Appropriateness of antibiotic prescriptions in community-acquired acute pediatric respiratory infections in Spanish emergency rooms

Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study

BACKGROUND

Antibiotic consumption can lead to antimicrobial resistance and microbiome imbalance. We sought to estimate global antibiotic consumption for sore throat, and the potential reduction in consumption due to effective vaccination against group A Streptococcus (Strep A).

METHODS

We reviewed and analysed articles published between January 2000 and February 2022, identified though Clarivate Analytics' Web of Science search platform, with reference to antibiotic prescribing or consumption, sore throat, pharyngitis, or tonsillitis. We then used those analyses, combined with assumptions for the effectiveness, duration of protection, and coverage of a vaccine, to calculate the estimated reduction in antibiotic prescribing due to the introduction of Strep A vaccines.

FINDINGS

We identified 101 studies covering 38 countries. The mean prescribing rate for sore throat was approximately 5 courses per 100 population per year, accounting for approximately 5% of all antibiotic consumption. Based on 2020 population estimates for countries with empiric prescribing rates, antibiotic consumption for sore throat was estimated to exceed 37 million courses annually, of which half could be attributable to treatment for Strep A. A vaccine that reduces rates of Strep A infection by 80%, with 80% coverage and 10 year's duration of protection, could avert 2.8 million courses of antibiotics prescribed for sore throat treatment among 5-14 year-olds in countries with observed prescribing rates, increasing to an estimated 7.5 million averted if an effective vaccination program also reduced precautionary prescribing.

INTERPRETATION

A vaccine that prevents Strep A throat infections in children may reduce antibiotic prescribing for sore throat by 32-87% depending on changes to prescribing and consumption behaviours.

FUNDING

The Wellcome Trust, grant agreement number 215490/Z/19/Z.

Antibiotic Use in Febrile Children Presenting to the Emergency Department: A Systematic Review

Introduction: While fever is the main complaint among pediatric emergency services and high antibiotic prescription are observed, only a few studies have been published addressing this subject. Therefore this systematic review aims to summarize antibiotic prescriptions in febrile children at the ED and assess its determinants. Methods: We extracted studies published from 2000 to 2017 on antibiotic use in febrile children at the ED from different databases. Author, year, and country of publishing, study design, inclusion criteria, primary outcome, age, and number of children included in the study was extracted. To compare the risk-of-bias all articles were assessed using the MINORS criteria. For the final quality assessment we additionally used the sample size and the primary outcome. Results: We included 26 studies reporting on antibiotic prescription and 28 intervention studies on the effect on antibiotic prescription. In all 54 studies antibiotic prescriptions in the ED varied from 15 to 90.5%, pending on study populations and diagnosis. Respiratory tract infections were mostly studied. Pediatric emergency physicians prescribed significantly less antibiotics then general emergency physicians. Most frequent reported interventions to reduce antibiotics are delayed antibiotic prescription in acute otitis media, viral testing and guidelines. Conclusion: Evidence on antibiotic prescriptions in children with fever presenting to the ED remains inconclusive. Delayed antibiotic prescription in acute otitis media and guidelines for fever and respiratory infections can effectively reduce antibiotic prescription in the ED. The large heterogeneity of type of studies and included populations limits strict conclusions, such a gap in knowledge on the determining factors that influence antibiotic prescription in febrile children presenting to the ED remains.

Survey of Spanish general practitioners' attitudes toward management of sore throat: an internet-based questionnaire study

Background

The management of sore throat varies widely in Europe. The objective of this study was to gain insight into clinicians’ perceptions on the current management of sore throat in Spain.

Methods

Cross-sectional, internet-based questionnaire study answered from July to September 2013. General practitioners (GPs) affiliated with the two largest scientific societies of primary care were invited to participate in the study. Questions were asked about physician knowledge, the use of current national guidelines for sore throat management, and management in two clinical scenarios, depicting a young adult with sore throat and: 1. cough, coriza with or without fever, and 2. fever without cough and coriza.

Results

The questionnaire was completed by 1476 GPs (5%) and 12.7% declared using rapid antigen detection tests. Antibiotics were considered by 18.8% of the GPs in the first scenario and by 32% in the second scenario (p < 0.001). The antibiotics most commonly mentioned by GPs were amoxicillin and amoxicillin + clavulanate (52.7 and 31.2%, respectively) whereas penicillin V was only prescribed in 11.9% of the cases. The drugs most commonly considered in both scenarios were analgesics and anti-inflammatory drugs. Antitussives, decongestants and expectorants were more commonly prescribed in cases of suspected viral infection (p < 0.001).

