Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
Healthcare-Associated Infections and Antimicrobial Resistance Program of the Communicable and Environmental Diseases and Emergency Preparedness Division, Tennessee Department of Health, Nashville.
JAMA Netw Open. 2024 Oct 1;7(10):e2437409. doi: 10.1001/jamanetworkopen.2024.37409.
In the US, 50% of all pediatric outpatient antibiotics prescribed are unnecessary or inappropriate. Less is known about the appropriateness of pediatric outpatient antibiotic prescribing.
To identify the overall percentage of outpatient antibiotic prescriptions that are optimal according to guideline recommendations for first-line antibiotic choice and duration.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study obtained data on any clinical encounter for a patient younger than 20 years with at least 1 outpatient oral antibiotic, intramuscular ceftriaxone, or penicillin prescription filled in the state of Tennessee from January 1 to December 31, 2022, from IQVIA's Longitudinal Prescription Claims and Medical Claims databases. Each clinical encounter was assigned a single diagnosis corresponding to the lowest applicable tier in a 3-tier antibiotic tier system. Antibiotics prescribed for tier 1 (nearly always required) or tier 2 (sometimes required) diagnoses were compared with published national guidelines. Antibiotics prescribed for tier 3 (rarely ever required) diagnoses were considered to be suboptimal for both choice and duration.
Primary outcome was the percentage of optimal antibiotic prescriptions consistent with guideline recommendations for first-line antibiotic choice and duration. Secondary outcomes were the associations of optimal prescribing by diagnosis, suboptimal antibiotic choice, and patient- and clinician-level factors (ie, age and Social Vulnerability Index) with optimal antibiotic choice, which were measured by odds ratios (ORs) and 95% CIs calculated using a multivariable logistic regression model.
A total of 506 633 antibiotics were prescribed in 488 818 clinical encounters (for 247 843 females [50.7%]; mean [SD] age, 8.36 [5.5] years). Of these antibiotics, 21 055 (4.2%) were for tier 1 diagnoses, 288 044 (56.9%) for tier 2 diagnoses, and 197 660 (39.0%) for tier 3 diagnoses. Additionally, 194 906 antibiotics (38.5%) were optimal for antibiotic choice, 259 786 (51.3%) for duration, and 159 050 (31.4%) for both choice and duration. Acute otitis media (AOM) and pharyngitis were the most common indications, with 85 635 of 127 312 (67.3%) clinical encounters for AOM and 42 969 of 76 865 (55.9%) clinical encounters for pharyngitis being optimal for antibiotic choice. Only 257 of 4472 (5.7%) antibiotics prescribed for community-acquired pneumonia had a 5-day duration. Optimal antibiotic choice was more likely in patients who were younger (OR, 0.98; 95% CI, 0.98-0.98) and were less socially vulnerable (OR, 0.84; 95% CI, 0.82-0.86).
This cross-sectional study found that less than one-third of antibiotics prescribed to pediatric outpatients in Tennessee were optimal for choice and duration. Four stewardship interventions may be targeted: (1) reduce the number of prescriptions for tier 3 diagnoses, (2) increase optimal prescribing for AOM and pharyngitis, (3) provide clinician education on shorter antibiotic treatment courses for community-acquired pneumonia, and (4) promote optimal antibiotic prescribing in resource-limited settings.
在美国，50%的儿科门诊开出的抗生素是不必要或不适当的。关于儿科门诊抗生素处方的适当性，人们了解得较少。
确定根据一线抗生素选择和持续时间的指南建议，门诊抗生素处方中最佳处方的总体百分比。
设计、地点和参与者：这项横断面研究从 IQVIA 的纵向处方和医疗索赔数据库中获取了 2022 年 1 月 1 日至 12 月 31 日期间田纳西州每个年龄小于 20 岁的患者至少有 1 次门诊口服抗生素、肌内头孢曲松或青霉素处方的任何临床就诊的数据。每个临床就诊都分配了一个与 3 级抗生素分层系统中最低适用层相对应的单一诊断。对于 1 级（几乎总是需要）或 2 级（有时需要）诊断开出的抗生素与公布的国家指南进行了比较。对于 3 级（很少需要）诊断开出的抗生素，无论是选择还是持续时间，都被认为是不合适的。
主要结果是与指南建议的一线抗生素选择和持续时间一致的最佳抗生素处方的百分比。次要结果是根据诊断、抗生素选择不佳和患者和临床医生水平因素（即年龄和社会脆弱性指数）进行最佳抗生素选择的关联，这些关联通过使用多变量逻辑回归模型计算的比值比（OR）和 95%置信区间进行测量。
在 488818 次临床就诊中开出了 506633 次抗生素（247843 名女性[50.7%]；平均[SD]年龄为 8.36[5.5]岁）。在这些抗生素中，21055 次（4.2%）用于 1 级诊断，288044 次（56.9%）用于 2 级诊断，197660 次（39.0%）用于 3 级诊断。此外，194906 次抗生素（38.5%）在抗生素选择方面是最佳的，259786 次（51.3%）在持续时间方面是最佳的，159050 次（31.4%）在选择和持续时间方面都是最佳的。急性中耳炎（AOM）和咽炎是最常见的适应症，127312 次临床就诊中有 85635 次（67.3%）为 AOM，76865 次临床就诊中有 42969 次（55.9%）为咽炎的抗生素选择是最佳的。只有 4472 次抗生素中的 257 次（5.7%）用于社区获得性肺炎，持续时间为 5 天。在年龄较小（OR，0.98；95%CI，0.98-0.98）和社会脆弱性较低的患者中，更有可能选择最佳抗生素（OR，0.84；95%CI，0.82-0.86）。
这项横断面研究发现，田纳西州儿科门诊开出的抗生素中，不到三分之一是最佳选择和持续时间。可能有四个管理干预措施需要针对：（1）减少 3 级诊断的处方数量，（2）增加 AOM 和咽炎的最佳处方，（3）为社区获得性肺炎提供较短抗生素治疗疗程的临床医生教育，以及（4）促进资源有限环境中的最佳抗生素处方。
