Despite current guidelines recommending amoxicillin in most children with community-acquired pneumonia (CAP), macrolides and broad-spectrum antibiotics continue to be prescribed for outpatient CAP. These differences in prescribing practices are not entirely driven by clinical factors. In fact, the antibiotic choice for CAP was heavily influenced by nonclinical factors unrelated to microbial etiology, according to a new study published in Pediatrics.
Lori K. Handy, MD, from the division of infectious diseases, Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware, and colleagues conducted a retrospective cohort study comprised of 31 primary care pediatric practices in Pennsylvania and New Jersey, all of which shared a common electronic health record system. Practices were located in urban, suburban, and rural areas.
Children age 3 months to 18 years with a diagnosis of pneumonia (using ICD-9-CM diagnosis) between July 1, 2009 and June 30, 2013 were included in the study. Children with a complex chronic condition, multiple antibiotic prescriptions, an emergency department visit within the previous 2 weeks, or from a practice with <50 pneumonia cases were excluded from the study.
The primary outcome, antibiotic prescription, was divided into 3 categories:
- Narrow spectrum: penicillin or amoxicillin
- Macrolide: azithromycin, erythromycin, and clarithromycin
- Broad-spectrum: amoxicillin–clavulanic acid, cephalosporin, or fluoroquinolone
Of the 10,414 children treated for CAP, 40.7% were treated with amoxicillin, 42.5% were treated with macrolides, and 16.8% were treated with broad-spectrum antibiotics.
In the multivariate logistic regression model of the 8669 patients treated with either amoxicillin or macrolides, the factors associated with an increased odds of receiving macrolides included:
- Age ≥5 years: adjusted odds ratio [aOR] 6.18; 95% CI, 5.53-6.91
- Previous antibiotics exposure: aOR 1.79; 95% CI, 1.56-2.04
- Private insurance: aOR 1.47; 95% CI, 1.28-1.70
The predicted probability of a child being prescribed a macrolide ranged significantly between 0.22 and 0.83 across all clinics.
In the 5984 patients treated with either amoxicillin or broad-spectrum antibiotics, the factors associated with increased odds of receiving broad-spectrum antibiotics included:
- Suburban practice: aOR 7.50; 95% CI, 4.16-13.55
- Private insurance: aOR 1.42; 95% CI 1.18-1.71
The predicted probability of a child being prescribed broad-spectrum antibiotics ranged from 0.02 to 0.81 across clinics.
“Management guidelines for CAP were published in 2011, emphasizing amoxicillin as first-line therapy due to the known epidemiology of the infection. The variability demonstrated in this study reflects that although guidelines were published, more work needs to be done to disseminate this information and help implement guideline recommendations in different care settings,” stressed Dr Handy in an email interview with Infectious Disease Advisor.
Handy LK, Bryan M, Gerber JS, Zaoutis T, Feemster KA. Variability in antibiotic prescribing for community-acquired pneumonia [published online March 7, 2017]. Pediatrics. doi: 10.1542/peds.2016-2331