2% of Providers Account for 25% of Tennessee's Pediatric Antibiotic Prescriptions

A recent study found that up to 43% of antibiotic prescriptions in the United States are potentially inappropriate. Inappropriate prescribing contributes to the problem of antibiotic resistance, a public health issue of serious concern for patients and clinicians.

A new study published in Infection Control and Hospital Epidemiology found that in Tennessee, less than 2% of providers account for 25% of pediatric antibiotic prescriptions.

Tennessee was selected because the Southeast region has disproportionate antibiotic prescription rates but 2016 US Centers for Disease Control and Prevention research found Tennessee has the sixth-highest outpatient antibiotic prescribing.

The investigators conducted a cross-sectional, descriptive study of pediatric patients in the IQVIA Xponent database. The database captures approximately 90% of all outpatient oral antibiotics prescribed in the United States.

The study population was defined as patients <20 years of age with an antibiotic prescription filled in an outpatient pharmacy in Tennessee between January 1, 2016, and December 31, 2016.

Prescriptions were evaluated in terms of overall and broad-spectrum antibiotics. Broad-spectrum antibiotics were defined as amoxicillin-clavulanate, fluoroquinolones, and third generation cephalosporins.

The study investigators found that an average of 1165 antibiotic prescriptions were written per 1000 Tennessee pediatric patients in 2016, culminating in 1,940,011 prescriptions.

Of all antibiotic prescriptions assessed, 475,414 (25%) were for broad-spectrum antibiotics. The most commonly prescribed antibiotics were amoxicillin (654,816 or 34%), azithromycin (292,540 or 15%), cefdinir (251,212 or 13%), amoxicillin-clavulanate (212,725 or 11%), and cephalexin (119,542or 6%).

Antibiotic prescribing rates varied significantly by patient age within the population. The rate of prescription for children 0-2 years of age was 1575 per 1000 patients, and 20% of pediatric antibiotic prescriptions were written for this age group.

When the investigators looked at prescription rates at the county level, they found significant variability. Rates ranged from 39 prescriptions per 1000 population to as much as 2482 per 1000 population. Variability was highest among the most rural counties studied.

Several provider characteristics were associated with high rates of antibiotic prescription. More prescriptions were written by physicians (1,043,030 or 53%) than nurse practitioners, dentists, or physician assistants. Comparative analyses found that pediatricians who graduated from medical school before the year 2000 were most likely to be among the high prescription group.

During the study period, 1712 providers (8%) wrote more than 300 antibiotic prescriptions. Among these providers, 360 were in the highest-prescribing group and were each responsible for more than 300 broad-spectrum antibiotic prescriptions.

The mean overall antibiotic prescription rate for the highest-prescribing pediatrician group was 1385 per provider (standard deviation = 711). Almost 20% of the 360 highest prescribing providers were from the same county, which included 16% of the state’s pediatric population.

Investigators encouraged further research to assess attitudes and beliefs among providers with a high rate of antibiotic prescription, as well as targeted stewardship interventions based on their data.

“These data indicate that pediatricians, especially those high-prescribing providers in a specific county, are excellent focal points for future antimicrobial stewardship interventions. Peer comparison of antibiotic prescribing rates may be a particularly effective intervention for outlier, high-prescribing providers,” study authors wrote.