Prescriptions of systemic antibiotics for children in Germany aged between 0 and 6 years

Rationality of Prescriptions by Rational Use of Medicine Consensus Approach in Common Respiratory and Gastrointestinal Infections: An Outpatient Department Based Cross-Sectional Study from India

BACKGROUND

Drug utilisation studies are relevant for the analysis of prescription rationality and are pertinent in today's context of the increasing burden of antimicrobial resistance. Prescriptions for patients with diarrhoea or Acute Respiratory Infection (ARI) have been analysed in this study to understand the prescription pattern among various categories of prescribers in two tertiary care centers.

METHODS

This cross-sectional study was conducted from August 2019 to December 2020 in the medicine and pediatrics outpatient departments of two government teaching hospitals in West Bengal, India. A total of 630 prescriptions were evaluated against WHO standards. Prescriptions were assessed by a 'Rational Use of Medicine Consensus committee' approach.

RESULTS

The Fixed Dose Combination (FDC) was used in half of the patients (51%). Both the generic prescription (23.3%) and adherence to hospital formulary rates (36.5%) were low. The antibiotics prescription rate was high (57%), and it was higher for diarrhoea than ARI. Deviations from the standard treatment guidelines were found in 98.9% of prescriptions. Deviations were commonly found with prescriptions written by the junior doctors (99.6%).

CONCLUSION

Irrational prescribing patterns prevail in tertiary care centers and indicate the necessity of awareness generation and capacity building among prescribers regarding AMR and its unseen consequences.

Prevalence and risk factors for antibiotic utilization in Chinese children

BACKGROUND

Antibiotic resistance poses a significant threat to public health globally. Irrational utilization of antibiotics being one of the main reasons of antibiotic resistant. Children as a special group, there's more chance of getting infected. Although most of the infection is viral in etiology, antibiotics still are the most frequently prescribed medications for children. Therefore, high use of antibiotics among children raises concern about the appropriateness of antibiotic prescribing. This systematic review aims to measuring prevalence and risk factors for antibiotic utilization in children in China.

METHODS

English and Chinese databases were searched to identify relevant studies evaluating the prevalence and risk factors for antibiotic utilization in Chinese children (0-18 years), which were published between 2010 and July 2020. A Meta-analysis of prevalence was performed using random effect model. The Agency for Healthcare Research and Quality (AHRQ) and modified Jadad score was used to assess risk of bias of studies. In addition, we explored the risk factors of antibiotic utilization in Chinese children using qualitative analysis.

RESULTS

Of 10,075 studies identified, 98 eligible studies were included after excluded duplicated studies. A total of 79 studies reported prevalence and 42 studies reported risk factors for antibiotic utilization in children. The overall prevalence of antibiotic utilization among outpatients and inpatients were 63.8% (35 studies, 95% confidence interval (CI): 55.1-72.4%), and 81.3% (41 studies, 95% CI: 77.3-85.2%), respectively. In addition, the overall prevalence of caregiver's self-medicating of antibiotics for children at home was 37.8% (4 studies, 95% CI: 7.9-67.6%). The high prevalence of antibiotics was associated with multiple factors, while lacking of skills and knowledge in both physicians and caregivers was the most recognized risk factor, caregivers put pressure on physicians to get antibiotics and self-medicating with antibiotics at home for children also were the main factors attributed to this issue.

CONCLUSION

The prevalence of antibiotic utilization in Chinese children is heavy both in hospitals and home. It is important for government to develop more effective strategies to improve the irrational use of antibiotic, especially in rural setting.

Echinacea reduces antibiotic usage in children through respiratory tract infection prevention: a randomized, blinded, controlled clinical trial

Background

In children, up to 30% of viral respiratory tract infections (RTIs) develop into bacterial complications associated with pneumonia, sinusitis or otitis media to trigger a tremendous need for antibiotics. This study investigated the efficacy of Echinacea for the prevention of viral RTIs, for the prevention of secondary bacterial complications and for reducing rates of antibiotic prescriptions in children.

Methods

Echinaforce® Junior tablets [400 mg freshly harvested Echinacea purpurea alcoholic extract] or vitamin C [50 mg] as control were given three times daily for prevention to children 4–12 years. Two × 2 months of prevention were separated by a 1-week treatment break. Parents assessed respiratory symptoms in children via e-diaries and collected nasopharyngeal secretions for screening of respiratory pathogens (Allplex® RT-PCR).

Results

Overall, 429 cold days occurred in N_ITT = 103 children with Echinacea in comparison to 602 days in N_ITT = 98 children with vitamin C (p < 0.001, Chi-square test). Echinacea prevented 32.5% of RTI episodes resulting in an odds ratio of OR = 0.52 [95% CI 0.30–0.91, p = 0.021]. Six children (5.8%) with Echinacea and 15 children (15.3%) with vitamin C required 6 and 24 courses of antibiotic treatment, respectively (reduction of 76.3%, p < 0.001). A total of 45 and 216 days of antibiotic therapy were reported in the two groups, respectively (reduction of 80.2% (p < 0.001). Eleven and 30 events of RTI complications (e.g., otitis media, sinusitis or pneumonia) occurred with Echinacea and vitamin C, respectively (p = 0.0030). Echinacea significantly prevented influenza (3 vs. 20 detections, p = 0.012) and enveloped virus infections (29 vs. 47 detections, p = 0.0038). Finally, 76 adverse events occurred with Echinacea and 105 events with vitamin C (p = 0.016), only three events were reported possibly related with Echinacea.

Conclusions

Our results support the use of Echinacea for the prevention of RTIs and reduction of associated antibiotic usage in children.

Trial registration clinicaltrials.gov, NCT02971384, 23th Nov 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-021-00499-6.

Characteristics of prescriptions and costs for acute upper respiratory tract infections in Chinese outpatient pediatric patients: a nationwide cross-sectional study

BACKGROUND

To understand the characteristics of prescriptions and costs in pediatric patients with acute upper respiratory infections (AURI) is important for the regulation of outpatient care and reimbursement policy. This study aims to provide evidence on these issues that was in short supply.

