Are pediatricians adhering to principles of judicious antibiotic use for upper respiratory tract infections?ABSTRACTBackground. In 1997, the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ), in collaboration with other professional organizations, released principles for judicious use of antibiotics in pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. upper respiratory illnesses (URI Uri, in the Bible Uri (y  `rī), in the Bible.1 Father of Bezaleel (1.) 2 Father of Geber (2.) 3 Porter. ). This study compared use of antibiotics for URI in children before (1995) and after (1998) publication of the principles and compared survey responses with practice habits. Methods. A questionnaire was mailed to a sample of pediatricians in northern Virginia Northern Virginia (NoVA) consists of Arlington, Fairfax, Loudoun, and Prince William counties and the independent cities of Alexandria, Falls Church, Fairfax, Manassas, and Manassas Park. . Office records of a randomly selected subset of pediatricians were reviewed. Results. Seventy-five percent of pediatricians completed the questionnaire; 51/149 (34%) chose to prescribe antibiotics for purulent pu·ru·lent adj. Containing, discharging, or causing the production of pus. Purulent Consisting of or containing pus Mentioned in: Lacrimal Duct Obstruction purulent containing or forming pus. rhinorrhea of less than 10 days' duration. This was significantly lower than that reported in the 1995 survey. However, review of office records of a random sample of these pediatricians revealed no significant difference in antibiotic use in children with uncomplicated URI in the 2 years studied. Conclusions. Injudicious in·ju·di·cious adj. Lacking or showing a lack of judgment or discretion; unwise. in  ju·di antibiotic use for URI is prevalent among
pediatricians in northern Virginia. Actual practice habits are at
variance with response to case vignettes.
********** ANTIBIOTICS are the second leading therapeutic category of drugs prescribed by office-based physicians in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . Respiratory tract infections Noun 1. respiratory tract infection - any infection of the respiratory tract respiratory infection infection - the pathological state resulting from the invasion of the body by pathogenic microorganisms account for more than three fourths of antimicrobial antimicrobial /an·ti·mi·cro·bi·al/ (-mi-kro´be-al) 1. killing microorganisms or suppressing their multiplication or growth. 2. an agent with such effects. drug prescriptions written annually in physician offices. (1) The recent emergence of penicillin and multi-drug-resistant strains of Streptoccoccus pneumoniae has further fueled the move to reduce unnecessary use of antibiotics. Representatives from the CDC, the American Academy of Pediatrics The American Academy of Pediatrics ("AAP") is an organization of pediatricians, physicians trained to deal with the medical care of infants, children, and adolescents. Its motto is: "Dedicated to the Health of All Children. (AAP AAP - Association of American Publishers ), and the American Academy of Family Physicians American Academy of Family Physicians, n.pr a national medical organization established in 1947 to promote the practice of family medicine. (AAFP AAFP American Academy of Family Physicians. AAFP abbr. American Academy of Family Physicians AAFP, n.pr See American Academy of Family Physicians. ) published a set of principles in 1997 for judicious use of antibiotics for pediatric upper respiratory tract infections upper respiratory tract infection URI Infectious disease A nonspecific term used to describe acute infections involving the nose, paranasal sinuses, pharynx, and larynx, the prototypic URI is the common cold; flu/influenza is a systemic illness involving the URT . (2-7) These experts recommend use of antibiotics for treatment of acute otitis media Acute otitis media Inflammation of the middle ear with signs of infection lasting less than three months. Mentioned in: Myringotomy and Ear Tubes acute otitis media and acute sinusitis sinusitis Inflammation of the sinuses. Acute sinusitis, usually due to infections such as the common cold, causes localized pain and tenderness, nasal obstruction and discharge, and malaise. , provided stringent diagnostic criteria are followed. They recommend that antibiotics be used with caution for common cold, otitis media with effusion otitis media with effusion Secretory otitis media, see there , and cough illness/bronchitis. In 1995, 198 pediatricians in northern Virginia had responded to a mailed survey designed to determine how they would manage a hypothetical child with recent onset of scant yellow-green nasal discharge. Results of this survey have been published previously. (8) In 1998, almost a year after the publication of the CDC/AAP/AAFP principles, we resurveyed these pediatricians, using a mailed questionnaire. To determine whether responses on the survey were congruent con·gru·ent adj. 1. Corresponding; congruous. 