Knowledge of the principles of judicious antibiotic use for upper respiratory infections: a survey of senior medical students.

Objective: Senior medical students (n = 2,433) from 21 accredited medical schools in New England and the mid-Atlantic states were surveyed to evaluate their knowledge of and compliance with principles of judicious antimicrobial use, as defined by the Centers for Disease Control and others.

Materials and Methods: A self-administered questionnaire with six vignettes on the clinical management of different upper respiratory tract infections was used. Compliance was calculated by using an ordinal response scale (1 to 4) for each question on the six vignettes.

Results: The adjusted response rate was 46%. More than 47% of the respondents had read none of the principles, and only 2.9% had read all six. Approximately 36% of the respondents would start antibiotics within 2 days of an 18-month-old presenting with purulent rhinitis, whereas 55.9% would immediately prescribe antibiotics if the child had wheezy bronchitis. For a 4-year-old with pharyngitis, 29.5% of respondents would either give an antibiotic office sample to start that night and a prescription for continuation of treatment at home, would give an antibiotic prescription with instructions to discontinue treatment with a negative throat culture, or would treat without a throat culture. Almost all of the respondents (99%) were informed regarding the problems of antibiotic resistance, usually from multiple sources. The number of sources of knowledge about problems of antibiotic resistance was the only predictor of compliance (P = 0.02). The number of principles read was not correlated with compliance.

Conclusions: Among students surveyed, large gaps remain regarding the appropriate use of antimicrobial agents for the treatment of upper respiratory infections.

Key Words: pediatric upper respiratory tract infection, judicious antibiotic use, senior medical students

**********

Adult and pediatric primary care providers often prescribe antibiotics for upper respiratory infections. A 1992 survey of physician offices found that health practitioners in the United States wrote 11 to 12 million antibiotic prescriptions for viral upper respiratory tract infections and bronchitis in children. (1) A 1996 review of the National Ambulatory Medical Survey (NAMCS) database showed that among adults ([greater than or equal to] 18 years), as many as 61%, 63%, and 72% of ambulatory patient visits for colds, upper respiratory infections, and acute bronchitis, respectively, ended with a prescription for an antibiotic. (2) Antibiotic prescriptions for minor upper respiratory infections and acute bronchitis are considered major contributors to the increasing antibiotic resistance worldwide. Such injudicious antibiotic use could also result in unwanted adverse events, thus further escalating health care costs. In 1998, a panel of experts from the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) established the Principles for Judicious Use of Antibiotics for Pediatric Upper Respiratory Traet Infections. (3-8) One year after the publication of these principles, general pediatricians in private practices in northern Virginia still prescribed antibiotics for one in three children with uncomplicated acute purulent rhinorrhea. (9)

Some encouraging progress has been documented in the nationwide effort to reduce inappropriate antibiotic prescribing for viral respiratory infections. In a 1998 to 1999 study using the NAMCS database, Halasa et al (10) found that among children younger than 5 years of age and diagnosed with bronchitis, pharyngitis, and upper respiratory tract infection, 66%, 53%, and 18%, respectively, received an antibiotic prescription. These findings suggest that much remains to be done to dissuade physicians from inappropriately prescribing antibiotics for children with bronchitis and non-group A streptococcal pharyngitis.

Since the goal of the combined CDC/AAP/AAFP effort is to educate primary care physicians, it seemed logical to inquire how well the principles were known by pediatric residents and senior medical students. Injudicious antibiotic use for upper respiratory tract infections was prevalent among pediatric residents in the mid-Atlantic area, although such practices were significantly less prevalent during the third year of training compared with the first year. (11) Nevertheless, findings from the study by Nambiar et al (11) underscore the importance of inculcating appropriate practice habits among physicians early in their training.

Medical students learn in part by modeling the prescribing practices of primary care practitioners, residents, and other mentors. Although medical students do not provide unsupervised direct patient care and legally cannot write prescriptions, they form a vital target group in the effort to establish judicious antibiotic prescribing practices. Have medical schools incorporated these principles into their curricula or during pediatric training, and to what extent have their students assimilated the knowledge?

