health threat [1]. Antimicrobial resistance (AMR) presents a substantial burden to humanity, with 1.14 million

attributable deaths worldwide in 2021, particularly among young children [2]. European research concerning AMR has revealed analogous concerns [3,4]. Unless there are substantial changes in the utilization of antibiotics, this estimate could escalate to 8 million deaths annually by the year 2050 [2].

<footnote><sup>a</sup> Pediatric Emergency Department, Children's Hospital, University Hospital of Nancy, Vandoeuvre-lès-Nancy, Nancy, France</footnote>

<footnote><sup>b</sup> Department of Hygiene, Environmental Risks and Healthcare Associated Risks, University of Lorraine, Vandoeuvre-lès-Nancy, Nancy, France</footnote>

<footnote><sup>c</sup> Université de Lorraine, APEMAC, F-54000, Nancy, France</footnote>

<footnote><sup>d</sup> Direction Régionale du Service Médicale Grand Est, Strasbourg, France</footnote>

<footnote><sup>e</sup> Pediatric Department, Children's Hospital, University Hospital of Nancy, Vandoeuvre-lès-Nancy, Nancy, France</footnote>

<footnote><sup>f</sup> EA3450-DevAH-Department of Physiology, Faculty of Medicine, University of Lorraine, 3450, Vandoeuvre-lès-Nancy, Nancy, EA, France</footnote>

<footnote><sup>g</sup> Infectious Diseases Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, Nancy, France</footnote>

<footnote><sup>h</sup> Grand-Est Antibiotic Stewardship Network, AntibioEst, F-54000, Nancy, France</footnote>

<footnote>* Corresponding author.
E-mail address: dr.benyaghlane@gmail.com (M. Ben Yaghlane).</footnote>
The WHO associates antimicrobial resistance with the utilization of antibiotics [5]. Among European nations, France is ranked as the fifth-highest consumer of antibiotics for outpatient use [6]. Out-of-hospital settings account for over 90 % of prescribed antibiotics [7]. The majority of these prescriptions are for children under the age of four [8].

To combat AMR, health authorities focus on two main strategies: preventing and controlling the spread of infectious diseases and promoting the appropriate use of antimicrobial agents [9]. One of the most effective approaches is implementing antimicrobial stewardship programs (ASPs). These programs involve all actions within a healthcare setting aimed at optimizing antimicrobial use, including reducing inappropriate antibiotic use, to decrease AMR and improve patient outcomes [10]. The WHO and the European Centre for Disease Prevention and Control recommend implementing ASPs in both adult and pediatric populations across inpatient and outpatient settings [11–13]. Among the key elements of ASPs, the implementation of prospective audit and feedback interventions is widely endorsed [14]. Additionally, the French National Authority for Health suggests developing clinical audits as part of ongoing professional development for healthcare providers [15].

Research concerning ASPs within pediatric populations remains relatively limited in comparison to adult groups [12]. In 2023, Brigadoi et al. identified 59 studies conducted in pediatric emergency departments (PEDs) and primary healthcare settings since 2007, predominantly in the United States [13]. The majority of these studies focused on a single type of infection, with 31 examining respiratory tract infections. Of the three studies conducted in France, two were in emergency departments, and all concentrated on respiratory tract infections. Additionally, few investigations have evaluated adherence to existing guidelines, and none have assessed the impact of repeated audits and feedback over time.

This study aimed to assess the impact of repeated prospective clinical audits with systematic feedback on antibiotic prescribing practices in the outpatient setting of the Pediatric Emergency Department at the University Hospital of Nancy, France.

## 2. Materials and methods

### 2.1. Setting

This study was conducted at the PED of the University Hospital of Nancy, France, from 2021 to 2023. The prescribers involved included both experienced practitioners and residents.

### 2.2. Study design

We employed a before-and-after design involving repeated clinical audits and feedback interventions. The core of the study was conducted from May to October 2022 and was divided into four assessment periods (P1 to P4, see Fig. 1). Each period consisted of two components.