Conclusions

GPs have misconceptions as to the indications for using rapid antigen detection tests and prescribing drugs in the management of sore throat. These results suggest that guidelines are seldom followed since one in five GPs declared giving antibiotics for patients with a suspected viral infection and the use of second-choice antibiotics seems considerable.

Antibiotic and Diagnostic Discordance Between ED Physicians and Hospitalists for Pediatric Respiratory Illness

BACKGROUND AND OBJECTIVE

Imperfect diagnostic tools make it difficult to know the extent to which a bacterial process is contributing to respiratory illness, complicating the decision to prescribe antibiotics. We sought to quantify diagnostic and antibiotic prescribing disagreements between emergency department (ED) and pediatric hospitalist physicians for children admitted with respiratory illness.

METHODS

Manual chart review was used to identify testing, diagnostic, and antibiotic prescribing decisions for consecutive children admitted for respiratory illness in a winter (starting February 20, 2012) and a summer (starting August 20, 2012) season to a tertiary, freestanding children's hospital. Respiratory illness diagnoses were grouped into 3 categories: bacterial, viral, and asthma.

RESULTS

A total of 181 children admitted for respiratory illness were studied. Diagnostic discordance was significant for all 3 types of respiratory illness but greatest for bacterial (P<.001). Antibiotic prescribing discordance was significant (P<.001), with pediatric hospitalists changing therapy for 93% of patients prescribed antibiotics in the ED, including stopping antibiotics altogether for 62% of patients.

CONCLUSIONS

Significant diagnostic and antibiotic discordance between ED and pediatric hospitalist physicians exists for children admitted to the hospital for respiratory illness.

Assessment of antibiotic prescribing at different hospitals and primary health care facilities

In this study, it was aimed to investigate the utilization of antibiotics at various health care facilities. Photocopies of 1250 prescriptions which were containing antibiotics and written out in primary health care facilities (PHCFs), public hospitals (PHs), private hospitals and university hospitals in 10 provinces across Turkey, were evaluated by some drug use indicators. The number of drugs per prescription was 3.23 ± 0.92 and it was highest in PHCFs (3.34 ± 0.84), (p < 0.05). The cost per prescription was 33.3 $, being highest in PHs while being lowest in PHCFs (38.6 $ and 28.2 $ respectively). Antibiotic cost per prescription was 16.7 $ and it was also highest and lowest in PHs and PHCFs respectively (p < 0.05). The most commonly prescribed group of antibiotics was "beta-lactam antibacterials, penicillins" (29.2%) while amoxicillin/clavulanic acid was the most commonly prescribed antibiotic (18.1%). Sixty-one percent of the antibiotics prescribed for acute infections was generics; among facilities being highest in PHCFs (66.5%) and among diagnosis being highest in acute pharyngitis. In general, the duration of antibiotic therapy was approximately 7 days for acute infections. Although much more drugs were prescribed in PHCFs than others, it was found to be in an inverse proportion with both the total cost of prescriptions and the cost of antibiotics. Broad-spectrum antibiotics, beta-lactamase combinations in particular, were considered to be more preferable in all health care facilities is also notable. These results do serve as a guide to achieve the rational use of antibiotics on the basis of health care facilities and indications.

[Prescribing of antibiotics in patients admitted from Emergency Departments: a multicenter study]

INTRODUCTION

The infectious disease is the main source of care demand in Pediatric Emergency Departments (PED) and is a frequent cause of hospital admission with antibiotics. Our objectives are: 1) to determine the diseases that are seen in PED that required admission with antibiotics; 2) to determine the microbiological methods used and, 3) to analyze the characteristics of the indicated treatment.

MATERIAL AND METHODS

A prospective multicenter study was conducted in 22 Spanish hospitals. We included patients younger than 18 years seen in PED on day 14 of each month between June 2009 and May 2010 who required hospitalization with systemic antibiotics. Patients admitted to Intensive Care Unit were excluded.

RESULTS

There were 30,632 consultations in the PED during the study period. A total of 1,446 (4.7%) patients were hospitalized, 395 (27.3%) of them with antibiotics. Ninety-five patients (24.1%) had received antibiotics before admission. Three hundred twenty (81%) children underwent at least one microbiological test, with blood culture (69.9%) and urine culture (30.9%) being the most requested ones. The main diagnoses at admission were pneumonia (29.4%), urinary tract infection (15.4%), and fever without source (12.1%). Twenty five different antibiotics were prescribed, with cefotaxime (27.8%) and amoxicillin-clavulanate (23.4%) being the most prescribed ones. A single antibiotic was prescribed to 80.8% of patients, and parenteral administration was the most indicated (93.7%).

