Antibiotic use in infants in the first year of life in five European countries

Inappropriate prescribing contributes to high antibiotic exposure in young children in Australia

BACKGROUND

Antibiotic exposure increases antimicrobial resistance and has also been associated with long-term harms, including allergies, inflammatory diseases and weight gain. We assessed antibiotic exposure in the first 2 years of life in Australian children, the factors influencing this and its appropriateness.

METHODS

Data from 1201 participants in the MIS BAIR randomized controlled trial were used. Multivariable logistic regression was used to identify factors associated with antibiotic exposure.

RESULTS

At 1 and 2 years of age, exposure to at least one course of antibiotics was 43% and 67%, with the highest first antibiotic prescription rate between 9 and 18 months. Amoxicillin was the most frequently used antibiotic (59%), followed by cefalexin (7%). The most common diagnoses for which antibiotics were prescribed were respiratory tract infections from 0 to 6 months of age and otitis media from 6 to 12 months. Factors associated with antibiotic exposure from 0 to 12 months of age were delivery by Caesarean section (adjusted odd-ratio (aOR) 1.5, 95%CI 1.1-1.9), birth in winter (aOR 1.7, 95%CI 1.2-2.4), maternal antibiotic exposure during the last trimester of pregnancy (aOR 1.6, 95%CI 1.1-2.3), cessation of breastfeeding by 6 months of age (aOR 1.5, 95%CI 1.1-2.0) and day-care attendance (aOR 1.4, 95%CI 1.1-1.8). Based on parent-reported questionnaires, 27% of infants were treated in the first year of life for conditions unlikely to need antibiotic treatment.

CONCLUSION

At least two-thirds of children were prescribed antibiotics in the first 2 years of life, and more than a quarter of these exposures may have been unnecessary.

Antimicrobial exposure during infancy in a longitudinal California cohort

BACKGROUND

To describe temporal and sociodemographic patterns of antimicrobial exposure during the first year of life in a large US cohort.

METHODS

Singleton infants born 1998-2014 enrolled in Kaiser Permanente Northern California integrated health system (n = 345,550) were followed longitudinally via comprehensive electronic health records, capturing all systemic antimicrobial inpatient administrations and outpatient dispensings. Antimicrobial exposure was summarized by maternal and infant characteristics, birth year, inpatient/outpatient status, age in months, and drug class.

RESULTS

Overall, 44% of infants in this cohort received at least one dose of antimicrobials during infancy. Decreases over time were driven by reduced outpatient dispensings specifically in later infancy, primarily for penicillins. Among infants receiving any antimicrobials the median number of exposure-days was 16. Inpatient dispensings peaked in the first 30 days of life and outpatient dispensings peaked at 10-11 months. Birth characteristics (i.e., NICU admission, gestational age) were strong independent predictors of antimicrobial exposure between 0- < 3 months; sociodemographic factors were modest predictors of exposure for 3-12 months.

CONCLUSION

Predictors of antimicrobial exposure in early and late infancy are distinct with early infancy exposures highly correlated to birth characteristics. The cumulative proportion of infants exposed has decreased due to fewer late infancy outpatient dispensings.

IMPACT

Comprehensive antimicrobial exposure histories and the maternal and infant characteristics predicting exposure have not been well described in US populations. This analysis provides estimates of cumulative antimicrobial exposures by sociodemographic factors, delivery characteristics, month of life, inpatient/outpatient status, and antibiotic class among one of the largest US HMOs. Predictors of early infancy antimicrobial exposures differ from those in late infancy, with early exposures strongly correlated to birth characteristics and late infancy exposures modestly related to sociodemographic factors. Antimicrobial exposure among infants decreased over the time period primarily due to reduced outpatient dispensings in later infancy.

Inappropriate prescription of intravenous antibiotics at a tertiary children's hospital in China

BACKGROUND

Antibiotics are one of the most frequently prescribed medication classes worldwide. Inappropriate prescription of antibiotics has increased the risk of drug-resistant infections and associated mortality. The aim of this study was to examine the patterns of intravenous antibiotics prescribing in emergency and outpatient departments of a tertiary children's hospital in China.

METHODS

Data on intravenous prescriptions dispensed by the emergency and outpatient department from January 1, 2015 to May 31, 2016 were extracted from the information system of the Children's Hospital of Fudan University. Prevalence of intravenous antibiotics use and the suitability of intravenous antibiotic prescription were evaluated on the basis of a completed microbiological examination, antibiotics susceptibility testing, and dose prescribed for patients diagnosed with pneumonia, acute bronchitis, fever, and acute upper respiratory infection (AURI) patients. The prescription rate was expressed as the number of intravenous antibiotic prescriptions per total number of prescriptions.

RESULTS

Overall, 94.2% of pediatric patients and 78.5% of issued intravenous prescriptions were for antibiotics. beta-lactam antibacterial (90.5%) and macrolides (18.5%) were the most commonly used categories of antibiotics, while cefuroxime (28.8%) was the most used antibiotic. Besides, pneumonia (31.3%), acute bronchitis (14.1%), fever (6.5%), and AURI (5.5%) were the most commonly recorded infections. However, in these four diseases, the rate of conducting microbiological examination was 0.3%, 0.2%, 2.1%, and 2.8%, respectively. Approximately, 52.1%, 40.0%, 40.4%, and 30.5% of intravenous antibiotic prescriptions were inappropriately used in pneumonia, acute bronchitis, fever, and AURI, respectively. Doses higher and lower than the recommended were often for each of these four diseases.

