Characterizing Antimicrobial Prescription Practices and Deviation from Published Guidelines in Pediatric Group A Streptococcal Pharyngitis: A Retrospective Study

Abstract Corresponding Author: Shannon Hamilton, DO, Ryan White Center for Pediatric Infectious Diseases, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, Indiana, USA, Email: [email protected] Abbreviations: GAS (group A Streptococcus), GASP (group A Streptococcus pharyngitis), Infectious Diseases Society of America (IDSA), emergency department (ED), primary care center (PCC) Sources of funds: This work was supported by the Pediatric Infectious Diseases Society Health Disparities Fellowship funded by Sanofi Pasteur. No conflicts of interest. Background Little is known about the relationship between patient demographics and prescriber adherence to treatment guidelines. Using group A streptococcal pharyngitis (GASP) as the model, the primary aim of this study is to evaluate the relationship between patient demographics and clinical practice guideline adherence with antibiotic prescribing. Methods This is a retrospective review of patients < 18 years old presenting to an emergency department (ED) and primary care center (PCC) in Indianapolis, IN between January 1, 2014 and December 31, 2019. Subjects were identified by ICD-9/10 diagnosis code for GASP and a positive streptococcal test. Patients were excluded if they had GASP in the previous 30 days, were treated for another bacterial infection at time of the visit, required hospitalization, or had an immunocompromising condition. Demographic and clinical data were collected via review of the electronic medical record. The primary endpoints were the number and types (relating to dosing and duration of antibiotics) of deviations from the IDSA 2012 GASP Guidelines. Results Of the 1,184 patients who met criteria, 33.5% had no guideline deviations, 54.1% had one, and 12.5% had more than one. The most common type of deviation was higher than recommended antibiotic dosing. Treatment in the PCC was associated with a lower number of guideline deviations (OR 0.5, 95% CI 0.3,0.9, p=0.021). Hispanic or Latinx ethnicity was associated with greater odds of undertreatment (OR 1.6; 95% CI 1.1, 2.3; p=0.011). Conclusions Treatment in the PCC was associated with a lower number of guideline deviations. Additionally, Hispanic or Latinx ethnicity was associated with higher odds of antibiotic undertreatment. This preliminary data demonstrates that there is an opportunity for systems- based guideline implementation for delivery of equitable care and improved antimicrobial stewardship for all patients.