Antibiotics overprescribed for pediatric patients with asthma

De Boeck K. Pediatrics. 2011;doi:10.1542/peds.2009-3068.

Paul I. Pediatrics. 2011;doi:10.1542/peds.2011-0218.

Despite many efforts to educate the public about judicious antibiotic use, some children continue to be prescribed higher than necessary amounts of antibiotics, according to two separate studies published recently.

This overuse of antibiotics happens frequently with pediatric patients with asthma, the two studies concluded.

“Unfortunately, simultaneous prescription of antibiotics and medications used for asthma is extremely common,” said Rita Mangione-Smith, MD, of the University of Washington in Seattle, and Paul Krogstad, MD of the University of California at Los Angeles, in a commentary that accompanied the two papers.

Ian M. Paul, MD, MSc, of Penn State College of Medicine in Hershey, Pa., and colleagues analyzed antibiotic prescription rates for children visiting medical centers between 1998 and 2007. Data were derived from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey.

The study results indicate that about one of six prescriptions written was unnecessary, which equates to about 1 million ambulatory visits in which an antibiotic would be prescribed inappropriately. The researchers said the most commonly prescribed antibiotics were macrolides, followed by aminopenicillins and cephalosporins, adding that corticosteroid use and time of the year were both important predictors in whether antibiotics were prescribed.

Similar findings were reported by Kris De Boeck, MD, and colleagues in Belgium. In that study, the researchers analyzed drug-dispensing data for 892,841 children from October 2005 to September 2006 using data from a health care insurer.

In that study, “an antibiotic was dispensed without an asthma drug to 38.62% of children vs. with an asthma drug to 73.5% of children (P<.0001). More frequent dispensing of antibiotics to children who received an asthma drug occurred in all age categories (P<.0001).

In Belgium, penicillins were most commonly prescribed, followed by macrolides and cephalosporins.

In their commentary, Mangione-Smith and Krogstad urged further education on antibiotic prescribing, including Web-based initiatives and those that focus on educating parents about judicious use of antibiotics.

Disclosure: The researchers report no relevant financial disclosures.

Matthew Greenhawt

The role of infection in initiating asthma attacks in asthmatic patients is a well-recognized risk factor, and is an important consideration in assessing the wheezing patient. Typically, though, most infectious-based precipitants are viral in origin, such as RSV, parainfluenza virus, adenovirus, or other agents. However, asthma may be commonly provoked in the setting of an acute bacterial sinusitis or bacterial pneumonia as well. The study by De Boek et al used data from a large insurance corporation in Belgium, to analyze and compare rates of asthma medication prescription and antibiotic prescriptions. The authors found that children with a history of being prescribed an asthma medication were more likely to be prescribed an antibiotic than children without a history of having been prescribed an asthma medication. They noted that antibiotics were also frequently co-prescribed on the same day as asthma medications. Their conclusions suggest that these antibiotics were potentially inappropriately overprescribed in lieu of asthma medications for respiratory symptoms, and they urge restrain in such practice, as well as further education about how to appropriately treat asthma.

While this study is interesting, I am troubled by the author's conclusions, given they use prescription of an asthma medication as a surrogate for a diagnosis of asthma (as opposed to objective measures such as spirometry or actual clinical symptoms), and did not examine any data other than medication coding to corroborate diagnosis at the time of the prescription of either the asthma medication or antibiotic. Use of such an indirect measures may be biased, inaccurate, or misleading, and without chart review the authors really would not have any way to objectively follow the clinical decision making that may have influenced the choice of medication prescribed (eg, presence of fever, abnormal chest x-ray, pulse oximetry, clinical suspicion, etc.).

Nonetheless, the authors touch upon an issue seen in several countries - antibiotic overprescribing. It is important to remember the triggers for asthma exacerbations, which often include viral infection, when making the decision in how to treat a patient suffering from an asthma flare. Though many children are treated with antibiotics for "bronchitis" when presenting with cough with or without wheeze, such a diagnosis does not exist. This clinical situation most likely represents a viral infection best not treated with antibiotics, or a viral-induced asthma exacerbation best treated with anti-inflammatory medications (eg, inhaled or oral corticosteroids) and short-acting beta-agonists. Antibiotics generally have a very limited role and efficacy in such patients.

Matthew Greenhawt, MD, MBA
Infectious Diseases in Children Editorial Board member

Disclosures: Dr. Greenhawt reports no relevant financial disclosures.

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