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Antibiotic Use for Upper Respiratory Tract Infections
How Well Do Pediatric Residents Do?
Sumathi Nambiar, MD;
Richard H. Schwartz, MD;
Michael J. Sheridan, ScD
Arch Pediatr Adolesc Med. 2002;156:621-624.
ABSTRACT
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Background Antibiotics are often used inappropriately for the treatment of upper
respiratory tract infections in children, and the emergence of resistant bacteria
is a growing public health concern.
Objective To assess awareness and compliance with the Centers for Disease Control
and Prevention (Atlanta, Ga) and American Academy of Pediatrics (Elk Grove
Village, Ill) principles for judicious antibiotic use for upper respiratory
tract infections among residents from a sample of pediatric residency programs
in the mid-Atlantic region of the United States.
Participants and Methods Residents at the participating programs were requested to complete a
survey questionnaire.
Results Of the 524 pediatric residents surveyed, 74% (388 participants) completed
the questionnaire. Familiarity with the principles increased with a year of
training; 16%, 36%, and 50% of first-year (PL1), second-year (PL2), and third-
or fourth-year (PL3/PL4) residents, respectively, had heard or read about
the principles ( 2trend; P<.001).
In response to a direct question about the use of antibiotics for an otherwise
well, afebrile 18-month-old child with purulent rhinorrhea, 29%, 25%, and
15% of PL1, PL2, and PL3/PL4 residents, respectively, would prescribe antibiotics
within 10 days of onset of illness (2trend; P = .008). A significant difference was found between PL1
vs PL3/PL4 participants (difference = 20%; 95% CI = 3%-26%). If the same infant
had a temperature of 38.8°C, then 63%, 45%, and 47% of PL1, PL2, and PL3/PL4
residents, respectively, would prescribe antibiotics (2trend; P = .008).
Conclusions Awareness among pediatric residents about the judicious use of antibiotics
for upper respiratory tract infections is often lacking, and inappropriate
use of antibiotics for this condition continues to be prevalent. This was
especially noted among PL1 residents, with an improving trend noted with increasing
years of training.
INTRODUCTION
OVERUSE OF antibiotics and the emergence of resistant bacteria continue
to be the subject of many debates. Reported figures on the number of prescriptions
written for patients with upper respiratory tract infections are alarming.
Antibiotics were prescribed for 46% of children with upper respiratory tract
infections and for 75% of children with bronchitis.1
In 1992, upper respiratory tract infections were the second leading cause
for antibiotic prescription and accounted for more than 17 million prescriptions.2 Bergus et al3 reported
that by ages 3 months and 6 months, 37% and 70% of children, respectively,
had received 1 or more antimicrobial agents.
The need to curtail outpatient antibiotic use has emerged from the dramatic
increase in multidrug-resistant Streptococcus pneumoniae. The US Pediatric Multicenter Pneumococcal Surveillance Study Group4 found that from 1993 to 1996, the percentage of pneumococci
that were penicillin nonsusceptible increased from 14% to 21%. A longitudinal
survey of children receiving amoxicillin prophylaxis for recurrent otitis
media showed that the proportion of children with resistant pneumococci increased
from 0% to 25% during prophylaxis and returned to baseline within 3 to 5 months
after discontinuation of treatment.5
In 1998, the Centers for Disease Control and Prevention (CDC), (Atlanta,
Ga) and the American Academy of Pediatrics (AAP), (Elk Grove Village, Ill)
published principles for the judicious use of antibiotics in common pediatric
respiratory tract infections, including common cold, otitis media, sinusitis,
and pharyngitis.6 Our study was done to assess
awareness and compliance with these principles among residents from a sample
of pediatric residency programs. A direct question asking residents to indicate
whether they had heard or read about the principles was used to assess their
awareness. Illustrative case vignettes were included in the survey to determine
antibiotic prescribing patterns, with the assumption that responses to vignettes
reflected their knowledge and application of the principles, or lack thereof.
We hope our data will highlight the need for improving awareness among this
group of healthcare providers, who represent practicing physicians of the
future.
PARTICIPANTS AND METHODS
PARTICIPANTS
The study, which involved survey responses to CDC/AAP principles and
to clinical vignettes by which residency programs, but not individual respondents,
could be identified, was ruled exempt from review by the institutional review
board at the Inova Fairfax Hospital (Falls Church, Va). We contacted large
residency programs in the mid-Atlantic region, and 12 programs responded.
These included 2 programs each in Maryland and the District of Columbia, and
4 each in Virginia and North Carolina. The median number of residents per
level of training per year in these programs was 13, and the range was between
9 and 22 residents. Pediatric residents at all levels of training were surveyed.
The chief residents of each program coordinated the distribution and collection
of completed questionnaires. Our predetermined goal was a response rate of
at least 70%. Follow-up letters and telephone calls were used to improve response
rates.