1. At the start of each period, meetings were held between infectious disease specialists and pediatric prescribers to provide feedback on

previously encountered clinical situations and to review typical pediatric infectious disease scenarios using pedagogical case vignettes. 2. At the end of each period, an audit of infectious disease prescriptions since the previous meeting was conducted. The findings were presented to prescribers at the start of the next period. To establish a comparative baseline, a retrospective analysis of infectious disease prescriptions from May to October 2021 (designated as P0) was conducted.

Additionally, a final evaluation (P5) was conducted in May 2023, twelve months after the start of the study, to assess the long-term impact of the interventions.

### 2.3. Secondary interventions

In addition to the core audit-feedback cycles, we introduced the following interventions:

- Updated pediatric infectious diseases management protocol to support the implementation of replacement practice procedures in 2023.

- Provided reminders of evidence-based guidelines for common pediatric infectious diseases.

- Provided pocket cards summarizing first-line antibiotic therapies for common pediatric infectious diseases.

- Introduced applications and websites for infectious disease treatment guidance, particularly those implemented by our Regional Antibiotic Therapy Center and supported by the Regional Health Authority.

- Sent emails containing studies, guidelines, and relevant documents to prescribers.

At the conclusion of the assessment period P4, residents were invited to participate in a satisfaction survey concerning the interventions.

### 2.4. Study population

We collected medical records for outpatients under 18 years of age who visited the PED and received antibiotics for systemic curative purposes. Cases of pediatric infectious diseases were identified using the relevant International Classification of Diseases, 10th Revision (ICD-10) codes (see Supplementary Appendix A).

Exclusion criteria included non-bacterial infectious diseases, cases requiring specialist assessment, ongoing antibiotic therapy, and situations without applicable treatment guidelines.

### 2.5. Data collection

We compiled epidemiologic and clinical data from each medical record, including consultation date, age, gender, weight, medical history, and allergies. We documented the discharge diagnosis and the medical prescription provided by the physician. In instances where a diagnosis was not explicitly documented, it was inferred from the medical description. Any ambiguities were resolved in favor of the physician.

<figure><img src="image_4.png" /><figcaption>**Fig. 1.** Timeline. P0 means assessment period 0; P1 means assessment period 1; P2 means assessment period 2; P3 means assessment period 3; P4 means assessment period 4; P5 means assessment period 5. Arrows denote interventions, which encompass meetings, feedback on previous prescriptions, case vignettes, reminders of guidelines, provision of opportunities for questions between physicians and infectious diseases specialists, and the transmission of pertinent documents.</figcaption></figure>
Data on antibiotic consumption were obtained from the French Health Insurance database ("Système National des Données de Santé"), which identified children residing in the administrative region who were outpatients for our PED and received ambulatory antibiotic therapy during the specified periods.

## 2.6. Guidelines

We summarized all relevant guidelines from French scientific societies active during the study periods (see Supplementary Appendix B). They were provided to prescribers and served as the reference for evaluating prescription conformity.

Updates to the guidelines for otitis, sinusitis, and pneumonia were made during the study: weight-based dosage ranges were replaced with fixed values.

## 2.7. Definitions

Adherence to antibiotic therapy guidelines was defined as avoiding unnecessary prescriptions and prescribing the appropriate antibiotic at the correct weight-based dosage, frequency, and duration as stipulated in the guidelines. The appropriateness of the prescription was evaluated solely if the correct antibiotic was administered (see Supplementary Appendix C). A 25 % margin was permitted for weight-related dosages due to the galenic formulations, and the maximum doses adhered to those used in adults.

## 2.8. Outcomes

We hypothesized that implementing an ASP would improve adherence to antibiotic prescribing guidelines among pediatric outpatients. The primary outcome was to assess the rate of adherence to current antibiotic prescribing guidelines before, during, and after the implementation of our ASP. The secondary objective was to evaluate the long-term impact of this program following its implementation.

