Antibiotics are the most common prescription medications given to children. Inappropriate use of antibiotics can lead to unnecessary adverse drug effects and the emergence of antimicrobial resistance. Our goal for this line of research is to provide achievable benchmarks and high-impact targets for improving antibiotic prescribing and then develop and implement effective interventions to promote antibiotic stewardship.
Epidemiology and Outcomes of Antibiotic Use
Through retrospective cohort studies and prospective observational studies we have compared the distribution and outcomes of antibiotic use in children across a variety of clinical settings to identify high-impact targets for intervention.
In this research we found that, for outpatient children, antibiotic prescribing ranges across practices from 18-36 percent of acute visits, and the proportion of antibiotic prescriptions that were broad-spectrum ranged from 15-58 percent across practices. Diagnosis of and broad-spectrum antibiotic prescribing for acute otitis media, sinusitis, Streptococcal pharyngitis, and pneumonia also varied by practice. Broad-spectrum antibiotic prescribing for these diagnoses are considered off-guideline. A different study found significant variability that could not be explained by relevant clinical or demographic factors.
Additionally, our research has found that hospitalized children with similar diagnoses receive different antibiotic regimens, depending on the hospital in which they are treated.
Our call-to-action: Our data supports clinician-targeted interventions to improve adherence to prescribing guidelines for this common condition.
As confirmed in our research and that of others, the variability in prescribing trends likely reflects opportunities to reduce excessive antibiotic use. Interventions targeting practices, providers, and the conditions accounting for inconsistent and off-guideline antibiotic use are worth exploring.
We are working to adapt the principles of antimicrobial stewardship programs, proven effective in inpatient settings, for use in outpatient or ambulatory settings. The majority of antimicrobial prescribing is for outpatients.
In CHOP’s large primary care network, CPCE researchers have used a variety of research methods, including a cluster randomized trial and qualitative semi-structured interviews, to pilot and refine a stewardship intervention involving clinician education followed by quarterly audit and feedback. During the 50-month study period, we captured data on 1,259,938 office visits by 185,868 unique patients.
Overall, the intervention improved adherence to prescribing guidelines for common bacterial acute respiratory tract infections (ARTI) as compared to usual practice. As seen in the chart below, for the 12-month audit and feedback period, broad-spectrum antibiotic prescribing decreased from 26.8% to 14.3% among intervention practices, and from 28.4% to 22.6% in the control group. It did not reduce off-guideline antibiotic prescribing rates for viral infections, which was already uncommon.
In later follow-up, we noted that in the absence of regular audit and feedback, prescribing practices returned to pre-intervention levels. This suggests that an ongoing stewardship program may be warranted. While it appeared that the use of electronic health record data to provide regular audit and feedback was effective, modifications to the program to better address clinician barriers to judicious use of antibiotics and acceptability of the program may be required for sustained behavior change.
Qualitative semi-structured interviews of some of the participating clinicians revealed deep skepticism of the audit and feedback reports. They recognized antibiotic overuse as a problem, but believed it was driven by the behaviors of non-pediatric physicians. Parent pressure for antibiotics was identified by all respondents as a major barrier to the more judicious use of antibiotics.
Our call-to-action: To improve the effectiveness and acceptability of outpatient antimicrobial stewardship, it is critical to:
- boost the perceived credibility of audit data
- engage primary care pediatricians in recognizing that their behavior contributes to antibiotic overuse
- address perceived parent pressure to prescribe antibiotics
- determine what is the least amount of audit and feedback needed to sustain consistent judicious use of antibiotics.
A study called Comparative Effectiveness of Antibiotics for Respiratory Infections (CEARI) compared broad- vs. narrow-spectrum antibiotics for treatment of children with common respiratory tract infections using patient-centered outcomes. Our team first interviewed more than 100 parents and children who visited primary care pediatric offices with acute respiratory tract infections to determine the outcomes related to antibiotics that were most important to them. Parents cited missed school days, additional childcare, adverse side effects, and persistent symptoms as outcomes to avoid.
The researchers then conducted phone interviews with 2,472 caregivers at 10 and 30 days after antibiotic prescription to measure these previously-identified patient-centered outcomes, as well as health-related quality of life using the validated PedsQL Survey. Treatment with narrow-spectrum antibiotics was associated with higher health-related quality of life and lower risk of adverse side effects, as compared to broad-spectrum antibiotics.
Our call-to-action: Given these findings and current national prescribing patterns, outpatient stewardship efforts should encourage prescribing of narrow-spectrum antibiotics.
Funding: Patient Centered Outcomes Research Institute
What’s Next: CPCE is part of a national network led by collaborators at Seattle Children’s Hospital to develop and test a distance-learning program to improve provider communication and treatment decisions around acute respiratory tract infections.
CPCE researchers are also building a cohort of newborns to examine the relationships between early exposure to antibiotics and development of the microbiome.
Please contact Jeffrey Gerber, MD, PhD, MSCE, CPCE Associate Director for Outpatient Research and CHOP Attending Physician, Infectious Diseases and Director of the Antimicrobial Stewardship Program, for more information about this line of research.
Epidemiology and Outcomes of Antibiotic Use
Milder EA, Rizzi MD, Morales KH, Ross RK, Lautenbach E, Gerber JS. Impact of a New Practice Guideline on Antibiotic Use with Pediatric Tonsillectomy. JAMA Otolaryngology- Head and Neck Surgery. 2015 May;141(5):410-6.
Fierro JL, Prasad PA, Localio AR, Grundmeier RW, Wasserman RC, Zaoutis TE, Gerber JS. Variability in the Diagnosis and Treatment of Group A Streptococcal Pharyngitis by Primary Care Pediatricians. Infection Control and Hospital Epidemiology. 2014 Oct;35 Suppl 3:S79-85.
Gerber JS, Prasad PA, Localio AR, Fiks AG, Grundmeier RW, Bell LM, Wasserman RC, Rubin DM, Keren R, Zaoutis TE. Racial Differences in Antibiotic Prescribing by Primary Care Pediatricians. Pediatrics. 2013 Apr;131(4):677-84.
Gerber JS, Newland JG, Coffin SE, Hall M, Thurm C, Prasad PA, Feudtner C, Zaoutis TE. Variability in Antibiotic Use at Children's Hospitals. Pediatrics. 2010 Dec;126(6):1067-73.
Gerber JS, Prasad PA, Fiks AG, Localio AR, Grundmeier RW, Bell LM, Wasserman RC, Keren R, Zaoutis TE. Effect of an Outpatient Antimicrobial Stewardship Intervention on Broad-spectrum Antibiotic Prescribing by Primary Care Pediatricians: A randomized trial. JAMA. 2013 Jun;309(22):2345-52.
Szymczak JE, Feemster KA, Zaoutis TE, Gerber JS. Pediatrician Perceptions of an Outpatient Antimicrobial Stewardship Intervention. Infection Control and Hospital Epidemiology. 2014 Oct;35 Suppl 3:S69-78.
Gerber JS, Prasad PA, Fiks AG, Localio AR, Bell LM, Keren R, Zaoutis TE. Durability of Benefits of an Outpatient Antimicrobial Stewardship Intervention After Discontinuation of Audit and Feedback. JAMA. 2014 Dec;312(23):2569-70.
Broad- vs. Narrow-Spectrum Antibiotics for Children with Common Respiratory Tract Infections
Gerber JS, Ross RK, Bryan M, Localio R, Szymczak JE, Wasserman R, Barkman D, Odeniyi F, Conaboy K, Bell L, Zaoutis TE, Fiks AG. Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections. JAMA. 2017 Dec; 318(23):2325-2336.