To answer this question, we surveyed senior medical students in New England and the mid-Atlantic States to evaluate their level and sources of knowledge of the CDC/AAP/AAFP principles for judicious antibiotic use in common pediatric respiratory tract infections.

Materials and Methods

Participating medical schools

Preliminary to the study, we sought permission from the office of student affairs and the senior class president of all accredited medical schools in the New England and mid-Atlantic states. The survey instrument was a structured self-administered questionnaire requiring forced-choice answers. The questionnaires were distributed to senior year students, typically during a large scheduled meeting over a 5-month interval (October 1999 through February 2000). Before distribution, two experts at the CDC (Benjamin Schwartz, MD [no relation to coauthor Richard Schwarz, MD], and Scott Dowell, MD) critically reviewed the questionnaire. In addition, Dr. Benjamin Schwartz wrote a formal letter expressing his support for the study.

Survey instrument

The questionnaire contained six pediatric case vignettes regarding clinical management of different upper respiratory tract infections (an 18-month-old infant with short-duration purulent rhinorrhea, acute otitis media, otitis media with effusion, acute wheezy bronchitis or pneumonia and a 4-year-old child with acute pharyngitis). Specifically, the vignettes sought to capture responses about diagnostic choices, duration of symptoms, and influence of day care attendance on the decision to prescribe antibiotics. The questionnaire also asked about familiarity with and sources of information on the CDC/AAP/AAFP principles for judicious antibiotic use as well as the number of the CDC/AAP/AAFP principles taught during their third year lectures or clinical rotations.

Data analysis

We used [chi square] or Fisher exact tests to compare categorical responses between geographical regions. Spearman rank correlation analysis was used to compare total compliance score (TCS) with each of the three parameters: (1) number of CDC/AAP/AAFP principles read, (2) number of sources of knowledge about problems of antibiotic resistance, and (3) number of Internet portals available to the respondent. Finally, we examined potential predictors of compliance with the CDC/AAP/AAFP principles by using a multivariate analysis with TCS as the outcome variable. Covariates in the regression model were the number of CDC/AAP/AAFP principles read, number of sources of knowledge about problems of antibiotic resistance, number of Internet portals available to the respondent and location of the medical school.

To calculate the TCS, we created an ordinal response scale (1 to 4) for each of the eight questions on the six vignettes. The response furthest from the approach outlined in the CDC/AAP/AAFP principles received a score of 1, as did uncertain or blank responses. The response closer to the approach in the CDC/AAP/AAFP principles received a higher score (2 to 4), depending on the number of options provided to the question.

The number of sources of knowledge about problems of antibiotic resistance and the number of Internet portals available to the respondent were also scored as follows: 0 scored 1; 1 scored 2; 2 scored 3; 3 scored 4; 4 scored 5; and >4 scored 6. The TCS ranged from 8 to 20. Further details on computation of the TCS are available on request.

All statistical analyses were performed using SAS software (v6.12, SAS Institute, Cary, NC). P values of <0.05 were considered statistically significant.

Results

A total of 2,433 questionnaires were administered to students from 21 medical schools in New England and the mid-Atlantic regions of the United States. The students returned 989 completed questionnaires by mail, for an overall response rate of 41%. The number of returned questionnaires from the University of Connecticut (22.5%), Brown University (18.5%), Yale University (12%), Duke University (6%), and the Medical College of Virginia (0%) was considered too low, relative to the response rates of the other medical schools. The main reason for the low response rates from these schools was the logistical difficulties in the distribution and collection of the questionnaires due to scheduling conflicts. Therefore, questionnaires returned from these five institutions were excluded from further analyses leaving a final adjusted response rate of 46% (934/2,054). All 934 of the retained questionnaires were usable. Overall, students from the mid-Atlantic medical schools returned a significantly higher proportion of questionnaires than students from New England medical schools (44.2% vs 36.0%, P < 0.0001). The respondents were predominantly students who would graduate in 2000 (959/989, 97%), whereas the rest were to graduate in 2001.

Number of CDC/AAP/AAFP principles read

Of the 912 respondents to this question, 436 (47.8%) had not read any of the Principles for Judicious Use of Antibiotics for Upper Respiratory Infections, 341 (37.4%) had only read one or two, and 109 (12.0%) had read three or four. Only 26 respondents (2.9%) had read them all.