2. Mathematics a. Coinciding exactly when superimposed: congruent triangles. b. with the respondents' actual practicing habits, patient charts from a random sample of pediatricians participating in the study were reviewed. The purposes of this study were to compare reported antibiotic use for upper respiratory tract respiratory tract n. The air passages from the nose to the pulmonary alveoli, including the pharynx, larynx, trachea, and bronchi. Respiratory tract illnesses before and after publication of the principles and to compare survey responses with actual practice habits by direct observation of medical records. MATERIALS AND METHODS A list of office-based general pediatricians was obtained from the medical staff office of 5 general hospitals and 1 childrens' hospital located in 5 counties in northern Virginia. The study was conducted from September to November 1998. The survey questionnaire consisted of 17 questions pertaining to demographic information, type of practice, number of years in practice, awareness and utilization of CDC/AAP principles, and current antibiotic prescribing habits, as well as case vignettes. Five vignettes described an 18-month-old child in the following clinical scenarios: (1) purulent rhinorrhea of 4 days' duration and a temperature of 38.3[degrees]C; (2) reddened, mobile tympanic membrane tympanic membrane n. See eardrum. Tympanic membrane A structure in the middle ear that can rupture if pressure in the ear is not equalized during airplane ascents and descents. that was not bulging; (3) immobile im·mo·bile adj. 1. Immovable; fixed. 2. Not moving; motionless. im mo·bil bulging dull-yellow tympanic membrane; (4) dull, immobile
tympanic membrane in neutral position; (5) cough illness without audible
rales; and (6) cough illness with audible rales. The sixth vignette VignetteA symbol or pictorial representation of the corporation on a stock certificate. Usually a complicated and artistic design, it is meant to make the counterfeiting of stock certificates as difficult as possible. described a 4-year-old child with sore throat Sore Throat Definition Sore throat, also called pharyngitis, is a painful inflammation of the mucous membranes lining the pharynx. It is a symptom of many conditions, but most often is associated with colds or influenza. . Use of antibiotics for each of these conditions was assessed. Each participant was assigned a unique identifier With reference to a given (possibly implicit) set of objects, a unique identifier is any identifier which is guaranteed to be unique among all identifiers used for those objects and for a specific purpose. , allowing for second and third mailings to nonrespondents. Reminders were sent by mail, fax, and/or telephone until our predetermined pre·de·ter·mine v. pre·de·ter·mined, pre·de·ter·min·ing, pre·de·ter·mines v.tr. 1. To determine, decide, or establish in advance: goal of 70% was achieved. Responses t o the clinical vignettes in the present survey were compared with responses to similar questions from the survey done in 1995. In the second phase of our study, we attempted to verify whether answers to the vignettes matched actual practicing habits of the respondents. The chairman of the department of pediatrics at our hospital personally requested the community pediatricians to permit chart review by a pediatric resident. A letter requesting cooperation was mailed to each respondent. The pediatricians were chosen at random from the list of pediatricians who responded to the questionnaire. A random sample of 10% of the respondents was chosen for chart review. If a pediatrician declined to have records reviewed, the next pediatrician on the randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. list was chosen. The principal investigator Noun 1. principal investigator - the scientist in charge of an experiment or research project PI scientist - a person with advanced knowledge of one or more sciences was blinded to the selection process. Based on the diagnostic code used by the pediatrician, office records were reviewed for antibiotic use for purulent rhinorrhea of less than 7 days' duration, otitis media with effusion, bronchitis, and nonstreptococcal pharyngitis pharyngitis Inflammation and infection (usually bacterial or viral) of the pharynx. Symptoms include pain (sore throat, worse on swallowing), redness, swollen lymph nodes, and fever. . Charts of children less than 5 years of age were reviewed for the years 199 5 and 1998. Residents from the pediatric residency program at our hospital and one of us (S.N.) reviewed the charts. Instruction on the diagnoses being studied and the data to be extracted from the charts was given to the residents by one of us (S.N.). Statistical Methods All survey responses were categorical. Differences in response frequencies across categories were assessed using various chi-square methods, as well as by the Fisher exact test if any of the frequencies in the table were less than 6. RESULTS Questionnaires were mailed to 200 general pediatricians in five counties of northern Virginia, and 149 pediatricians (75%) returned completed surveys. Seventy-eight respondents (52%) were male. Twenty-six (17%) had been in practice for less than 5 years, 44 (30%) for 6 to 15 years, and 78 (52%) for more than 15 years. Thirty-two (22%) were either in solo or two-pediatrician practice, 93 (62%) were in group practice, and 20 (14%) worked for a large HMO HMO health maintenance organization. HMO n. A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial, . Of the 110 respondents (74%) who had heard or read about the guidelines, 96 (87%) agreed with them. In response to a direct question about antibiotic use for purulent rhinorrhea in an afebrile afebrile /afe·brile/ (a-feb´ril) without fever. a·feb·rile adj. Apyretic. afebrile without fever. afebrile adjective Feverless 18-month-old child, 34% (51/149) would prescribe antibiotics before 10 days, 49% (73/149) would prescribe antibiotics only after 10 