An intervention that included physician education and auditing of antibiotic prescriptions significantly reduced inappropriate prescribing for acute respiratory tract infections in a study of a large pediatric primary care network, according to a report in the June 12 issue of JAMA
During the course of 1 year, the intervention nearly halved prescribing of broad-spectrum antibiotics at visits for acute sinusitis and strep pharyngitis, and also cut the off-guideline prescription of antibiotics for acute pneumonia by 75%, said Dr. Jeffrey S. Gerber of the division of infectious diseases at Children’s Hospital of Philadelphia, and his associates.
The intervention was modeled on antimicrobial stewardship programs used in hospitals, which have been shown to reduce the use of antibiotics, improve patient outcomes, and reduce health care costs for both pediatric and adult inpatients. "Our findings suggest that extending antimicrobial stewardship to the ambulatory setting, where such programs generally have not been implemented, may have important health benefits," the investigators said.
"Because most antibiotic use occurs in outpatients, it is essential to apply stewardship principles to ambulatory medicine to maximize the population benefits of more judicious antibiotic use, including reduced antibiotic resistance pressure and unnecessary adverse drug effects and health care costs," they noted.
Dr. Gerber and his colleagues assessed the effectiveness of one such stewardship intervention in a cluster-randomized trial involving a hospital-affiliated network of 18 pediatric primary care sites. Nine practice groups were randomly assigned to receive the intervention and nine to serve as controls.
The practices "served children of diverse racial and socioeconomic backgrounds within urban, suburban, and rural settings across southeastern Pennsylvania and southern New Jersey."
Data were collected for the 20 months before the intervention was implemented and the 12 months afterward. This involved 1,291,824 office visits by 185,212 patients to 162 physicians at the 18 practices.
The intervention included a one-time, 1-hour clinician education session delivered at each practice by a physician who was board certified in pediatric infectious diseases. At this session, the study goals were outlined and the pediatricians were updated on current prescribing guidelines for common acute respiratory tract infections.
Prescribing practices for cases of acute sinusitis, streptococcal pharyngitis, and pneumonia were then audited electronically. Patients with chronic diseases and drug allergies were excluded from the study, as were patients who had previously received antibiotics for the index infection.
Every 4 months, each pediatrician received a private feedback report via secure office email on his or her prescribing practices, as well as peer benchmarking.
The control group received no intervention and no feedback.
After 1 year, the prescription of broad-spectrum antibiotics decreased from 26.8% to 14.3% of visits for acute respiratory tract infections in the intervention group. In contrast, this rate decreased only from 28.4% to 22.6% in the control group, Dr. Gerber and his associates said (JAMA 2013;309:2345-52).
In particular, off-guideline prescribing of broad-spectrum antibiotics for pneumonia decreased in the intervention group from 15.7% of cases to 4.2%. In comparison, this rate dropped only from 17.1% to 16.3% in the control group.
Inappropriate prescribing for acute sinusitis decreased from 38.9% to 18.8% in the intervention group, compared with a relatively small drop 40.0% to 33.9% in the control group.
Inappropriate prescribing for strep pharyngitis started low and remained low for both study groups, decreasing from 4.4% to 3.4% with the intervention and from 5.6% to 3.5% in the control group.
The investigators also tracked inappropriate antibiotic prescribing for viral infections. These rates were low at baseline for both groups and did not change significantly during the study.
This study was limited in that it did not examine patient outcomes, so there was no way to assess how prescribing practices may have altered those outcomes. In addition, with only 1 year of follow-up, there is no way to determine whether continued auditing and feedback are necessary to maintain the changes in prescribing patterns, the investigators noted.
This study was supported by the U.S. Agency for Healthcare Research and Quality. Dr. Gerber’s associates reported ties to several industry sources.