Study: Children may get antibiotics too often

Sore throats receiving them exceed strep numbers

Do ED physicians overprescribe antibiotics for children with sore throats? They do, according to a new study in the Journal of the American Medical Association.1 In fact, while the study of EDs, outpatient facilities, and physicians’ offices showed that on average doctors prescribe antibiotics for more than 50% of children with sore throat, when the statistics were broken down, the EDs prescribed antibiotics for 60% of children with sore throats.

This number is significant, says the paper’s lead author Jeffrey A. Linder, MD, MPH, associate physician in the division of general and internal medicine at Brigham and Women’s Hospital in Boston, because "other studies have shown that among kids, somewhere between 15% and 36% of patients with sore throat will have Group A strep — and that’s the only common cause of sore throat for which antibiotics are needed."

Unnecessary prescriptions of antibiotics are not benign, he stresses. They increase the prevalence of antibiotic-resistant bacteria, expose patients to adverse drug events, and increase costs. "The point I try to hammer home is that the real risk is to the individual kid," says Linder. "Giving medicine they don’t need could cause anything from a little bit of diarrhea or a rash all the way to anaphylactic shock — and they may not get any benefit at all if they have a viral sore throat." Unnecessary broad-spectrum meds could cost as much as $80-$100 a dose, he says.

The study showed physicians prescribed nonrecommended drugs 27% of the time, although Linder says EDs were a bit less likely to do so. "The most important thing to know about strep is that the bug is never resistant to penicillin, so for kids, amoxicillin or penicillin is recommended, or erythromycin for those allergic to penicillin," he says. "The other option is first-generation cephalosporins. There’s really not much reason to use anything else."

Finally, he notes, to improve diagnostic accuracy and reduce unnecessary antibiotic treatment, the American Academy of Pediatrics and the Infectious Diseases Society of America recommended that a Group A beta-hemolytic streptococci (GABHS) test be done before children are prescribed an antibiotic.

As significant as Linder’s findings appear to be, you should look beyond the numbers before concluding that EDs are missing the boat in this area, says Richard Ruddy, MD, director of emergency services at Cincinnati Children’s Hospital Medical Center.

He notes, for example, that the numbers were abstracted out of the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1995 to 2003. "Some of the good exclusions are not there, and that does not tell you the whole truth," Ruddy says. For example, he says, "Culture results prove the presence of strep bacteria, but that does not necessarily means there is infection. The child could be carrying it."

In addition, there are patients who have symptoms of a sore throat for whom ED physicians can empirically say the likely causative reasons for their pain and symptoms is Group A strep, he says. "For example, if I believe a 5-year-old has strep, and we treated his brother three days ago, I do not culture him," Ruddy shares.

Finally, says Ruddy, the rapid strep test is close to 80% positive when there is infection, and the culture is closer to 90%, but you still miss 10%. Still, he does not entirely dismiss the study. "This study would suggest at least from data that we still have a ways to go to improve antibiotic utilization and our testing skills," he says.

He also concedes that antibiotics sometimes are given unnecessarily. "In some EDs, people tend to not stick with the simple treatment for strep," Ruddy says. "Part of the time, preferences may be coaxed by the pharmaceutical industry or by what the parent says is best for the child." In his own ED, says Ruddy, "We strongly recommend amoxicillin or long-acting benzocene penicillin, depending on whether the parent wants the child to have one shot or an antibiotic several times a day for 10 days."

If your ED has the resources, it can track compliance, he says. "In our center we have seven or eight clinical guidelines that are evidence-based," he notes. One they have pushed very hard is antibiotics used for community-associated pneumonia. "We have gotten close to 95% use in the ED of what’s recommended," Ruddy says. "We don’t have the resources, however, to measure all things all the time, but ED managers should do all they can to make sure their people are not practicing antibiotic prescription willy-nilly."

Reference

  1. Linder JA, Bates DW, Lee GM, et al. Antibiotic treatment of children with sore throat. JAMA 2006; 294:2,315-2,322.

Sources

For more information on prescribing antibiotics for children, contact:

  • Jeffrey A. Linder, MD, MPH, Division of General Medicine, Brigham and Women’s Hospital, 1620 Tremont St., BC-3-2X, Boston, MA 02120. Phone: (617) 525-6654. E-mail: jlinder@partners.org.
  • Richard Ruddy, MD, Director of Emergency Services, Cincinnati Children’s Hospital Medical Center. Phone: (513) 636-7973. E-mail: richard.ruddy@cchmc.org.