Clinician Survey about Antibiotic Prescribing for Children without Definitive Radiographic Pneumonia
Authors: Cotter Jillian , Ziniel Sonja , Weber Matthew , Ambroggio Lilliam , Parker Sarah 
Published: January 2025

Abstract

Corresponding Author: Jillian M. Cotter, MD, MSCS; Assistant Professor, Department of Pediatrics, Section of Hospital Medicine; Children’s Hospital Colorado and University of Colorado School of Medicine; 13123 E 16th Ave, Box B302, Aurora, CO 80045; jillian.cotter@childrenscolorado.org; 720-777-5241
Alternate Corresponding Author: Matthew J. Weber, MPH, Department of Pediatrics, Section of Infectious Diseases; Children’s Hospital Colorado and University of Colorado School of Medicine; 13123 E 16th Ave, Box B055, Aurora, CO 80045; matthew.weber@childrenscolorado.org; 720-777-8811
Conflicts of interest/disclosures: Drs. Cotter and Ambroggio receive grant support from Pfizer Inc for a study unrelated to this manuscript. The authors have no other conflicts of interest or financial disclosures.
Funding sources: This was funded by an internal Children’s Hospital of Colorado Clinical Effectiveness and Patient Safety grant.

Background
Antibiotics are commonly overused in pediatric community acquired pneumonia (CAP). While children without definitive evidence of pneumonia on chest radiograph (CXR) are less likely to have bacterial CAP, many still receive antibiotics. We aimed to 1) evaluate the proportion of patients treated for bacterial CAP who had non-radiographic CAP (i.e., no definitive radiographic evidence of pneumonia, including equivocal or non-focal CXRs), and 2) understand clinician certainty and factors that influenced the decision to prescribe antibiotics for children with non-radiographic CAP.

Methods
This was a cross-sectional study of children who were treated for CAP (i.e., received at least one antibiotic dose or prescription) and were discharged from the emergency department (ED) or hospitalized at four affiliated children’s hospitals from 5/2022-11/2022. Children were classified as radiographic CAP (e.g., “focal consolidation”, “pneumonia”) vs. non-radiographic CAP (e.g., equivocal CXR – “atelectasis vs pneumonia, likely atelectasis but cannot rule out pneumonia” or non-focal – “peribronchial thickening without focality, normal CXR, airway disease”) based on the radiology report. Electronic surveys, designed to understand near real-time decision making in non-radiographic CAP, were sent to ED and inpatient clinicians who treated children with non-radiographic CAP in the preceding 48 hours. Chi-squared, Fisher’s exact and Student t-tests compared findings between various subgroups.

Results
Of 874 patients treated for CAP, 30% had non-radiographic CAP (11% non-focal and 19% equivocal CXRs). Among children with non-radiographic CAP, 60% were &lt;5 years old, 56% hospitalized, and 86% received a full antibiotic course (Table 1). Receipt of a full antibiotic course did not differ between those with non-focal vs. equivocal CXRs (p&gt;0.05). Among 177 completed clinician surveys (53% response rate), 60% were very or mostly certain about the diagnosis. Factors that most influenced antibiotic prescribing in non-radiographic CAP were CXR results (including 47% of clinicians who treated non-focal CXRs), other diagnostics, and physical exam findings (Figure 1). For patients already started on antibiotics by prior clinicians, 93% felt this prior decision strongly or somewhat influenced their decision to continue therapy.

Conclusion
Nearly a third of children treated for bacterial CAP had non-radiographic CAP, and 1 in 10 had a non-focal CXR. Most went onto receive a full antibiotic course. This suggests that non-radiographic CAP is an important target for antibiotic stewardship. We identified potential barriers (e.g., clinician certainty) and facilitators of future interventions. Specifically, targeted education regarding CXR interpretation and strategies to address antibiotic momentum may help reduce antibiotic overuse.
Table 1. Characteristics of Children Treated for Non-Radiographic CAP

Figure 1. Factors Influencing Decision to Prescribe Antibiotics for Non-Radiographic CAP