METHODS

We conducted a retrospective cross-sectional study based on data from National Engineering Laboratory of Application Technology in Medical Big Data. All outpatient pediatric patients aged 0-14 years with an uncomplicated AURI from 1 January 2015 to 31 December 2017 in 138 hospitals across the country were included. We reported characteristics of patients, the average number of medications prescribed per encounter, the categories of medication used and their percentages, the cost per visit and prescription costs of drugs. For these measurements, discrepancies among diverse groups of age, regions, insurance types, and AURI categories were compared. Kruskal-Wallis nonparametric test and Student-Newman-Keuls test were performed to identify differences among subgroups. A multinomial logistic regression was conducted to examine the independent effects of those factors on the prescribing behavior.

RESULTS

A total of 1,002,687 clinical records with 2,682,118 prescriptions were collected and analyzed. The average number of drugs prescribed per encounter was 2.8. The most frequently prescribed medication was Chinese traditional patent medicines (CTPM) (36.5% of overall prescriptions) followed by antibiotics (18.1%). It showed a preference of CPTM over conventional medicines. The median cost per visit was 17.91 USD. The median drug cost per visit was 13.84 USD. The expenditures of antibiotics and CTPM per visit (6.05 USD and 5.87 USD) were among the three highest categories of drugs. The percentage of out-of-pocket patients reached 65.9%. Disparities were showed among subgroups of different ages, regions, and insurance types.

CONCLUSIONS

The high volume of CPTM usage is the typical feature in outpatient care of AURI pediatric patients in China. The rational and cost-effective use of CPTM and antibiotics still faces challenges. The reimbursement for child AURI cases needs to be enhanced.

A cross-sectional study on antibiotic prescription in a teaching hospital in Ghana

Introduction

Antibiotic misuse is the paramount factor for antibiotic resistance. Tamale Teaching Hospital (TTH), located in Ghana’s Northern Region, is the biggest tertiary hospital in the Northern half of the country and consequently one of the biggest prescribers of antibiotics. Understanding the use of antibiotics in the TTH and providing information that could be inferred to develop strategies for antibiotic prescription is of extreme importance in this era of multiple and pan-resistant strains of pathogenic microorganisms.

Methods

A cross-sectional study on the use of antibiotics at TTH in the Northern region of Ghana was performed. Data were collected by reviewing 10% of patients’ files from January to June 2015 and then assessed for its appropriateness against the criteria based on the British National Formulary (BNF) 2015 and BNF children 2013-2014. Results were expressed in frequencies and percentages.

Results

A total of 617 patients’ records were included in this study. Up to 385 cases of different antibiotic misuse were found, comprising of 335 errors in prescriptions and 50 non-completed treatments. The most common prescription error was made on treatment duration (29.6%). The potential interactions were 16.7%.

Conclusion

The study revealed a high burden of antibiotics misuse in TTH. This suggests a need for the development of an antibiotic stewardship programme for the hospital.

Comparing outpatient oral antibiotic use in Germany and the Netherlands from 2012 to 2016

PURPOSE

Overuse of antibiotics is of concern, but may differ between European countries. This study compares outpatient use of oral antibiotics between Germany (DE) and the Netherlands (NL).

METHODS

For DE, we used the DAPI database with information on dispensings at the expense of the Statutory Health Insurance Funds from > 80% of community pharmacies. For NL, data were obtained from the Dutch Foundation for Pharmaceutical Statistics. Use of oral antibiotics was estimated as defined daily doses per 1000 inhabitants per day (DID), except for age comparisons as packages per 1000 inhabitants annually. National time trends were assessed with linear regression, stratified for the major antibiotic classes, and individual substances.

RESULTS

From 2012 to 2016, outpatient antibiotic use was lower in NL than in DE (9.64 vs 14.14 DID in 2016) and non-significantly decreased slightly over time in both countries. In DE, dispensings of oral antibiotics to children were higher compared with NL for the age groups 2 to 5 (2.0-fold in 2016) and 6 to 14 years (2.7-fold in 2016). Use of cephalosporins was very low in NL (0.02 DID in 2016), but the second most frequently dispensed class in DE (2.95 DID in 2016).

CONCLUSION

From 2012 to 2016, outpatient use of oral antibiotics was lower in NL than in DE. Differences were primarily observed in the age groups 2 to 5 and 6 to 14 years, although the recommendations of evidence-based guidelines in both countries were in agreement.

Observational Study of Antibiotic Usage at the Children's Clinical University Hospital in Riga, Latvia

Background and objectives: Many pediatric patients have been treated with antibiotics during their hospitalization. There is a need to improve antibiotic prescribing for pediatric patients because many of these prescriptions are inappropriate. Antibiotic consumption analysis was conducted at the Children's Clinical University Hospital to identify targets for quality improvement. Materials and Methods: A one day cross-sectional point prevalence survey (PPS) was conducted in May and November 2011⁻2013 using a previously validated and standardized method. The survey included all inpatient pediatric and neonatal beds and identified all children receiving an antibiotic treatment on the day of survey. Total consumption of systemic antibiotics belonging to the ATC J01 class (except amphenicols (J01B) and a combination of antibacterials (J01R)) was also analyzed by using a defined daily dose (DDD) approach and antibiotic drug utilization (90%DU) for the period 2006⁻2015. Results were compared with results in 2017 using the DDD and 90%DU methodology. Results: The most commonly used antibiotic group in all PPS, except in May and November 2011, was other β-lactam antibiotics (J01D): 42 (40%) prescriptions in May 2013 and 66 (42%) and November 2011. In 2006⁻2015 and also in 2017, the most commonly used antibiotic groups were penicillins (J01C) and other β-lactam antibiotics (J01D)-76% (90%DU) of the total antibiotic consumption registered in 2006, 73% in 2015 and 70% in 2017. Starting in 2008, amoxicillin was the most commonly used antibiotic at the hospital. The usage of ceftriaxone increased from 3% in 2006 to 13% in 2015, but decreased in 2017 (7%). Conclusions: Study results from 2006⁻2015 showed that there was a need to establish a stronger antibiotic prescribing policy in the hospital reducing the use of broad-spectrum antibiotics (especially 3rd generation cephalosporins) and increasing the use of narrower spectrum antibiotics. It was partly achieved in 2017 with some reduction in ceftriaxone use.

