Inappropriate Antibiotic Use for Pneumonia Common

Bridget M. Kuehn

March 08, 2017

Inappropriate use of broad-spectrum antibiotics to treat children with pneumonia remains common, despite guidelines recommending more targeted treatment, two studies published online March 7 in Pediatrics have found. But some evidence suggests that stewardship efforts are starting to improve adherence to evidence-based prescribing practices.

Numerous efforts are underway to promote better antibiotic stewardship. For example, the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America released guidelines in 2011 promoting amoxicillin or penicillin as first-line choice for treatment of community-acquired pneumonia in children. Still, prescribing of broad-spectrum antibiotics for childhood pneumonia remains common in inpatient and outpatient settings.

"Antibiotic choice for [community-acquired pneumonia] varied widely across practices," Lori Handy, MD, professor of pediatrics at Thomas Jefferson University in Philadelphia, and colleagues write in the first study. "Factors unlikely related to the microbiologic etiology of [community-acquired pneumonia] were significant drivers of antibiotic choice."

To better understand the factors driving inappropriate prescribing, the researchers analyzed the electronic medical records of more than 10,000 children treated for pneumonia at a network of outpatient pediatric practices. The practices were located in rural, suburban, and urban settings in Pennsylvania and New Jersey. The investigators found that 40.7% (4239) of the children appropriately received amoxicillin, but 42.5% (4430) received macrolides, and 16.8% (1745) received other broad-spectrum antibiotics.

Clinicians at suburban practices were more likely to prescribe broad-spectrum antibiotics than in other settings (adjusted odds ratio [aOR], 7.50; 95% confidence interval [CI], 4.16 - 13.55), and patients with private insurance were more likely to receive these less targeted drugs (aOR, 1.42; 95% CI, 1.18 - 1.71).

These differences were so great that at one practice, two of 10 average children with community-acquired pneumonia would have received macrolides compared with eight of 10 similar children at another practice.

Four of five of the urban practices were associated with academic centers and used resident physicians, so it is possible that these settings are more likely to follow guidelines, the authors note. But more study is needed to understand these differences. In some cases, physicians may be acting out of biases about the respective populations they are treating, they write.

The study also found some situations in which physicians were appropriately taking into account clinical factors, such as a lack of a fever or a child being older than 5 years of age, when choosing broad-spectrum antibiotics. These physicians may have been concerned about atypical pneumonia. Children who received chest X-rays were also more likely to receive broad-spectrum medications, perhaps because they were sicker, the authors suggest.

Evidence-based decision support tools may help reduce such inappropriate outpatient prescribing, Adam L. Hersh, MD, PhD, from the Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, and Matthew P. Kronman, MD, from the Division of Infectious Disease, Department of Pediatrics, University of Washington, Seattle, write in an accompanying editorial. Efforts to identify prescribing variations and compare physicians to benchmarks may also help, they explain.

Hospital-Based Initiatives Effective

Local efforts to promote adherence to the 2011 guideline appear to be helpful in promoting judicious use of antibiotics to treat pneumonia in hospitalized children, the authors of the second study found. Derek J. Williams, MD, assistant professor of pediatrics at Vanderbilt University in Nashville, Tennessee, and colleagues examined prescribing for pneumonia at 28 children's hospitals between August 2009 and March 2015.

The study suggests that overall, the improved prescribing habits promoted in the guideline seem to have staying power. Before the guideline, fewer than 10% of children hospitalized for pneumonia received penicillin. But by March 2015, penicillin prescribing increased by 27.6% (95% CI, 23.7% - 31.5%). Hospitals that created initiatives to boost adherence to the guidelines saw an average increase in penicillin prescribing of 29.5% (interquartile range, 19.6% - 39.1%) compared with just a 20.1% (interquartile range, 9.5% - 44.5%) average increase at hospitals that did not.

Releasing local clinical practice guidelines or order sets, in particular, appeared to speed adoption of the new guidelines.

"Changes in antibiotic prescribing occurred quickly among hospitals that implemented a local [clinical practice guideline] or order set targeting guideline-concordant antibiotic use," the researchers write.

Inappropriate prescribing of antibiotics is a persistent problem in medicine, despite known harms, Dr Hersh and Dr Kronman explain. In some cases, physicians choose to prescribe antibiotics for conditions, such as viral infections, for which they provide little benefit. In fact, 30% of all antibiotics prescribed to outpatients fall into this unnecessary category. In other cases, physicians may choose a broad-spectrum antibiotic when a more targeted one would do; they also may prescribe the medication for too long or order intravenous therapy when oral treatment is sufficient. All kinds of antibiotic misuse contribute to the emergence of antibiotic-resistant infections and expose patients to unnecessary costs and potential complications.

Dr Hersh and Dr Kronman are optimistic that studies of prescribing patterns and ongoing judicious use efforts would continue to improve antibiotic prescribing.

"Much work in improving antibiotic prescribing remains to be done, although we believe we have the wind at our backs," they conclude. "The promising findings from recent interventions and the unprecedented level of focus on this issue combine to provide substantial momentum in the right direction."

The authors and editorialists have disclosed no relevant financial relationships.

Pediatrics. Published online March 7, 2017. Handy abstract, Editorial extract. Published online March 8, 2017. Williams abstract

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