Antibiotic prescription for an 18-month-old, previously healthy child with a 4-day history of yellow-green rhinorrhea and a bedtime cough who has a temperature of 38.3[degrees]C but is otherwise well

Overall, 581 (63.5%) of 915 respondents would wait for a total of 10 days before starting such a child on antibiotics, whereas 334 (36.5%) would start antibiotics on the same day or wait for only 2 days before commencing antibiotics. If the same child were noted to be tugging on the right ear, with a red, mobile, and nonbulging right tympanic membrane, 354 (38.6%) of the 917 respondents would immediately prescribe an antibiotic, whereas 432 (47.1%) would not. The remaining students were uncertain what to do. If, however, the same 18-month-old child, were diagnosed with otitis media with effusion, 459 (50.1%) of the 920 respondents would still prescribe an antibiotic, whereas 355 (38.6%) and 106 (11.5%), respectively, would not prescribe or were uncertain about their use of antibiotics. When presented with another 18-month-old child with ear tugging associated with an immobile, bulging, and dull yellow tympanic membrane, 90.9% (837/921) of respondents would immediately prescribe antibiotics.

Antibiotic prescription for an 18-month-old wheezy child with a temperature of 38.3[degrees]C, upper respiratory tract infection symptoms, normal tympanic membranes, and localized, fine crackles at the right base and right axilla suggestive of bronchopneumonia 

Of 909 respondents to this vignette, 508 (55.9%) would immediately prescribe antibiotics, 336 (37%) would prescribe antibiotic treatment only if the chest radiograph was suggestive, 21 (2.3%) would prescribe no antibiotic at all, and 44 (4.8%) were uncertain about what to do.

Antibiotic prescription for a 4-year-old child with a temperature of 38.3[degrees]C, sore throat, shotty cervical lymph nodes, and pharyngeal erythema without exudate seen in an office lacking the ability to do a rapid Streptococcal antigen test

A total of 911 students responded to this vignette. Of these, 598 (65.6%) would wait for the result of a throat culture before antibiotic prescription, 163 (17.9%) would give an antibiotic office sample to start that night and a prescription for continuation of treatment at home, and 106 (11.6%) would give an antibiotic prescription with instructions to discontinue treatment if the throat culture returned negative. A few respondents elected to just treat without obtaining a throat culture (26/911, 2.8%) or would opt for some other form of management different from those listed above (18/911, 2.0%).

Duration of symptoms in an 18-month-old daycare attendee presenting with profuse rhinorrhea without fever

Of 855 respondents, 81 (9.5%) would wait for less than 4 days before prescribing an antibiotic for the child, 179 (20.9%) would wait for 4 to 6 days, and 176 (20.6%) for 7 to 10 days. Only 208 (24.3%) respondents would wait greater than 10 days, whereas another 214 (25%) would not prescribe an antibiotic for such a child irrespective of the duration of symptoms.

Settings where responders acquired knowledge about problems of antibiotic resistance

Of 967 respondents, only 10 (1%) denied being informed about antibiotic resistance and treatment of an upper respiratory tract infection. A large proportion of the respondents received this information from multiple sources: grand rounds (570, 58.9%), didactic lectures (807, 83.4%), teaching sessions during outpatient rotations (654, 67.6%), and teaching sessions during inpatient rotations (678, 70.1%). An additional 41 (4.2%) received information from other sources as part of the multiple settings. Very few (11.1%) received information on antibiotic resistance from a single source (grand rounds, 26; lectures, 48; outpatient rotation teaching sessions, 16; inpatient rotation teaching sessions, 12; and other single sources, 6).

The single most helpful resource for learning about judicious antibiotic prescription and antibiotic resistance

Among 909 respondents to this question, the five single most helpful resources for learning about judicious antibiotic prescription and antibiotic resistance in rank order were (1) interactive sessions between students, residents, and faculty (26.1%); (2) lecture series for medical students (21.4%); (3) feedback from faculty on diagnosis and antibiotic use in students' outpatient continuity clinic (15.8%); (4) patient-oriented problem-solving modules completed by small groups of medical students or residents (15.1); and (5) grand round presentations (7.1%).