Impact of Implementing National Guidelines on Antibiotic Prescriptions for Acute Respiratory Tract Infections in Pediatric Emergency Departments: An Interrupted Time Series Analysis

Background

Many antibiotics are prescribed inappropriately in pediatric emergency departments (PEDs), but little data are available in these settings about effective interventions based on guidelines that follow the antimicrobial stewardship principle. Our aim was to assess the impact of implementing the 2011 national guidelines on antibiotic prescriptions for acute respiratory tract infection (ARTI) in PEDs.

Method

We conducted a multicentric, quasiexperimental, interrupted time series analysis of prospectively collected electronic data from 7 French PEDs. We included all pediatric patients who visited a participating PED during the study period from November 2009 to October 2014 and were diagnosed with an ARTI. The intervention consisted of local protocol implementation, education sessions, and feedback. The main outcome was the antibiotic prescription rate of discharge prescriptions for ARTI per 1000 PED visits before and after implementation, analyzed using the segmented regression model.

Results

We included 242534 patients with an ARTI. The intervention was associated with a significant change in slope for the antibiotic prescription rate per 1000 PED visits (-0.4% per 15-day period, P = .04), and the cumulative effect at the end of the study was estimated to be -30.9%, (95% CI [-45.2 to -20.1]), representing 13136 avoided antibiotic prescriptions. The broad-spectrum antibiotic prescription relative percentage decreased dramatically (-62.7%, 95% CI [-92.8; -32.7]) and was replaced by amoxicillin.

Conclusion

Implementation of the 2011 national French guidelines led to a significant decrease in the antibiotic prescription rate for ARTI and a dramatic drop in broad-spectrum antibiotic prescriptions, in favor of amoxicillin.

Survey on attitudes of Italian pediatricians toward cough

CONTEXT

Children's cough is a daily concern for most pediatricians. The management of both acute and chronic cough requires a systematic and comprehensive approach. Despite the approved protocols for management, the pediatric assessment of cough and the corresponding prescribing attitude frequently do not fit these protocols, which can be affected by parental suggestions - sometimes substantially.

OBJECTIVE

The objective of this study was to investigate both the perception and the behavior of a representative sample of Italian pediatricians toward cough in real life.

METHODS

A specific questionnaire consisting of 18 questions was prepared. The questionnaire was completed by 300 pediatricians (all members of PAIDOSS: Italian National Observatory on Health of Childhood and Adolescence) who represented ~300,000 children.

RESULTS

A vast majority of children have cough throughout the year (99.3% of respondents have cough during autumn/winter and 64.7% in spring/summer). Allergic disease is the most frequent suspected cause of chronic cough in children (53%), and this is supported by the high demand for consultations: 73% seek the opinion of allergologists, 62% of otorhinolaryngologists and only 33% of pulmonologists. The majority of pediatricians (92%) reported that they prescribe therapy in acute cough regardless of cough guidelines. Moreover, the survey pointed out the abuse of aerosol therapy (26% in acute cough and 38% in chronic cough) and of antibiotics prescription (22% in acute cough and 42% in chronic cough).

CONCLUSION

Our survey suggests that some Italian pediatricians' therapeutic attitudes should be substantially improved in order to achieve better management of cough in children and to minimize the burden of cough.

Prescription patterns and appropriateness of antibiotics in the management of cough/cold and diarrhea in a rural tertiary care teaching hospital

BACKGROUND

Acute gastroenteritis and respiratory illnesses are the major causes of morbidity and mortality in children under 5 years of age. The objective of this study was to evaluate the prescription pattern of antibiotic utilization during the treatment of cough/cold and/or diarrhea in pediatric patients.

METHODS

A descriptive, cross-sectional study was conducted for 6 months in pediatric units of a tertiary care hospital in South India. Children under 5 years of age presenting with illness related to diarrhea and/or cough/cold were included in this study. Data were collected by reviewing patient files and then assessed for its appropriateness against the criteria developed in view of the Medication Appropriateness Index and Guidelines of the Indian Academy of Pediatrics. The results were expressed in frequencies and percentages. Chi-square test was used to analyze the data. A P < 0.05 was considered statistically significant.

RESULTS

A total of 303 patients were studied during the study period. The mean age of the patients was 3.5 ± 0.6 years. The majority of children were admitted mainly due to chief complaint of fever (63%) and cough and cold (56.4%). The appropriateness of antibiotic prescriptions was higher in bloody and watery diarrhea (83.3% and 82.6%; P < 0.05). Cephalosporins (46.2%) and penicillins (39.9%) were the most commonly prescribed antibiotics, though the generic prescriptions of these drugs were the lowest (13.5% and 10%, respectively). The seniority of prescriber was significantly associated with the appropriateness of prescriptions (P < 0.05). Antibiotics prescription was higher in cold/cough and diarrhea (93.5%) in comparison to cough/cold (85%) or diarrhea (75%) alone.

CONCLUSIONS

The study observed high rates of antibiotic utilization in Chidambaram during the treatment of cough/cold and/or diarrhea in pediatric patients. The findings highlight the need for combined interventions using education and expert counseling, targeted to the clinical conditions and classes of antibiotic for which inappropriate usage is most common.

The rate of antibiotic utilization in Iranian under 5-year-old children with acute respiratory tract illness: A nationwide community-based study

Background:

To investigate the prevalence of antibiotic usage in children aged <5 years with acute respiratory tract illness (ARTI) in Iran.

Materials and Methods:

Data were collected from a national health survey conducted in 2010 (Iran's Multiple Indicator Demographic and Health Survey). Participants of this cross-sectional study were selected by multistage stratified cluster-random sampling from 31 provinces of Iran. Parents of children with <5 years of age responded to questions about the occurrence of any cough during the previous 2 weeks, referral to private/governmental/other health care systems, and utilization of any oral/injection form of antibiotics. Data were analyzed using SPSS software18. The chi-square test was used to determine antibiotic consumption in various gender and residency groups and also a place of residence with the referral health care system.

