O2165: Effectiveness of Standardizing Chest Radiograph Reporting to Reduce Antibiotic Overuse in Pediatric Pneumonia

Purpose/Objectives: Antibiotics are overused for children with community-acquired pneumonia (CAP). Chest radiograph (CXR) is the most used diagnostic tool, yet report terminology varies, CXRs cannot identify etiology, and terms such as “pneumonia” may contribute to antibiotic overuse. The objective of this study was to implement a radiology-based intervention to decrease the percent of children with lower respiratory tract infections (LRTI) and CXRs who receive antibiotics for typical CAP from 31% to 21% by January 2025.

Design/Methods: We recruited a multidisciplinary team and identified key drivers of antibiotic overuse in pneumonia. We focused on 1) developing standard CXR impressions, 2) removing the term “pneumonia” 3) adding an education statement highlighting CXR limitations in distinguishing viral and bacterial CAP, and 4) referencing our institutional CAP clinical pathway. Hospital-wide education began in March and standard impressions went live in June 2023. Our study population included non-medically complex, non-critically ill children with a CXR and diagnosis code for LRTI including CAP, bronchiolitis, influenza, and asthma in the emergency department (ED), inpatient, or outpatient settings of a multi-site children’s hospital network from 2022-2025. Aim 1 was the percent of inpatients with ≥ 1 dose of antibiotics for CAP, based on selection of mandatory institutional antibiotic order indications. Aim 2 was the percent of inpatients who received a full course of antibiotics and Aim 3 was the percent of ED/outpatients prescribed antibiotics for CAP. Our process measure was percent of CXR results with standard impressions. Balancing measures included rate of 7-day ED visit or readmission, ICU transfer, chest tube placement, and length of stay. We used statistical process control charts to evaluate outcomes over time and measured balancing measures pre vs. post intervention using Pearson’s chi-squared and Kruskal-Wallis tests.

Results: We included 12,811 patients over the study period. For Aims 1 and 2, there was special cause variation around the time of our interventions with a decrease in antibiotic initiation (34% to 29%; Figure 1) and full course of antibiotics (29% to 25%) for inpatients. However, this decrease was not sustained and there was subsequent special cause variation with an increase in antibiotic initiation to 41% and receipt of full course to 36%. Aim 3 did not show a decrease and similarly increased towards the end of the study. Utilization of standard CXR impressions was 79% and sustained over the study period. There were small statistically significant differences in some balancing measures (Table 1).

Conclusion/Discussion: While standardizing CXR impressions may have temporarily reduced antibiotic prescribing for CAP, it was not sustained and there has been a recent unexplained increase in antibiotic prescribing in 2024. Our improvement team is working to understand and improve these findings by collecting further data and modifying standard CXR impressions based on feedback from end users.