Can Antibiotic Prescribing to Children be Reduced?

Abstract & Commentary

Synopsis: An educational outreach program, based on CDC materials, was effective in reducing unnecessary antibiotic use in a pediatric population.

Source: Finkelstein JA, et al. Pediatrics. 2001;108:1-7.

Finkelstein and colleagues performed a randomized clinical trial involving 12 practices affiliated with 2 managed care organizations to determine whether educational outreach based on the CDC program of judicious antibiotic use was associated with decreased antibiotic use in children younger than 6 years of age. Physicians in the practices assigned to the intervention group participated in 2 meetings outlining the CDC recommendations and also received information concerning their prior prescribing rates. They also received instruction on the importance and means of distinguishing between acute otitis media and otitis media with effusion. Parents whose children were cared for at the intervention sites received a CDC brochure on antibiotic use by mail and were exposed to supporting materials displayed in waiting rooms.

Almost two-thirds of antibiotic prescriptions were for otitis media; 9.2% were for illnesses caused by viral infection. Antibiotic prescription rates during a pre-intervention baseline year varied significantly—especially among children from 3 to < 36 months of age in whom the number of antibiotic courses per person year of observation ranged from 1.61 to 3.73. Clinics randomly assigned as controls prescribed fewer antibiotic courses than did the experimental group during the baseline year.

The primary analysis included 8815 patients who were cared for in both the baseline and intervention years. Multivariate analysis demonstrated an adjusted intervention effect of a 16% (95%; CI = 8-23%) reduction in children 3 to < 36 months of age and a 12% (95%; CI = 2-21%) reduction in antibiotic administration to the older children.

Comment by Stan Deresinski, MD, FACP

In the comment by Dr. Tice in the preceding contribution, he reviews a paper indicating that patient education can reduce their expectation of antibiotic therapy and enhance their level of satisfaction when appropriately denied such therapy. Dr. Tice ends his comment by pointing out that concerns about litigation may drive some antibiotic use and also by indicating that it is the physician who is the ultimate key in reducing unnecessary antibiotic use.

Programs, such as that of the CDC, undoubtedly provide physicians with some degree of protection in the medicolegal arena—authoritative statements often win the day in that setting. The study reviewed here demonstrates that the CDC intervention is also effective in its primary aim, the reduction of unnecessary antibiotic use.

The data on antibiotic use in this study was extracted from automated pharmacy claims data. This method would not account for any provision of antibiotic samples to patients at the point of care, a potential confounding factor.

Finkelstein et al also do not mention anything about patient-informed consent. Since this was not a randomization of individual patients to therapy or no therapy, it would seem that this is acceptable. However, a full discussion of the need for patient consent when they are participating in what is, after all, a clinical trial, would be welcome. This actually extends to the entire issue of "managed care," which has been an experimental procedure in which a large proportion of the American population has participated, in most cases without realizing its experimental nature—although many of them have become aware of the adverse results.

Stan Derensinski, Editor of Infectious Disease Alert, is Clinical Professor of Medicine at Stanford, Director of the AIDS Community Research Consortium, and Associate Chief of Infectious Diseases at Santa Clara Valley Medical Center.