The Journal of Pediatrics, 12/2018, Vol.203, C, pp.76-85.e8
Byline: Holly M. Frost, MD [firstname.lastname@example.org] (1,2,3), Huong Q. McLean, PhD (3), Brian D.W. Chow, MD (4,5) Keywords antimicrobial stewardship; outpatient; pediatrics; respiratory infection; specialty Objective To evaluate variation in antibiotic prescribing between pediatric and nonpediatric providers for common upper respiratory illnesses. Study design Patient encounters for children aged 〈18 years from a regional health care system were identified. Electronic medical records from 2011 to 2016 were extracted for diagnoses of upper respiratory infection, pharyngitis, acute otitis media, and sinusitis. Encounters with competing medical diagnoses, recent hospitalization, and antibiotic prescriptions within 30 days were excluded. Adherence to antibiotic guidelines was assessed by provider training (pediatric, nonpediatric physicians, and advance practice providers). Additional factors assessed were calendar year, and patient's age, sex, insurance status, and number of sick visits in the prior year. Results Across 6 years, 141 361 visits were examined: 43 914 for upper respiratory infection, 43 701 for pharyngitis, 43 925 for acute otitis media, and 9821 for sinusitis. Pediatricians were more likely than Advanced practice providers (APP) and nonpediatric providers to have guideline-concordant prescribing for pharyngitis (pediatricians, 66.7% [95% CI, 54.5-77.0]; nonpediatricians, 49.1% [95% CI, 36.3-62.0], APPs, 52.2% [95% CI, 39.4-64.7]; P 〈 .0001) and sinusitis (pediatricians, 70.8% [95% CI, 53.8-83.4], nonpediatricians, 63.3% [95% CI, 46.8-77.2], APPs, 62.1% [95% CI, 45.1-76.5]; P = .48) and to withhold antibiotics for upper respiratory infection than APPs and nonpediatric providers (pediatricians, 86.6% [95% CI, 81.2-90.6], nonpediatricians, 80.8% [95% CI, 73.0-86.8], APPs, 76.8% [95% CI, 68.4-83.5]; P 〈 .0001). Pediatricians were less likely to prescribe antibiotics for pharyngitis without a positive test for group A Streptococcus than APPs and nonpediatric providers (pediatricians, 15.1% [95% CI, 10.4-21.6], nonpediatricians, 29.4% [95% CI, 20.8-39.6], APPs, 27.2% [95% CI, 19.3-36.9]; P 〈 .0001). First-line antibiotic prescribing for acute otitis media did not differ between provider specialties. A trend toward more guideline-concordant prescribing was seen for pharyngitis and sinusitis over the study period. Conclusions Pediatricians were more likely to adhere to guidelines for management of pediatric acute respiratory infections. Pediatric antibiotic stewardship efforts should also target nonpediatricians. Abbreviations AOM, Acute otitis media; APP, Advanced practice provider; ARI, Acute respiratory illness; ASP, Antimicrobial stewardship program; GAS, Group A Streptococcus; ICD, International Classification of Diseases; MCHS, Marshfield Clinic Health System; URI, Upper respiratory infectionw Author Affiliation: (1) University of Colorado, Department of Pediatrics, Aurora, CO (2) Denver Health and Hospital Authority, Department of Pediatrics, Denver, CO (3) Marshfield Clinic Research Institute, Marshfield, WI (4) Tufts Medical Center, Division of Geographic Medicine and Infectious Diseases, Boston, MA (5) Tufts University School of Medicine, Boston, MA * Reprint requests: Holly M. Frost, MD, 777 Bannock St, Denver, CO. Article History: Received 9 May 2018; Revised 11 June 2018; Accepted 11 July 2018 (footnote) The authors declare no conflicts of interest. (footnote)* Previously associated with Marshfield Clinic Health System, Marshfield, Wisconsin.
Antibiotics ; Medical Research ; Respiratory Tract Diseases ; Medical Records;