## 2.9. Statistical analysis

A binary ranking system was employed to assess the appropriateness of either antibiotic selection or antibiotic withholding. Prescriptions were similarly evaluated with respect to weight-related dosage, frequency, and duration. Missing data were deemed unsuitable for analysis of complete prescriptions and were therefore excluded from subgroup analyses of dosage, frequency, or duration.

Statistical analyses were conducted independently. Guideline adherence rates were expressed as percentages. Depending on the sample size in each category, either the $\chi^2$ test or the Fisher's exact test was utilized to compare adherence rates. Adjusted results facilitated subgroup analyses: adherence rates for each prescription component (dosage, frequency, and duration) were compared across different periods. Furthermore, the adherence rate to guidelines in instances where antibiotics were explicitly indicated was compared with those reported in other studies.

## 2.10. Software

Data were extracted from ResUrgences 5 Version PEDIA PROD (Berger-Levrault, 2022) and compiled in Excel (Microsoft® 365, 2022) for prescribing assessment. Statistical analysis was performed using R software Version 4.3.1 (R Core Team, 2023).

## 2.11. Ethical statement

The study obtained approval from the Delegation for Clinical Research and Innovation at the University Hospital of Nancy, France. Approval from the Research Ethics Committee was not required, as this

study assesses professional practices without direct intervention in patient care.

# 3. Results

## 3.1. Population and diagnoses

Between May 2021 and October 2021, May 2022 and October 2022, and in May 2023, the PED recorded a total of 28,942 consultations, including 22,857 (79 %) outpatient visits. After applying the selection criteria, 1477 prescriptions were eligible for analysis: 677 in 2021 (45.8 %), 711 in 2022 (48.1 %), and 89 in 2023 (6.0 %) (see Fig. 2). Focusing exclusively on instances where antibiotics were indicated, a total of 654 prescriptions were analyzed: 304 in 2021 (46.5 %), 306 in 2022 (46.8 %), and 44 in 2023 (6.7 %). The remaining cases involved situations in which antibiotic prescriptions were withheld because therapeutic abstinence was required.

Among eligible prescriptions, 781 (52.9 %) were for male children. The average patient age was 4.5 years (range, 0–17 years), and weight ranged from 4 to 124 kg. Demographic characteristics and discharge diagnoses were consistent across the periods studied, except for a higher mean age in 2022 (4.9 years) compared to 2021 and 2023 (4 and 4.4 years, respectively). Missing data were minimal, with 12 instances for weight, 6 for dosage, 4 for frequency, and 5 for duration.

The most prevalent disease category identified was upper respiratory tract infections, followed by digestive tract infections, lower respiratory tract infections, skin and soft tissue infections, and urinary tract infections. Additional diagnoses are detailed in Supplementary Appendix D. The most frequently observed diagnosis was non-specific gastroenteritis and colitis, comprising 26.2 % of all cases. The primary diagnosis necessitating antibiotic therapy was acute suppurative otitis media (ASOM), accounting for 22.3 % of all prescriptions and representing 48.4 % of upper respiratory tract infection diagnoses. A comprehensive overview of discharge diagnoses is provided in Supplementary Appendix E.

## 3.2. Overall guideline adherence

Across all diagnoses, the adherence rate to guidelines for antibiotic selection or decisions to withhold antibiotics demonstrated a significant improvement, increasing from 88.9 % at baseline to 94.7 % in 2022 and 96.6 % in 2023 ($p < 0.001$). Specifically, for diagnoses that necessitate antibiotics, the adherence rate for antibiotic selection also exhibited a significant increase ($p = 0.001$) (see Table 1).

Nevertheless, the overall adherence to guidelines remained consistent over time, with rates of 75 % in 2021, 75.9 % in 2022, and 75.3 % in 2023 ($p = 0.942$). In clinical situations requiring antibiotics, the global guideline adherence rate remained stable at 51.6 %, 49.0 %, and 50 % for the respective years ($p = 0.810$).

