Microsoft word - joc130058supp1_edited.doc

Supplementary Online Content
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. doi:10.1001/jama.2013.6287 eAppendix. Content Summaries of Clinician Education for Sinusitis, Pharyngitis, and
Pneumonia
eFigure 1. Example Clinician Feedback Report
eFigure 2. Study Timeline
eTable 1. ICD-9 Codes and Laboratory Test Results Used for ARTI Case Definitions
eTable 2. ICD-9 Codes Used for Defining Non-ARTI Diagnoses Excluded From
Analyses
eTable 3. Antibiotic Prescribing by Condition With Supplementary (Post Hoc) Pre-Post
Analyses Confirming the Results of the Primary Analyses
This supplementary material has been provided by the authors to give readers additional information about their work.
 2013 American Medical Association. All rights reserved.  Downloaded From: http://pubs.jamanetwork.com/ on 03/09/2014
eAppendix. Content Summaries of Clinician Education for Sinusitis, Pharyngitis, and
Antimicrobial Treatment of PHARYNGITIS in Children
 Most cases of pharyngitis are viral in origin.  Antimicrobial therapy should NOT be given to a child with pharyngitis in the absence of positive rapid test or positive culture for Group A Streptococcus (GAS).  For the treatment of the non-allergic patient with documented GAS pharyngitis: Penicillin (PO or IM) is recommended
Amoxicillin is an acceptable alternative
 A clinical isolate of GAS resistant to penicillin has NEVER been documented.  Azithromycin and cephalosporins (e.g. cephalexin/keflex, cefdinir/omnicef), though active
against GAS, are not recommended for routine treatment of GAS pharyngitis because: These drugs have NOT been shown to be superior for the treatment of GAS pharyngitis, or for the prevention of suppurative or non-suppurative sequelae (e.g. acute rheumatic fever) of GAS pharyngitis. Data does not support increased patient compliance of these oral medications over oral penicillin or amoxicillin. Exposure to such broad-spectrum agents promotes resistance to these and other antibiotics.
Sources:

 Red Book: Report of the Committee on Infectious Diseases. 2009. American Academy of  2013 American Medical Association. All rights reserved.  Downloaded From: http://pubs.jamanetwork.com/ on 03/09/2014
Antimicrobial Treatment of PNEUMONIA in Children
 After respiratory viruses, Streptococcus pneumoniae remains the predominant organism causing uncomplicated, community-acquired pneumonia in children, particularly in those between ages 3 months and 6 years of age.  Initial antimicrobial treatment of uncomplicated, community-acquired pneumonia in children should be with a narrow-spectrum agent with good activity against Streptococcus pneumoniae.  Because of its effectiveness, safety, tolerability, low cost, and narrow spectrum: amoxicillin (80-90 mg/kg/day) is recommended
(zithromax), cefdinir (omnicef), and cefixime (suprax) have inferior activity, relative to amoxicillin, against Streptococcus pneumoniae.  The addition of clavulanate to amoxicillin (amoxicillin-clavulanate/augmentin) does NOT enhance its activity against Streptococcus pneumoniae. Sources:
 Red Book: Report of the Committee on Infectious Diseases. 2009. American Academy of Antimicrobial Treatment of SINUSITIS in Children
 Based on the available data, initial antimicrobial treatment of acute, uncomplicated sinusitis should be with a narrow-spectrum agent targeting Streptococcus pneumoniae.

