Putting Antibiotic Prescribing for Children Into Context

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  • EDITORIAL Editorials represent the opinionsof the authors and JAMA and

    not those of the American Medical Association.

    Putting Antibiotic Prescribing for ChildrenInto ContextJonathan A. Finkelstein, MD, MPH

    PRESCRIBINGANTIBIOTICS JUDICIOUSLY IS BECOMINGUNI-versally embraced as a virtue by clinicians. The goalis to avoid antibiotics when no clear benefit existsand to use agents that best balance the benefits andrisks to the individual aswell as population-level effects suchas promotion of antibiotic resistance. For children in par-ticular, the decrease in rates of antibiotic use since the early1990s represents an underappreciated public health suc-cess story. The decline in antibiotic use for young childrenwith acute respiratory tract infections (ARTIs) of 36% overa decade1 represents a remarkable shift in clinical practice.It is difficult to connect this with a particular guideline, in-tervention, or campaign. However, most of this change hasbeen driven by decreases in the diagnosis of otitis media inyoung children1 coincident with focused attention by theCenters forDiseaseControl and Prevention,2 guidelines fromprofessional societies,3 and introduction of new vaccines thatlikely had small but important effects on the incidence ofotitis media.4

    On the backdrop of this success, unnecessary broad-spectrum antibiotic use for both adults and children in pri-mary care settings remains a substantial concern.5-7 In thisissue of JAMA, Gerber et al8 report findings from a clusterrandomized trial that tested a reproducible intervention toimprove prescribing for patients with ARTIs. The interven-tion included a 1-hour physician education session basedon current guidelines and audit and feedback of practice-and clinician-level prescribing rates in 18 linked pediatricpractices involving 162 clinicians. Similar interventions haveshown varying results,9 but Gerber et al report a 6.7% ab-solute decrease in the proportionof patients prescribedbroad-spectrum agents in intervention practices compared withcontrol practices.The time-series analysis the authors conducted has ad-

    vantages over the usual pre-post comparison and indicatesa persistent downward trajectory in broad-spectrum pre-scribing after the intervention rather than an abrupt de-crease after its implementation. This may reflect the cumu-lative influence of physician feedback or gradual reeducationof patients about the benefits of narrow-spectrum agents for

    most illnesses. In fact, the overall effect of the interventionon practice may be underestimated. By excluding acute oti-tis media, the single most common reason for antibiotic usein children, the investigators were left with a set of condi-tions that are relatively infrequent in very young children,who have the highest rates of antibiotic use.1 Althoughthe authors did not include data on use of antibiotics forchildren with acute otitis media, it seems quite possiblethat broad-spectrum antibiotic use for these patients alsodecreased.Use of antibiotics generally, and broad-spectrum agents

    in particular, are not just issues in pediatric practice. Al-though progress has also occurred in treatment of ARTIsin adults, frustration persists regarding the magnitude ofchange in treatment of bronchitis despite even more inten-sive intervention than that described here.10,11 The compari-son between adults and children suggests that it is more dif-ficult to convince patients (and clinicians) that a diagnosedcondition (bronchitis) does not require antibiotic treat-ment than to decrease the frequency of the diagnosis (oti-tis) in the first place. Taking this one step further, perhapsthe best way to avoid prescribing a broad-spectrum agentis, when appropriate, not to prescribe an antibiotic at all.In addition to the results reported by Gerber et al,8 the

    study also provides lessons about the promise and limits ofresearch that seeks to implement current best practices. Theinvestigators randomized practices of a single health sys-tem that use a common electronic health record. Indi-vidual informed consent of patients was deemed unneces-sary because the goal was bringing actual practice in linewith accepted standards, and the primary data were col-lected from automated systems rather than by expensivemethods such as chart review or patient report. The abilityto leverage practice networks and information systems toefficiently measure and improve care will be a core featureof the learning health care system that must develop overthe coming decade.12

    The question, raised by others aswell,11,13 is how andwhento move from such trials to other methods for implemen-tation of guideline-recommended care across the entire health

    See also p 2345.

    Author Affiliation: Department of Medicine, Boston Childrens Hospital, andDepartments of Pediatrics and PopulationMedicine, HarvardMedical School, Boston,Massachusetts.Corresponding Author: Jonathan A. Finkelstein, MD,MPH, Department of Medi-cine, Boston Childrens Hospital, 300 Longwood Ave, Hunnewell 2, Boston, MA02115 (jonathan.finkelstein@childrens.harvard.edu).