CONCLUSIONS

Antibiotic therapy was prescribed in one in every 4 patients who required admission to hospital. Pneumonia was the most common source. Blood culture was the most frequent microbiological test requested in the PED. A limited number of beta-lactam antibiotics represented the majority of antibiotic prescriptions.

Community-acquired lobar pneumonia in children in the era of universal 7-valent pneumococcal vaccination: a review of clinical presentations and antimicrobial treatment from a Canadian pediatric hospital

BACKGROUND

Community-acquired pneumonia (CAP) is a common cause of pediatric admission to hospital. The objectives of this study were twofold: 1) to describe the clinical characteristics of CAP in children admitted to a tertiary care pediatric hospital in the pneumococcal vaccination era and, 2) to examine the antimicrobial selection in hospital and on discharge.

METHODS

A retrospective review of healthy immunocompetent children admitted to a tertiary pediatric hospital from January 2007 to December 2008 with clinical features consistent with pneumonia and a radiographically-confirmed consolidation was performed. Clinical, microbiological and antimicrobial data were collected.

RESULTS

One hundred and thirty-five hospitalized children with pneumonia were evaluated. Mean age at admission was 4.8 years (range 0-17 years). Two thirds of patients had been seen by a physician in the 24 hours prior to presentation; 56 (41.5%) were on antimicrobials at admission. 52 (38.5%) of patients developed an effusion, and 22/52 (42.3%) had pleural fluid sampled. Of 117 children who had specimens (blood/pleural fluid) cultured, 9 (7.7%) had pathogens identified (7 Streptococcus pneumoniae, 1 Group A Streptococcus, and 1 Rhodococcus). 55% of patients received 2 or more antimicrobials in hospital. Cephalosporins were given to 130 patients (96.1%) in hospital. Only 21/126 patients (16.7%) were discharged on amoxicillin. The median length of stay was 3 days (IQR 2-4) for those without effusion and 9 (IQR 5-13) for those with effusion. No deaths were related to pneumonia.

CONCLUSIONS

This study provides comprehensive data on the clinical characteristics of hospitalized children with CAP in the pneumococcal 7-valent vaccine era. Empiric antimicrobial choice at our institution is variable, highlighting a need for heightened antimicrobial stewardship.

[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.

Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme

Background

Excessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance.

Methods

GPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention.

Results

A total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.

Conclusion

A multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.

Health Alliance for Prudent Prescribing, Yield and Use of Antimicrobial Drugs in the Treatment of Respiratory Tract Infections (HAPPY AUDIT)

Background

Excessive and inappropriate use of antibiotics is considered to be the most important reason for development of bacterial resistance to antibiotics. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries.

The majority of respiratory tract infections (RTIs) are treated in general practice. Most infections are caused by virus and antibiotics are therefore unlikely to have any clinical benefit. Several intervention initiatives have been taken to reduce the inappropriate use of antibiotics in primary health care, but the effectiveness of these interventions is only modest. Only few studies have been designed to determine the effectiveness of multifaceted strategies in countries with different practice setting. The aim of this study is to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different prevalence of antibiotic resistance: Two Nordic countries (Denmark and Sweden), two Baltic Countries (Lithuania and Kaliningrad-Russia) and two Hispano-American countries (Spain and Argentina).

Methods/Design

HAPPY AUDIT was initiated in 2008 and the project is still ongoing. The project includes 15 partners from 9 countries. GPs participating in HAPPY AUDIT will be audited by the Audit Project Odense (APO) method. The APO method will be used at a multinational level involving GPs from six countries with different cultural background and different organisation of primary health care. Research on the effect of the intervention will be performed by analysing audit registrations carried out before and after the intervention. The intervention includes training courses on management of RTIs, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting room, brochures to patients and implementation of point of care tests (Strep A and CRP) to be used in the GPs'surgeries.

To ensure public awareness of the risk of resistant bacteria, media campaigns targeting both professionals and the public will be developed and the results will be published and widely disseminated at a Working Conference hosted by the World Association of Family Doctors (WONCA-Europe) at the end of the project period.

Discussion

HAPPY AUDIT is an EU-financed project with the aim of contributing to the battle against antibiotic resistance through quality improvement of GPs' diagnosis and treatment of RTIs through development of intervention programmes targeting GPs, parents of young children and healthy adults. It is hypothesized that the use of multifaceted strategies combining active intervention by GPs will be effective in reducing prescribing of unnecessary antibiotics for RTIs and improving the use of appropriate antibiotics in suspected bacterial infections.

