Kids Still Getting Too Many Antibiotics

Crystal Phend, Staff Writer, MedPage Today
Med Page Today
October 10, 2011

 Half of antibiotics given to kids are broad-specrum drugs, often with inappropriate indicatoins, a national ambulatory care study found. 

Asthma, viral pneumonia, and other respiratory conditions for which antibiotics are not typically indicated accounted for 30% of broad-spectrum antibiotic use, Adam L. Hersh, MD, PhD, of the University of Utah in Salt Lake City, and colleagues reported.

These findings raise "serious concerns about the overuse of broad-spectrum antibiotics, particularly for patients for whom antibiotic therapy is not indicated at all," they warned in the December issue of Pediatrics.

That prescribing problem not only promotes resistance and adverse events but also carries a high economic cost, they noted.

The group analyzed the National Ambulatory and National Hospital Ambulatory Medical Care surveys from 2006 to 2008, which covered a nationally representative sample of pediatric care visits at physician offices and hospital outpatient and emergency departments.

Overall, kids got an antibiotic prescription at 21% of ambulatory visits. Broad-spectrum antibiotics accounted for 50% of ambulatory visits at which children were prescribed antibiotics.

Of all the antibiotics that were prescribed, 23% were for respiratory conditions for which antibiotics were either inappropriate or not clearly indicated, representing about 10 million pediatric visits each year.

But that percentage was higher for broad-spectrum antibiotics -- of those that were prescribed, 30% were for conditions for which antibiotics were either inappropriate or not clearly indicated, representing about six million visits associated with potentially inappropriate pediatric prescriptions each year.

Macrolides -- primarily azithromycin (Zithromax) -- accounted for 40% of broad-spectrum antibiotic prescriptions, and 20% of overall antibiotic prescriptions.

Clinicians may be attracted to macrolides because of their long half-life that allows for a short course of therapy and once-daily dosing, but macrolide-resistant bacterial pneumonia is a growing concern, Hersh's group noted.

Next most common among the broad-spectrum drugs prescribed were cephalosporins (31%) and penicillins (26%).

Independent predictors of getting a broad-spectrum rather than narrow-spectrum antibiotic were:

  • Diagnosis with an acute respiratory tract infection for which antibiotics are not indicated (odds ratio 1.80, 95% confidence interval 1.34 –2.42)
  • Diagnosis with respiratory conditions other than the acute infections for which antibiotics are indicated (OR 1.93, 95% CI 1.40 to 2.66)
  • Age younger than 6 years (OR 1.27 versus 6 to 12, 95% CI 1.04 to 1.54)
  • Care at centers in the South versus in the West (OR 1.82, 95% CI 1.30 to 2.55)
  • Private insurance (OR 0.79 with public or no insurance versus private insurance, 95% CI 0.66 to 0.94)

Hospitals weren't any less likely to prescribe broad-spectrum antibiotics to kids than were office-based physicians. Nor did the specialty of the treating physician make any difference.

The researchers cautioned that use of administrative diagnosis codes to determine diagnoses may have led to some misclassification in the study.

Reasonable justifications for antibiotic prescription may have existed for some visits categorized as ones for which antibiotics were not indicated.

But the study was conservatively designed so that the net effect of bias would have been to underestimate unnecessary antibiotic prescribing, they explained.

For example, pharyngitis was considered an antibiotic-indicated condition even though a number of viral causes typically predominate.

"Antibiotic stewardship programs have been shown to be effective interventions for improving antibiotic-prescribing patterns in hospital settings, including reducing overuse of broad-spectrum antibiotics," Hersh's group noted in the paper. Similar programs for ambulatory care settings should be a public health priority, they concluded.