October 2014

To Maintain Appropriate Antibiotic Use, Sustained Feedback Needed

A program that provides guidance to primary care physicians about appropriately prescribing antibiotics for children is effective, but its improvements wear off after regular auditing and feedback are discontinued.

“Our findings suggest that interventions with outpatient healthcare providers should include continued feedback to clinicians to remain effective,” said the study’s leader, Jeffrey S. Gerber, MD, PhD, an infectious diseases specialist at The Children’s Hospital of Philadelphia.

Dr. Gerber and colleagues recently published their research in the Journal of the American Medical Association and presented their findings at the infectious disease-focused IDWeek 2014 meeting in Philadelphia. In addition to Dr. Gerber, CHOP’s Theoklis Zaoutis, MD, MSCE, and Louis M. Bell, MD, chief of the Division of General Pediatrics, contributed to the study.

Because disease-causing microorganisms have been developing resistance to commonly used antibiotics, public health experts advocate more selective usage of those medications. The “antimicrobial stewardship” program in the current study included prospective audits of prescription patterns — evaluating prescriptions based on current prescribing guidelines for specific conditions issued by professional organizations. The program staff then provided personalized, private feedback reports to the practitioners, advising them whether their prescriptions followed current recommendations.

The study team analyzed electronic health records of 1.2 million office visits at 18 community-based primary care offices within the CHOP pediatric network, focusing on prescriptions for common bacterial respiratory infections in children. The researchers randomized the 18 practices into two groups — one receiving the intervention (an hour-long session of clinician education, followed by audit and feedback) and the other group receiving no intervention.

The researchers previously reported in June 2013 that inappropriate prescribing decreased significantly in the intervention group, from 26.8 percent to 14.3 percent, compared to a decrease from 28.4 percent to 22.6 percent in the control group.

Because the previous study covered a 12-month intervention period, the current study evaluated the durability of the effects. The team followed antibiotic prescription patterns for 18 months after the auditing and feedback ended.

Prescribing of broad-spectrum antibiotics, which according to guidelines are typically reserved as second-line treatments, increased over the extended time period, reverting to above-baseline levels. After adjusting the data set for the additional 18 months after intervention ended, the study team found inappropriate prescribing rose from 16.7 percent to 27.9 percent in the intervention group, and from 25.4 percent to 30.2 percent in controls.

“Our results suggest that audit and feedback were crucial parts of this intervention,” said Dr. Gerber, who added, “For the initial benefits of this program to persist, there needs to be continued, active feedback to the clinicians in primary care offices.”

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