Conversely, the adherence rate concerning the frequency of administration experienced a significant decline across all diagnoses combined, decreasing from 98.4 % in 2021 to 73.3 % in 2022 and 73.7 % in 2023 ($p < 0.001$).

## 3.3. Infectious disease categories

Adherence to guidelines improved across most infectious disease categories, although these changes were not statistically significant. An exception was observed for upper respiratory tract infections, where adherence to the recommended administration frequency declined from 100 % in 2021 to 59.9 % in 2022, then rose to 69.0 % in 2023. Conversely, adherence to the recommended duration of treatment exhibited a positive upward trend.

Regarding lower respiratory tract infections, adherence to guidelines improved considerably, with increases of 36.7 % in 2022 and 89.9 % in 2023 compared with the pre-intervention period, although these
<figure><img src="image_5.png" /><figcaption>Fig. 2. Flowchart. Three patients had complex clinical situations requiring two discharge prescriptions.</figcaption></figure>

improvements did not reach statistical significance. Notably, significant progress was observed in the selection of antibiotics or the decision to withhold antibiotics. Parallel upward trends were also evident in adherence to urinary tract infection and skin and soft tissue infection guidelines.

Prior to the interventions, physicians generally prescribed longer antibiotic courses than recommended for AOSM in children, community-acquired pneumonia, and acute cystitis in pediatric patients, whereas shorter treatments were administered for ASOM in infants. The prescribing patterns demonstrated improvement by the conclusion of the study (see Fig. 3).

### 3.4. Comparison of study periods

Across all categories, global guideline adherence increased significantly from P0 to P3, as did the proportion of decisions to initiate appropriate antibiotics or refrain from prescribing. There was no significant increase in adherence to dosage, frequency, or duration, although adherence to treatment duration showed a positive trend. During the September-October 2021 period (P4), a statistically significant decline in adherence to frequency recommendations was observed, which affected the overall guideline adherence (Fig. 4).

### 3.5. Avoidance of antibiotic therapy

We evaluated compliance with guidelines advising against antibiotic

prescription. The conditions identified encompassed otitis externa, acute non-suppurative otitis media, poorly symptomatic ASOM in children, non-streptococcal tonsillitis or tonsillitis in children under three years of age, common acute parotitis, acute rhinopharyngitis, acute bronchitis, bronchiolitis, non-severe impetigo, uncomplicated furuncle, paronychia, and non-specific gastroenteritis and colitis. Compliance rates were notably high for these conditions, indicating strong familiarity with the relevant guidelines (see Supplementary Appendix E).

### 3.6. Antibiotic consumption

In 2021, 406 visits resulted in antibiotic prescriptions, leading to the dispensing of 793 boxes of antibiotics. In 2022, 380 consultations were recorded, resulting in the dispensing of 742 boxes of antibiotics (see Table 2). This results in a 6.4 % decrease in antibiotic prescriptions and the same reduction in antibiotic utilization. In May 2023, owing to the limited duration of observation, comparative statistical analyses could not be conducted.

