PROJECT SUMMARY
Lower respiratory tract infections (LRTI), including pneumonia, bronchiolitis, and infection-related
exacerbations of asthma, are responsible for nearly one-third of all emergency department (ED) visits and 40%
of all infection-related hospitalizations in children each year in the United States. While viruses are responsible
for the vast majority of LRTIs, antibiotics are very frequently prescribed. In fact, more days of antibiotic use are
attributable to LRTI than any other condition in children’s hospitals. Starting antibiotics unnecessarily, using
less effective or overly broad-spectrum antibiotics, and treating for longer durations than necessary all
contribute to inappropriate antibiotic use in pediatric LRTI in both ED and inpatient settings. Use of
unnecessary antibiotics has profound consequences, including common and uncommon but severe adverse
side effects, increased health care utilization and costs, and fueling the development of antimicrobial
resistance, an ongoing global public health threat. To curtail inappropriate antibiotic use, Antimicrobial
Stewardship Programs (ASPs) have become commonplace in United States hospitals and have proven to be
effective. Unfortunately, the benefits of ASPs have largely failed to translate to the unique and fast-paced ED
environment. This represents a key missed opportunity since many more children are cared for in the ED as
compared to inpatient settings, and because ED care often critically influences subsequent hospital care. Our
prior research suggests that high quality electronic health record-based clinical decision support (CDS) is a
strategy that could bridge the ED antibiotic stewardship gap and reduce inappropriate prescribing in the ED
and hospital. Our proposed research builds upon this foundational work and leverages an accomplished and
diverse study team with expertise across the continuum of clinical care and in biomedical informatics, clinical
and health services research, implementation science, and biostatistics, all housed within supportive and well-
resourced research environments. Within three children’s hospitals, we will: define critical facilitators and
barriers governing use and acceptance of antibiotic CDS at the point of care in the ED and inpatient settings
(Aim 1); create two CDS interventions seamlessly integrated into clinician workflows in the ED and inpatient
settings, including a) an antibiotic advisor (Abx CDS), and b) a real-time ASP tool (ASP CDS) (Aim 2);
measure the effectiveness of Abx CDS and ASP CDS, alone and in combination, against usual care for
increasing appropriate antibiotic use in pediatric LRTI in the ED and inpatient settings within the framework of a
pragmatic randomized controlled trial (Aim 3); and evaluate Reach, Adoption, and Implementation domains
within the trial among encounters receiving Abx CDS and ASP CDS (Aim 4). We hypothesize that we will
create stewardship-focused CDS tools that meaningfully improve antibiotic use for children with LRTI and that
are scalable in order to optimize care delivery and outcomes across a wide variety of settings.