Random Sampling for Inappropriate Prescribing Informs Intervention Opportunities for Antimicrobial Stewardship Programs
Authors: Ahmad Zayd , Jaggi Preeti , Lu Lydia 
Published: January 2025

Abstract

Corresponding Author Information:
Zayd Ahmad, PharmD, Corresponding Author, No conflict, Antimicrobial Stewardship Clinical Pharmacist Specialist, Department of Pharmacy, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States, 404-785-5437, 1405 Clifton Rd NE, Atlanta, Georgia 30322, zayd.ahmad@choa.org
Preeti Jaggi, MD, Alternate Corresponding Author, No conflict, Director of Antimicrobial Stewardship, Children’s Healthcare of Atlanta, Associate Professor of Pediatrics, Emory University, Atlanta, Georgia, United States, 614-353-2588, 1405 Clifton Rd NE, Atlanta, Georgia 30322, preeti.jaggi@emory.edu

Introduction
Antibiotics are commonly prescribed in pediatrics. Recent literature suggests the rate of suboptimal therapy exceeds 10% of all antibiotics ordered in children’s hospitals. Prospective audit and feedback is one strategy to achieve antimicrobial stewardship goals. However, this practice is labor intensive, does not comprehensively address all clinical areas, and may not improve future prescribing if not documented and reported. Tracking and reporting of appropriate antibiotic prescribing to medical services is recommended by the Joint Commission. We sought to characterize inappropriate antimicrobial prescribing in a pediatric hospital to pinpoint specific antimicrobial and diagnostic stewardship opportunities.

Methods
In this cross-sectional analysis performed September 2023 – March 2024, the antimicrobial stewardship team reviewed 10% of patients for each medical service on a weekly basis. Unique patients with active antimicrobial orders were randomly selected the morning of each data collection day. We then evaluated each antimicrobial order for appropriateness. Primary endpoints were the rate of inappropriate use, percent of inappropriate prescribing by hospital service, and the reason the prescription was considered suboptimal. Other endpoints were proportion of inappropriateness by medication, rate of inappropriate use stratified by number of concomitant active antimicrobial orders, and system issues that most frequently contributed to erroneous use.

Results
In total, 509 patient charts with 788 antibiotic orders were sampled for review. The percentage of patients with ≥1 inappropriate antimicrobial prescription was 117/509 (22.98%). The overall rate of inappropriate prescriptions was 126/788 (15.99%). The most common reasons for inappropriate use were unnecessarily long duration of therapy (27%), missed opportunities for IV to PO switch (19.8%), and antimicrobials not indicated for treatment (15.1%) or prophylaxis (9.5%) of diagnosis. Among all services, General Pediatrics (12.1%), Pediatric Intensive Care (11.1%), and Bone Marrow Transplant (8.5%) contributed the most inappropriate use.

Conclusion
Once-weekly sampling was instructive and feasible for our program. By sampling 10% of patients receiving antibiotics, we found similar rates of inappropriate prescribing compared to national studies with a more comprehensive screening approach. Our results highlighted the shortcomings of our institutional guidelines and antibiotic prescribing practices among individual services. These methods may be replicated in other health systems to efficiently elucidate stewardship opportunities.