 Because of its effectiveness, safety, tolerability, low cost, and narrow spectrum: amoxicillin (80-90 mg/kg/day) is recommended
(zithromax) and cefdinir (omnicef) have inferior activity, relative to amoxicillin, against Streptococcus pneumoniae.  The addition of clavulanate to amoxicillin (amoxicillin-clavulanate/augmentin) does NOT enhance its activity against Streptococcus pneumoniae. Sources:
 Red Book: Report of the Committee on Infectious Diseases. 2009. American Academy of  IDSA Clinical Practice Guidelines. Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Sinusitis. 2002. Available at: http://www.idsociety.org/  2013 American Medical Association. All rights reserved.  Downloaded From: http://pubs.jamanetwork.com/ on 03/09/2014
eFigure 1. Example Clinician Feedback Report
Abbreviations: Rx, Prescription; Q, Quarter.  2013 American Medical Association. All rights reserved.  Downloaded From: http://pubs.jamanetwork.com/ on 03/09/2014
eFigure 2. Study Timeline
Feedback reports occurred at 4-month intervals  2013 American Medical Association. All rights reserved.  Downloaded From: http://pubs.jamanetwork.com/ on 03/09/2014
eTable 1. ICD-9 Codes and Laboratory Test Results Used for ARTI Case Definitions
Viral ARTIs
ICD-9 Codes
Bacterial ARTIs
ICD-9 Codes
461.8, 461.9, 473.9, 473.2, 473.1, 473.0, 487.1 (034.0 or 462 or 463) AND (rapid strep or culture positive) Abbreviations: ICD-9, International Classification of Disease, 9th edition; ARTI, Acute Respiratory Tract Infections; URI, Upper Respiratory Tract Infection  2013 American Medical Association. All rights reserved.  Downloaded From: http://pubs.jamanetwork.com/ on 03/09/2014
eTable 2. ICD-9 Codes Used for Defining Non-ARTI Diagnoses Excluded From Analyses
Non-ARTIs
ICD-9 Codes
380.10, 380.11, 380.12, 380.13, 380.14, 380.15, 380.16 680, 680.0, 680.1, 680.2, 680.3, 680.4, 680.5, 680.6, 680.7, 680.8, 680.9, 681, 681.0, 681.00, 681.01, 681.02, 681.1, 681.10, 681.11, 681.9, 682, 682.0, 682.1, 682.2, 682.3, 682.4, 682.5, 682.6, 682.7, 682.8, 682.9 879.8, 879.9, 959.9, E906.5, E906.0, E906.3, 891.0, 890.0, 884.0, 883.0, 882.0, 881.00 Streptococcal) Streptococcal infection (without 034.1, 041, 041.00, 041.01, 041.1, 041.09, 390, 040.82, 566, 079.9, 079.88, 079.98, 614.9, 616.1, 616.10 730.20, 730.21, 730.22, 730.23, 730.24, 730.25, 730.26, 730.27, 730.28, 730.29, 711.06, 711.05, 711.03, 711.00 008.5, 008.43, 008.00, 004.9, 004.3, 003.9, 003.1, 003.0 Abbreviations: ICD-9, International Classification of Disease, 9th edition; ARTI, Acute Respiratory Tract Infections  2013 American Medical Association. All rights reserved.  Downloaded From: http://pubs.jamanetwork.com/ on 03/09/2014
eTable 3. Antibiotic Prescribing by Condition With Supplementary (Post Hoc) Pre-Post Analyses Confirming the Results of the
Primary Analyses
Rate (%):
Difference
Post – Pre %
In period
In period
ABX/sick visit
0.5 (-0.1, 1.1); p=0.13
Strep/sick visit
0.2 (-0.2, 0.6); p=0.42
PNA/sick visit
-0.1 (-0.3, 0.1); p=0.25
Sinu/sick visit
0.2 (-0.2, 0.6); p=0.52
Broad/All ABX INT
-7.3 (-11.9, -2.7); p<0.001
Broad/Strep
0.8 (-2.3, 4.0); p=0.82
Broad/PNA
-3.2 (-10.8, 4.4); p=0.05
Broad/SINU
-15.9 (-26.1, -5.8); p=0.002
Tx: treatment (I=intervention; C=control; Diff = difference between treatment and control groups All rates are standardized estimates (see text and references for details on standardization) based on a logistic regression model with main effects for period (pre vs. post), a main effect for intervention, and the interaction. Covariates used for standardization are the same as those listed in the text. P-values are based on the Wald test for the interaction term. P-values and confidence intervals allow for the cluster-randomized design. P-values can differ from the primary models (displayed in the figures and reported in the text), which account for the trajectories of prescribing prior to the intervention and then compare these trajectories to those after the intervention. Counts represent the number of prescriptions/number of visits during the entire period, pre-intervention or intervention.  2013 American Medical Association. All rights reserved.  Downloaded From: http://pubs.jamanetwork.com/ on 03/09/2014

Source: http://pubs.jamanetwork.com/data/Journals/JAMA/927088/JOC130058_supp.pdf