Sociodemographic Differences in Treatment of Acute Respiratory Infections in Pediatric Urgent Cares
Authors: El Feghaly Rana E , Sainz Luis , Lee Brian , Kronman Matthew , Hersh Adam , Parente Victoria , Bizune Destani , Sanchez Guillermo V , Hamdy Rana F , Nedved Amanda ,   For REDUCE (Reducing Differences in Urgent Care Encounters – Antibiotic Choice) Collaborative
Published: January 2025

Abstract

Corresponding author: Amanda Nedved, MD, 6035 W 135th Street, Overland Park, KS 66223 785-243-6865 anedved@cmh.edu
Funding Source: This work was supported by an investigator-initiated grant from Merck.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Conflict of Interest Disclosures: Dr. El Feghaly has research support from the Association for Professionals in Infection Control and Epidemiology (APIC). Dr. Nedved is the primary investigator for an antibiotic stewardship collaborative through the American Academy of Pediatrics sponsored by Pfizer.

Background
Multiple studies have shown differences in antibiotic prescribing for children with common infections by race, ethnicity, sex, age, socioeconomic factors, and healthcare setting. This study aims to characterize differences in antibiotic prescribing for respiratory illnesses in pediatric urgent cares (PUC) by these sociodemographic variables through a multi-center collaborative.

Methods
We recruited 30 PUC sites from 22 states and Washington, D.C. Sites submitted individual data from all PUC encounters of patients 6 months-18 years of age, evaluated between April 2022 and August 2023, with ICD-10 code diagnoses of acute respiratory infections (ARI). We collected primary and secondary diagnoses, antibiotic prescribed, age, race, ethnicity, health insurance type, primary language, use of interpreter, and penicillin allergy label for all encounters. We defined first-line (FL) management based on national guidelines, with no antibiotics being FL for acute viral respiratory infections and otitis media with effusion, amoxicillin or amoxicillin-clavulanate for acute otitis media and acute bacterial rhinosinusitis, amoxicillin for community acquired pneumonia, and penicillin or amoxicillin for streptococcal pharyngitis. We ran adjusted multivariate logistic regression models that included all above sociodemographic factors.

Results
We evaluated 396,340 ARI encounters, of which 351,930 (88.8%) received FL therapy (Table 1). Of 168,549 viral respiratory infections where antibiotics are not recommended, only 2% received antibiotics. Otitis media with effusion and community-acquired pneumonia had the lowest rates of FL therapy (49.9% and 60.7% respectively). Of the 206,049 encounters where antibiotics were prescribed, the most commonly prescribed antibiotics included amoxicillin and penicillin (141,285, 65.6%), followed by amoxicillin-clavulanate (30,825, 15.0%), and cefdinir (23,807, 11.5%). Azithromycin was rarely prescribed in our cohort (n= 4,535, 2.2%). The odds of receiving FL therapy were highest in Black Non-Hispanic children (OR 1.16, CI 1.13, 1.20), children with Medicaid/Medicare and Self-Pay (OR 1.21, CI 1.18, 1.24; OR 1.18, CI 1.10, 1.27 respectively) and children whose language is Spanish (OR 1.21, CI 1.12, 1.31) compared to their demographic counterparts (Table 2).

Conclusions
This national, multicenter collaborative shows higher rates of FL management for children of Black Non-Hispanic race, those with Medicaid/Medicare or Self-Pay insurance, and whose language is Spanish compared to other groups. Quality improvement frameworks can characterize the drivers of these variations in antibiotic prescribing to address potential inequities.
Table 1: Proportion of Patients Receiving First-line Management by Diagnosis

Table 2: Odds of First-Line Management