Intervention Halves Off-Guideline Antibiotic Use in Children

SAN DIEGO – An outpatient antimicrobial stewardship intervention dramatically reduced inappropriate use of antibiotics for acute respiratory tract infections in children, judging from the findings of a trial reported at IDWeek.

In the cluster-randomized trial, which involved 185,212 pediatric patients making more than 1.4 million outpatient visits, the rate of inappropriate prescribing for these infections – use of a broad-spectrum antibiotic when guidelines recommended a narrow-spectrum one – fell by nearly half in the intervention group over a year, compared with about one-fifth in the control group.

Susan London/IMNG Medical Media

Led by Dr. Jeffrey Gerber, the investigators enrolled 18 practices in a large pediatric primary care network that share an electronic health record, randomizing them evenly to intervention and control groups.

The intervention had two parts: an on-site clinician education session, including a refresher in current guidelines for treating sinusitis, group A streptococcal pharyngitis, and pneumonia, and then private quarterly audit and feedback reports to physicians of their antibiotic prescribing for these conditions.

The reports "showed how they were prescribing relative to national guidelines at baseline and over time throughout the intervention for 12 months, compared with those in the practice group and across the network," explained Dr. Gerber of Children’s Hospital of Philadelphia. "So the idea is to not only show providers how they prescribe relative to national recommendations, but also to have what we call achievable benchmarks available, to show how other folks in busy practices just like theirs are prescribing."

The rate of off-guideline antibiotic prescribing for acute respiratory tract infections was 28% overall, with a range of 15%-60% across practices, according to data reported at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

One year after the intervention, the rate had fallen by 48% in the intervention group and by 18% in the control group (P = .001).

In stratified analyses, the greatest reduction was seen for pneumonia: The rate of off-guideline prescribing fell by 75% in the intervention group, compared with 6% in the control group.

For acute respiratory tract infections overall, azithromycin was the greatest contributor to off-guideline antibiotic prescribing. For pneumonia specifically, amoxicillin plus clavulanic acid (Augmentin) was the greatest contributor.

"We are really encouraged by these results. We think that it is a relatively simple intervention that we hope will be scalable to other pediatric practices that have electronic health records," Dr. Gerber commented in a related press briefing. The Agency for Healthcare Research and Quality, which funded the study, has provided an extra year of funding so that the intervention can be packaged and disseminated for use by other practices.

He predicted that the findings would be largely generalizable, given the good mix of practices and patients in the trial. "We don’t think yet it’s broadly applicable to every practice, but at the same time, to practices that use electronic health records," he said, noting that the simple algorithms used in the study draw on data routinely captured in these records.

The findings could have a major impact nationally, given that broad-spectrum antibiotics account for roughly half of the 40 million antibiotic prescriptions written per year for children in the United States for acute respiratory tract infections in the outpatient setting, according to Dr. Gerber. Not only are they more expensive than narrow-spectrum ones, but they also more rapidly promote resistance.

The study’s findings are "very powerful," commented Dr. Liise-Anne Pirofski, moderator of the press briefing and IDWeek Chair. "This is a fairly unique study and probably pretty groundbreaking."

Susan London/IMNG Medical Media

She wondered whether factors such as better taste or greater ease of once-daily dosing of several broad-spectrum antibiotics contribute to off-guideline prescribing and need to be taken into account. "In children, multidosing is difficult because most schools don’t administer antibiotics to children in school," she pointed out. Also, parents sometimes request specific antibiotics.

"These are real issues," and likely driving forces behind at least some off-guideline prescribing, Dr. Gerber agreed. "However, the societies that recommend antibiotics really have to take into account the spectrum of activity to be careful because of the development of antibiotic resistance."

In addition, emerging research suggests that, in at least some cases, more frequent dosing of narrow-spectrum agents is not necessary. For example, the American Academy of Pediatrics now endorses once-daily amoxicillin for treating strep throat. "That used to be dosed more frequently, but studies have shown that once-daily dosing is actually as effective. So that’s helped combat this issue a bit," he said.

Dr. Pirofski noted that it’s nice to see evidence of the benefits of electronic health records, as putting them in place is typically a major undertaking. "It will be very interesting if good studies are done to determine how much that watchdog effect is driving people’s behavior. If it is, then I think the electronic component is absolutely essential because it’s the only way that you can really generate that data and data that people will believe."