SURVEY INSTRUMENT
The survey questionnaire contained 17 questions, including information
about year of training, awareness of CDC/AAP principles, and 6 vignettes,
each requiring forced-choice answers (yes, no, or uncertain). These vignettes
were on (1) short-duration, purulent rhinorrhea; (2) acute otitis media; (3)
otitis media with effusion; (4) acute wheezy bronchitis; (5) pneumonia; and
(6) pharyngitis. The first 5 case scenarios pertained to an 18-month-old child,
and the sixth scenario, to a 4-year-old child. In addition, direct questions
regarding management of an afebrile and a febrile 18-month-old child with
purulent rhinorrhea were included. Attendance at a childcare center was introduced
as a variable to see whether it had any effect on the decision to use antibiotics.
The study was conducted from October 1998 to April 1999.
STATISTICAL ANALYSIS
All survey responses were categorical in nature. For comparisons between
residency groups, percentage differences with 95% confidence intervals (CIs)
are reported. For comparisons among residency groups, 2 analysis
for trend is reported. All calculations were performed using SAS software
version 6.12 (SAS Institute, Cary, NC).
RESULTS
Of the 524 residents in the participating residency programs, 74% (388
residents) returned completed questionnaires. Distribution of residents across
the different years of training was comparable with 130, 121, and 137 residents
in the first (PL1), second (PL2), or the third or fourth (PL3/PL4) year of
training, respectively. As only 14 (3.5%) of the residents were PL4, PL3 and
PL4 residents were combined as a single group. Overall, only 34% (133/388)
of the respondents had read or heard about the principles (Figure 1). Familiarity with the principles increased with year of
training; 16%, 36%, and 50% of PL1, PL2, and PL3/PL4 residents, respectively,
had heard or read about the principles (2trend; P<.001). Differences between resident groups were significant
(PL1 vs PL2: difference = 20%, 95% CI = 8%-32%; PL1 vs PL3/PL4: difference
= 34%, 95% CI = 23%-46%; PL2 vs PL3/PL4: difference = 14%, 95% CI = 2.5%-28%).
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Figure 1. Awareness of the Centers for Disease
Control and Prevention and American Academy of Pediatrics principles for treating
upper respiratory tract infections with antibiotics. PL1 indicates first-year
residents; PL2, second-year residents; and PL3/PL4, third- or fourth-year
residents.
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In response to a direct question about the use of antibiotics for an
otherwise well, afebrile 18-month-old child with purulent rhinorrhea, 29%,
25%, and 15% of PL1, PL2, and PL3/PL4 residents, respectively, chose to prescribe
antibiotics within 10 days of onset of illness (2trend; P = .008). No significant difference was
seen between PL1 vs PL2 residents, but a significant difference was found
between PL1 vs PL3/PL4 residents (difference = 20%, 95% CI = 3%-26%). The
difference between PL2 vs PL3/PL4 residents was only marginally significant
(difference = 10%, 95% CI = 0.3%-19%).
If the same infant had a temperature of 38.8°C, then 63%, 45%, and
47% of PL1, PL2, and PL3/PL4 residents, respectively, would prescribe antibiotics
(2trend; P = .008). Willingness
to treat in the presence of fever was significantly higher for all groups
(PL1: difference = 34%, 95% CI = 22%-46%; PL2: difference = 20%, 95% CI =
7%-32%; PL3/PL4: difference = 32%, 95% CI = 20%-43%). Attendance in day care
had no significant effect on the decision to prescribe antibiotics.
In response to a vignette about an 18-month-old child with purulent
rhinorrhea of 4 days' duration, 74%, 88%, and 87% of PL1, PL2, and PL3/PL4
residents, respectively, chose to wait 10 days or longer or not to treat with
antibiotics (Figure 2). Although
this trend was significant (2trend; P = .007), significant differences were seen only between PL1 vs PL2
and PL3/PL4 (PL1 vs PL2: difference = 14%, 95% CI = 4%-27%; PL1 vs PL3/PL4:
difference = 13%, 95% CI = 3%-26%).
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Figure 2. Use of antibiotics for purulent
rhinorrhea of less than 10 days' duration (response to a vignette). PL1 indicates
first-year residents; PL2, second-year residents; and PL3, third-year residents.
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Ninety-five percent of respondents (367/385) correctly diagnosed an
18-month-old child with a painful, bulging, and immobile tympanic membrane
as having acute otitis media, and treated the child accordingly. However,
21% (82/383) prescribed antibiotics for a mobile, nonbulging, red tympanic
membrane, and 48% (184/384) prescribed antibiotics for secretory otitis media.
In response to the vignette pertaining to a 4-year-old with sore throat and
pharyngeal erythema in the absence of a rapid streptococcal antigen test,
76%, 86%, and 84% of PL1, PL2, and PL3/PL4 residents, respectively, opted
to withhold antibiotics until throat culture results were available (2trend; P = .10).