Results:

Of the 9345 children under 5 years who participated in the study, 1506 cases (16.2%) had ARTI during 2 weeks prior to the interview, in whom 1143 (75.9%) were referred to urban or rural health care centers (43.4 vs. 30.4%; P < 0.001). Antibiotics were utilized by 715 (62.6%) of affected children. Injection formulations were used for 150 (13.1%) patients. The frequency of receiving antibiotics was higher in urban than in rural inhabitants (66.0% vs. 57.7% P < 0.05).

Conclusion:

The prevalence of total and injection antibiotics usage in children <5 years with ARTI is alarmingly high in Iran. Therefore, interventions to reduce antibiotic use are urgently needed.

Is the prescribing behavior of Chinese physicians driven by financial incentives?

The prescribing behavior to prescribe high-priced drugs has been hypothesized to be related to the increasing drug expenditures in China, but little empirical evidence exists. The purpose of this study was to examine whether Chinese physicians, driven by financial incentives, tend to prescribe high-priced drugs. The 2000-2008 drug data in the Yangtze River Basin Hospitals' Drug Use Analysis System were analyzed to examine the prescription patterns of penicillins and cephalosporins in Shanghai. Among the top-100 drugs (by volume), cephalosporins cost as 1.1- 2.3 times as penicillins and their volume was 1.7-18.2 times. Revenues generated from prescribing cephalosporins were 3.4-24.2 times as those from prescribing penicillins. The tendency of prescribing relatively high-priced drugs was observed given the same chemical name, dosage, and specification but different trade names. Furthermore, high-priced drugs remained on the top-100 list with increasing volumes, while some lower-priced drugs exited from the list due to decreases in volumes. Facing the policy dilemmas, the Chinese government needs to implement a new financially rewarding system in which hospitals and physicians are able to achieve financial gains in a cost-effective way including prescribing similar drugs with lower prices. Reforming hospitals' payment methods is necessary and feasible to reshape financial incentives of healthcare providers. The combination of the global budget policy and financial incentive measures would be likely to change providers' prescribing behaviors towards a cost-effective direction.

Randomized controlled trial of parent therapeutic education on antibiotics to improve parent satisfaction and attitudes in a pediatric emergency department

OBJECTIVE

To evaluate therapeutic education delivered in a pediatric emergency department to improve parents' satisfaction and attitudes about judicious antibiotic use.

METHODS

In an emergency department of a tertiary pediatric hospital, children aged 1 month to 6 years and discharged with an oral antibiotic prescription for an acute respiratory or urinary tract infection were randomized to a patient therapeutic education on antibiotic use (intervention group) or fever control (control group) delivered to the parents (in the presence of the children) by a pharmacist trained in therapeutic education. Education consisted in a 30-minute face-to-face session with four components: educational diagnosis, educational contract, education, and evaluation. The main outcome measure was parent satisfaction about information on antibiotics received at the hospital, as assessed by a telephone interview on day 14. The secondary outcome was attitudes about antibiotic use evaluated on day 14 and at month 6.

RESULTS

Of the 300 randomized children, 150 per arm, 259 were evaluated on day 14. Parent satisfaction with information on antibiotics was higher in the intervention group (125/129, 96.9%, versus 108/130, 83.0%; P=0.002, exact Fisher test).

INTERVENTION

Group parents had higher proportions of correct answers on day 14 to questions on attitudes about judicious antibiotic use than did control-group parents (P=0.017, Mann-Whitney U test).

CONCLUSION

Therapeutic education delivered by a clinical pharmacist in the pediatric emergency department holds promise for improving the use of antibiotics prescribed to pediatric outpatients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00948779 http://clinicaltrials.gov/show/NCT00948779.

Systemic antibiotic use among children and adolescents in Germany: a population-based study

The aim of the study was to comprehensively describe antibiotic use among children and young adolescents in Germany. Outpatient prescriptions of systemic antibiotics to children (<15 years) were analysed using data from four German statutory health insurances for the years 2004 to 2006. Annual prevalence of antibiotic prescriptions was determined using the average number of insured children during the respective year as reference population. Annual antibiotic prescription rates were calculated per 1,000 person years. Both figures were stratified by age (0-4, 5-9 and 10-14 years) and sex. Frequent indications for prescribing were analysed. Annual prevalence of antibiotic prescriptions rose from 35.68 % [95 % confidence intervals (CI), 35.62-35.75] in 2004 to 37.79 % [95 % CI, 37.72-37.86] in 2006. Prescription rates slightly increased by 6.01 % from 668.54 [95 % CI, 667.34-669.72] antibiotic prescriptions per 1,000 person years in 2004 to 708.71 [95 % CI, 707.47-709.95] in 2006. In 2006, prescriptions of broad-spectrum penicillins (25.09 %), second-generation cephalosporins (18.11 %) and narrow-spectrum penicillins (16.45 %) were most frequent. The most common indication for antibiotic prescribing was tonsillitis followed by bronchitis, otitis media, acute upper respiratory infections and scarlet fever.

CONCLUSION

In contrast to other northern European countries, paediatric prescription rates are high in Germany. This and the frequent prescribing of broad spectrum agents for the treatment of mostly viral self-limiting conditions indicate limited adherence to evidence-based practice guidelines in antibiotic prescribing in the German outpatient setting.

Comparing neonatal and paediatric antibiotic prescribing between hospitals: a new algorithm to help international benchmarking

OBJECTIVES

The WHO anatomical therapeutic chemical (ATC)/defined daily dose (DDD) methodology is a standardized method of comparing antimicrobial use. The ATC/DDD is defined as the average maintenance daily dose of a drug used in a 70 kg adult, ignoring the considerable differences in body weight of neonates and children. The aim of this study was to develop a new standardized way of comparing rates of antimicrobial prescribing between European children's hospitals.

