Date of Award

1-1-2019

Document Type

Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Louise-Marie Dembry

Abstract

Background. Misuse of antibiotics for upper respiratory tract infections (URTIs) in pediatric primary care settings persists despite growing concern over antibiotic resistance. Interventions aimed at improving prescription use, coined Antibiotic Stewardship Programs (ASPs) often target clinicians for improved clinical decision-making. More recently, ASPs have begun educating patients to antibiotic needs, and for pediatric cases, parents who might pressure clinicians into prescribing unneeded antibiotics. While many reviews have targeted adult patients or emergency settings, few evaluate practices for pediatric populations. For this reason, we performed a review of the literature to summarize common strategies used to reduce antibiotic overprescribing for pediatric patients in the United States.

Methods. We searched the PubMed and Web of Science databases as well as manually reviewed abstracts of commonly cited literature. Studies were included if they had a randomized control trial design or alternative study design specifically reporting differences in before-after antibiotic use or perceptions. One independent reviewer abstracted all data. The primary outcomes were numerous across all reviewed studies, however, consistently pertained to reductions in unnecessary prescriptions for URTIs, streamlining prescribing workflow for physicians in the pediatric primary care setting, and reductions to antibiotic resistance.

Results. 11 studies met inclusion criteria with 5 studies addressing clinicians, 5 studies addressing patient parents/guardians, and 1 study addressing both clinicians and patient parents. Within the three study groupings, interventions were categorized by methodology. Clinician-focused studies included clinician-decision-support (CDS) systems, education, and both (CDS and education) categories. Patient/guardian-focused studies included ‘poster and pamphlet’ and ‘audiovisual and pamphlet’ categories. The single study targeting both clinicians and parents used education and CDS system methods. After analysis, interventions using combinations of strategies were clearly superior in affecting behavior change and reductions in antibiotic prescribing rates.

Conclusions. Though ASPs have demonstrated some efficacy, few groups have established consistent findings, methods, or outcomes. Studies show impacts on behaviors leading to antibiotic over-prescription, misuse, and subsequent development of antibiotic resistance while interventions did not lead to persistent long-term effects. Inconsistent conclusions arise from high prescribing rates among pediatric subpopulations as well as difficulties quantifying qualitative health education outcomes. Moving forward, ASP interventions must incorporate integrated and multi-faceted interventions to achieve reductions in URTI-related antibiotic prescriptions and antimicrobial resistance.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 08/28/2021

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