title: Variability in Antibiotic Prescribing for Community-Acquired Pneumonia.
abstract: OBJECTIVE
  Published guidelines recommend amoxicillin for most children with community-acquired pneumonia (CAP), yet macrolides and broad-spectrum antibiotics are more commonly prescribed. We aimed to determine the patient and clinician characteristics associated with the prescription of amoxicillin versus macrolide or broad-spectrum antibiotics for CAP.
  
  
  METHODS
  Retrospective cohort study in an outpatient pediatric primary care network from July 1, 2009 to June 30, 2013. Patients prescribed amoxicillin, macrolides, or a broad-spectrum antibiotic (amoxicillin-clavulanic acid, cephalosporin, or fluoroquinolone) for CAP were included. Multivariable logistic regression models were implemented to identify predictors of antibiotic choice for CAP based on patient- and clinician-level characteristics, controlling for practice.
  
  
  RESULTS
  Of 10 414 children, 4239 (40.7%) received amoxicillin, 4430 (42.5%) received macrolides and 1745 (16.8%) received broad-spectrum antibiotics. The factors associated with an increased odds of receipt of macrolides compared with amoxicillin included patient age ≥5 years (adjusted odds ratio [aOR]: 6.18; 95% confidence interval [CI]: 5.53-6.91), previous antibiotic receipt (aOR: 1.79; 95% CI: 1.56-2.04), and private insurance (aOR: 1.47; 95% CI: 1.28-1.70). The predicted probability of a child being prescribed a macrolide ranged significantly between 0.22 and 0.83 across clinics. The nonclinical characteristics associated with an increased odds of receipt of broad-spectrum antibiotics compared with amoxicillin included suburban practice (aOR: 7.50; 95% CI: 4.16-13.55) and private insurance (aOR: 1.42; 95% CI: 1.18-1.71).
  
  
  CONCLUSIONS
  Antibiotic choice for CAP varied widely across practices. Factors unlikely related to the microbiologic etiology of CAP were significant drivers of antibiotic choice. Understanding drivers of off-guideline prescribing can inform targeted antimicrobial stewardship initiatives.
authors.affiliation: Division of Infectious Diseases, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; lori.handy@nemours.org.|Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
authors.forename: Lori K
authors.initials: LK
authors.lastname: Handy
authors.affiliation: Center for Pediatric Clinical Effectiveness and.|Department of Biostatistics and Epidemiology.|Center for Clinical Epidemiology and Biostatistics, and.
authors.forename: Matthew
authors.initials: M
authors.lastname: Bryan
authors.affiliation: Center for Pediatric Clinical Effectiveness and.|Department of Biostatistics and Epidemiology.|Center for Clinical Epidemiology and Biostatistics, and.|Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Gerber
authors.affiliation: Center for Pediatric Clinical Effectiveness and.|Department of Biostatistics and Epidemiology.|Center for Clinical Epidemiology and Biostatistics, and.|Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Theoklis
authors.initials: T
authors.lastname: Zaoutis
authors.affiliation: Center for Pediatric Clinical Effectiveness and.|Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and.|Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Kristen A
authors.initials: KA
authors.lastname: Feemster
mesh_terms: D000293:Adolescent; D000553:Ambulatory Care; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D017714:Community-Acquired Infections / Q000188:drug therapy*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D011014:Pneumonia / Q000188:drug therapy*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies
chemical_list: D000900:Anti-Bacterial Agents