Community-acquired pneumonia (CAP) is diagnosed in >1.2 million children in outpatient settings and emergency departments (EDs) each year in the United States. 1, 2 Most antibiotic prescribing for CAP occurs in the outpatient setting. In 2011, members of the Pediatric Infectious Diseases Society and Infectious Diseases Society of America published an evidence-based guideline for the management of CAP in children. The authors of the recommendations encourage prescribing narrow Guideline Adoption for Community-Acquired Pneumonia in the Outpatient Setting Lilliam Ambroggio, PhD, MPH, a,b,c Colleen Mangeot, MS, b Eileen Murtagh Kurowski, MD, MS, c,d Camille Graham, MD, c,e,f Paul Korn, MD, g Marcie Strasser, MD, h Charles Cavallo, MD, i Katherine Brady, MD, j Suzanne Campanella, MPH, a Caitlin Clohessy, BA, a William B. Brinkman, MD, MEd, MSc, c,e Samir S. Shah, MD, MSCE a,c,k BACKGROUND: The Pediatric Infectious Diseases Society and Infectious Diseases Society of America national childhood community-acquired pneumonia (CAP) guideline encouraged the standard evaluation and treatment of children who were managed as outpatients. Our objectives were to (1) increase adherence to guideline-recommended diagnostics and antibiotic treatment of CAP at 5 pediatric primary care practices (PPCPs) by using quality-improvement methods and (2) evaluate the association between guideline adherence and unscheduled follow-up visits. METHODS: Immunocompetent children >3 months of age with no complex chronic conditions and who were diagnosed with CAP were eligible for inclusion in this stepped-wedge study. Interventions were focused on education, knowledge of colleagues’ prescribing practices, and feedback sessions. Statistical process control charts were used to assess changes in recommendations and antibiotic treatment. Unscheduled follow-up visits were compared across time by using generalized estimating equations that were clustered by PPCP. RESULTS: CAP was diagnosed in 1906 children. Guideline recommended therapy and pulse oximetry use increased from a mean baseline of 24.9% to a mean of 68.0% and from 4.3% to 85.0%, respectively, over the study period. Among children >5 years of age, but not among those who were younger, the receipt of guideline recommended antibiotics, as compared with nonguideline therapy, was associated with the increased likelihood of unscheduled follow-up (adjusted odds ratio, 2.12; 95% confidence interval: 1.31–3.43). Chest radiographs and complete blood cell counts were rarely performed at baseline. CONCLUSIONS: Recommendations for limited use of chest radiographs and complete blood cell counts and standardized antibiotic therapy in children is supported at PPCPs. However, the guideline may need to include macrolide monotherapy as appropriate antibiotic therapy for older children. abstract To cite: Ambroggio L, Mangeot C, Murtagh Kurowski E, et al. Guideline Adoption for Community- Acquired Pneumonia in the Outpatient Setting. Pediatrics. 2018;142(4):e20180331 Divisions of a Hospital Medicine, b Biostatistics and Epidemiology, d Emergency Medicine, e General and Community Pediatrics, and k Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; c Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; f Mid City Pediatrics, Cincinnati, Ohio; g Landen Lake Pediatrics, Mason, Ohio; h Pediatric Care Inc, Cincinnati, Ohio; i Pediatric Associates PSC, Crestview Hills, Kentucky; and j Anderson Hills Pediatrics, Cincinnati, Ohio Dr Ambroggio participated in the design of the study, developed the data collection criteria, conducted the statistical analysis, executed interventions, and drafted the initial manuscript; Mrs Mangeot participated in the design of the study, conducted the statistical analysis, and reviewed all drafts of the manuscript; Drs Murtagh Kurowski and Brinkman participated in the design of the study and reviewed all drafts of the manuscript; Drs Graham, Korn, Strasser, Cavallo, and Brady participated in the design of the study, performed chart reviews, designed and executed interventions, and reviewed all drafts of the manuscript; Ms Campanella participated in the design of the study, developed the data collection criteria, participated in data collection, and reviewed all drafts of the manuscript; Ms Clohessy participated in data collection, executed interventions, and reviewed all drafts of the manuscript; Dr Shah participated in the design of the study, designed and executed interventions, and reviewed all drafts of the manuscript; and all authors approved the final manuscript for submission. DOI: https://doi.org/10.1542/peds.2018-0331 Accepted for publication Jul 2, 2018 PEDIATRICS Volume 142, number 4, October 2018:e20180331 QUALITY REPORT by guest on June 4, 2020 www.aappublications.org/news Downloaded from