### 3.7. Participants

During the implementation period, five meetings were scheduled for prescribers in 2022: early May, early June, early July, early September, and late October. Resident physicians attended all meetings, with participation ranging from 12 to 22 of the 25 team members working in the PED (attendance rate from 48.0 % to 88.0 %). Senior physicians
<table><caption>**Table 1**
Adherence to guidelines for antibiotic prescribing in the pediatric outpatient population.</caption><thead><tr><th rowspan="2">Infectious diseases categories</th><th rowspan="2">Prescription component</th><th colspan="3">Adherence to the guideline, n (%)</th><th rowspan="2">p-value</th></tr><tr><th>2021 (Preintervention)</th><th>2022 (Post-intervention)</th><th>2023 (Post-intervention)</th></tr></thead><tbody><tr><td rowspan="3">All infectious diseases (n = 1477)</td><td>Antibiotic prescription or abstention</td><td>602/677 (88.9)</td><td>673/711 (94.7)</td><td>86/89 (96.6)</td><td>&lt;0.001<sup>*,§</sup></td></tr><tr><td>Dosage</td><td>238/245 (97.1)</td><td>265/277 (95.7)</td><td>37/38 (97.4)</td><td>0.629</td></tr><tr><td>Frequency</td><td>242/246 (98.4)</td><td>203/277 (73.3)</td><td>28/38 (73.7)</td><td>&lt;0.001<sup>*,§</sup></td></tr><tr><td rowspan="5">Diagnoses requiring antibiotics (n = 654)</td><td>Duration</td><td>164/244 (67.2)</td><td>193/277 (69.7)</td><td>30/40 (75.0)</td><td>0.578</td></tr><tr><td>Entire prescription</td><td>508/677 (75.0)</td><td>540/711 (75.9)</td><td>67/89 (75.3)</td><td>0.924</td></tr><tr><td>Antibiotic prescription</td><td>250/304 (82.2)</td><td>281/306 (91.8)</td><td>41/44 (93.2)</td><td>0.001<sup>*</sup></td></tr><tr><td>Dosage</td><td>236/243 (97.1)</td><td>263/275 (95.6)</td><td>36/37 (97.3)</td><td>0.766</td></tr><tr><td>Frequency</td><td>240/244 (98.4)</td><td>201/275 (73.1)</td><td>27/37 (73.0)</td><td>&lt;0.001<sup>*,§</sup></td></tr><tr><td rowspan="5">Upper respiratory tract infections (n = 682)</td><td>Duration</td><td>163/242 (67.4)</td><td>193/275 (70.2)</td><td>29/39 (74.4)</td><td>0.607</td></tr><tr><td>Entire prescription</td><td>157/304 (51.6)</td><td>150/306 (49.0)</td><td>22/44 (50.0)</td><td>0.810</td></tr><tr><td>Antibiotic prescription or abstention</td><td>282/312 (90.4)</td><td>299/321 (93.1)</td><td>46/49 (93.9)</td><td>0.412</td></tr><tr><td>Dosage</td><td>143/147 (97.3)</td><td>160/172 (93.0)</td><td>28/29 (96.6)</td><td>0.196</td></tr><tr><td>Frequency</td><td>147/147 (100.0)</td><td>103/172 (59.9)</td><td>20/29 (69.0)</td><td>&lt;0.001<sup>*,§</sup></td></tr><tr><td rowspan="3">Lower respiratory tract infections (n = 148)</td><td>Duration</td><td>99/146 (67.8)</td><td>118/172 (68.6)</td><td>23/31 (74.2)</td><td>0.783</td></tr><tr><td>Entire prescription</td><td>231/312 (74.0)</td><td>199/321 (62.0)</td><td>30/49 (61.2)</td><td>0.003<sup>*</sup></td></tr><tr><td>Antibiotic