days, and 17% (25/149) would not use antibiotics for this condition. The following responses were based on the case vignettes in the questionnaire. Sixty-eight respondents (46%) chose to prescribe antibiotics for a child with red tympanic membrane with good mobility, 38 (26%) for otitis media with effusion, and 48 (32%) for cough illness in the absence of rales (Fig 1). One hundred twenty-seven (85%) would not prescribe antibiotics for a child with a sore throat without a positive culture report in the absence of a rapid diagnostic test. Because of the differences between the 1995 and 1998 questionnaires, only one direct comparison of respondents' reported use of antibiotics in a hypothetical situation was possible. The vignette related to a toddler with short duration purulent rhinorrhea (2 to 3 days). In 1995, 53% of pediatricians (106/198) chose to prescribe antibiotics, in contrast to only 5% (8/149) in 1998 (P = < .001) (Fig 2). Office records of 15 pediatricians were carefully reviewed for a total of 247 office visits (average of 16 office visits per pediatrician, range 15 to 20). These reviews revealed that antibiotic use was still prevalent for common respiratory illnesses, regardless of responses on the questionnaire. Of all the office visits for the illnesses as a group, antibiotics were used in 38% of children (47/125) in 1995 and in 32% (39/122) in 1998 (P = .2). In children with purulent rhinorrhea of less than 7 days' duration, 26% (12/47) and 24% (11/46) received antibiotics in 1995 and 1998, respectively. Antibiotics were prescribed for 57% of children (15/26) with secretory otitis media secretory otitis media n. Inflammation of the mucosa of the middle ear, often the result of obstruction of the eustachian tube and accompanied by an accumulation of fluid. Also called serous otitis. and for 56% (11/20) with cough illness (Table). DISCUSSION According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. the survey responses, the majority of the surveyed pediatricians in northern Virginia reported having heard or read about the CDC/AAP/AAFP guidelines for treatment of upper respiratory tract illnesses. In hypothetical scenarios, physicians appear to choose appropriately not to prescribe antibiotics for upper respiratory tract infections, but in actual office practice adherence to guidelines seems more challenging. The discrepancy between what should be done and what is actually practiced is concerning. In contrast to the 5% who said they would prescribe antibiotics for short duration purulent rhinorrhea (less than 7 days' duration) in response to a hypothetical case, 24% actually prescribed it for this indication in their offices. It was, however, encouraging that misuse of antibiotics for streptococcal pharyngitis streptococcal pharyngitis (strep·tō·kôˑ·k was less common. Although there was a slight. downward trend, we found no significant reduction in antibiotic use for common respiratory illnesses since 1995. Watson et a1 (9) conducted a statewide survey of pediatricians and family physicians in Georgia regarding reported antibiotic use for upper respiratory tract infection. Responses were compared with the CDC/AAP/AAFP principles for judicious antibiotic use. Thirty percent of the pediatricians surveyed routinely prescribed antibiotics for the common cold, similar to the 34% rate in our survey. Eighty-one percent routinely prescribed antibiotics for bronchitis, in contrast to 32% in our study. Curtailing the tendency to use antibiotics for such self-limited illnesses will be an important element in the success of the CDC/AAP/AAFP campaign for judicious antibiotic use. Interestingly, in a recent study from Canada, reviews of pediatricians' patient charts showed that antibiotics were prescribed in only 6.6% of visits for the common cold. (10) If this is a true reflection of the antibiotic prescribing habits of pediatricians in Canada, it is encouraging and should serve as a model for other physicians. Results from focus groups, surveys, and analyses of outpatient databases suggest that reasons for overprescribing may include education, experience, expectations, and economics. (11) Physicians' perceptions of parental expectations for antimicrobials was a significant predictor of prescribing antimicrobials for conditions of presumed viral etiology. (12) Studies have shown that the impact of practice guidelines practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. is small when they are passively disseminated by publication in the medical literature. (13) Knowledge-based interventions such as practice guidelines are most likely to change clinical behavior if measures are taken at the local level to ensure "buying" from the practice community, to address barriers to change, and to rectify relevant gaps in clinical knowledge. (14) In summary, although much information is available to the medical community about the prevalence of antibiotic resistance antibiotic resistance, n the ability of certain strains of microorganisms to develop resistance to antibiotics. antibiotic resistance and its clear association with injudicious antibiotic use, significant work still remains to be done to win the war against spread of resistant pathogens. A multifaceted approach, including changing prescribing practices of physicians, better surveillance techniques, media crusades about the danger of resistant bacteria, and educating the public about the natural history of several respiratory tract infections, could be beneficial.
