Mission possible: Drug stewardship in pediatrics

Prescribing for pneumonia drops 75%

Although efforts to cut the overuse of antibiotics have made some headway in hospitals, the majority of prescriptions are written by community-based clinicians — often for pediatric patients with common ailments.

"If you really want to impact antibiotic use, you have to do it with outpatient prescribing," says Jeffrey Gerber, MD, an assistant professor of pediatrics at Children's Hospital of Philadelphia. "Our message is that targeting common conditions and intervening in the outpatient setting is doable."

In a study presented recently at the IDWeek 2012 conference in San Diego, Gerber and colleagues tried to reduce inappropriate antibiotic use and underscore current prescribing guidelines.1

"In a network of primary care out-patient practices we performed a cluster randomized trial of encounters for common pediatric infections — ear infections, sinus infections, strep throat, and pneumonia," he says.

The researchers focused on the hospital's affiliated primary care network of more than two dozen practices. Eighteen of those pediatric practices agreed to participate, offering a look at 174 clinicians' prescribing habits in urban, suburban and rural communities from the Main Line of Philadelphia to the New Jersey shore. Over nearly three years, that included more than 1.4 million office visits by 185,212 patients. Half of the groups randomized in the intervention received onsite education about the prescribing guidelines, and were provided individual provider-based audit and feedback of their prescribing for the targeted infections.

"[This] greatly affected prescribing in a group of practices after only a year," Gerber says. "The biggest impact was with inappropriate use of antibiotics for pneumonia, which dropped from 16% to just 4%. A 75% reduction where there was no change in the control group."

The practices were randomly divided into two groups and their prescriptions tracked through the network's electronic health record. The researchers reviewed prescribing for sinusitis, Group A 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.

The control group was merely told the study was under way. In the intervention group, however, each practice was given a short lunch-hour refresher on the latest prescribing guidelines recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America. Additionally, each clinician in the intervention group received quarterly one-page updates on his or her prescribing habits. This feedback showed how individuals compared to the guidelines and to others within their own practice, as well as how practices compared to each other. It involved no clinical decision-making support tools.

The initial data showed that about 28% of all children inappropriately received a broad-spectrum antibiotic for a targeted condition — with the variance across practices ranging from 15% to 60%.

But after the antibiotic primer session and a year of regular prescribing evaluations, clinicians in the intervention group cut their off-guideline use to 14%. The control group rate also declined, but only to 23%.

There was little change in the already low prescribing of broad-spectrum antibiotics for strep throat. Inappropriate prescribing for sinusitis had already been trending down in both groups, but it dropped by half, to 20%, in the practices that had gotten the refresher and regular feedback.

"The impact in the intervention group was much better than we thought it would be," Gerber says. "It shows that getting people up to speed and providing simple reminders are helpful. It also shows that you can leverage electronic health records to put together a relatively low-maintenance system to improve prescribing."

The researchers say they now need to look at the staying power of their effort. Have clinicians continued to be vigilant or returned to old habits? Gerber acknowledges that pediatricians often are pressured to see patients quickly and by families that often demand antibiotics when a child is sick. Writing that prescription sometimes seems like the most expeditious solution.


  1. Gerber J, et al. Effect of an Outpatient Antimicrobial Stewardship Intervention on Appropriate Prescribing by Primary Care Pediatricians. IDWeek 2012. San Diego, CA. Oct 17-21 2012.