Prescribing Broad-Spectrum Antibiotics by Pediatricians

The most common prescription drugs given to children are antibiotics, and the vast majority of these prescriptions are prescribed in the outpatient setting. Approximately 75% of pediatric antibiotic prescriptions are written to treat acute respiratory tract infections (ARTIs).

There have been studies documenting unnecessary antibiotic prescribing for viral ARTIs; however, according to researchers, inappropriate prescribing is also associated with bacterial ARTIs, particularly when a broad-spectrum drug is used to treat an infection for which narrow-spectrum drugs are indicated and recommended. Penicillin or amoxicillin is recommended by the American Academy of Pediatrics as first-line treatment for common ARTIs, but it is estimated that 50% of children with an ARTI are treated with a broader-spectrum drug.

There are few programs, such as the antimicrobial stewardship programs, implemented in hospitals that are applicable to antibiotic prescribing in the outpatient setting. To evaluate the effect of an antimicrobial stewardship intervention in the outpatient setting, researchers recently conducted a cluster randomized trial that compared intervention practices with usual care. They reported trial results in JAMA [2013;309(22):2345-2352].

The study was conducted in a network of 25 pediatric primary care practices in Pennsylvania and New Jersey. The final cohort included 18 practices, with a total of 162 clinicians. Children with chronic medical conditions, antibiotic allergies, and prior antibiotic use were excluded from the study.

The researchers estimated prescribing rates for targeted ARTIs standardized for age, sex, race, and insurance status from 230 months prior to the intervention to 12 months following the intervention. The study period was October 2008 through June 2011.

The intervention consisted of one 1-hour onsite clinician education session (June 2010) followed by 1 year of personalized, quarterly audits and feedback of prescribing for bacterial and viral ARTIs. The primary outcome measure was the rate of broad-spectrum (off-guideline) antibiotic prescribing for bacterial ARTIs and antibiotics for viral ARTIs for 1 year following the intervention.

Of the 18 pediatric primary care practices participating in the study, 9 were randomized to the intervention group and 9 to usual care (control). Overall, there were 1,291,824 office visits by 185,212 unique patients to 162 clinicians at the 18 practices during the study period. Characteristics between the 2 groups were similar.

During the study period, among patients who were prescribed antibiotics for any indication, the overall proportion of prescriptions for broad-spectrum antibiotics decreased from 26.8% to 14.3% (absolute difference, 12.5%) in the intervention group. In the control group, the proportion dropped from 28.4% to 22.6% (absolute difference, 5.8%).

The difference of differences (DOD) was 6.7%. The difference was significant when the researchers considered the relative changes in trajectories of broad-spectrum prescribing before and during the intervention between the 2 groups (P=.01).

When the researchers stratified by the individual bacterial ARTI targeted by the intervention, broad-spectrum (off-guideline) prescribing decreased from 15.7% to 4.2% in the intervention group and from 17.1% to 16.3% in the control group (DOD, 10.7%; P<001).

In conclusion, the researchers stated, “In this large pediatric primary care network, clinician education coupled with audit and feedback, compared with usual practice, improved adherence to prescribing guidelines for common bacterial ARTIs, and the intervention did not affect antibiotic prescribing for viral infections. Future studies should examine the drivers of these effects, as well as the generalizability, sustainability, and clinical outcomes of outpatient antimicrobial stewardship.”