That said, face-to-face interaction should not be underestimated in such interventions, she maintained. "The personal interaction, I believe, is really what drove the early success of some of these antibiotic stewardships, because medicine can be very lonely. If somebody comes in and chats you up a little bit, you feel like you are more in tune with what’s going on. ... My own feeling is that personal interaction always drives change better than these other things," said Dr. Pirofski, who is chief of the division of infectious diseases at Albert Einstein College of Medicine, New York.

Ascertaining the cost effectiveness of the intervention would be complicated because of copayment and reimbursement issues, according to Dr. Gerber, but "most of these broad-spectrum agents are between five and ten times more expensive than the narrow-spectrum agents." He predicted that, as insurers move toward a bundled-payment model, costs will get greater attention. "Maybe insurance companies won’t reimburse for broad-spectrum agents if we can show that recommendations should be followed, and there are no differences in outcomes," he said.

The investigators plan to assess the impact of the intervention on health outcomes and will monitor the durability of its efficacy, Dr. Gerber said. "We are going to follow up for at least another year, now that there are no more feedback reports coming in, to see if it continues or if people revert back to their initial prescribing patterns," he explained. In addition, they are interviewing participating clinicians to obtain their viewpoints on prescribing and auditing, along with suggestions for improving the intervention.

Neither Dr. Gerber nor Dr. Pirofski disclosed any relevant conflicts of interest.

SAN DIEGO – An outpatient antimicrobial stewardship intervention dramatically reduced inappropriate use of antibiotics for acute respiratory tract infections in children, judging from the findings of a trial reported at IDWeek.

In the cluster-randomized trial, which involved 185,212 pediatric patients making more than 1.4 million outpatient visits, the rate of inappropriate prescribing for these infections – use of a broad-spectrum antibiotic when guidelines recommended a narrow-spectrum one – fell by nearly half in the intervention group over a year, compared with about one-fifth in the control group.

Susan London/IMNG Medical Media

Led by Dr. Jeffrey Gerber, the investigators enrolled 18 practices in a large pediatric primary care network that share an electronic health record, randomizing them evenly to intervention and control groups.

The intervention had two parts: an on-site clinician education session, including a refresher in current guidelines for treating sinusitis, group A streptococcal pharyngitis, and pneumonia, and then private quarterly audit and feedback reports to physicians of their antibiotic prescribing for these conditions.

The reports "showed how they were prescribing relative to national guidelines at baseline and over time throughout the intervention for 12 months, compared with those in the practice group and across the network," explained Dr. Gerber of Children’s Hospital of Philadelphia. "So the idea is to not only show providers how they prescribe relative to national recommendations, but also to have what we call achievable benchmarks available, to show how other folks in busy practices just like theirs are prescribing."

The rate of off-guideline antibiotic prescribing for acute respiratory tract infections was 28% overall, with a range of 15%-60% across practices, according to data reported at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

One year after the intervention, the rate had fallen by 48% in the intervention group and by 18% in the control group (P = .001).

In stratified analyses, the greatest reduction was seen for pneumonia: The rate of off-guideline prescribing fell by 75% in the intervention group, compared with 6% in the control group.

For acute respiratory tract infections overall, azithromycin was the greatest contributor to off-guideline antibiotic prescribing. For pneumonia specifically, amoxicillin plus clavulanic acid (Augmentin) was the greatest contributor.

"We are really encouraged by these results. We think that it is a relatively simple intervention that we hope will be scalable to other pediatric practices that have electronic health records," Dr. Gerber commented in a related press briefing. The Agency for Healthcare Research and Quality, which funded the study, has provided an extra year of funding so that the intervention can be packaged and disseminated for use by other practices.

He predicted that the findings would be largely generalizable, given the good mix of practices and patients in the trial. "We don’t think yet it’s broadly applicable to every practice, but at the same time, to practices that use electronic health records," he said, noting that the simple algorithms used in the study draw on data routinely captured in these records.

The findings could have a major impact nationally, given that broad-spectrum antibiotics account for roughly half of the 40 million antibiotic prescriptions written per year for children in the United States for acute respiratory tract infections in the outpatient setting, according to Dr. Gerber. Not only are they more expensive than narrow-spectrum ones, but they also more rapidly promote resistance.

