Acute otitis media (AOM) is the most-common indication for antibiotics in children. Delayed antibiotic prescribing for AOM can significantly reduce unnecessary antibiotic use and is recommended by the American Academy of Pediatrics for select children. We sought to improve delayed prescribing for AOM across 8 outpatient pediatric practices in Colorado.


Through a collaborative initiative with American Academy of Pediatrics and the Centers for Disease Control and Prevention, we implemented an economical 6-month antimicrobial stewardship intervention that included education, audit and feedback, online resources, and content expertise. Practices used The Model for Improvement and plan-do-study-act cycles to improve delayed antibiotic prescribing. Generalized estimating equations were used to generate relative risk ratios (RRRs) for outcomes at the intervention end and 3- and 6-months postintervention. Practice surveys were evaluated.


In total, 69 clinicians at 8 practice sites implemented 27 plan-do-study-act cycles. Practices varied by size (range: 6–37 providers), payer type, and geographic setting. The rate of delayed antibiotic prescribing increased from 2% at baseline to 21% at intervention end (RRR: 8.96; 95% confidence interval [CI]: 4.68–17.17). Five practices submitted postintervention data. The rate of delayed prescribing at 3 months and 6 months postintervention remained significantly higher than baseline (3 months postintervention, RRR: 8.46; 95% CI: 4.18–17.11; 6 months postintervention, RRR: 6.69; 95% CI: 3.53–12.65) and did not differ from intervention end (3 months postintervention, RRR: 1.12; 95% CI: 0.62–2.05; 6-months postintervention, RRR: 0.89; 95% CI: 0.53–1.49).


Baseline rate of delayed prescribing was low. A low-cost intervention resulted in a significant and sustained increase in delayed antibiotic prescribing across a diversity of settings.

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