title: Pediatrician perceptions of an outpatient antimicrobial stewardship intervention.
abstract: 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.
authors.affiliation: Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Julia E
authors.initials: JE
authors.lastname: Szymczak
authors.forename: Kristen A
authors.initials: KA
authors.lastname: Feemster
authors.forename: Theoklis E
authors.initials: TE
authors.lastname: Zaoutis
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Gerber
mesh_terms: D000553:Ambulatory Care / Q000592:standards*; D000900:Anti-Bacterial Agents; D001291:Attitude of Health Personnel; D017723:Drug Utilization Review; D006801:Humans; D057970:Inappropriate Prescribing / Q000517:prevention & control; D007407:Interviews as Topic; D010372:Pediatrics / Q000592:standards*
chemical_list: D000900:Anti-Bacterial Agents