Effect of intervention promoting a reduction in antibiotic prescribing by improvement of diagnostic procedures: a prospective, before and after study in general practice

OBJECTIVE

To investigate if an intervention aimed at improving the quality of the diagnostic procedures in Spanish general practice could lower antibiotic prescribing in patients with respiratory tract infections (RTIs).

METHODS

GPs in the intervention group (n=17) registered all patients with RTIs during a 3-week period before and after the intervention. The intervention was aimed at reducing prescribing of inappropriate antibiotics for RTIs by improving the diagnostic procedures and thereby helping the GPs to distinguish between bacterial and viral infections. It consisted of courses in management of RTI according to local clinical guidelines, and included implementation of two rapid diagnostic tests (StrepA and CRP measurement). Diagnoses and prescribing of antibiotics were assessed before and after the intervention, and compared to a control group not exposed to intervention (35 GPs).

RESULTS

The intervention led to a significant reduction in antibiotic prescribing. Before the intervention 36% (29%-44%) of consultations were followed by antibiotic prescribing, after the intervention 24% (20%-29%). Antibiotic prescribing in the control group not exposed to intervention was 32% (27%-38%). The reduction was most pronounced in patients with sinusitis and lower RTIs.

CONCLUSION

Quality improvement of diagnostic procedures may lead to a reduction of antibiotic prescribing in primary health care in Spain.

[Consistency of clinical practice with the scientific evidence in the management of childhood asthma]

INTRODUCTION

There is substantial inconsistency between the evidence available on the management of childhood asthma and its application in practice.

OBJECTIVE

To evaluate the degree of appropriateness of current management of childhood asthma.

MATERIAL AND METHODS

We performed a structured review of the articles published on appropriateness in the recent biomedical literature (last 5 years). Methodological analysis and qualitative synthesis were performed.

RESULTS

Twenty-three articles were identified that reflected the following problems: insufficient documentation on trigger factors, evolution of pulmonary function and symptoms, inadequate guidelines on the treatment of exacerbations, inadequate use of inhaler devices, insufficient use of anti-inflammatory drugs, unjustified heterogeneity in the selection of anti-inflammatory drugs, lack of correlation between severity and level of treatment, lack of written guidelines on customized self-management, unjustified use of antibiotics, and lack of pulmonary function testing devices.

CONCLUSIONS

The management of childhood asthma should be reviewed since a large number of decisions made in clinical practice are not always based on valid scientific evidence.

Availability of antibiotics without prescription in New York City

Misuse of antibiotics in the community has been associated with emergence of increasingly antibiotic-resistant bacterial strains. Although antibiotics in the United States are to be prescribed by a health care provider, the extent to which they are obtained by other means is not known. The purpose of this article is to describe a survey of the availability of nonprescription antibiotics in neighborhood independent businesses in several Manhattan, New York, neighborhoods. A survey was conducted of 101 stores in three neighborhoods--one primarily Hispanic; one primarily black, non-Hispanic; and one primarily white, non-Hispanic. Antibiotics were available in all stores in the Hispanic neighborhood (n = 34), but in none of the others (P < .001). If efforts to rationalize the use of antibiotics are to be successful, the beliefs and cultural norms of subpopulations must be considered, and interventions must be culturally relevant.

Bacteraemia and antibiotic use in respiratory syncytial virus infections

AIMS

To examine the frequency of and risk factors for bacteraemia in children hospitalised with respiratory syncytial virus (RSV) infection; and to determine current use of antibiotics in hospitalised children with RSV infection.

METHODS

Retrospective study of all children, aged 0-14 years, admitted to a tertiary children's hospital with proven RSV infection over a four year period. Children with concurrent bacteraemia and RSV infection were identified, and risk factors examined for bacteraemia. The case notes of a randomly selected comparison sample of 100 of these RSV infected children were examined to assess antibiotic use and population incidence of risk factors for severe RSV infection.

RESULTS

A total of 1795 children had proven RSV infection, and blood cultures were sent on 861 (48%). Eleven (0.6%) of the 1795 RSV positive children had bacteraemia. RSV positive children had a significantly higher incidence of bacteraemia if they had nosocomial RSV infection (6.5%), cyanotic congenital heart disease (6.6%), or were admitted to the paediatric intensive care unit (2.9%). Forty five (45%) of the random comparison sample of RSV infected children received antibiotics.