prescription or abstention</td><td>57/81 (70.4)</td><td>58/63 (92.1)</td><td>4/4 (100)</td><td>0.003<sup>*</sup></td></tr><tr><td rowspan="5">Urinary tract infections (n = 99)</td><td>Dosage</td><td>44/46 (95.7)</td><td>47/47 (100)</td><td>3/3 (100)</td><td>0.289</td></tr><tr><td>Frequency</td><td>44/47 (93.6)</td><td>43/47 (91.5)</td><td>3/3 (100)</td><td>1</td></tr><tr><td>Duration</td><td>26/45 (57.8)</td><td>25/47 (53.2)</td><td>2/3 (66.7)</td><td>0.866</td></tr><tr><td>Entire prescription</td><td>32/81 (39.5)</td><td>34/63 (54.0)</td><td>3/4 (75.0)</td><td>0.125</td></tr><tr><td>Antibiotic prescription or abstention</td><td>38/50 (76.0)</td><td>42/45 (93.3)</td><td>4/4 (100)</td><td>0.043<sup>*</sup></td></tr><tr><td rowspan="5">Skin and soft tissue infections (n = 144)</td><td>Dosage</td><td>32/32 (100)</td><td>41/41 (100)</td><td>4/4 (100)</td><td>N/A</td></tr><tr><td>Frequency</td><td>32/32 (100)</td><td>40/41 (97.6)</td><td>4/4 (100)</td><td>1</td></tr><tr><td>Duration</td><td>24/32 (75.0)</td><td>35/41 (85.4)</td><td>4/4 (100)</td><td>0.402</td></tr><tr><td>Entire prescription</td><td>29/50 (58.0)</td><td>35/45 (77.8)</td><td>4/4 (100)</td><td>0.042<sup>*</sup></td></tr><tr><td>Antibiotic prescription or abstention</td><td>46/55 (83.6)</td><td>71/77 (92.2)</td><td>12/12 (100)</td><td>0.149</td></tr><tr><td rowspan="5">Digestive Tract Infections (n = 396)</td><td>Dosage</td><td>18/19 (94.7)</td><td>14/14 (100)</td><td>2/2 (100)</td><td>1</td></tr><tr><td>Frequency</td><td>18/19 (94.7)</td><td>14/14 (100)</td><td>1/2 (50.0)</td><td>0.113</td></tr><tr><td>Duration</td><td>14/20 (70.0)</td><td>12/14 (85.7)</td><td>1/2 (50.0)</td><td>0.359</td></tr><tr><td>Entire prescription</td><td>37/55 (67.3)</td><td>69/77 (89.6)</td><td>10/12 (83.3)</td><td>0.006<sup>*,§</sup></td></tr><tr><td>Antibiotic prescription or abstention</td><td>176/176 (100)</td><td>200/200 (100)</td><td>20/20 (100)</td><td>1</td></tr><tr><td rowspan="5">Others (n = 8)</td><td>Dosage</td><td>1/1 (100)</td><td>3/3 (100)</td><td>0/0 (0.0)</td><td>N/A</td></tr><tr><td>Frequency</td><td>1/1 (100)</td><td>3/3 (100)</td><td>0/0 (0.0)</td><td>N/A</td></tr><tr><td>Duration</td><td>1/1 (100)</td><td>3/3 (100)</td><td>0/0 (0.0)</td><td>N/A</td></tr><tr><td>Entire prescription</td><td>176/176 (100)</td><td>200/200 (100)</td><td>20/20 (100)</td><td>1</td></tr><tr><td>Antibiotic prescription or abstention</td><td>100</td><td>N/A</td><td>N/A</td><td>N/A</td></tr><tr><td rowspan="5"></td><td>Dosage</td><td>N/A</td><td>N/A</td><td>N/A</td><td>N/A</td></tr><tr><td>Frequency</td><td>N/A</td><td>N/A</td><td>N/A</td><td>N/A</td></tr><tr><td>Duration</td><td>N/A</td><td>N/A</td><td>N/A</td><td>N/A</td></tr><tr><td>Entire prescription</td><td>3/3 (100)</td><td>0 (0.0)</td><td>0 (0.0)</td><td>N/A</td></tr></tbody></table>

