Implementation of a pediatric antibiotic stewardship intervention across a large integrated health system: protocol to optimize antibiotic selection and prescription duration for acute respiratory tract infections in children

Abstract Background Appropriate antibiotic prescribing for routine childhood illnesses in ambulatory settings remains a major challenge especially at scale. The frequent overuse and misuse of antibiotics may lead to side effects in the children receiving them and contribute to the emergence of antibiotic-resistant bacteria. Substantial evidence suggests that adherence to established antibiotic prescribing guidelines curtails negative consequences without compromising treatment outcomes. However, adoption of guidelines remains stubbornly static. Implementation studies show specific strategies are effective at improving antibiotic stewardship (e.g., audit and feedback, electronic medical records EMR tools); however, there is limited evidence on how these strategies function when implemented across a large health system. As a large integrated health system, Intermountain Health (IH) is well-positioned for a scaled implementation of guideline-concordance antibiotic stewardship for acute respiratory tract infections (ARTIs) in children due to its previous stewardship work, culture of continuous quality improvement, and implementation infrastructure. Methods This study will evaluate the implementation of guideline-concordance prescribing for Acute Respiratory Tract Infections (ARTIs) in children 6 months to less than 18 years of age in ~ 250 sites across 5 care specialties (pediatrics, family medicine, urgent care, emergency department, and telehealth). The evaluation will focus on: (1) the overall effectiveness of implementation strategies at driving adherence to guideline-concordant care across the organization, (2) the nature of variability in strategy implementation and adherence by context (e.g., specialty, rurality, region), and (3) the utility of a more intensive implementation, termed “Boost,” for sites with lower adherence after general implementation. Primary effectiveness outcome is adherence to guideline-concordant antibiotic selection. Secondary outcomes include adherence to guideline-concordant antibiotic prescription duration , and the combination of both selection and duration termed Recommended Antibiotic and Duration Adherence Rate (RADAR). We will employ an observational, quasi-experimental approach comparing adherence before and after implementation in two waves across the organization and pre-post Boost for sites selected for intensive implementation support. In addition, we will investigate the correlations between use of implementation strategies and changes in adherence. Discussion This study aims to fill a critical gap in the literature concerning implementation of antibiotic stewardship at large scale. Following established implementation science regarding effective implementation strategies, this evaluation tests their utility across diverse settings thus enabling investigation of contextual determinants. In addition, the evaluation will investigate the response to general implementation strategies at scale as well as more targeted strategies, akin to academic detailing, for selected sites which require additional focused resources. Trial registration ClinicalTrials.gov registration #NCT07334795.