COMMENT
Inappropriate use of antibiotics for upper respiratory tract illnesses
in children continues to be commonly reported among pediatric residents. This
was especially noted among PL1 residents. It was encouraging to see an improving
trend with increasing years of training both in awareness of the principles
and reported antibiotic use. This could represent experience accrued during
training or possibly greater familiarity with current literature. Instilling
correct practice habits and increasing awareness among physicians-in-training
should be a priority. Investing additional resources in this important target
group could be rewarding. Developing appropriate prescribing habits during
the period of training could have long-lasting benefits both for the physicians
and the community at large. The CDC/AAP principles could serve as an evidence-based
framework to develop practice methods more scientifically.
Studies from Finland and Japan have shown that restricting the use of
macrolides reduced the prevalence of macrolide resistance among group A streptococci.7-8 Similarly, a reduction in the prevalence
of penicillin-resistant Streptococcus pneumoniae nasal carriage has been demonstrated
after restricting antibiotic use.9 Thus, reducing
inappropriate antibiotic use is an important first step in reducing the prevalence
of resistant microorganisms.
Barriers faced by physicians in adhering to clinical practice guidelines
were recently reviewed.10 Lack of awareness,
lack of familiarity, lack of agreement with the guidelines, and the inertia
of previous practice were some of the barriers identified. Rather than difficulty
with acceptance of guidelines, lack of awareness and familiarity are the more
likely barriers for physicians-in-training, thus emphasizing the need for
continued efforts at improving education and awareness.
In a survey of family practice residents regarding use of clinical practice
guidelines, 78% of residents felt that such guidelines improved their residency
education, and 75% thought it improved patient care.11
In a study from Israel, more senior residents and certified family practitioners
felt that clinical practice guidelines did not constrain clinical freedom
as compared with uncertified general practitioners and junior residents.12
Our study included 12 different institutions in the mid-Atlantic region
and may not be representative of overall attitudes and practices of residents
in this region. Before these results can be generalized, studies spread across
different geographic regions will be needed to provide a more comprehensive
representation. As in any study based on a survey, there is a concern around
whether respondents differed from nonrespondents, and it is not possible for
us to ascertain differences based on this study. As the responses were based
on self-report, they do not clearly reflect what residents would do when faced
with similar situations in actual practice. It is possible that the respondents
overstated their compliance with the principles, as they were aware of our
intentions. If so, our data may be an underrepresentation of the magnitude
of the problem.
In collaboration with the CDC, AAP, or other professional organizations,
educational modules can be developed that specifically target the needs of
residents. Knowledge gaps will have to be identified so that appropriate interventions
can be designed. Seminars, noon conferences, and other teaching sessions can
be used as platforms to disseminate this information. Introducing this topic
at the beginning of each academic year may be valuable, as it will provide
PL1 residents the opportunity to learn correct concepts from the very beginning
and also reinforce them among senior residents. Online physician education
is becoming a popular teaching tool. Web-based tutorial systems may be more
efficacious than print-based guidelines.13
It is possible to assess the practice patterns of residents in relation
to common ambulatory ailments at continuity and outpatient clinics. Residents
can be encouraged to keep a log of the antibiotic prescriptions given and
its indications. Outpatient morning reports can be used to cover topics not
covered elsewhere during training.14 A recent
review has identified different ambulatory-based clinical teaching methods.15 Leaders among residents could spearhead this campaign
and serve as role models to practice judicious antibiotic use. Residents have
an important role as valuable medical educators, and there is a need to improve
residents' teaching skills to make them more efficient teachers.16-17
In summary, results of this regional study bring to light the fact that
awareness among pediatric residents about the judicious use of antibiotics
for upper respiratory tract infections is often lacking. Although PL3/PL4
residents were better informed and used antibiotics more judiciously than
PL1 residents, intervention measures targeted at this group as a whole could
have a beneficial impact on limiting unnecessary antibiotic use.
| What This Study Adds
Upper respiratory tract infections are a leading rationale for outpatient
antibiotic prescription. In 1998, the CDC and the AAP published principles
for the judicious use of antibiotics for common pediatric respiratory tract
infections. Our study was done to assess awareness and compliance with these
principles among residents from a sample of pediatric residency programs.
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AUTHOR INFORMATION
Accepted for publication February 25, 2002.
Presented in part at the 39th Interscience Conference on Antimicrobial
Agents and Chemotherapy, San Francisco, Calif, September 1999.
We would like to thank all the residents who participated in this study.
Corresponding author: Sumathi Nambiar, MD, Department of Infectious
Diseases, 111 Michigan Ave NW, Washington, DC 20010 (e-mail: nambiars{at}cder.fda.gov).
From the Department of Pediatrics, Inova Fairfax Hospital for Children
(Drs Nambiar and Schwartz), and the Department of Medicine, Inova Fairfax
Hospital (Dr Sheridan), Falls Church, Va. Dr Nambiar is now with the Food
and Drug Administration and the Children's National Medical Center, Washington,
DC.
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