Medical students' perceived solutions to the problem of antibiotic resistance

Students were given a list of four potential solutions for the increasing prevalence of antibiotic resistance. Table 1 summarizes students' responses to perceived solutions regarding antibiotic misuse.

Aecess to the Internet

Of 963 respondents, only eight students reported having no access to the Internet. The majority of the students had multiple access sites, including at the medical school (783, 81.3%), at the outpatient clinic (331, 34.4%), at home (612, 63.6%), and at the hospital (701, 72.8%). One hundred fifty-four respondents had access to the Internet only from a single source, primarily at the medical school (110, 71.4%) or at home (35, 22.7%).

Comparison of responses from the two participating regions

Questionnaire responses were compared between students attending medical schools in New England and those attending medical schools in the mid-Atlantic region. No statistically significant differences between these two regions were found for any of the following: clinical vignettes, settings of knowledge acquisition regarding antibiotic resistance, the single most helpful resource for learning about judicious antibiotic prescription and antibiotic resistance, medical students' perceived solutions to the problem of antibiotic resistance, or access to the Internet.

Since no significant differences in median TCS were found between the regions (New England versus mid-Atlantic), data from all respondents were pooled for correlation and regression analyses. Three primary methods for learning more about the CDC/AAP/AAFP guidelines (grand rounds, interactive sessions with students, residents and faculty, and patient-oriented problem-solving modules completed by small groups of medical students or residents) were not highly correlated among one another, suggesting they represented independent avenues of learning. However, TCS was not meaningfully correlated with any of the three methods (r < 0.10).

Predictors of compliance

In the regression model, only the number of sources of knowledge about problems of antibiotic resistance emerged as a significant predictor of TCS (P = 0.02). Number of accessible Internet portals (P = 0.06) and region of medical school location (P = 0.051) were marginally significant. No statistically significant relation was found between number of CDC/AAP/AAFP principles read in clinic rotations/lectures and TCS (P = 0.64).

Discussion

Using claims data from nine health plans, Finkelstein et al (12) observed a decline in antibiotic use after pediatric outpatient visits during the period from 1996 to 2000, which coincides with the period of our study. Although such declining trends are desirable, many primary healthcare providers still prescribe antibiotics inappropriately for self-limited viral upper respiratory illnesses, despite the widespread availability of learning resources for teaching judicious antibiotic prescription techniques. One contributing factor to inappropriate prescribing could be entrenched habits learned during training and early in the career. Indeed, a recent survey (13) of internal medicine, family practice, medicine-pediatrics, and emergency medicine residents from 11 residency programs in southeastern Michigan is informative. The authors noted that although 92% recalled receiving one or more lectures per year on upper respiratory tract infections and 97% were familiar with guidelines related to upper respiratory tract infection, 57% would give antibiotics for acute bronchitis, 42% for purulent nasal discharge, and 30% for patients with symptoms of viral rhinosinusitis. Furthermore, 30% would prescribe antibiotics for pharyngitis even with an uncertain diagnosis. (13)

How do students in our study compare with similar published studies of qualified practitioners? In our survey of senior medical students, inappropriate antibiotic prescriptions were common. There was no clear understanding of the connection between the wide use of antibiotics in agriculture and animal husbandry and antibiotic resistance. Qualified practitioners also misuse antibiotics and may not be overly concerned about antibiotic resistance resulting from such misuse. A recent study by Metlay et al (14) found that both generalists and infectious disease specialists were more likely to prefer newer, broader drugs for the treatment of community-acquired pneumonia compared with older agents still recommended by national guidelines. Moreover in the study by Metlay et al. (14) physicians rated the issue of contributing to antibiotic resistance lowest among seven determinants of their choices.

It is interesting to note from our study that only the number of sources of knowledge regarding antibiotic resistance problems emerged as a significant predictor of TCS, whereas the number of Internet portals and region of medical school were marginally significant predictors. Although there is need to confirm the findings from our study, exactly what factors in the two regions could predict TCS was not clear. Of note, the number of principles read was not a significant predictor of compliance, although this finding might have resulted from the fact that a large number of the respondents read just one or none of the principles. Overall, the findings from our study seem to suggest that these medical students require exposure to multiple sources of knowledge and modes of instruction to adequately assimilate such knowledge.