attended only one meeting in June 2022, with eight present out of the 17 physicians working in the PED (attendance rate of 47.1 %). The final meeting, conducted in May 2023, served exclusively as a feedback session, given that the teams had been reorganized.

Upon the conclusion of the interventions, the satisfaction survey administered to the residents demonstrated their overall appreciation for this audit and systematic feedback initiative. Fourteen residents participated. They perceived a positive impact on patient care, with an average rating of 4.4 out of 5, and acknowledged the educational value of the initiative, rated at 4.5 out of 5. Moreover, they expressed interest in future interventions, with a rating of 4.6 out of 5, and indicated their willingness to recommend this program to their peers, scoring at 4.5 out of 5.

## 4. Discussion

This study found consistent adherence to antibiotic prescription guidelines for infectious diseases within outpatient settings throughout the duration of our Antimicrobial Stewardship Program (ASP). However, a significant enhancement was observed in compliance with the decision to prescribe the appropriate antibiotic or to withhold prescription.

Our baseline overall guideline adherence rate of 75 % was notably high in comparison to previous studies conducted in France (28–72 %) [16–20] and internationally (20–78 %) [20–27]. This could explain our challenges in identifying a significant temporal variation. Regarding conditions necessitating antibiotic therapy, our adherence rate of 51.6 % aligns with those documented in the existing literature. Moreover, the

<footnote>* Significant evolution between 2021 and 2022.</footnote>

<footnote>§ Significant evolution between 2021 and 2023.</footnote>

<footnote>Had oc analysis comparing periods in pairs without attributing the significant evolution to a specific period
 N/A: not applicable.</footnote>
<figure><img src="image_6.png" /><figcaption>**Fig. 3.** Prescribed treatment durations for the most common diseases encountered. ASOM, acute suppurative otitis media; CAP, community-acquired pneumonia. The sum of situations in the period is shown above each column. The recommended treatment duration is highlighted in bold and underlined.</figcaption></figure>

<figure><img src="image_7.png" /><figcaption>**Fig. 4.** Evolution of guideline adherence over different periods. The significant p-value compares P0 with P3 and P0 with P4. The lines indicate trends.</figcaption></figure>

distribution of infectious diseases observed was consistent with prior reports [28].

A comparable study conducted by Nedved et al. across three medical centers involving 36,000 pediatric outpatients reported an initial guidelines adherence rate of 32.7 %. This rate increased to 52.4 % subsequent to the implementation of a comprehensive ASP intervention, which included pediatric infectious disease physicians and pharmacists [27]. Conversely, our study was of shorter duration, involved fewer dedicated staff members, and exhibited a higher baseline adherence

rate, which may have constrained our capacity to demonstrate significant improvements.

One finding of this study was the lower adherence rate to guidelines for antibiotic frequency in upper respiratory tract infections, which notably influenced the overall results. Despite being among the most prevalent diseases, compliance with the ASOM guidelines remained modest. The observed decline in performance during the autumn months (P4) indicates a seasonal effect of ear-nose-and-throat infections. The 2021 revisions to the ASOM guidelines, which introduced
<table><caption>**Table 2**
Antibiotic consumption report from the regional medical services department of french health insurance.</caption><thead><tr><th></th><th>Number of emergency room visits leading to an antibiotic prescription</th><th>Number of patients affected</th><th>Number of antibiotic boxes dispensed</th><th>Variation of emergency room visits leading to an antibiotic prescription compared to the previous year</th><th>Variation of antibiotic boxes dispensed compared to the previous year</th></tr></thead><tbody><tr><td>2021</td><td>406</td><td>394</td><td>793</td><td>-</td><td>-</td></tr><tr><td>2022</td><td>380</td><td>371</td><td>742</td><td>-6.4 %</td><td>-6.4 %</td></tr><tr><td>2023</td><td>52</td><td>51</td><td>88</td><td>N/A</td><td>N/A</td></tr></tbody></table>

N/A, not applicable.

more precise parameters for dosage, frequency, and duration, may have contributed to inappropriate prescriptions if inadvertently overlooked. Excluding ASOM cases, adherence to guidelines would have increased to 78.7 % in 2021, 86.8 % in 2022, and 91.4 % in 2023 (p < 0.001).

The most significant improvements occurred between 2021 and 2022, followed by stabilization in 2023, indicating a sustained effect of the interventions, particularly among senior physicians who participated throughout all the study periods. Notably, the highest adherence rates to the guidelines were recorded for less common infections, suggesting that physicians tend to consult guidelines more frequently when managing rarer diseases.

This study exhibits several notable strengths. To the best of our knowledge, this is the first study in France to evaluate the impact of repeated antimicrobial stewardship interventions with systematic feedback in a pediatric emergency department. Recent guidance from the Joint Programming Initiative on Antimicrobial Resistance underscores the importance of regular audits and feedback regarding antibiotic prescribing practices in primary care settings [14]. Although the optimal frequency remains undetermined, it is recommended that such evaluations be conducted at least annually. Furthermore, to our knowledge, our study is unique in examining the decision-making process for withholding antibiotics, thereby emphasizing healthcare providers' awareness of situations that warrant withholding antibiotics. Indeed, one of the primary roles of an antimicrobial stewardship team is to support prescribers in cases where antimicrobials should be withheld.

