Despite guidelines, pediatricians vary in antibiotic choice for pneumonia

1. The majority of children in outpatient clinics were prescribed a macrolide antibiotic for treatment of community acquired pneumonia (CAP) despite clear guidelines recommending amoxicillin in most cases.

2. Pediatrician antibiotic choice for CAP varied broadly by clinic and was influenced by both clinical and non-clinical factors.

Evidence rating level: 2 (Good)

 Study Rundown: Guidelines from the Pediatric Infectious Diseases Society of America 2011 recommend amoxicillin as the first-line agent for most cases of outpatient pediatric CAP to ensure appropriate coverage for Streptococcus pneumonia. Despite recommendations, there continues to be variability among pediatricians in antibiotic use for CAP. Researchers conducted a retrospective electronic health record (EHR) review of 31 pediatric primary care offices to identify factors influencing physicians’ prescribing patterns. Results showed more children were prescribed macrolides than amoxicillin to treat CAP in the outpatient setting even though >25% of S. pneumonia strains are resistant to this antibiotic class. Prescription choice was found to be influenced by both appropriate factors related to patient clinical presentation (e.g. age, previous antibiotic use) as well as nonclinical factors (e.g. insurance status, urban vs. rural practice setting). As a retrospective review, this study is limited by potential confounding variables influencing treatment choice that were not well documented in the EHR. Nonetheless, this data highlights the importance of understanding clinical and nonclinical factors that affect inappropriate antibiotic prescribing patterns in outpatient management of pediatric infections.

Click to read the study, published today in Pediatrics

Click to read the commentary, published today in Pediatrics

Relevant reading: Roles of Clinician, Patient, and Community Characteristics in the Management of Pediatric Upper Respiratory Tract Infections

In-depth [retrospective cohort]: Study participants included 10 414 children aged 3 months to 18 years treated for CAP by a total of 196 physicians. These physicians practiced in 31 urban, suburban, and rural primary care practices in Pennsylvania and New Jersey from 2009 to 2013.Researchers collected EHR data on patient and provider demographics, practice setting, and patient medical history and clinical presentation to identify variables affecting antibiotic prescribing patterns. Results indicated that 42.5% of children were treated with macrolides, 40.1% received amoxicillin, and 16.8% received broad-spectrum antibiotics. Clinical factors associated with increased odds of macrolide prescription vs. amoxicillin included age ≥5 years (aOR: 6.18, 95% CI 5.53-6.91) and previous antibiotic exposures (aOR: 1.70; 95% CI 1.56-2.04), while decreased odds of macrolide prescription were associated with abnormal exam results (aOR: 0.80; 95% CI 0.66-0.97) and presence of fever (aOR: 0.44; 95% CI 0.37-0.53). These clinical factors help differentiate pneumococcal from atypical pneumonia and appropriately drive antibiotic choice. However, various nonclinical, sociodemographic factors also impacted the odds of macrolide vs. amoxicillin use. Private was associated with increased macrolide vs. amoxicillin prescription (aOR: 1.47; 95% CI 1.28-1.70), while >10 years of provider experience (aOR: 0.75; 95% CI 0.65-0.85) and patient race (aOR: 0.83; 95% CI (0.71-0.99) were associated with lower odds of macrolide vs. amoxicillin prescription.

Image: PD

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