FIGURE 1
Antibiotic use for common respiratory illnesses (response to survey,
1998).
Clinical Diagnosis Used Not Used
Red TM 68 81
OME 68 111
Cough Illness 48 101
Note: Table made from bar graph
FIGURE 2
Use of antibiotics for purulent rhinorrhea (2 to 3 days duration).
Comparison of survey responses.
Year survey conducted Used Not Used
1995 106 92
1998 8 141
Note: Table made from bar graph
TABLE
Comparison of Questionnaire Responses and Office Practice
Questionnaire
Doctor ID Response
Purulent Rhinorrhea for Less
than 7 Days
13 No antibiotics
16 Antibiotics in 2 days
36 Antibiotics in 10 days
54 Antibiotics in 10 days
79 Antibiotics in 2 days
89 Antibiotics in 10 days
94 Antibiotics in 2 days
105 Antibiotics in 10 days
107 No antibiotics
118 Antibiotics in 10 days
128 Antibiotics in 10 days
129 No antibiotics
Otitis Media With Effusion,
Duration Less Than 3 Months
86 No antibiotics
89 No antibiotics
105 Will use Antibiotics
110 Uncertain
128 Uncertain
129 Uncertain
Acute Bronchitis
13 Use antibiotics
16 Use antibiotics
33 Uncertain
54 Will use antibiotics
79 Use antibiotics
Nonstreptococcal Pharyngitis
33 No antibiotics
36 No antibiotics
86 No antibiotics
94 No antibiotics
107 No antibiotics
110 No antibiotics
118 No antibiotics
1995 Antibiotic Use 1998 Antibiotic Use
Doctor ID (Chart Review) (Chart Review)
Purulent Rhinorrhea for Less
than 7 Days
13 1/4 0/4
16 1/4 1/4
36 1/4 0/4
54 3/4 3/3
79 3/4 1/3
89 0/4 0/4
94 0/4 0/4
105 1/4 3/4
107 2/4 3/4
118 0/4 0/4
128 0/4 0/4
129 0/3 0/4
Otitis Media With Effusion,
Duration Less Than 3 Months
86 5/5 5/5
89 1/4 0/4
105 3/4 1/4
110 5/5 5/5
128 1/4 1/4
129 4/4 3/4
Acute Bronchitis
13 3/5 2/4
16 3/4 3/4
33 1/4 0/4
54 4/4 3/4
79 3/5 3/4
Nonstreptococcal Pharyngitis
33 1/4 1/4
36 0/4 0/4
86 0/5 1/5
94 0/4 0/4
107 2/4 0/4
110 0/5 0/5
118 0/4 0/4
Agree/Disagree
Doctor ID With Guidelines
Purulent Rhinorrhea for Less
than 7 Days
13 Not read
16 Uncertain
36 Agree
54 Agree
79 Agree
89 Agree
94 Agree
105 Not read
107 Agree
118 Agree
128 Agree
129 Agree
Otitis Media With Effusion,
Duration Less Than 3 Months
86 Uncertain
89 Agree
105 Not read
110 Agree
128 Agree
129 Agree
Acute Bronchitis
13 Not read
16 Uncertain
33 Agree
54 Agree
79 Agree
Nonstreptococcal Pharyngitis
33 Agree
36 Agree
86 Uncertain
94 Agree
107 Agree
110 Agree
118 Agree
References (1.) McCaig LF, Hughes JM: Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA JAMA abbr. Journal of the American Medical Association 1995; 273:214-219 (2.) Dowell SF, Marcy SM, Phillips WR, et al: Principles of judicious use of antimicrobial agents Antimicrobial agents Chemical compounds biosynthetically or synthetically produced which either destroy or usefully suppress the growth or metabolism of a variety of microscopic or submicroscopic forms of life. for pediatric upper respiratory tract infections. Pediatrics 1998; 101(suppl):163-165 (3.) Dowell SF, Marcy SM, Phillips WR, et al: Otitis media Otitis Media Definition Otitis media is an infection of the middle ear space, behind the eardrum (tympanic membrane). It is characterized by pain, dizziness, and partial loss of hearing. . principles of judicious use of antimicrobial agents. Pediatrics 1998; 101 (suppl):165-171 (4.) Rosenstein N, Phillips WR, Gerber MA, et al: The common cold, principles of judicious use