METHODS

This pilot study at four European children's hospitals (in the UK, Greece and Italy) collected data including demographics, antibiotic use, dosing and indication in children and neonates over a 14 day period.

RESULTS

A total of 1217 antibiotic prescriptions were issued with 47 different antibiotics used. Approximately half of all children and a third of all neonates received antibiotics, with wide variation between centres in the type and dose of antibiotic used. We propose a new pragmatic three-step algorithm. The first step includes a simple comparison of the proportion of hospitalized children on antibiotics by weight bands and the number of antimicrobials that account for 90% of total DDD drug usage (DU90%). The second step is a comparison of the dosing used (mg/kg/day). The third step is to compare overall drug exposure using DDD/100 bed days for standardized weight bands between centres.

CONCLUSIONS

This novel method has the potential to be a useful tool to provide antibiotic use comparator data and requires validation in a large prospective point prevalence study.

[Prudent use of antibiotics and suggestions for improvement from the paediatric health community]

A high use of antibiotics and a high resistance rate in some of the most common microorganisms have been found in Spain; evidence shows they are related. The appearance of organisms with high rates of antibiotic resistance represents a clinical and general problem with possibly catastrophic consequences. Primary health care and prehospital emergency departments are the places where 3 out of every 4 antibiotics are prescribed for children, most of them for respiratory infections. The data show a high number of inappropriate prescriptions according to standard therapeutic guidelines. To reverse this situation, it is necessary to implement multilateral and systematic interventions that are sustainable over time; some addressed to the general population and others to healthcare professionals. The general population needs to have reasonable expectations of antibiotics, based on accurate information. Health professionals need training (self-education), means (access to information sources), and time (organisation), to tackle this complex issue. The goal of this article is to highlight the importance of the problem of antibiotic resistance and its clinical consequences, such as treatment failure, and to promote the prudent use of antibiotics in paediatric care by suggesting measures that can be implemented in the healthcare system.

Poor adherence to antibiotic prescribing guidelines in acute otitis media--obstacles, implications, and possible solutions

Many countries now have guidelines on the clinical management of acute otitis media. In almost all, the public health goal of containing acquired resistance in bacteria through reduced antibiotic prescribing is the main aim and basis for recommendations. Despite some partial short-term successes, clinical activity databases and opinion surveys suggest that such restrictive guidelines are not followed closely, so this aim is not achieved. Radical new solutions are needed to tackle irrationalities in healthcare systems which set the short-term physician-patient relationship against long-term public health. Resolving this opposition will require comprehensive policy appraisal and co-ordinated actions at many levels, not just dissemination of evidence and promotion of guidelines. The inappropriate clinical rationales that underpin non-compliance with guidelines can be questioned by evidence, but also need specific developments promoting alternative solutions, within a framework of whole-system thinking. Promising developments would be (a) physician training modules on age-appropriate analgesia and on detection plus referral of rare complications like mastoiditis, and (b) vaccination against the most common and serious bacterial pathogens.

Challenges in reducing the burden of otitis media disease: an ENT perspective on improving management and prospects for prevention

Acute otitis media (AOM) is a major public health concern. This frequent disease of childhood is a leading cause of physician visits, a major component of paediatric healthcare burden, and a key contributor to antibiotic resistance. An international expert group comprising mainly ear, nose, and throat physicians met in June 2008 to discuss the optimal management of AOM, particularly with regards to unmet needs in diagnosis and management. Current guidelines do not help identify which patients are most at risk for severe or complicated AOM. Diagnosis of AOM is also complicated by a lack of correlation between clinical signs and symptoms and responsible pathogens. Consequently, treatment of AOM is not always appropriate, and the long-term overuse of antibiotics in AOM reduces the effectiveness of treatment and places children at risk for drug-resistant infections. There is a need for educational and research initiatives to improve diagnostic accuracy and management of AOM. Because there is currently no ideal treatment, vaccination is an attractive additional approach for managing AOM and reducing its burden.

Antibiotic usage, dosage and course length in children between 0 and 4 years

AIM

Antibiotic drugs are most frequently used by 0- to 4-year-old children. We performed a cross-sectional study in the Netherlands using a pharmacy prescription database to investigate the use, dose and course length of antibiotic drugs in 0- to 4-year-olds.

METHODS

We used a database with pharmacy drug-dispensing data. We investigated all prescriptions of systemic antibiotics prescribed in the years 2002-2006 for children of 0-4 years of age. Prescriptions for children under the age of 3 months were excluded.

RESULTS

Children of 9-12 months of age received more antibiotics than children in other age groups. In the 3- to 6-month-olds, amoxicillin was prescribed in 75.2% of the cases. This percentage was 50.4% in the 4-year-olds. The contribution of other broad-spectrum antibiotics increased with age (clarithromycin and amoxicillin/clavulanic acid). Small-spectrum penicillins were prescribed less often than the broad-spectrum antibiotics. From the prescriptions of the five most used drugs, 97.6% were within the recommended dose range. Most course lengths corresponded with the guidelines. Of the prescriptions, 3.9% were unlicensed or off-label.

CONCLUSION

Within the group of 0- to 4-year-old children, most antibiotics were used by 9- to 12-month-olds. The doses and course lengths were mostly correct, but the choice of antibiotics was not according to the guidelines. Young children received unlicensed and off-label prescribed antibiotics.

Review on use of German health insurance medication claims data for epidemiological research

PURPOSE

The objective was to evaluate the use of German health insurance claims data on medications over the last 10 years by a review of published studies.

METHODS

PubMed and Scopus were searched for relevant studies published in 1998 through 2007.

RESULTS

A total of 70 studies were included. Use of these data increased from 32 reports (45.7%) between 1998 and 2005 to 38 (54.3%) over the last 2 years (2006-2007). Over half of the studies (57.1%; n = 40) were written in English and the most frequent research types were health service utilization (51.4%; n = 36) and cost analyses (18.6%; n = 13). In most of the studies (65.7%; n = 46), medication data were linked with other health care utilization claims (e.g. hospitalization data and physicians' outpatient services). Data validity was not taken into consideration in 40.6% (n = 13) of the 32 studies that also analysed hospitalization or physicians' outpatient diagnoses.