CONCLUSIONS

Bacteraemia is rare in RSV infection. Children with RSV infection are more likely to be bacteraemic, however, if they have nosocomial RSV infection, cyanotic congenital heart disease, or require intensive care unit admission.

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.

¿Cuál es la importancia de la erradicación bacteriana en el tratamiento de la infección respiratoria?

During the last few years, increasing antibiotic resistance amongst the major respiratory pathogens in the community has compromised the choice of empirical therapy for some respiratory tract infections. Of special interest has been the progressive increase in the resistance rates of Streptococcus pneumoniae to macrolides and penicillin, and of S. pyogenes to macrolides. Several studies have confirmed the association between community use of certain antibiotics and the development of resistance in S. pneumoniae and S. pyogenes. Nevertheless, not all the antibiotics have the same ability to select resistance and not all microorganisms are affected in the same way. The aim of antimicrobial therapy in respiratory tract infections is bacterial eradication. Pharmacokinetic and pharmacodynamics can be used to predict bacteriological eradication with antimicrobial therapy.

Current Management Issues Associated with Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is a significant cause of morbidity, mortality, and increased cost. Despite numerous managementguidelines, CAP continues to existas a challenge to the learned clinician. Due to a lack of sensitive diagnostic testing, causative pathogens are often not identified, making most therapy empiric. Increasing levels of bacterial resistance to available antimicrobials worldwide has been implicated in driving up the costs of treatment and adversely effecting clinical outcomes. Pharmacists can be part of the solution by encouraging appropriate antimicrobial selection based on resistance patterns in their communities and ensuring appropriate vaccines are employed to prevent CAP.

Antibiotic prescribing for adults and children in Israeli emergency rooms

The emergency room (ER) is an important focal point for the initiation of antimicrobial therapy but there are few data on antimicrobial prescribing in the ER. The objective of the study was to describe antimicrobial prescribing in Israeli ERs and to compare patterns of prescribing between four different ERs in Northern Israel. The medical records of all patients who attended the ERs during February 2001 were examined. Those patients who were discharged home with a prescription for an antibiotic formed the sample. Paediatric data were only available for two of the four ERs. A total of 970 adults and 470 children attended the four ERs during 1 month and were discharged home with an antibiotic prescription representing 14.6 and 19.9%, respectively, of the total number of patients who visited the ERs. The most common diagnosis leading to an antibiotic prescription was respiratory tract infections (64 in adults and 90% in children). In adults, cefuroxime-axetil and amoxycillin-clavulanate (both second-line antibiotics) were the most frequently prescribed antibiotics, together accounting for 50% of all antibiotic prescriptions, while in children amoxycillin-clavulanate was favoured (58.9%). 'Viral infections' accounted for 22.5% of all prescriptions in adults, but only 2.3% in children. Otitis media accounted for almost half of all prescriptions in children. For some diagnoses, such as pneumonia in adults and tonsillitis in children, there was uniformity of prescribing among the different ERs, while for other diagnoses, there were large discrepancies. The ER represents an important source of inappropriate antibiotic prescribing, and measures to curb inappropriate prescribing are urgently needed.

[Appropriateness of treatment of acute pharyngotonsillitis according to the scientific evidence]

OBJECTIVE

To evaluate the appropriateness of antibiotic prescriptions in children with acute pharyngotonsillitis.

METHODS

A descriptive study was performed in a series of pediatric patients diagnosed with acute pharyngotonsillitis in the emergency rooms of 11 Spanish hospitals. The appropriateness of antibiotic prescriptions was assessed by comparing our clinical practice in the use of antibiotics for pharyngotonsillitis with consensus guidelines developed for this study.

RESULTS

We collected data from 1716 patients with acute pharyngotonsillitis. Antibiotics were prescribed in 80.9 %, mainly according to empirical criteria. The most commonly used antibiotics were amoxicillin (36 %), amoxicillin-clavulanate (22.5 %), cefixime (6.6 %), azithromycin (5.8 %) and cefuroxime (5.2 %). A total of 39.5 % of the patients were aged less than 3 years, of which 75.9 % were treated empirically. Of the prescribed treatments, 22.8 % were considered as the treatment of choice; 22.4 % as alternatives and 54.8 % as inappropriate.

CONCLUSIONS

Antibiotic treatment was prescribed in most of the cases of pharyngotonsillitis and nearly always according to empirical criteria. The number of antibiotic prescriptions was far higher than the expected cases of bacterial pharyngotonsillitis and, in many cases, the antibiotic prescriptions were inappropriate.