The study’s findings are "very powerful," commented Dr. Liise-Anne Pirofski, moderator of the press briefing and IDWeek Chair. "This is a fairly unique study and probably pretty groundbreaking."

Susan London/IMNG Medical Media

She wondered whether factors such as better taste or greater ease of once-daily dosing of several broad-spectrum antibiotics contribute to off-guideline prescribing and need to be taken into account. "In children, multidosing is difficult because most schools don’t administer antibiotics to children in school," she pointed out. Also, parents sometimes request specific antibiotics.

"These are real issues," and likely driving forces behind at least some off-guideline prescribing, Dr. Gerber agreed. "However, the societies that recommend antibiotics really have to take into account the spectrum of activity to be careful because of the development of antibiotic resistance."

In addition, emerging research suggests that, in at least some cases, more frequent dosing of narrow-spectrum agents is not necessary. For example, the American Academy of Pediatrics now endorses once-daily amoxicillin for treating strep throat. "That used to be dosed more frequently, but studies have shown that once-daily dosing is actually as effective. So that’s helped combat this issue a bit," he said.

Dr. Pirofski noted that it’s nice to see evidence of the benefits of electronic health records, as putting them in place is typically a major undertaking. "It will be very interesting if good studies are done to determine how much that watchdog effect is driving people’s behavior. If it is, then I think the electronic component is absolutely essential because it’s the only way that you can really generate that data and data that people will believe."

That said, face-to-face interaction should not be underestimated in such interventions, she maintained. "The personal interaction, I believe, is really what drove the early success of some of these antibiotic stewardships, because medicine can be very lonely. If somebody comes in and chats you up a little bit, you feel like you are more in tune with what’s going on. ... My own feeling is that personal interaction always drives change better than these other things," said Dr. Pirofski, who is chief of the division of infectious diseases at Albert Einstein College of Medicine, New York.

Ascertaining the cost effectiveness of the intervention would be complicated because of copayment and reimbursement issues, according to Dr. Gerber, but "most of these broad-spectrum agents are between five and ten times more expensive than the narrow-spectrum agents." He predicted that, as insurers move toward a bundled-payment model, costs will get greater attention. "Maybe insurance companies won’t reimburse for broad-spectrum agents if we can show that recommendations should be followed, and there are no differences in outcomes," he said.

The investigators plan to assess the impact of the intervention on health outcomes and will monitor the durability of its efficacy, Dr. Gerber said. "We are going to follow up for at least another year, now that there are no more feedback reports coming in, to see if it continues or if people revert back to their initial prescribing patterns," he explained. In addition, they are interviewing participating clinicians to obtain their viewpoints on prescribing and auditing, along with suggestions for improving the intervention.

Neither Dr. Gerber nor Dr. Pirofski disclosed any relevant conflicts of interest.

SAN DIEGO – An outpatient antimicrobial stewardship intervention dramatically reduced inappropriate use of antibiotics for acute respiratory tract infections in children, judging from the findings of a trial reported at IDWeek.

In the cluster-randomized trial, which involved 185,212 pediatric patients making more than 1.4 million outpatient visits, the rate of inappropriate prescribing for these infections – use of a broad-spectrum antibiotic when guidelines recommended a narrow-spectrum one – fell by nearly half in the intervention group over a year, compared with about one-fifth in the control group.

Susan London/IMNG Medical Media

Led by Dr. Jeffrey Gerber, the investigators enrolled 18 practices in a large pediatric primary care network that share an electronic health record, randomizing them evenly to intervention and control groups.

The intervention had two parts: an on-site clinician education session, including a refresher in current guidelines for treating sinusitis, group A streptococcal pharyngitis, and pneumonia, and then private quarterly audit and feedback reports to physicians of their antibiotic prescribing for these conditions.

The reports "showed how they were prescribing relative to national guidelines at baseline and over time throughout the intervention for 12 months, compared with those in the practice group and across the network," explained Dr. Gerber of Children’s Hospital of Philadelphia. "So the idea is to not only show providers how they prescribe relative to national recommendations, but also to have what we call achievable benchmarks available, to show how other folks in busy practices just like theirs are prescribing."

