A study today in JAMA Network Open found that less than one-third of outpatient antibiotics prescribed for children in Tennessee were consistent with guidelines for antibiotic choice and duration.
Conducted by researchers with Vanderbilt University Medical Center, the Tennessee Department of Health, and the University of Utah, the cross-sectional study of nearly 500,000 children in Tennessee found that only 31.4% of the antibiotics prescribed in outpatient settings were optimal for choice and duration. Furthermore, 39% of pediatric antibiotic prescriptions were for diagnoses that rarely require antibiotics.
The study authors say the findings highlight several areas where antimicrobial stewardship interventions could help boost optimal prescribing.
Assessing optimal prescribing
Using data from IQVIA's Longitudinal Prescription Claims and Medical Database, the researchers examined clinical encounters for patients younger than 20 years with at least one oral antibiotic prescription from January 1 to December 31, 2022. To assess whether the prescriptions were optimal for choice and duration, they categorized each diagnosis using a 3-tier antibiotic appropriateness system and compared prescriptions for tier 1 (antibiotics nearly always required) and tier 2 (antibiotics sometimes required) diagnoses with published national guidelines.
An antibiotic was deemed optimal if it was consistent with guideline recommendations for first-line antibiotic choice and duration for the specific diagnosis. Antibiotics prescribed for tier 3 diagnoses (rarely ever required) were deemed suboptimal for both.
The study authors note that while previous research by the Centers for Disease Control and Prevention indicates roughly 50% of all pediatric outpatient antibiotics prescribed are unnecessary, few studies have looked at optimal antibiotic choice and duration, which are important elements of antimicrobial stewardship.
"Outpatient antimicrobial stewardship is of particular importance, and identifying factors in suboptimal antibiotic prescribing will allow health departments and stewardship programs in high-prescribing states to target, design, and implement future interventions," they wrote.
A total of 506,633 antibiotics were prescribed in 488,818 clinical encounters (mean age, 8.4 years; 50.7% female). Of these antibiotics, 4.2% were for tier 1 diagnoses, 56.9% were for tier 2 diagnoses, and 39.0% were for tier 3 diagnoses. The three most common indications for antibiotic prescriptions were ear infections (acute otitis media, or AOM), which accounted for 26% of encounters; pharyngitis (15.7%); and acute sinusitis (6.6%). The most common tier 3 diagnosis was unspecified acute upper respiratory infection.
Outpatient antimicrobial stewardship is of particular importance, and identifying factors in suboptimal antibiotic prescribing will allow health departments and stewardship programs in high-prescribing states to target, design, and implement future interventions.
Further analysis showed that 38.5% of antibiotic prescriptions had the optimal antibiotic choice, 51.3% had the optimal duration, and 31.4% were optimal for both choice and duration. AOM was treated with the optimal choice of antibiotic in only 67.3% of encounters and pharyngitis in only 55.9%.
While a higher percentage of antibiotic prescriptions were optimal for duration, the study also found that prescribing didn't reflect recent evidence supporting shorter durations for several indications. For example, only 5.7% of antibiotics prescribed for community-acquired pneumonia (CAP) had a 5-day duration.
Analysis of factors associated with optimal prescribing found that optimal antibiotic choice was more likely in patients who were younger (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.98 to 0.98) and less socially vulnerable (OR, 0.84; 95% CI, 0.82 to 0.86). For every 1-year increase in age, the odds of being prescribed an optimal antibiotic decreased by 2.2%, and for each 0.1 increase in social vulnerability, the odds of being prescribed an optimal antibiotic decreased by 1.5%.
High-yield stewardship targets
The authors note that while the study is directly applicable only to Tennessee—which in 2016 had a pediatric prescribing rate that was 50% higher than the national average—and may not be generalizable outside of other high-prescribing states in the southeast, it outlines specific, "high-yield" stewardship targets that health systems could focus on to improve pediatric outpatient prescribing.
For example, they suggest that drastically reducing the number of antibiotic prescriptions for tier 3 diagnoses would likely increase optimal pediatric antibiotic prescribing in the state to 50%. Improving antibiotic choice for AOM and pharyngitis could make a substantial difference.
"While we do not expect 100% optimal prescribing rates (approximately 10% of patients have a penicillin allergy, and some pediatric patients with AOM experience treatment failure), there is room for improvement," they wrote. "If optimal antibiotic choice for these 2 diagnoses increased to approximately 80%, that would equate to over 163,000 optimal prescriptions annually for 1 state."
They also call for more clinician education on shorter treatment courses for CAP and promotion of optimal prescribing in resource-limited settings.
