Skip to main content Accessibility help
×
Home

Pediatrician Perceptions of an Outpatient Antimicrobial Stewardship Intervention

  • Julia E. Szymczak (a1), Kristen A. Feemster (a1) (a2) (a3), Theoklis E. Zaoutis (a1) (a2) (a3) (a4) and Jeffrey S. Gerber (a1) (a2) (a3)

Extract

Objective.

Inappropriate antibiotic prescribing commonly occurs in pediatric outpatients with acute respiratory tract infections. Antimicrobial stewardship programs are recommended for use in the hospital, but less is known about whether and how they will work in the ambulatory setting. Following a successful cluster-randomized trial to improve prescribing for common acute respiratory tract infections using education plus audit and feedback in a large, pediatric primary care network, we sought to explore the perceptions of the intervention and antibiotic overuse among participating clinicians.

Methods.

We conducted a qualitative study using semistructured interviews with 24 pediatricians from 6 primary care practices who participated in an outpatient antimicrobial stewardship intervention. All interviews were transcribed and analyzed using a modified grounded theory approach.

Results.

Deep skepticism of the audit and feedback reports emerged. Respondents ignored reports or expressed distrust about them. One respondent admitted to gaming behavior. When asked about antibiotic overuse, respondents recognized it as a problem, but they believed it was driven by the behaviors of nonpediatric physicians. Parent pressure for antibiotics was identified by all respondents as a major barrier to the more judicious use of antibiotics. Respondents reported that they sometimes “caved” to parent pressure for social reasons.

Conclusions.

To improve the effectiveness and sustainability of outpatient antimicrobial stewardship, it is critical to boost the credibility of audit data, engage primary care pediatricians in recognizing that their behavior contributes to antibiotic overuse, and address parent pressure to prescribe antibiotics.

    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Pediatrician Perceptions of an Outpatient Antimicrobial Stewardship Intervention
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Pediatrician Perceptions of an Outpatient Antimicrobial Stewardship Intervention
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Pediatrician Perceptions of an Outpatient Antimicrobial Stewardship Intervention
      Available formats
      ×