Certain limitations are inherent in our study. First, our compliance scale (TCS) may not be a valid or an adequate assessment tool. Second, our results are based on self-reported responses to clinical scenarios and not on observed practice patterns. Nevertheless, we believe our study provides useful information on senior medical students' understanding of issues relevant to judicious antimicrobial use for upper respiratory infections. In addition, our study provides a method that could be used to assess knowledge acquisition as it relates to quantity and methods of instruction. Finally, it would be interesting to conduct a follow-up survey of the respondents after graduation from medical school.

In conclusion, for those senior medical students surveyed, large gaps remain in their knowledge of the appropriate use of antimicrobial agents for the treatment of upper respiratory infections. Filling in these gaps may require multiple modalities of instruction and exposure to available knowledge for these students.

Treatment of Children with Purulent Rhinorrhea, Pharyngitis, Bronchitis, Sinusitis and Otitis Media: A Survey of Medical Students

Please answer, as you actually would react to real case vignettes. Your name will not be used and no grade will be given for this survey. Please, no discussion at all until everyone completes this survey.

1. Circle your medical school

a. Dartmouth University School of Medicine

b. University of Vermont School of Medicine

c. Brown University School of Medicine

d. University of Connecticut School of Medicine

e. Yale University School of Medicine

f. University of Massachusetts School of Medicine

g. Boston University School of Medicine 

h. Tufts University School of Medicine 

i. Harvard University School of Medicine

2. Year of medical school graduation____________________

3. Please indicate the last four digits of your social security number____________________

4. During your clinic rotations or lectures, how many of the six 1997 AAP / CDC recommendations on antibiotic treatment of purulent rhinorrhea, pharyngitis, bronchitis, sinusitis and otitis media have you read?

a. Zero

b. 1-2

c. 3-4

d. 5-6

Case Vignettes

Case 1:

An 18-month-old is brought to your outpatient department with yellow-green rhinorrhea, daytime and bedtime cough of four days' bedtime duration. She has been a bit fussy but eats and sleeps well. She has not had acute otitis media previously. On examination the child seems comfortable. The tympanic temperature is 38.3[degrees]C. Exam of face, eardrums and throat are normal. The chest is clear.

5. In addition to symptomatic care, your management plan would be:

a. Prescribe antibiotics today

b. Withhold antibiotics for an additional 2 days, assuming no new signs or symptoms.

c. Withhold antibiotics until at least 10 days of cough and nasal mucopurulent drainage without improvement.

d. No antibiotics are needed for this condition

Best option is c. Consistent with the CDC/AAP/AAFP Principles.

6. The same child was noted to tug at her right ear. On otoscopic exam, her right eardrum is red. There is no TM bulging. Mobility is O.K. Would you prescribe antibiotics today?

a. Yes

b. No

c. Uncertain

Best option is b. Child has nonspecific features with normal otoscopic findings.

Case 2:

An 18-month-old is tugging at her right ear. She has manifested cranky behavior since last night. Otoscopic exam reveals an immobile, bulging, dull-yellow right tympanic membrane.

7. Would you prescribe antibiotics today?

a. Yes

b. No

c. Uncertain

Best option is a. Features are consistent with acute otitis media and child is symptomatic.

Case 3:

An 18-month-old not seen previously is noted to have a dulled right TM: which is in neutral position (not bulging or retracted). It is immobile to pneumo-otoscopy. The left TM is normal. You diagnose otitis media with effusion (ie OME, middle ear effusion or secretory otitis media).

8. Would you prescribe an antibiotic at this time?

a. Yes

b. No

c. Uncertain

Best option is b. Evidence shows that antibiotics do not impact course of OME.

Case 4:

An 18-month-old has temperature of 38.3[degrees]C, mucopurulent nasal discharge of 4 days' duration, intermittent cough. RR = 30, and normal otoscopic exam. Sleeping and drinking are reduced. Auscultation reveals bilateral expiratory wheezes and coarse rhonchi in both lung fields. No crackles are heard. Your clinical diagnosis is bronchitis and a URI. This is the child's first such episode. There is no history of gastroesophageal reflux or aspiration.

