Training, advising pediatricians in antibiotic usage improves compliance with prescription guidelines

Educating pediatricians in their offices, auditing their prescription patterns, and leveraging a shared electronic health record, encourages them to choose more appropriate antibiotics for children with common respiratory infections, according to a study published in the June 12 issue of the Journal of the American Medical Association.

Study leader Jeffrey S. Gerber, MD, PhD, an infectious diseases specialist at The Children’s Hospital of Philadelphia (CHOP), and colleagues conducted a cluster-randomized trial, and randomized 18 pediatric primary care practices in CHOP’s primary care network in New Jersey and Pennsylvania into 2 groups. One group received the intervention (an hour-long clinician-education session at the practice office, followed by audit and feedback of antibiotic prescribing) and a control group that did not receive the educational session, audit, and feedback. The study encompassed nearly 1.3 million office visits by some 185,000 patients to 162 clinicians over a study period of 32 months, from 2008 to 2011.

Dr Gerber

Among the intervention practices, broad-spectrum antibiotic prescribing decreased from 26.8% to 14.3%, or nearly half, compared to a decrease from 28.4% to 22.6% in the control group. For children with pneumonia, the inappropriate broad-spectrum prescriptions declined by 75% among practices receiving the intervention.

The researchers followed the effects of the intervention program for only 12 months, according to Dr Gerber, so it is not known how long the benefits persist. In addition, the study team did not examine whether there were differences between the intervention and control groups in the outcomes of their patients’ infections.

The study concentrated on whether the pediatricians prescribed narrow-spectrum antibiotics, as recommended, or broad-spectrum antibiotics for acute bacterial respiratory infections such as pneumonia, acute sinusitis, and streptococcal pharyngitis (or “strep throat”). All are common conditions for which children receive antibiotics.

“Using a relatively simple intervention, we were able to improve antibiotic prescribing to children with common outpatient infections,” Dr Gerber told Formulary. “Overall, the intervention nearly halved prescribing of broad-spectrum antibiotics, which are typically not indicated, for children at acute primary care encounters, and decreased the use of off-guideline antibiotics for children with pneumonia by 75% by 1 year after the intervention.

“Our results demonstrate the ability to leverage an electronic health record to ensure that children receive guideline-recommended care,” Dr Gerber continued. “Although our study did not directly examine clinical outcomes and costs, this approach has the potential to improve clinical outcomes while reducing healthcare costs.”

According to Dr Gerber, unnecessary prescribing for viral infections, which don't benefit from any antibiotic use, is well documented and has been declining. “However, inappropriate prescribing also occurs for bacterial infections, particularly when broad-spectrum antibiotics are used to treat infections for which narrow-spectrum antibiotics are indicated and recommended. We wanted to find a way to help address this emerging problem,” he said.

“Just as there are many types of bacteria that can cause infections, there are also many different types of antibiotics,” he added. “’Narrow-spectrum’” antibiotics treat very few types of bacteria while ‘broad-spectrum’ antibiotics can treat many different types of bacteria.”

Broad-spectrum antibiotics are not “stronger” against the bacteria that cause common respiratory tract infections in children than narrow-spectrum drugs; both types can kill these germs, according to Dr Gerber.

But use of broad-spectrum antibiotics will unnecessarily expose the patient to drugs that are more likely to 1) kill “good” bacteria that live in and on the patient, which can be harmful or 2) create an environment that permits the creation or selection for antibiotic resistant germs, which can complicate the treatment of subsequent infections.

“Therefore, when prescribing antibiotics, it is important to choose an agent that targets the offending pathogen [germ] but as few other types of bacteria as possible,” he said.

“By partnering with pediatricians and leveraging a shared, electronic heath record, we were able to improve antibiotic prescribing to children with common infections,” Dr Gerber said. “It is our hope that this relatively simple intervention can be applied to other practices and patient populations to help improve patient care.”