    2388 JAMA, June 12, 2013Vol 309, No. 22 2013 American Medical Association. All rights reserved.

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  • care system. There is a robust literature on the effective-ness of a variety of strategies to change physician behavior,including to promote judicious antibiotic prescribing.9 Pre-vious work suggests that some strategies, especially multi-modal interventions, are more likely to help but that noneis reliably effective across all settings. Some view inconsis-tency in these studies as a lack of clear evidence of effec-tivenesssimilar to a drug that seems to have worked insome randomized trials but not others. In the case of sucha drug, researchers might conclude that more studies areneeded to determine its real effect, and clinicians wouldnot knowwhether to prescribe that medication to their nextpatient. Interventions to promote improved prescribing (andother practice improvements) should be approached dif-ferently. Rather than seeking precision about effects in prac-tices on average, it may be more useful to ask why an ap-proach worked in a particular context and how it could beadapted to the next one.14,15 This is not to say that strate-gies used in one setting should not guide future attemptselsewhere. However, attention to the particular barriers toadoption and the facilitators that might overcome them isas critical to success as the details of the intervention itself.As Linder recently suggested,11 quality improvement meth-ods for repeated intervention and continuous measure-ment over time should be viewed as a complement to trialsof fixed interventions.Gerber et al and the participating practices and clini-

    cians have accomplished meaningful improvement in an-tibiotic prescribing forARTIs in their pediatric patients.How-ever, broad-spectrumantibiotic overuse continues in humansacross age groups and conditions, as well as in agriculturaluse and other factors that drive emerging resistance. Thegood news is that a range of effective techniques for pro-moting judicious prescribing in ambulatory care have beendeveloped and tested; it is also apparent that the influenceand benefit of any of these interventions will vary greatlyacross settings. Tailoring strategies to contextual factors and

    adapting them further during implementation may well bemore effective than merely rolling out the approach withthe greatest average effect in the average practice.

    Conflict of Interest Disclosures: The author has completed and submitted the ICMJEForm for Disclosure of Potential Conflicts of Interest. Dr Finkelstein reports pre-vious consultancy for the Institute for Healthcare Improvement.

    REFERENCES

    1. Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription rates for acute respi-ratory tract infections in US ambulatory settings. JAMA. 2009;302(7):758-766.2. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Principles of judi-cious use of antimicrobial agents for pediatric upper respiratory tract infections.Pediatrics. 1998;101:163-165.3. American Academy of Pediatrics Subcommittee onManagement of Acute Oti-tis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113(5):1451-1465.4. Eskola J, Kilpi T, Palmu A, et al; Finnish Otitis Media Study Group. Efficacy of apneumococcal conjugate vaccine against acute otitis media. N Engl J Med. 2001;344(6):403-409.5. Steinman MAL, Landefeld CS, Gonzales R. Predictors of broad-spectrum an-tibiotic prescribing for acute respiratory tract infections in adult primary care. JAMA.2003;289(6):719-725.6. Stille CJ, Andrade SE, Huang SS, et al. Increased use of second-generation mac-rolide antibiotics for children in 9 health plans in the United States. Pediatrics. 2004;114(5):1206-1211.7. Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatorypediatrics in the United States. Pediatrics. 2011;128(6):1053-1061.8. Gerber JS, Prasad PA, Fiks AG, et al. Effect of an outpatient antimicrobial stew-ardship intervention on broad-spectrum antibiotic prescribing by primary care pe-diatricians: a randomized trial. JAMA. 2013;309(22):2345-2352.9. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practicesin ambulatory care. Cochrane Database Syst Rev. 2005;(4):CD003539.10. Gonzales RA, Anderer T, McCulloch CE, et al. A cluster randomized trial ofdecision support strategies for reducing antibiotic use in acute bronchitis. JAMAIntern Med. 2013;173(4):267-273.11. Linder JA. Antibiotic prescribing for acute respiratory infectionssuccess thatsway off the mark. JAMA Intern Med. 2013;173(4):273-275.12. IOMRoundtable on Evidence-BasedMedicine: The Learning Healthcare Sys-tem [workshop summary]. Washington, DC: National Academies Press; 2007.13. Toltzis P, GoldmannD. Rethinking infection prevention research. Lancet. 2013;381(9872):1078-1079.14. Glasgow RE, Chambers D. Developing robust, sustainable, implementationsystems using rigorous, rapid and relevant science. Clin Transl Sci. 2012;5(1):48-55.15. vretveit J, Leviton L, Parry G. Increasing the generalisability of improve-ment research with an improvement replication programme. BMJQual Saf. 2011;20(suppl 1):i87-i91.

    EDITORIAL

    2013 American Medical Association. All rights reserved. JAMA, June 12, 2013Vol 309, No. 22 2389

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