Antibiotic Stewardship Program Lowers Improper Prescribing

SAN DIEGO, California — An intervention that combined clinician education with audit and feedback improved adherence to guidelines for antibiotic prescribing for acute respiratory tract infections (ARTIs) by community-based primary care pediatricians, according to a new study.

The improvement was most pronounced for pneumonia, said study author Jeffrey Gerber, MD, PhD, MSCE, from the Center for Pediatric Clinical Effectiveness at the Children's Hospital of Philadelphia (CHOP) in Pennsylvania, here at ID Week 2012.

Although antibiotic stewardship programs are generally recommended for hospitals, most antibiotic use and misuse occurs in the outpatient setting, Dr. Gerber explained. More than 40 million outpatient prescriptions are written every year for children with ARTIs, and half of these are for broad-spectrum antibiotics, he added.

A pediatric outpatient antibiotic stewardship program is relatively straightforward, Dr. Gerber noted at a news conference. "There are just a few conditions that make up the vast majority of antibiotic prescribing in kids. They're typically acute respiratory tract infections, ear infections, strep throat, pneumonia, and sinus infections." These conditions account for 80% to 90% of all outpatient antibiotic prescriptions for children.

To test the impact of outpatient antibiotic stewardship on antibiotic prescribing for common pediatric ARTIs, Dr. Gerber and colleagues designed an outpatient antibiotic stewardship bundle within a pediatric primary care network affiliated with CHOP. The network was comprised of 5 urban academic practices and 24 private practices in urban, suburban, and rural settings.

The researchers enrolled 18 practice groups, each defined by location and volume. They block-randomized 9 sites to bundled intervention and 9 to no intervention.

Targets of the program were antibiotic prescribing for viral infections and prescribing of broad-spectrum antibiotics for conditions for which narrow-spectrum antibiotics are indicated. The researchers focused on amoxicillin and clavulanate, the cephalosporins, and azithromycin (not considered broad-spectrum therapy for pneumonia).

The antimicrobial stewardship intervention consisted of 1 onsite clinician education session on guideline-based antibiotic prescribing and a quarterly audit and feedback at the individual prescriber level. Results for that prescriber's practice group and for the entire network were provided for comparison.

ARTI cases of sinusitis, group A streptococcus (GAS) pharyngitis, and pneumonia were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes, and the network's electronic health record (EHR) system identified antibiotic orders.

The stewardship program excluded cases in which there was antibiotic allergy; there was an antibiotic prescription in the previous 3 months; there was a concurrent bacterial infection, exposure, or prophylaxis; and conditions were complex and chronic.

Prescribing Patterns Change in Just 1 Month

Over the 32 months of study, data were collected on 185,212 patients who made 1,435,605 office visits to 174 clinicians.

"Our intervention group decreased broad-spectrum prescribing by 48%, and the control group went down by 18%," Dr. Gerber reported. In the intervention group, off-guideline prescribing fell from about 29% at baseline to 15% 12 months after the intervention; in the control group, it decreased from about 30% to 24% (P = .001). A difference in the rates of inappropriate prescribing between the 2 groups began to appear as early as 1 month after the intervention. In the 20 months before the intervention, inappropriate prescribing rates were the same for the 2 groups.

After the start of the intervention, the use of broad-spectrum antibiotics declined in both groups. In the intervention group, use decreased from 31% of sick visits 20 months before the intervention to 15% at 12 months; in the control group, use decreased to about 25% (P = .01).

"We found that the most significant improvement was in broad-spectrum prescribing for pneumonia," Dr. Gerber said. "It dropped by 75% in the intervention group and only 6% in the control group" (P < .001), he reported.

There were no significant differences for sinusitis (P = .12) or for GAS pharyngitis (P = .82), although the rates for GAS pharyngitis were very low to begin with. There was also no difference between the intervention and control groups in the rate of antibiotic use for viral infections (P = .093).

Dr. Gerber said he was encouraged by the study findings and hopes the relatively simple techniques can be scaled to other kinds of practices that have EHRs.

Some limitations of the study were possible contamination of the control group by the intervention, ICD-9 code misclassification, and the generalizability of the findings from this academic-affiliated primary care network to outpatient pediatric primary care practice settings.

In summary, he said the study showed that clinician education coupled with audit and feedback significantly improved guideline adherence for the treatment of common ARTIs, with the most pronounced effect being for pneumonia. He said future work will gauge the durability of the effect.

Education for Parents Needed Too

Liise-anne Pirofski, MD, chief of the division of infectious diseases at the Albert Einstein College of Medicine and Montefiore Medical Center in Bronx, New York, and a meeting chair, who moderated the news conference at which these results were reported, told Medscape Medical News that she thinks the study is "groundbreaking" and that the findings are "very powerful."

Dr. Pirofski is not aware of many outpatient stewardship programs, but believes this approach is important because most oral antibiotics are prescribed in the outpatient setting. One barrier is that many older generic narrow-spectrum antibiotics require multiple daily dosing and are, therefore, less convenient than some of the newer antibiotics. "A lot of the broader-spectrum antibiotics are marketed specifically for ease of [use] — especially azithromycin and the oral third-generation cephalosporin formulations," Dr. Pirofski noted.

She views the educational component of stewardship as essential. Not only clinicians but also parents need education about antibiotic use, and that task falls to the practitioner, Dr. Pirofski explained.

"There is tension between parents and physicians now; physicians are holding back on antibiotics and parents are demanding them in a lot of instances. Sometimes when the desired outcome...doesn't happen, there can [even] be...anger," Dr. Pirofski pointed out.

Although an EHR system is necessary to audit physician performance and provide feedback, the educational component of the stewardship program can be done with or without an EHR system. "The personal interaction, I believe, is really what drove the early success of some of these antibiotic stewardships," Dr. Pirofski said.

There was no commercial funding for the study. Dr. Gerber and Dr. Pirofski have disclosed no relevant financial relationships.

ID Week 2012: Abstract 109. Presented October 18, 2012.