HealthDay News — Clinician education coupled with audit and feedback can improve adherence of antibiotic prescribing guidelines for common bacterial acute respiratory tract infections (ARTIs), study results indicate.

Within the first year the educational intervention was implemented, the number of broad-spectrum antibiotics prescribed for any indication decreased 12.5% compared with 5.8% in usual practice (P=0.01), Jeffrey S. Gerber, MD, PhD, from the Children’s Hospital of Philadelphia, and colleagues reported in the Journal of the American Medical Association.

The decrease was largely attributable to less use of antibiotics for pneumonia (P<0.001), according to the researchers. Reductions in antibiotic use for sinusitis and streptococcal pharyngitis were not statistically significant (P>0.01 for both). 

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Although research shows antibiotic stewardship programs are effective in hospital settings, little is known about whether they can improve adherence to prescribing guidelines in outpatient settings, where most antibiotic prescriptions for acute respiratory tract infections are written.

To better understand this issue, Gerber and colleagues evaluated randomized trial to assess an antimicrobial stewardship intervention within a network of 18 pediatric primary care practices in Pennsylvania and New Jersey. Data was collected from an electronic health record used by all of the practices, and encompassed information from 162 providers.

They assessed antibiotic prescribing habits in the 20 months before and 20 months after the intervention period. A total of 1,291,824 office visits occurred during the study period among 185,212 unique patients. Patients with chronic medical conditions and antibiotic allergies were excluded.

The antimicrobial stewardship intervention consisted of a single, one-hour on-site education session, in which a board-certified infectious disease pediatrician provided information about current antibiotic prescribing guidelines, followed by personalized audits and feedback on prescribing patterns every four months for one year.

Among practices that participated in the intervention, broad-spectrum antibiotic prescribing decreased from 26.8% before the intervention to 14.3% after, the researchers found. A smaller decline was observed in the control group from 28.4% to 22.6%.

Declines in off-guideline antibiotic prescribing were greatest among children with pneumonia, decreasing from 15.7% to 4.2% in practices that participated in the intervention compared with a decline from 17.1% to 16.3% in the control group. The absolute rate reduction was significantly greater in the intervention group (11.5% vs. 0.8%, P<0.001).

For acute sinusitis, prescriptions declined from 38.9% to 18.8% in intervention practices vs. 40% to 33.9% in controls. However, the absolute rate reduction was not statistically significant (20.1% vs. 6.1%, P=0.12).

For streptococcal pharyngitis, off-guideline prescribing was uncommon at baseline and changed little (intervention, 4.4% to 3.4%; control, 5.6% to 3.5%). For viral infections there was also little change (intervention, 7.9% to 7.7%; control, 6.4% to 4.5%).

“Future studies should examine the drivers of these effects, as well as the generalizability, sustainability, and clinical outcomes of outpatient antimicrobial stewardship,” the researchers wrote.

Study limitations included inability to determine which element of the intervention was responsible for changes in prescribing patterns and the relatively short one-year follow-up period.

In an accompanying editorial, Jonathan Finkelstein, MD, MPH, of Boston Children’s Hospital, praised the study for showing the ability of interventions to improve antibiotic prescribing patterns, but noted that “the influence and benefit” of such interventions “vary greatly across settings.”

“Tailoring strategies to contextual factors and adapting them further during implementation may well be more effective than merely rolling out the approach with the greatest average effect in the average practice,” Finkelstein noted.


  1. Gerber J et al. JAMA 2013; 309: 2345-2352.
  2. Finkelstein J. JAMA 2013; 309: 2388-2389.