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This module includes five case scenarios that cover common pediatric problems that interns may encounter. The cases were developed for interactive small-group teaching settings. Students are provided with patient sign-outs and then have a case presented to them by a faculty member. Participants then work together to respond to the patient's clinical problems. In addition, to reviewing the management of common problems such as respiratory distress, fever, and pain, students practice using and creating cross-cover sign outs. The cases work best in groups of 10–12 students, and are most appropriate for students entering the field of pediatrics. They can easily be modified for other students entering fields that care for children (e.g., family medicine or emergency medicine). The cases are improved if you also use X-rays (teaching files are fine). Each year between 20 and 40 students participate in the case discussions. Overall rating on a Likert scale from 1–5 (with 5 strongly agree) for the cases administered in 2007 and 2008 ranged from 4.4 to the item “confident managing and signing out this type of patient” to 4.8 to the item “relevant and realistic cases.”

Background Urinary tract infections (UTIs) are the most common serious bacterial infection in children; nearly 10% of girls and 2% of boys are affected during their first 8 years of life. Broad-spectrum antibiotics are popular first-line treatment agents; however, these medications can lead to resistant organisms and more severe infections over time. In July 2010, our institution implemented a clinical pathway for children presenting to the ED with UTI based on national guidelines and local consensus regarding the need for antimicrobial stewardship. A goal of the pathway was to increase narrow spectrum (cephalexin) and decrease broad spectrum (cefixime) antibiotic use for children with uncomplicated UTI presenting to the ED. Objectives To determine the impact of a UTI clinical pathway on provider antibiotic prescribing patterns. Methods We used statistical process control (p-charts) to analyze the percentage of patients receiving each antibiotic over time. Data were analyzed over a 6-year period; 1.5 years before and 4.5 years after pathway implementation. Results 2292 patients were included. The percentage of patients receiving targeted narrow spectrum antibiotics increased from an average of 19% to 73% (figure 1). There was a concomitant decrease in the percentage of patients receiving broad-spectrum antibiotics (cefixime) from 46% to 3% (figure 2). Special cause variation was noted twice during the study period; immediately following pathway implementation and again 6 months later when the pathway was revised to increase provider education regarding appropriate antibiotic use. Conclusions Implementation of clinical pathways for UTI can result in sustained improvements in antimicrobial stewardship among children seen in ED settings.

Study Data • Patient demographic information was collected as well as initial episode classification, and complex chronic conditions (CCC) • The initial episodes were classified into the following epidemiologic groups: healthcare-acquired; community-acquired; or healthcare-associated, community onset • Administrative pharmacy data was used to identify initial treatment regimens and non-CDI antibiotic use • Concomitant antibiotic use was defined as ≥3 consecutive days during which both CDI treatment and non-CDI antibiotics were given on the same day • Immunocompromised patients were defined as those with malignancy, solid organ transplant, or bone marrow transplant (BMT) using ICD-9 and procedure codes Use of concomitant antibiotics during treatment for Clostridium difficile infection (CDI) in pediatric inpatients