CONCLUSIONS

German health insurance medication claims data were increasingly used for research purposes over the last 10 years. Especially methodological and validation studies are clearly needed.

[The quality of antibiotics prescription in public health services of Belo Horizonte, MG]

This study investigates the use of antibiotics and prescribing patterns and identifies the antibiotics most frequently prescribed in public health units of Belo Horizonte, MG. The methods used were observational, cross-sectional study aimed at analyzing the consistency between a sample of medical records and antibiotic prescriptions dispensed during March 2002 in eleven public health units in Belo Horizonte, Minas Gerais, Brazil. Pediatrics showed the highest proportion of antibiotic prescribing among four specialties; amoxicillin was the most frequently prescribed antibiotic, followed by benzathine penicillin G, sulfamethoxazole/trimethoprim, and erythromycin. Upper respiratory tract infections, tonsillitis, acute otitis media and urinary tract infections were the diagnostic hypotheses most frequently recorded. Overall consistency between the recorded diagnostic hypotheses and the prescribed antibiotic was lower than 75%. The duration of the therapy prescribed varied largely and in approximately 10% of the prescriptions this information was lacking. Moreover, data on the patient such as age, body weight, co-morbidity, diagnostic hypotheses and adverse reactions, were systematically absent in the medical records. This study demonstrates the need for interventions in order to promote a more rational use of antibiotics.

Antibiotic prescription and prevalence rate in the outpatient paediatric population: analysis of surveys published during 2000–2005

OBJECTIVE

To evaluate antibiotic paediatric consumption data in the community setting using data from studies published between 2000 and 2005 and to compare inter- and intra-country antibiotic prescribing patterns.

METHODS

A literature search was performed in EMBASE and MEDLINE to identify pharmacoepidemiological studies published between 2000 and 2005.

RESULTS

Large differences between studies were found, with significant heterogeneity in epidemiological indicators. Only 20 studies reporting comparable drug prescription data were considered in the analysis, all of which were from the USA, Canada, North-Central Europe and Italy. Pre-school children were reported as comprising the most exposed age group to antibiotic therapy (prevalence 72%; prescription rate 2.2 prescriptions/person per year). In the overall child and adolescent population (<or=19 years), prevalence varied from 14 to 57% (mean 34%), and the prescription rate from 0.2 to 1.3 prescriptions/person per year. Relevant inter-country qualitative and quantitative differences in antibiotic prescribing were apparent, although these were observed in only a few countries: prevalence was higher in Italy and Canada (prevalence range 42-57%) and lower in the Netherlands and the United Kingdom (prevalence range 14-21%). Penicillins were the most prescribed antibiotics in all cases (40-70% of antibiotic prescriptions), followed by macrolides (16-45%), while cephalosporins accounted for a large proportion of the prescriptions in Italy (30-40%) and Canada, but were practically absent in North European prescriptions.

CONCLUSION

Comparative drug utilisation studies on antibiotic use in children are needed, as are improvements in regulatory and educational programmes aimed at limiting the number prescriptions given for antibiotics. Both approaches would address public health problems, such as bacterial resistance and safety and elevated costs, related to the use and misuse of these drugs.

An assessment of the shared-decision model in parents of children with acute otitis media

OBJECTIVE

Medicine is shifting from a doctor-centered approach to a model entailing more shared decision-making. Many organizations now recommend a shared-decision approach to treating children with acute otitis media (AOM). Our primary objectives in this study were to assess (1) which style of decision-making on the physician's part would most effectively reduce parents' proclivity to use antibiotics for treatment of their child's AOM and (2) parental satisfaction with different doctor-patient decision-making styles.

METHODS

We conducted a cross-sectional survey to examine how parents respond to doctor-patient communication styles in 3 clinical vignettes that presented 2 versions of a shared-decision model (SDM) and 1 paternalistic model. Parents were randomly assigned to receive 1 of 3 vignettes. The main predictor variable was the vignette assignment, and the main outcomes were (1) parent proclivity to use antibiotics and (2) parent ratings of care by the physician in the vignette. Using logistic regression, we adjusted for caregivers' age, gender, income, knowledge of antibiotics, decision-making preference, confidence in physician, and length of relationship with personal physician.

RESULTS

Four hundred sixty-six parents met inclusion criteria, with a response rate of 94%. General characteristics were similar across vignette assignment groups. Parents who received the paternalistic-model vignettes were more likely to say that they would use antibiotics than those who received the SDM vignettes (odds ratio: 4.9; 95% confidence interval: 2.3-10.6). This result remained statistically significant after adjustment for potential confounders. In addition, parents in the shared-decision groups were more satisfied (93% and 84%) than those in the paternalistic-model group (76%).

CONCLUSIONS

To our knowledge, this is the first study to examine parent interest, acceptance, and satisfaction with the SDM. Our findings suggest that shared decision-making for AOM may lead to less antibiotic usage and higher levels of parental satisfaction. Although more studies are needed to examine how best to incorporate parents in the SDM, our study serves as an example of the potential benefit of this approach in pediatric medicine.

Prescribers' indications for drugs in childhood: a survey of five European countries (Spain, France, Bulgaria, Slovakia and Russia)

BACKGROUND

Indication-based, in comparison to diagnoses-based, drug utilization studies in children are scarce in the literature.

AIM

To determine the adequacy of the prescriber's indications for specific drug treatments compared to the current literature in five different European countries; and to show the possibilities of performing indication-based drug utilization studies.

DESIGN

a descriptive, cross-sectional, international study.

PATIENTS AND METHODS

Randomly selected sample of 12,264 paediatric outpatients seen in consultation rooms attended by paediatricians or general practitioners. Data on patient demographics, diagnoses, and pharmacological treatment, with therapeutic indications for each drug, were collected in pre-designed forms. Diagnoses and indications were coded using the ICD-9 and drugs according to the ATC classifications.

