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Vigilance needed for antibiotic prescribing
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Antibiotics are frequently given to children and adults and are the most common class of therapeutic medications used in the pediatric population. Most prescribing of antibiotics for children occurs in the ambulatory setting, and most of these antibiotics are prescribed for respiratory tract infections. As resistance to antibiotics by bacterial pathogens is considered a significant health care problem, numerous efforts have been made in recent years to improve the appropriate use of antibiotics.
Past assessments in pediatrics have shown that usage of antibiotics increased during the 1980s and early 1990s. Efforts by numerous organizations, such as the CDC and professional medical organizations (eg, AAP), targeted health care professionals and the lay public on the adverse consequences of inappropriate antibiotic use. The publication of specific, clinical treatment guidelines have additionally been employed to improve the appropriate use and prescribing of antibiotics. Recent publications have assessed these efforts.
Edward A. Bell
Antibiotic prescribing in pediatrics
Several assessments of national antibiotic prescribing rates in the pediatric population have been published. McCaig evaluated data from the National Ambulatory Medical Care Survey (NAMCS) during 2-year periods from 1989-1990 through 1999-2000. NAMCS is a national probability sample survey of visits to non-federal, office-based physicians and is conducted annually by the CDC. Office visits are sampled by randomly assigned 1-week periods, with collection of various demographic and medical data (including prescription information). Collected data are weighted to produce national estimates.
In this study, population-based and visit-based antimicrobial prescribing rates were determined overall and more specifically for respiratory tract infections (RTIs) — otitis media (OM), pharyngitis, bronchitis, sinusitis, and upper RTI — for children younger than 15 years. The population-based prescribing rate was the number of antibiotics prescribed per child in the United States, whereas the visit-based prescribing rate described the prescribing rate when a visit occurred.
The changes in the population-based prescribing rate may reflect changes in the visit or prescribing rate, or both. During the study period, the average population-based annual rate of antibiotic prescribing decreased 40% from 1989-1990 to 1999-2000 (838/1,000 children to 503/1,000 children, respectively). For the combined five RTIs evaluated, antibiotic prescribing rates decreased 44%. Similar decreases in antibiotic prescribing were found when prescribing rates for children younger than 5 years were evaluated. When visit-based annual prescribing rates were evaluated, antibiotic prescribing was found to decrease by 29% overall, and by 14% for the five RTIs assessed.
Other researchers have evaluated more recent prescribing-rate data from NAMCS. Grijalva and colleagues evaluated annual visit and antibiotic prescription rates for children and adults with acute RTI using data from NAMCS and the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the period 1995-1996 to 2005-2006. NHAMCS collects data on a representative sample of visits to outpatient clinics and hospital-based EDs. During these periods, annual visit rates for children younger than 5 years decreased 17%, which primarily resulted from a 33% reduction in visit rates for OM. This period also demonstrated a 36% reduction in antibiotic prescribing rate overall for RTI. For children aged 5 to 17 years, antibiotic prescribing rates decreased 18%, although visit rates did not change. Antibiotic prescribing rates for non-OM RTI decreased by 41% and 24% for children younger than 5 years and children aged 5 to 17 years, respectively. Prescribing rates for different antibiotic classes decreased overall, with the exception of macrolide antibiotics, namely azithromycin, which demonstrated an increased prescribing rate.
Researchers have more recently evaluated data from the National Ambulatory Medical Care Survey (NAMCS). Hersh and colleagues evaluated data from the NAMCS and the NHAMCS for one period, 2006-2008, assessing antibiotic usage for children younger than 18 years by antibiotic class, and over a spectrum of diagnoses. As expected, more than 72% of antibiotic prescribing during this period was for acute RTI. When a visit was given an RTI diagnosis, an antibiotic was prescribed for 48.4% of these visits. Of these prescriptions, the authors assessed that 29.6% of visits for RTI were inappropriately prescribed an antibiotic (eg, for diagnoses of nasopharyngitis, bronchitis, asthma, etc). When an antibiotic was appropriately prescribed for a RTI, 16.9% of the antibiotics given were classified as broad spectrum, and the most common sub-class prescribed within broad-spectrum antibiotics was the macrolide class. Overall, a broad-spectrum antibiotic was prescribed for more than 50% of visits for infection.
The most recent data on office-based prescribing in children were published early this year by the CDC. NAMCS data on antibiotic prescribing from the periods 1993-1994 and 2007-2008 were compared for children aged 14 years and younger. Antibiotic prescribing rates decreased 24% from 1993-1994 to 2007-2008 (300 antibiotic courses/1,000 office visits to 229 antibiotics/1,000 office visits, respectively). Similar to the studies above, five acute RTIs were specifically assessed. During the comparative study period, antibiotic-prescribing rates decreased 26% for pharyngitis and 19% for non-specific upper RTI (ie, the common cold). Antibiotic prescribing rates for OM, sinusitis and bronchitis did not change significantly. Overall, the rate of both population-based (antibiotic prescriptions per person) and visit-based (antibiotic prescriptions per office visit) antibiotic prescribing decreased from 1993-1994 to 2007-2008.
Poor prescribing implications
The above data indicate that during the past 10 to 15 years, population-based and visit-based prescribing rates for antibiotics have decreased. Factors responsible for this decrease have been described as likely to be multifactorial, including introduction of new vaccines targeting important bacterial pathogens (eg, pneumococcal vaccines), publication of clinical treatment guidelines with specific antibiotic choice recommendations (see Table), and national campaigns on the appropriate use of antibiotics from the CDC and major professional organizations that target the lay public and health care professionals, among other factors.
While these trends in antibiotic use are beneficial, there is room for additional improvement. Many children may continue to receive an antibiotic for common RTI, when use of an antibiotic is unnecessary. Additionally, as several studies have documented, use of broad-spectrum antibiotics may be inappropriately high. Some data indicate that, despite the publication of national guidelines for the treatment of OM, including observation or watchful waiting, this treatment strategy has not been well accepted.
Many studies that evaluate prescriber behavior and methods for improved prescribing, or judicious antibiotic use, have been published, and these studies generally demonstrate that such programs are effective. How these differing programs can be adapted to different settings has not been fully determined, however. Antibiotic stewardship programs have been shown to successfully improve judicious antibiotic use in inpatient settings and have been financially beneficial. Recent evidence has demonstrated that these principles can also be successfully applied in the ambulatory setting as well in pediatrics.
Clinicians should continue to strive to use antibiotics judiciously and now have several treatment guidelines for assistance (see Table). As bacterial pathogens continue to develop resistance to current antibiotics, development and labeling of new and innovative antibiotic agents is likely to lag behind.
References:
Finkelstein JA. JAMA. 2013;309:2388-2389.
Gerber JS. JAMA. 2013;309:2345-2352.
Grijalva CG. JAMA. 2009;302:758-766.
Hersch AL. Pediatrics. 2011;128:1053-1061.
McCaig LF. JAMA. 2002;287:3096-3102.
McCaig LF. MMWR. 2014;60:1153-1156.
For more information:
Edward A. Bell, PharmD, BCPS, is professor of pharmacy practice at Drake University College of Pharmacy and Health Sciences and Blank Children’s Hospital and Clinics, Des Moines, Iowa. He is also a member of the Infectious Diseases in Children Editorial Board. Bell can be reached at ed.bell@drake.edu.
Disclosure: Bell reports no relevant financial disclosures.