A quality improvement project nearly quintupled the rate of children receiving evidence-based, shorter courses of antibiotics for pneumonia and sinus infections, cutting unnecessary drug exposure without increasing treatment failures, according to the researchers.

Research increasingly shows shorter courses of antibiotics — 3-5 days for community-acquired pneumonia and 5-7 days for acute bacterial rhinosinusitis — are safe in children. But clinical adoption has lagged, leaving kids exposed to 10-day regimens that elevate risks for antibiotic resistance, adverse drug side effects, and unnecessary costs.

The new study, published in Pediatrics, demonstrates that combining EHR modifications and peer comparison data with frontline clinician champions can establish shorter antibiotic durations as standard care.

“There’s a lot of evidence for adults that 5-7 days is fine — the only reason pediatrics is not included in that is because there were not enough studies on kids. But the physiology of sinusitis is not different between a kid and an adult,” said Rana El Feghaly, MD, MSCI, director of the Division of Infectious Diseases at Children’s Mercy Kansas City in Kansas City, Missouri, who helped lead the research.

El Feghaly and her team targeted uncomplicated pneumonia and sinusitis because the last guidelines from the Infectious Diseases Society of America on these conditions were issued in 2011 and 2012, respectively, and are now retired.

“There’s been a lot of studies since then that show that 5 days or even 3 days are as good as a 7- to 10-day course,” she said.

Prior to the initiative, clinicians across the health system’s emergency and urgent care departments selected the recommended first-line antibiotic in more than 90% of visits, but just 13.8% vs 5.4% of pneumonia cases vs sinusitis cases received shortened durations aligned with Children’s Mercy’s institutional guidelines for 3-5 days for community-acquired pneumonia and 5-7 days for sinusitis.

At the end of the intervention, rates increased to 64.4% vs 66.9% for pneumonia vs sinusitis. A run chart showed a median of 2.5% encounters resulting in returns within 14 days per month with no shifts in trends after the intervention launched.

The intervention was conducted across two academic pediatric emergency departments in Missouri and Kansas between February 2024 and July 25, covering 1931 patient encounters. A 16-month period starting in August 2022 served as the baseline (1013 encounters).

Nearly 3000 children aged between 6 months and 18 years who had pneumonia or sinusitis and were discharged with oral antibiotics were included in the analysis. Children with concurrent infections who were admitted to the hospital or discharged without a prescription were excluded from the study.

The researchers analyzed the type of antibiotic prescribed, duration, and return visits to the health system with the same diagnosis within 2 weeks of the index visit.

Early on, clinicians completed a survey on usual prescribing practices and attitudes toward shorter durations. Most respondents had been practicing for more than 15 years. Many said seeing more data would provide comfort in changing their prescribing habits.

In response, El Feghaly and colleagues provided educational materials with evidence for shorter treatment durations in workrooms. Clinicians also received quarterly feedback emails on their prescribing patterns compared with those of their colleagues, which also included summaries of supporting evidence and a solicitation for feedback.

They also updated the clinical pathway for community-acquired pneumonia and sinusitis, which included a diagnostic workup and recommendations for shorter courses. Order sets were also changed to show shorter courses at the top and longer courses at the bottom.

“If you were trained that you need 10-14 days to treat pneumonia in a child and to do less is dangerous, to do less risks resistance, it often takes a preponderance of data and time to change practice because then you have to see that it is working, that a shorter course isn’t a problem,” said David J. Cennimo, MD, associate professor of pediatrics and infectious diseases at Rutgers New Jersey Medical School in Newark, who was not involved with the study.

El Feghaly said another contributing factor to the success was a frontline physician from the emergency department who helped lead the project.

“If you have a frontline clinician who is willing to lead the work with you, it increases your chances of success because they know the intricacies of their own location and they know how to potentially help people adapt to the change differently.”

Cennimo said the return rate shows treatment durations can be safely reduced when appropriate.

They were “‘only’ treated for 3-5 days and nothing bad happened, and we have to keep pointing out the ‘and nothing bad happened’ because that’s the corollary to, ‘I’m worried something bad is going to happen,’ which is why a clinician might prescribe a longer course, he said. ‘I don’t have to be worried that these FY durations are too short.’”

El Feghaly said she and her colleagues are now working on a project with outpatient practices that are affiliated with the health system to improve antibiotic durations, including conducting a similar survey to identify barriers.

“If our ED and urgent care is giving you a 5-day course for pneumonia, and then you go to your primary care provider and they’re still prescribing 14 days, that’s a little confusing for families,” she said. “We want to make sure we are practicing at the same level.”

Various study authors reported receiving grant funding from Merck and an honoraria from Pfizer.

Lisa Gillespie is a senior editor at Medscape.