RESULTS

Indications were registered for every drug prescribed in all locations. Antibiotic indications considered incorrect (common cold, upper respiratory tract infections, viral infections, general symptoms or "not specified") accounted from 24.1% of the total antibiotics prescribed in Tenerife to 67.4% in Slovakia. Incorrect indication of first-choice antibiotics prescribed in acute otitis media and tonsillitis ranged from 28.9% of total antibiotics use in Russia to 75.4% in Tenerife. Correct antibiotic indications ranged from 23.4% of total antibiotics used in Slovakia to 65.7% in Tenerife. Aspirin use in febrile viral conditions was detected mainly in Toulouse and Russia.

CONCLUSION

The main areas for improvement detected were high use of mucolytics, prescription of aspirin in potential or established viral infections, overuse of antibiotics and identification of specific patterns of incorrect antibiotic prescription and clinical entities associated with each location.

Neonatal antibiotic treatment alters gastrointestinal tract developmental gene expression and intestinal barrier transcriptome

The postnatal maturation of the gut, partially modulated by bacterial colonization, ends up in the establishment of an efficient barrier to luminal antigens and bacteria. The use of broad-spectrum antibiotics in pediatric practices alters the gut bacterial colonization and, consequently, may impair the maturation of the gut barrier function. To test this hypothesis, suckling Sprague-Dawley rats received a daily intragastric gavage of antibiotic (Clamoxyl; an amoxicillin-based commercial preparation) or saline solution from postnatal day 7 (d7) until d17 or d21. Luminal microbiota composition and global gene expression profile were analyzed on samples from small intestine and colon of each group. The treatment with Clamoxyl resulted in the almost-complete eradication of Lactobacillus in the whole intestine and in a drastic reduction of colonic total aerobic and anaerobic bacteria, in particular Enterobacteriacae and Enterococcus. The global gene expression analysis revealed that Clamoxyl affects the maturation process of 249 and 149 Affymetrix probe sets in the proximal and distal small intestine, respectively, and 163 probe sets in the colon. The expression of genes coding for Paneth cell products (defensins, matrilysin, and phospholipase A2) was significantly downregulated by the Clamoxyl treatment. A significant downregulation of major histocompatibility complex (MHC) class Ib and II genes, involved in antigen presentation, was also observed. Conversely, mast cell proteases expression was upregulated. These results suggest that early treatment with a large-spectrum antibiotic deeply affects the gut barrier function at the suckling-weaning interface, a period during which the gut is challenged by an array of novel food-borne antigens.

Small proportions: what to report for confidence intervals?

PURPOSE

It is generally agreed that a confidence interval (CI) is usually more informative than a point estimate or p-value, but we rarely encounter small proportions with CI in the pharmaco-epidemiological literature. When a CI is given it is sporadically reported, how it was calculated. This incorrectly suggests one single method to calculate CIs. To identify the method best suited for small proportions, seven approximate methods and the Clopper-Pearson Exact method to calculate CIs were compared.

METHODS

In a simulation study for 90-, 95- and 99%CIs, with sample size 1000 and proportions ranging from 0.001 to 0.01, were evaluated systematically. Main quality criteria were coverage and interval width. The methods are illustrated using data from pharmaco-epidemiology studies.

RESULTS

Simulations showed that standard Wald methods have insufficient coverage probability regardless of how the desired coverage is perceived. Overall, the Exact method and the Score method with continuity correction (CC) performed best. Real life examples showed the methods to yield different results too.

CONCLUSIONS

For CIs for small proportions (pi < or = 0.01), the use of the Exact method and the Score method with CC are advocated based on this study.

Antimicrobial drug use in hospitalised paediatric patients: a cross-national comparison between Germany and Croatia

PURPOSE

To compare the utilisation of systemic antimicrobials at the paediatric units of the university hospitals in Marburg (Germany) and Rijeka (Croatia).

METHODS

A prospective, observational analysis of hospital records from 300 incident users of antimicrobials in each study centre that were younger than 19 years. Antimicrobial utilisation was analysed in six gender-specific age groups with respect to drug choice, duration of treatment and hospital stay, indication and route of administration. The extent of antimicrobial drug use was assessed by the number of treatment courses.

RESULTS

In each hospital, more than 1/3 of the patients were younger than 1 year. The duration of hospital stay was about two-fold longer in Rijeka (18.5 +/- 5.8 days) than in Marburg (8.6 +/- 3.8 days). Pneumonia and other respiratory tract infections were the most common indications in Marburg (38.6%) and Rijeka (58.7%). The cumulative percentage of patients treated with an equal number of different antimicrobials was lower in Rijeka than in Marburg. The most commonly used antimicrobials were ampicillin (40.3%) and cefuroxim (35.9%) in Marburg, but ceftriaxone (43.3%) and cefotaxim (14.0%) in Rijeka.

CONCLUSIONS

A shorter treatment duration, less variation in the prescribing pattern and a greater adherence to the use of recommended antimicrobials argue for a more rational antimicrobial drug use in Marburg than in Rijeka. However, a further identification of drug choice determinants is warranted.

Antibiotic prescribing for respiratory tract infections in Dutch primary care in relation to patient age and clinical entities

OBJECTIVES

To obtain detailed information on current prescribing rates of antibiotics for respiratory tract infections (RTIs) in Dutch general practice and its relation with age and respiratory tract clinical entities.

METHODS

We assessed the mean proportion of antibiotics prescribed for RTIs per age group, contact-based and population-based using all patient contacts concerning RTIs in the year 2000 selected from the IPCI database, containing information on general practice consultations of 235,290 patients.

RESULTS

In one-third of all contacts concerning RTIs, antibiotics were prescribed, with much variation between age groups and clinical entities. For children (0-15 years) and the elderly (over 75 years), the lowest contact-based percentages of prescribed antibiotics for RTIs were found, while population-based, children of age 0-5 years received far more antibiotics for RTIs. High prescribing rates were seen in patients with sinusitis-like complaints (67%) or pneumonia (78%), whereas low rates were found for patients with upper RTIs (16%).