The rate of off-guideline antibiotic prescribing for acute respiratory tract infections was 28% overall, with a range of 15%-60% across practices, according to data reported at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

One year after the intervention, the rate had fallen by 48% in the intervention group and by 18% in the control group (P = .001).

In stratified analyses, the greatest reduction was seen for pneumonia: The rate of off-guideline prescribing fell by 75% in the intervention group, compared with 6% in the control group.

For acute respiratory tract infections overall, azithromycin was the greatest contributor to off-guideline antibiotic prescribing. For pneumonia specifically, amoxicillin plus clavulanic acid (Augmentin) was the greatest contributor.

"We are really encouraged by these results. We think that it is a relatively simple intervention that we hope will be scalable to other pediatric practices that have electronic health records," Dr. Gerber commented in a related press briefing. The Agency for Healthcare Research and Quality, which funded the study, has provided an extra year of funding so that the intervention can be packaged and disseminated for use by other practices.

He predicted that the findings would be largely generalizable, given the good mix of practices and patients in the trial. "We don’t think yet it’s broadly applicable to every practice, but at the same time, to practices that use electronic health records," he said, noting that the simple algorithms used in the study draw on data routinely captured in these records.

The findings could have a major impact nationally, given that broad-spectrum antibiotics account for roughly half of the 40 million antibiotic prescriptions written per year for children in the United States for acute respiratory tract infections in the outpatient setting, according to Dr. Gerber. Not only are they more expensive than narrow-spectrum ones, but they also more rapidly promote resistance.

The study’s findings are "very powerful," commented Dr. Liise-Anne Pirofski, moderator of the press briefing and IDWeek Chair. "This is a fairly unique study and probably pretty groundbreaking."

Susan London/IMNG Medical Media

She wondered whether factors such as better taste or greater ease of once-daily dosing of several broad-spectrum antibiotics contribute to off-guideline prescribing and need to be taken into account. "In children, multidosing is difficult because most schools don’t administer antibiotics to children in school," she pointed out. Also, parents sometimes request specific antibiotics.

"These are real issues," and likely driving forces behind at least some off-guideline prescribing, Dr. Gerber agreed. "However, the societies that recommend antibiotics really have to take into account the spectrum of activity to be careful because of the development of antibiotic resistance."

In addition, emerging research suggests that, in at least some cases, more frequent dosing of narrow-spectrum agents is not necessary. For example, the American Academy of Pediatrics now endorses once-daily amoxicillin for treating strep throat. "That used to be dosed more frequently, but studies have shown that once-daily dosing is actually as effective. So that’s helped combat this issue a bit," he said.

Dr. Pirofski noted that it’s nice to see evidence of the benefits of electronic health records, as putting them in place is typically a major undertaking. "It will be very interesting if good studies are done to determine how much that watchdog effect is driving people’s behavior. If it is, then I think the electronic component is absolutely essential because it’s the only way that you can really generate that data and data that people will believe."

That said, face-to-face interaction should not be underestimated in such interventions, she maintained. "The personal interaction, I believe, is really what drove the early success of some of these antibiotic stewardships, because medicine can be very lonely. If somebody comes in and chats you up a little bit, you feel like you are more in tune with what’s going on. ... My own feeling is that personal interaction always drives change better than these other things," said Dr. Pirofski, who is chief of the division of infectious diseases at Albert Einstein College of Medicine, New York.

Ascertaining the cost effectiveness of the intervention would be complicated because of copayment and reimbursement issues, according to Dr. Gerber, but "most of these broad-spectrum agents are between five and ten times more expensive than the narrow-spectrum agents." He predicted that, as insurers move toward a bundled-payment model, costs will get greater attention. "Maybe insurance companies won’t reimburse for broad-spectrum agents if we can show that recommendations should be followed, and there are no differences in outcomes," he said.

The investigators plan to assess the impact of the intervention on health outcomes and will monitor the durability of its efficacy, Dr. Gerber said. "We are going to follow up for at least another year, now that there are no more feedback reports coming in, to see if it continues or if people revert back to their initial prescribing patterns," he explained. In addition, they are interviewing participating clinicians to obtain their viewpoints on prescribing and auditing, along with suggestions for improving the intervention.

Neither Dr. Gerber nor Dr. Pirofski disclosed any relevant conflicts of interest.