With the use of strict screening criteria, a substantial number of febrile one-to-two-month-old infants can be cared for safely as outpatients and without antibiotics.

NTIBIOTICS ARE THE MOST COMmon prescription drugs given to children. 1 Although hospitalized children frequently receive antibiotics, 2 the vast majority of antibiotic use occurs in the outpatient setting, roughly 75% of which is for acute respiratory tract infections (ARTIs). 3 Unnecessary prescribing for viral AR-TIs is well documented 3-8 and has been declining. 7-9 However, inappropriate prescribing also occurs for bacterial ARTIs, particularly when broadspectrum antibiotics are used to treat infections for which narrow-spectrum antibiotics are indicated and recommended. 1,3,6,8,9 The American Academy of Pediatrics (AAP) recommends penicillin or amoxicillin as first-line agents for streptococcal pharyngitis, acute sinusitis, and pneumonia 10,11 ; however, roughly 50% of children receive broader-spectrum antibiotics for these common infections. 3 Antimicro-Author Affiliations are listed at the end of this article.

WHAT'S KNOWN ON THIS SUBJECT: Despite proven health benefits, human papillomavirus (HPV) vaccination rates are among the lowest of all routine immunizations. No previous largescale trial has compared the benefit of automated decision support directed at clinicians, families, or both in any context. WHAT THIS STUDY ADDS:We found that a clinician-focused intervention was most effective for initiating the HPV vaccine series, whereas a family-focused intervention supported completion. Decision support directed at both clinicians and families most effectively promotes HPV vaccine series receipt. abstract OBJECTIVE: To improve human papillomavirus (HPV) vaccination rates, we studied the effectiveness of targeting automated decision support to families, clinicians, or both.METHODS: Twenty-two primary care practices were cluster-randomized to receive a 3-part clinician-focused intervention (education, electronic health record-based alerts, and audit and feedback) or none. Overall, 22 486 girls aged 11 to 17 years due for HPV vaccine dose 1, 2, or 3 were randomly assigned within each practice to receive family-focused decision support with educational telephone calls. Randomization established 4 groups: family-focused, clinician-focused, combined, and no intervention. We measured decision support effectiveness by final vaccination rates and time to vaccine receipt, standardized for covariates and limited to those having received the previous dose for HPV #2 and 3. The 1-year study began in May 2010. RESULTS:Final vaccination rates for HPV #1, 2, and 3 were 16%, 65%, and 63% among controls. The combined intervention increased vaccination rates by 9, 8, and 13 percentage points, respectively. The control group achieved 15% vaccination for HPV #1 and 50% vaccination for HPV #2 and 3 after 318, 178, and 215 days. The combined intervention significantly accelerated vaccination by 151, 68, and 93 days. The clinician-focused intervention was more effective than the familyfocused intervention for HPV #1, but less effective for HPV #2 and 3.CONCLUSIONS: A clinician-focused intervention was most effective for initiating the HPV vaccination series, whereas a family-focused intervention promoted completion. Decision support directed at both clinicians and families most effectively promotes HPV vaccine series receipt.