CONCLUSIONS

Potential over-prescribing of antibiotics for RTIs occurs in the age group 31-65 years, not in children and the elderly, and in patients with upper RTIs, sinusitis and most likely acute bronchitis (contact-based). The management of these subgroups of patients should be addressed in quality assurance programmes. Children and the elderly visit the GP much more often than adults, which can be explained by more frequent (children) or more severe (elderly) RTI morbidity, but in proportion they do not receive more antibiotics.

Drug Use Patterns in Young German Women and Association with Mental Disorders

BACKGROUND:

There is a lack of data about drug use patterns in young women. Mental disorders may influence those drug use patterns.

OBJECTIVE:

To evaluate drug use patterns (prescribed drugs, self-medication) in general and in relation to the prevalence rates of mental disorders in young German women.

METHODS:

A total of 2064 women (18–24 y old), obtained in a random clustered sample, were asked about their actual and former medication use. Moreover, a structured psychological interview (Diagnostic Interview for Mental Disorders) was conducted with each woman to evaluate the prevalence of mental disorders (according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition).

RESULTS:

Oral contraceptives (55.9%), thyroid preparations (7.1%), respiratory system drugs (9.4%), and nervous system drugs (8%) were the most commonly used medications. Only 10% of the women with one or more mental disorders used psychotropic medication. As expected, women with mental disorders were significantly more likely to use antidepressants and psycholeptic agents (ie, sedatives/hypnotics, antipsychotics) than were women without any mental disorder. However, there were no significant differences in use of pain medication.

CONCLUSIONS:

The results of this study indicate an apparently inadequate supply of drugs acting on the nervous system for women with mental disorders in Germany. Further studies on different age and gender groups are needed. It is important to evaluate the prevalence of diseases and drug use at the same time so as to identify deficits in drug therapy and optimize prescription and self-medication use.

Drug utilisation in outpatient children. A comparison among Tenerife, Valencia, and Barcelona (Spain), Toulouse (France), Sofia (Bulgaria), Bratislava (Slovakia) and Smolensk (Russia)

INTRODUCTION

Scarce information about comparative diagnostic and therapeutic patterns in paediatric outpatients of different countries is found in the literature.

OBJECTIVE

To describe the similarities and differences observed in diagnosis and therapeutic patterns of paediatric patients of seven locations in different countries.

DESIGN

Cross-sectional, prospective, international comparative, descriptive study.

PATIENTS AND METHODS

A randomly selected sample of 12,264 paediatric outpatients seen in consultation rooms of urban and rural areas and attended by paediatricians or general practitioners of the participating locations. Data on patient demographic information, diagnosis and pharmacological treatment were collected using pre-designed forms. Diagnoses were coded using the ICD-9 and drugs according to the ATC classification.

RESULTS

Among the ten most common diagnoses, upper respiratory tract infections are in the first position in all locations; asthma prevalence is highest in Tenerife (8.4%). Tonsillitis, otitis, bronchitis and dermatological affections are the most common diagnoses in all locations. Pneumonia is only reported in Sofia (3.8%) and Smolensk (2.3%). The average number of drugs prescribed per child varied from 1.3 in Barcelona to 2.9 in Smolensk. There are no great differences in the profile of pharmacological groups prescribed, but a considerable range of variations in antibiotic therapy is observed: prescription of cephalosporins is low in Smolensk (0.7%) and higher in the other locations, from 16.5% (Bratislava) to 28% (Tenerife). Macrolides prescriptions range from 12.6% (Toulouse) to 24.7% (Smolensk), except in Sofia where they drop to 5.6%. Trimethoprim and its combinations are used in Smolensk (23.3%), Sofia (11.8%) and Bratislava (8.7%). Check-up consultations are not recorded in Smolensk and Bratislava, whereas in Toulouse these visits account for 16.2% of all consultations and in the other locations the percentage varies from 6.1% (Tenerife) to 1.9% (Sofia). Homeopathic treatments are registered only in Toulouse.

CONCLUSION

Except in asthma prevalence, there are no great differences in diagnostic maps among locations. Significant variations in the number of drugs prescribed per child and antibiotic therapies are observed. Areas for improvement have been identified.

Tratamiento antimicrobiano de las infecciones bronquiales en los servicios de urgencias hospitalarios

OBJECTIVE

To analyze antimicrobial prescribing habits in children diagnosed with bronchial infections in hospital emergency rooms.

METHODS

A descriptive study was performed in a random sample of children diagnosed with acute bronchitis and bronchiolitis in the emergency rooms of 11 Spanish hospitals. Information about the type of bronchial infection diagnosed and the antimicrobial treatment prescribed was gathered. The appropriateness of antibiotic prescriptions was assessed by comparing clinical practice in the use of antibiotics for bronchial infections with consensus guidelines developed for this study.

RESULTS

A total of 731 children were selected. The diagnosis was acute bronchitis in 531 (73 %) and bronchiolitis in 200 (27 %). Antimicrobial treatment was prescribed to 234 children (32 %; 95 % CI: 29-35 %). The most commonly prescribed antimicrobials were the aminopenicillins in 138 children (19 %; 95 % CI 16-22 %), cephalosporins in 54 (7 %; 95 % CI 5-9 %) and macrolides in 45 (6 % 95 % CI 4-8 %). The prescribed treatment was inappropriate in 26 % (95 % CI 23-29 %) of patients [31.5 % (95 % CI 27-35 %) of cases of acute bronchitis and 11.5 % (95 % CI 95 % 7-16 %) of cases of bronchiolitis]. Wide variability was observed in the inappropriate use of antimicrobial agents among the different hospitals, both in acute bronchitis (14-80 %) and in bronchiolitis (0-71 %).

CONCLUSION

Inappropriate antimicrobial treatment is prescribed to a considerable proportion of the children with bronchial infections attended in hospital emergency rooms, although there is wide variability among different hospitals. Programs to improve the quality of antimicrobial prescription should be developed. These should combine regulatory and educational measures directed at health professionals and the general public.