Abstract & Commentary

Respiratory infections drive inappropriate antibiotic use in ambulatory pediatrics

By Hal B. Jenson, MD, FAAP, Dean, School of Medicine, Western Michigan University School of Medicine, Kalamazoo, MI., is Associate Editor for Infectious Disease Alert.

Dr. Jenson reports no financial relationships relevant to this field of study.

Source: Hersh AL, et al. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics 2011;128:1053-1061.

A representative analysis of national oral antibiotic prescribing in ambulatory pediatrics was conducted using the National Ambulatory and the National Hospital Ambulatory Medical Care Surveys during 2006—2008 among patients younger than 18 years of age. These surveys, administered by the National Center for Health Statistics, provide geographic sampling data for patient visits to physician practices, hospital outpatient departments, and emergency departments. Visits were categorized based on the primary diagnosis as: respiratory conditions; skin/cutaneous/mucosal conditions; urinary tract infections; gastrointestinal infections; miscellaneous infections; and other conditions.

For respiratory conditions, 3 subcategories were: acute respiratory tract infections for which antibiotics are typically indicated (e.g., otitis media, sinusitis, pharyngitis, pneumonia); acute respiratory tract infections for which antibiotics are not indicated (e.g., nasopharyngitis, bronchitis, viral pneumonia, influenza); and other respiratory conditions for which antibiotics are not definitely indicated (e.g., asthma, allergy, chronic sinusitis, chronic bronchitis). Antibiotics categorized as broad spectrum included antipseudomonal penicillins, β—lactam/β—lactamase inhibitor combinations, second— to fourth—generation cephalosporins, macrolides, quinolones, clindamycin, and carbapenems. Use of topical antibiotics was excluded from the study.

There were 10,273 patient visits that were sampled that included prescribing antibiotics. Between 2006—2008, antibiotics were prescribed in an estimated 49 million visits annually (95% CI: 43-55 million), representing 21% of all pediatric ambulatory encounters. Among classes of antibiotics, broad-spectrum antibiotics were prescribed in 50% of the visits for which antibiotics were prescribed, an average of 24.6 million visits annually (95% CI: 21.2—28.1 million). The most commonly prescribed individual antibiotics were for narrow-spectrum penicillins (38%) followed by macrolides (20%).

Among diagnoses, respiratory conditions accounted for 72.3% of visits for which antibiotics were prescribed and included 48.9% of all prescriptions that were for acute respiratory tract infections for which antibiotics are indicated; 13.1% for acute respiratory tract infections for which antibiotics are not indicated; and 10.3% for other respiratory conditions for which antibiotics are not definitely indicated. Thus, 23.4% of antibiotic prescriptions were for respiratory conditions for which antibiotics were not appropriate.

Overall, antibiotics were prescribed for 48.4% of visits for which a respiratory condition was the primary diagnosis.Of the 29.9 million annual visits for acute respiratory conditions for which antibiotics are indicated, 71.7% were prescribed an antibiotic. The next most common diagnostic categories for which antibiotics were prescribed were urinary tract infections (59.3% of 1.4 million annual visits) and skin/cutaneous/mucosal conditions (18.6% of 28.2 million annual visits).

Subanalyses showed that relative to other antibiotics, broad-spectrum antibiotics were more likely to be prescribed for acute respiratory infections for which antibiotics are not indicated (OR: 1.80; 95% CI: 1.34—2.42), patients younger than 6 years of age (OR: 1.27; 95% CI: 1.04-1.54), visits in the South compared to the West (OR: 1.82; 95% CI: 1.30-2.55), and less likely to be prescribed among children with public or no insurance compared to those with private insurance (OR: 0.79; 95% CI: 0.66—0.94).

Commentary

Antibiotic prescriptions are given in 21% pediatric ambulatory visits. Respiratory conditions account for the majority of antibiotic prescriptions in children, with the use of broad-spectrum antibiotics accounting for 50% of antibiotic prescribing and highest for conditions such as viral infections and asthma for which antibiotics are not typically indicated. These data show that respiratory conditions for which antibiotics are potentially inappropriate (23.4%) account for >10 million pediatric visits annually, with >6 million visits with prescriptions for broad-spectrum antibiotics. In addition, the results show that prescriptions are given for only 48.4% of acute respiratory infections for which antibiotics are indicated.

While there are significant limitations of such retrospective analyses, these results show there are substantial gaps in the appropriate use of antibiotics in ambulatory pediatrics. The subanalyses give insights into differences of use among younger children and even practice differences based on geographic region and insurance status.

Antibiotic overuse in pediatrics increases the costs of health care, contributes to avoidable adverse events, and promotes the development of antibiotic resistance. Antibiotic stewardship programs, which have been effective in improving antibiotic prescribing patterns in hospital settings, appear needed in ambulatory pediatric settings to reduce overuse of broad-spectrum antibiotics.