Study cuts down on unnecessary antibiotic prescribing by pediatricians

A program that combined education and feedback of physicians' prescribing habits reduced the amount of unnecessary antibiotics prescribed to kids in pediatrician's offices, according to a study in the June 12 issue of JAMA.

Overprescribing has resulted in antibiotics losing their effectiveness, which makes infections harder to treat.

Led by researchers from The Children's Hospital of Philadelphia, the study included 162 clinicians from 18 of the Children's network pediatric primary care practices in Pennsylvania and New Jersey, participated.

The practices were randomly divided into two groups: one group was told the study would take place, and the other group had a one hour course on the latest recommendations for antibiotic usage and each pediatrician received a quarterly update on prescribing habits. During the nearly three years of the study, there were 1,291,824 office visits by 185,212 different patients.

The vast majority of antibiotic use occurs in the outpatient setting, roughly 75 percent of which is for acute respiratory tract infections (ARTIs). Through the network's electronic health record, the researchers reviewed prescribing for sinus infection, strep throat and pneumonia after omitting cases that involved children with chronic medical conditions, antibiotic allergies or antibiotic use during the three months preceding the study period.

We asked study author Jeffrey S Gerber, MD, PhD, from the division of infectious diseases at The Children's Hospital of Philadelphia and assistant professor of pediatrics at the University Of Pennsylvania School Of Medicine to tell us more about the study's findings and what we need to know about antibiotics.

In general, why has the overprescribing of antibiotics taken place?

This is a complex question with many contributing forces. But it can sometimes be difficult to distinguish between bacterial infections (which often benefit from antibiotics) and viral infections (which do not benefit from antibiotics), so the conservative play is to give them. This would be ok if there was not a downside to antibiotic use, but there is.

The study notes that unnecessary prescribing for viral ARTIs has been in the decline. However, inappropriate prescribing also occurs for bacterial ARTIs, particularly when broad-spectrum antibiotics are used to treat infections for which narrow-spectrum antibiotics are recommended. Why is it important not to treat infections with a broad-spectrum antibiotic when a narrow-spectrum one is recommended?

Just as there are many types of bacteria that can cause infections, there are also many different types of antibiotics. "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.

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.

We were able to nearly halve the prescribing of broad-spectrum antibiotics to children and decreased use of off-guideline antibiotics for children with pneumonia by 75 percent by one year after the study.

The initial data showed that about 28 percent of all children inappropriately received a broad-spectrum antibiotic for a targeted condition in the practices. After the study, clinicians in the group with education and follow up cut their off-guideline use to 14 percent.

What is the challenge for pediatricians when determining the treatment for ARTI conditions such as sinus infection, strep throat and pneumonia?

There are many antibiotics to choose from and keeping up with the data comparing the effectiveness of different antibiotics against common infections can be overwhelming for busy primary care doctors who care for children with a variety of health conditions. We partnered with primary care doctors to help influence prescribing to reflect the most up to date expert guidelines.

Are parents demanding antibiotics more now? What are some of the misconceptions parents have about how antibiotics will help their child?

Some doctors report that they feel parental pressure to prescribe antibiotics even when they are not indicated. This might be driven by the parents' belief that antibiotics will help treat infections that are actually caused by viruses, which are unaffected by antibiotics, or by their belief that certain "stronger" antibiotics will work better. It is important for doctors to understand and address these concerns with parents.

What are the next steps after this study? Will programs need to be put in place in primary care practices to reduce overprescribing?

We need to see if the effects of the intervention are sustainable and if they require ongoing audit and feedback. We also are in the process of comparing clinical outcomes of patients in each group, including rates of clinical cure as well as adverse drug effects.

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