9. Would you prescribe an antibiotic now?

a. Yes

b. No

c. Uncertain

Best option is b. Needs testing, supportive care, and return appointment.

10. Assume that you had detected localized, fine crackles at the right base and right axilla. Would you now prescribe antibiotics for possible bronchopneumonia?

a. Yes

b. No

c. Uncertain

d. I would send for x-ray and treat only if bronchopneumonia

Best option is d. Consistent with CDC/AAP/AAFP Principles. In practice, option a is reasonable.

Case 5:

The mother of a 4-year-old (temperature 38.3[degrees]C), states that her child has a sore throat, Physical exam is normal except for pharyngeal erythema and shotty nontender cervical nodes. No tonsillar exudate is noted. No rapid strep test is available because the child's managed care organization is cutting costs.

11. At this point you would (choose one):

a. Ask the lab to process a throat culture. No penicillin/amoxicillin for now. If the culture is positive, prescribe penicillin/amoxicillin by telephone.

b. Ask the lab to process a throat culture and give parents a penicillin/amoxicillin sample for tonight and a prescription to be filled tomorrow if the culture is positive.

c. Obtain a throat culture. Give parents a prescription for penicillin/amoxicillin to be started as soon as possible. If the culture is negative, call them to D/C the antibiotics.

d. Treat with penicillin/amoxicillin without performing a throat culture.

e. Other____________________

Best option is a. Other options are wrong or send the wrong message.

Case 6:

An 18-month-old (who is afebrile) has profuse purulent rhinorrhea. This child attends day care.

12. After how many days of continuous purulent rhinorrhea would you prescribe antibiotics?

a. 1-3 days

b. 4-6 days

c. 7-9 days

d. > 10 days

e. I would not prescribe antibiotics

Best option is d. Consistent with CDC/AAP/AAFP Principles and published literature.

13. During your medical school training, in what settings have you received information about the problem of antibiotic resistance among outpatients? (Circle all that apply)

a. Grand Rounds

b. Lectures

c. Outpatient rotation teaching sessions

d. Inpatient rotation teaching sessions

e. Others (Specify)____________________

f. I have not received any information about antibiotic resistance for URIs

14. Which of the following would you find helpful in learning more about judicious prescribing of antibiotics and resistance of respiratory bacterial pathogens? (Circle all that apply)

a. Grand Rounds Lectures

b. Lecture series for medical students

c. Interactive sessions including students, residents, and faculty

d. Interactive patient-oriented problem-solving modules on the internet

e. Interactive patient-oriented problem-solving modules on CD-ROM 

f. Patient-oriented problem-solving modules completed by small groups of medical students or residents

g. Role-playing sessions focused on improving communications with patients

h. Feedback from faculty on diagnoses and antibiotic use in your outpatient continuity clinic

i. Others (Specify)____________________

j. I have no desire to learn more about outpatient antibiotic use or antibiotic resistance of respiratory pathogens

15. From Question 14 above, identify the single choice (a through j) that you would find most useful in learning more about judicious prescribing of antibiotics and resistance of respiratory bacterial pathogens? Answer:____________________

For questions 16 through 19 below--Which solutions during your training have been proposed to decrease antibiotic resistance?

16. Decrease antibiotic use in animals in agriculture.

a. Yes

b. No

c. Uncertain

17. More judicious antibiotic use for outpatients.

a. Yes

b. No

c. Uncertain

18. Using newer broad-spectrum antibioties to treat infections.

a. Yes

b. No

c. Uncertain

19. Assuring compliance with the entire course of antibiotic therapy.

a. Yes

b. No

c. Uncertain

20. Regarding your access to the Internet: (Circle all that apply)

a. I do not have access to the Internet

b. Internet access is available to me at my medical school

c. Internet access is available in the outpatient clinic

d. Internet access is available on my home personal computer

e. Internet access is available at my hospital

Thank you for your help with this survey. Please read the AAP/CDC recommendations on judicious antibiotic use for respiratory infections.