Nonetheless, our study has certain limitations. It was conducted at a single center with a relatively small sample size, thereby limiting its statistical power. The incomplete participation of senior practitioners may have led to an underestimation of the interventions on guideline adherence, despite them being provided with the same feedback and relevant documents as residents, and infectious disease specialists remaining accessible over time. Since senior physicians supervise all resident prescriptions and are pivotal long-term practitioners within the department, their full engagement is essential for fostering sustainable changes in clinical practice. However, their varied responsibilities across the pediatric emergency department, other hospital units, and external facilities posed challenges in organizing dedicated educational sessions due to staffing and time constraints. This lack of dedicated human resources, as opposed to the structured antimicrobial stewardship team successfully implemented in other countries, likely limited the effectiveness of this ASP. Lastly, utilizing the International Classification of Disease 10th Revision for data collection may have resulted in the omission of pertinent medical cases.

Notwithstanding these limitations, compliance with guidelines in our PED is comparable to that documented in international literature. Nonetheless, there remains scope for improvement, especially in the management of prevalent infections such as ASOM, community-acquired pneumonia, and skin and soft tissue infections, which are common sources of antibiotic overprescription. The frequency and duration of antibiotic therapies should be subjected to meticulous

consideration, despite an observed upward trend in our study. Moreover, broadening guidelines to encompass presently uncovered clinical circumstances could further refine prescribing practices.

Collaboration with the regional department of the French Health Insurance has facilitated an assessment of the impact of our Antimicrobial Stewardship Program (ASP) on antibiotic consumption. All consultations in PED resulting in an antibiotic prescription were considered, encompassing local antibiotic therapy and prophylactic antibiotic treatment. This explains the discrepancies between the number of consultations reported by the French Health Insurance (406 visits in 2021, 380 in 2022, and 52 in 2023, see Table 2) and our data (304, 306, and 44, respectively, see Table 1). Nevertheless, a promising downward trend in antibiotic consumption over time was observed. However, further research is required to evaluate the cost-effectiveness of pediatric ASPs, as the current body of evidence remains limited [13, 29].

Our program received positive feedback from practitioners, who acknowledge its pedagogical significance and expressed willingness to endorse it to their peers. Future initiatives should incorporate pediatricians, infectious diseases specialists, microbiologists, pharmacists, and hygienists into a permanent medical team to further enhance prescribing practices, reduce AMR, decrease adverse drug reactions, improve patient safety, and consequently reduce drug costs. The Pediatric ASP, as implemented in Germany since 2015 and the United Kingdom since 2019, may serve as a valuable model [10,26,27].

## 5. Conclusion

Few studies have examined the implementation of pediatric antimicrobial stewardship programs, particularly in France. This may be due to the financial and human resources required to develop local programs tailored to the needs of facilities, practitioners, and their pediatric populations.

Our study demonstrated a positive impact of an antimicrobial stewardship program in the pediatric emergency department of our French university hospital. These results provide a promising foundation for the development and implementation of similar programs in pediatric settings, which seem essential to improve antibiotic prescribing practices and combat the rise of antibiotic resistance in this vulnerable population.

## Declaration of competing interest

The authors have no conflicts of interest relevant to this article to disclose.

## Author contribution statement

MB and AC conceived and designed the study. ABD and CS facilitated the implementation of the study. MB collected clinical data. AF performed the statistical analyses. OP contributed to acquisition and interpretation of consumption data. MB, AF and AC interpreted the data. MB drafted the manuscript. All authors critically revised the manuscript for important intellectual content and approved the final version of the manuscript.

## Acknowledgments

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

## Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.arcped.2026.01.002.
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