It’s just a handful of pediatricians in Tennessee responsible for making Tennessee one of the highest prescribers of antibiotics in the country. A new study from Vanderbilt University Medical Center and the Tennessee Department of Health finds 2% of pediatricians account for 25% of the antibiotic prescriptions in the state.

According to the analysis, published in the journal Infection Control & Hospital Epidemiology, the physicians tend to be older. Most left medical school more than 20 years ago, meaning they likely received less training on the risk of antibiotic resistance and the emergence of superbugs.

“We’re realizing more and more now that a lot of the diseases that we have always thought of as bacterial and always need to be treated with antibiotics are more and more caused by viruses, or even if they are caused by bacteria that they don’t necessarily need antibiotics,” says Sophie Katz, the lead author who is also tasked with overseeing antimicrobial stewardship for Monroe Carrell Jr. Children’s Hospital at Vanderbilt.

Katz says patients have expectations and physicians have time constraints, and the result seems to be pediatricians freely prescribing antibiotics for earaches and colds when the more prudent approach would be to wait and see if the symptoms get better on their own.

Researchers reviewed outpatient prescription fulfillment data and found startlingly high rates of antibiotic use: in 2016, the rate was 1,165 antibiotic prescriptions for every 1,000 children. That’s not a typo. On average, every child got at least one antibiotic during the year. That’s 50% more than the national average. The figure is even higher for Tennessee children under the age of 2.

Amoxicillin, which is often used for earaches, accounted for more than a third of all the prescriptions. The study could not tell whether the prescriptions were necessary, but Katz has her doubts given her own experience as a pediatrician.

“There are expectations that patients have,” she says. “There are time constraints that physicians have.”

Tennessee has the country’s sixth-highest rate of antibiotic prescribing, with most of the leading states clustered in the South. There has been little explanation for the geographic disparity, but researchers note these are some of the same states that have struggled with the overprescription of pain medication.