of antimicrobial agents. Pediatrics 1998; 101 (suppl):181-184 (5.) Schwartz B, Marcy SM, Phillips WR, et al: Pharyngitis. principles of judicious use of antimicrobial agents. Pediatrics 1998; 101 (suppl):171-174 (6.) O'Brien KL, Dowell SF, Schwartz B, et al: Acute sinusitis. Principles of judicious use of antimicrobial agents. Pediatrics 1998; 101 (suppl):174-177 (7.) O'Brien KL, Dowell SF, Schwartz B, et al: cough illness/ bronchitis. principles of judicious use of antimicrobial agents. Pediatrics 1998; 101 (suppl):178-181 (8.) Schwartz RH, Freij BJ, Ziai M, et al: Antimicrobial prescribing for acute purulent rhinitis purulent rhinitis n. Chronic rhinitis in which pus formation is excessive. in children: a survey of pediatricians and family practitioners. Pediatr Infect Dis J 1997;16:185-190 (9.) Watson RL, Dowell SF, Jayaraman M: Antimicrobial use for pediatric upper respiratory infections Noun 1. upper respiratory infection - infection of the upper respiratory tract respiratory infection, respiratory tract infection - any infection of the respiratory tract : reported practice, actual practice, and parent beliefs. Pediatrics 1999; 104:1251-1257 (10.) Arnold SR, Allen UD, Al-Zaharani M, et al: Antibiotic prescribing by pediatricians for respiratory tract infection in children. Clin Infect Dis 1999;29:312-317 (11.) Schwartz B, Mainous AG III, Marcy SM: Why do physicians prescribe antibiotics for children with upper respiratory tract infections? JAMA 1998; 279:881-882 (12.) Mangione-Smith R, McGlynn EA, Elliot MN: The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics 1999; 103:711-718 (13.) Lomas J: words without action? the production, dissemination, and impact of consensus recommendations. Annu Rev Public Health 1991; 12:41-65 (14.) Davis DA, Thompson MA,.Oxman AD, et al: Changing physician performance. a systematic review of the effect of continuing medical education continuing medical education See CME. strategies. JAMA 1995; 274:700-705 RELATED ARTICLE: KEY POINTS * Injudicious use of antibiotics for upper respiratory tract infections is still prevalent. * A significant reduction in reported antibiotic use for upper respiratory tract infections from 1995 to 1998 was noted. * Discrepancy was noted between reported practice habits and actual practice habits. From the Department of Pediatrics, Inova Fairfax Hospital Inova Fairfax Hospital is the largest hospital in the Washington D.C. area. Located in Fairfax County, Virginia, Inova Fairfax Hospital is the flagship hospital of Inova Health System, one of the largest employers in Fairfax County. for Children and Inova Institute for Research and Education, Falls Church Falls Church, independent city (1990 pop. 9,578), NE Va., a residential suburb of Washington, D.C.; inc. as a town 1875, as a city 1948. There is diverse light manufacturing, including telecommunications equipment. , Va. Reprint requests to Sumathi Nambiar, MD, Children's National Medical Center  This article or section is written like an .Please help [ rewrite this article] from a neutral point of view. Mark blatant advertising for , using . , Department of Infectious Diseases infectious diseases: see communicable diseases. , 111 Michigan Ave NW, Washington, DC 20010. |
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