Intervention Improves Antibiotic Use by Pediatricians

Laurie Barclay, MD

June 11, 2013

An intervention involving clinician education, audit, and feedback improved adherence to prescribing guidelines for common pediatric bacterial, but not viral, acute respiratory tract infections (ARTIs), according to a cluster randomized trial published in the June 12 issue of JAMA.

"Antimicrobial stewardship programs have been effective for inpatients, often through prescribing audit and feedback," write Jeffrey S. Gerber, MD, PhD, from the Children's Hospital in Philadelphia, Pennsylvania, and colleagues. "However, most antimicrobial use occurs in outpatients with [ARTIs]."

In a network of 25 pediatric primary care practices in Pennsylvania and New Jersey, 162 clinicians at 18 practices participated in the trial. Using a common electronic health record, the investigators compared antibiotic prescribing rates for targeted ARTIs between control practices and those receiving an antimicrobial stewardship intervention.

The intervention consisted of a single, 1-hour, on-site clinician education session in June 2010, followed by 1 year of personalized quarterly audit of and feedback on prescribing for bacterial and viral ARTIs. The primary endpoints were prescribing rates, standardized for age, sex, race, and insurance, of broad-spectrum (off-guideline) antibiotic prescribing for bacterial ARTIs and antibiotics for viral ARTIs for 1 year after the intervention.

In the intervention practices, broad-spectrum antibiotic prescribing decreased from 26.8% to 14.3% compared with 28.4% to 22.6% in control practices (difference of differences [DOD], 6.7%; P = .01). Reductions in off-guideline prescribing were better with the intervention among children with pneumonia (DOD, 10.7%; P <.001), but there was no significant difference in the treatment of children with acute sinusitis (DOD, 14.0%; P = .12).

"This intervention nearly halved prescribing of broad-spectrum antibiotics to children during acute primary care encounters and decreased use of off-guideline antibiotics for children with pneumonia by 75 percent by 1 year after the intervention," the authors write.

For streptococcal pharyngitis and viral infections, off-guideline prescribing was uncommon at baseline and changed little during the study, with no significant between-group differences.

Study Implications

"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," the study authors write. "Future studies should examine the drivers of these effects, as well as the generalizability, sustainability, and clinical outcomes of outpatient antimicrobial stewardship."

Study limitations include only 12-month observation and possibly low generalizability. The investigators could not determine which element or elements of the intervention drove the reduction in prescribing, could not identify heterogeneity of treatment effect, and could not compare infection outcomes between groups.

In an accompanying editorial, Jonathan A. Finkelstein, MD, MPH, from Boston Children's Hospital and Harvard Medical School in Massachusetts, notes that the success of such interventions depends in part on barriers to adoption and the facilitators that might overcome them.

"[B]road-spectrum antibiotic overuse continues in humans across age groups and conditions, as well as in agricultural use and other factors that drive emerging resistance," Dr. Finkelstein writes. "The good news is that a range of effective techniques for promoting judicious prescribing in ambulatory care have been developed and tested; it is also apparent that the influence and benefit of any of these interventions will vary greatly across settings. Tailoring strategies to contextual factors and adapting them further during implementation may well be more effective than merely rolling out the approach with the greatest average effect in the average practice."

The Agency for Healthcare Research and Quality supported this study. One coauthor has reported consultancy for the Taylor Collaboration. One coauthor has reported consultancy for Nemours/PCORI and receipt of an honorarium from Elsevier; this coauthor also is a coinventor of clinical decision support software. One coauthor has reported board membership for Tengion Inc and providing expert testimony for various entities. One coauthor has reported consultancy for Merck, Pfizer, Astellas, Cubist, and HemoCue and payment for lectures/speakers bureaus from Merck. Dr. Finkelstein reports previous consultancy for the Institute for Healthcare Improvement.

JAMA. 2013;309:2345-2352, 2388-2389.

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