Acknowledgments The authors thank Benjamin Schwartz, MD, and Scott Dowell, MD, of the Centers for Disease Control and Prevention, Atlanta, GA, for their help with the design of the survey questionnaire. We are also indebted to Kristen Prescott, MD, of Gilford, NH, for her role in data collection.

References

1. Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis, JAMA 1998;279:875-877.

2. Cantrell R, Young AF, Martin BC. Antibiotic prescribing in ambulatory care settings for adults with colds, upper respiratory tract infections, and bronchitis. Clin Ther 2002;24:170-182.

3. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics 1998;101:163-165.

4. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis media: principles of judicious use of antimicrobial agents. Pediatrics 1998;101:165-171.

5. Schwartz B, Marcy SM, Phillips WR, Gerber MA, Dowell SF. Pharyngitis: principles of judicious use of antimicrobial agents. Pediatrics 1998;101:171-174.

6. O'Brien KL, Dowell SF, Schwartz B, S Marcy SM, Phillips WR, Gerber MA. Acute sinusitis-principles of judicious use of antimicrobial agents. Pediatrics 1998;101:174-177.

7. O'Brien KL, Dowell SF, Schwartz B, S Marcy SM, Phillips WR, Gerber MA. Cough illness/bronchitis-principles of judicious use of antimicrobial agents. Pediatrics 1998;101:178-181.

8. Rosenstein N, Phillips WR, Gerber MA, Marcy SM, Schwartz B, Dowell SF. The common cold-principles of judicious use of antimicrobial agents. Pediatrics 1998;101:181-184.

9. Nambiar S, Schwartz, RH, Sheridan MJ. Are pediatricians adhering to principles of judicious antibiotic use for upper respiratory tract infections? South Med J 2002;95:1163-1167.

10. Halasa NB, Griffin MR, Zhu Y, Edwards KM. Decreased number of antibiotic prescriptions in office-based settings from 1993 to 1999 in children less than five years of age. Pediatr Infect Dis J 2002;21:1023-1028.

11. Nambiar S, Schwartz RH, Sheridan MJ. Antibiotic use for upper respiratory tract infections: how well do pediatric residents do? Arch Pediatr Adolese Med 2002;156:621-624.

12. Finkelstein JA, Stille C, Nordin J, et al. Reduction in antibiotic use among US children, 1996-2000. Pediatrics 2003;112:620-627.

13. Fakih MG, Hilu RC, Savoy-Moore RT, Saravolatz LD. Do resident physicians use antibiotics appropriately in treating upper respiratory infections? A survey of 11 programs. Clin Infect Dis. 2003;37:853-856.

14. Metlay JP, Shea JA, Crossette LB, Asch DA. Tensions in antibiotic prescribing: pitting social concerns against the interests of individual patients. J Gen Intern Med 2002;17:87-94.

Ekopimo Ibia, MD, Michael Sheridan, SCD, and Richard Schwartz, MD

From Children's National Medical Center, Washington, DC; Inova Fairfax Hospital for Children, Falls Church, VA; and Advanced Pediatrics, Vienna, VA.

Reprint requests to Dr. Ekopimo Ibia, 651 Township Line Road, PO Box 369, Blue Bell, PA 19422. Email: [e-mail]

Accepted May 10, 2005.

RELATED ARTICLE: Key Points

* Most senior medical students in New England and the mid-Atlantic states are informed about the problem of antibiotic resistance.

* Given a clinical scenario, many of these same students would use antibiotics inappropriately.

* Instructions about judicious antibiotic use need to be further reinforced in medical schools, using multiple learning modules.

Table. Summary of student responses to perceived solutions to antibiotic
misuse

                                 Medical student responses
Perceived solutions   Agree n (%)  Disagree n (%)  Uncertain n (%)

Decrease antibiotic   354 (37.6)   408 (43.3)      180 (19.1)
  use in animals and
  agriculture
More judicious        858 (89.9)    85 (8.9)        11 (1.2)
  antibiotic use for
  outpatients
Use newer broad-       84 (8.9)    792 (83.7)       70 (7.4)
  Spectrum
  antibiotics for
  infections
Assure compliance     913 (95.9)    25 (2.6)        14 (1.5)
  with the entire
  course of
  antibiotic
  therapy