Copyright

References

Hide All
1. McCaig, LF, Besser, RE, Hughes, JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA 2002;287(23): 30963102.
2. Hersh, AL, Shapiro, DJ, Pavia, AT, Shah, SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics 2011; 128(6):10531061.
3. Costelloe, C, Metcalfe, C, Lovering, A, Mant, D, Hay, AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
4. Centers for Disease Control and Prevention (CDC). Antibiotic Resistance Threats in the United States, 2013. Atlanta, GA: CDC, 2013.
5. Fishman, N. Antimicrobial stewardship. Am J Infect Control 2006; 34(5 suppl 1): S55-63Ascussion S64S73.
6. Dellit, TH, Owens, RC, McGowan, JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44(2): 159177.
7. Gerber, JS, Prasad, PA, Fiks, AG, et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA 2013;309(22):23452352.
8. Pronovost, PJ. Navigating adaptive challenges in quality improvement. BMJ Qual Saf 2011;20(7):560563.
9. Charani, E, Edwards, R, Sevdalis, N, et al. Behavior change strategies to influence antimicrobial prescribing in acute care: a systematic review. Clin Infect Dis 2011;53(7):651662.
10. Dixon-Woods, M, Suokas, A, Pitchforth, E, Tarrant, C. An ethnographic study of classifying and accounting for risk at the sharp end of medical wards. Soc Sci Med 2009;69(3):362369.
11. Charani, E, Castro-Sanchez, E, Sevdalis, N, et al. Understanding the determinants of antimicrobial prescribing within hospitals: the role of “prescribing etiquette.” Clin Infect Dis 2013;57(2): 188196.
12. Forman, J, Creswell, JW, Damschroder, L, Kowalski, CP, Krein, SL. Qualitative research methods: key features and insights gained from use in infection prevention research. Am J Infect Control 2008;36(10):764771.
13. Strauss, AL, Corbin, JM. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, CA: Sage, 1998.
14. Weiss, RS. Learning from Strangers: The Art and Method of Qualitative interview Studies. New York: Free Press, 1994.
15. NVivo 10 [computer program]. Victoria, Australia: QSR International, 2013.
16. Bryant, A, Charmaz, K. The SAGE Handbook of Grounded Theory. Thousand Oaks, CA: Sage, 2007.
17. Miles, MB, Huberman, AM, Class of 1924 Book Fund. Qualitative Data Analysis: An Expanded Sourcebook. Thousand Oaks, CA: Sage, 1994.
18. Mangione-Smith, R, Elliott, MN, McDonald, L, McGlynn, EA. An observational study of antibiotic prescribing behavior and the Hawthorne effect. Health Serv Res 2002;37(6):16031623.
19. Kelman, S, Friedman, JN. Performance improvement and performance dysfunction: an empirical examination of distortionary impacts of the emergency room wait-time target in the English national health service. J Public Admin Res Theory 2009; 19(4):917946.
20. Jamtvedt, G, Young, JM, Kristoffersen, DT, O'Brien, MA, Oxman, AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2006(2): CD000259.
21. Patel, SJ, Larson, EL, Kubin, CJ, Saiman, L. A review of antimicrobial control strategies in hospitalized and ambulatory pediatric populations. Pediatr Infect Dis J 2007;26(6):531537.
22. Ranji, SR, Steinman, MA, Shojania, KG, Gonzales, R. Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Med Care 2008;46(8):847862.
23. Mugford, M, Banfield, P, O'Hanlon, M. Effects of feedback of information on clinical practice: a review. BMJ 1991;303(6799): 398402.
24. Dixon-Woods, M, Bosk, CL, Aveling, EL, Goeschel, CA, Pronovost, PJ. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q 2011;89(2): 167205.
25. Evans, WD. How social marketing works in health care. BMJ 2006;332(7551):12071210.
26. Bjorkman, I, Berg, J, Roing, M, Erntell, M, Lundborg, CS. Perceptions among Swedish hospital physicians on prescribing of antibiotics and antibiotic resistance. Qual Saf Health Care 2010; 19(6):e8.
27. Brinsley, K, Sinkowitz-Cochran, R, Cardo, D, Team CDCCtPAR. An assessment of issues surrounding implementation of the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. Am J Infect Control 2005;33(7):402409.
28. Giblin, TB, Sinkowitz-Cochran, RL, Harris, PL, et al. Clinicians' perceptions of the problem of antimicrobial resistance in health care facilities. Arch Intern Med 2004;164(15):16621668.
29. Wester, CW, Durairaj, L, Evans, AT, Schwartz, DN, Husain, S, Martinez, E. Antibiotic resistance: a survey of physician perceptions. Arch Intern Med 2002;162(19):22102216.
30. Bauchner, H, Pelton, SI, Klein, JO. Parents, physicians, and antibiotic use. Pediatrics 1999;103(2):395401.
31. Mangione-Smith, R, McGlynn, EA, Elliott, MN, Krogstad, P, Brook, RH. The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics 1999;103(4 Pt 1):711718.
32. Mangione-Smith, R, Elliott, MN, Stivers, T, McDonald, LL, Heritage, J. Ruling out the need for antibiotics: are we sending the right message? Arch Pediatr Adolesc Med 2006;160(9):945952.
33. Stivers, T, Mangione-Smith, R, Elliott, MN, McDonald, L, Heritage, J. Why do physicians think parents expect antibiotics? what parents report vs what physicians believe. J Fam Pract 2003; 52(2):140148.
34. Mangione-Smith, R, McGlynn, EA, Elliott, MN, McDonald, L, Franz, CE, Kravitz, RL. Parent expectations for antibiotics, physician-parent communication, and satisfaction. Arch Pediatr Adolesc Med 2001;155(7):800806.
35. Finkelstein, JA, Dutta-Linn, M, Meyer, R, Goldman, R. Childhood infections, antibiotics, and resistance: what are parents saying now? Clin Pediatr (Phila) 2014;53:145150.
36. Mangione-Smith, R, Stivers, T, Elliott, M, McDonald, L, Heritage, J. Online commentary during the physical examination: a communication tool for avoiding inappropriate antibiotic prescribing? Soc Sci Med 2003;56(2):313320.
37. Schnellinger, M, Finkelstein, M, Thygeson, MV, Vander Velden, H, Karpas, A, Madhok, M. Animated video vs pamphlet: comparing the success of educating parents about proper antibiotic use. Pediatrics 2010;125(5):990996.
38. Taylor, JA, Kwan-Gett, TS, McMahon, EM Jr. Effectiveness of an educational intervention in modifying parental attitudes about antibiotic usage in children. Pediatrics 2003;111(5 Pt l):e548e554.
39. Wheeler, JG, Fair, M, Simpson, PM, Rowlands, LA, Aitken, ME, Jacobs, RF. Impact of a waiting room videotape message on parent attitudes toward pediatric antibiotic use. Pediatrics 2001; 108(3):591596.

Related content

Powered by UNSILO

Pediatrician Perceptions of an Outpatient Antimicrobial Stewardship Intervention

  • Julia E. Szymczak (a1), Kristen A. Feemster (a1) (a2) (a3), Theoklis E. Zaoutis (a1) (a2) (a3) (a4) and Jeffrey S. Gerber (a1) (a2) (a3)

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.