CONCLUSIONS

The frequency of intravenous antibiotic prescription was high in pediatric emergency and outpatient departments. Inappropriate use of intravenous antibiotics commonly occurred in pneumonia, acute bronchitis, fever, and AURI. Appropriate interventions and prevention strategies need to be developed to curtail inappropriate prescribing of antibiotics.

Antibiotic consumption in the first months of life: A cross-sectional study

INTRODUCTION

The factors and patterns associated with antibiotic consumption in infants are unclear. Our aim was to assess the cumulative incidence of antibiotic consumption from birth to 16 months and identify factors associated with antibiotic consumption among infants aged 4-16 months.

MATERIAL AND METHODS

We conducted a cross-sectional study in 2016 in a sample of 18 882 women from Galicia, Spain, who had given birth to a live child between September 1, 2015 and August 31, 2016. We calculated the cumulative incidence of antibiotic consumption based on maternal reports regarding the infant's consumption from birth to 14 months obtained through interviews; we did not estimate consumption at ages 15 and 16 months due to the small sample size. To assess which factors were associated with antibiotic consumption, we carried out a nested case-control study matching cases and controls for birth month on a 1:1 ratio.

RESULTS

The cumulative incidence of antibiotic consumption among infants aged 0-14 months increased from 7.5% to 66.0%. The case-control study included data for 1852 cases and 1852 controls. Daycare attendance (OR: 3.8 [95% CI: 3.2-4.6]), having older siblings (OR: 1.8 [95% CI: 1.6-2.1]), health care visits to private clinics (OR: 1.6 [95% CI: 1.4-2.0]), and passive smoking (OR: 1.3 [95% CI: 1.1-1.6]) were associated with an increased probability of antibiotic consumption. Maternal age between 30-39 years or 40 years and over at the time of birth was associated with a decreased probability of antibiotic consumption (OR: 0.8 [95% CI, 0.7-1.0] and OR: 0.6 [95% CI: 0.5-0.8], respectively).

CONCLUSIONS

Some of the factors associated with antibiotic consumption in infants are modifiable and should be considered in the development of public health measures aimed at reducing antibiotic consumption.

Over-investigation and overtreatment in pediatrics: a survey from the European Academy of Paediatrics and Japan Pediatric Society

Introduction

Avoiding over-investigation and overtreatment in health care is a challenge for clinicians across the world, prompting the international Choosing Wisely campaign. Lists of recommendations regarding medical overactivity are helpful tools to guide clinicians and quality improvement initiatives. We aimed to identify the most frequent and important clinical challenges related to pediatric medical overactivity in Europe and Japan. Based on the results, we aim to establish a (European) list of Choosing Wisely recommendations.

Methods

In an online survey, clinicians responsible for child health care in Europe and Japan were invited to rate 18 predefined examples of medical overactivity. This list was compiled by a specific strategic advisory group belonging to the European Academy of Paediatrics (EAP). Participants were asked to rate on a Likert scale (5 as the most frequent/important) according to how frequent these examples were in their working environment, and how important they were considered for change in practice.

Results

Of 2,716 physicians who completed the survey, 93% (n = 2,524) came from 17 countries, Japan (n = 549) being the largest contributor. Pediatricians or pediatric residents comprised 89%, and 51% had 10-30 years of clinical experience. Cough and cold medicines, and inhaled drugs in bronchiolitis were ranked as the most frequent (3.18 and 3.07 on the Likert scale, respectively), followed by intravenous antibiotics for a predefined duration (3.01), antibiotics in uncomplicated acute otitis media (2.96) and in well-appearing newborns. Regarding importance, the above-mentioned five topics in addition to two other examples of antibiotic overtreatment were among the top 10. Also, IgE tests for food allergies without relevant medical history and acid blockers for infant GER were ranked high.

Conclusion

Overtreatment with antibiotics together with cough/cold medicines and inhaled drugs in bronchiolitis were rated as the most frequent and important examples of overtreatment across countries in Europe and Japan.

Comparative Analysis of Outpatient Antibiotic Prescribing in Early Life: A Population-Based Study Across Birth Cohorts in Denmark and Germany

INTRODUCTION

Comparing antibiotic prescribing between countries can provide important insights into potential needs of improving antibiotic stewardship programs. We aimed to compare outpatient antibiotic prescribing in early life between children born in Denmark and Germany.

METHODS

Using the Danish nationwide healthcare registries and a German claims database (GePaRD, ~ 20% population coverage), we included children born between 2004 and 2016, and followed them regarding outpatient antibiotic prescriptions until end of enrollment or the end of 2018. We then determined the median time to first antibiotic prescription. Based on all prescriptions in the first 2 years of life, we calculated the rate of antibiotic treatment episodes and for the children's first prescriptions in this period, we determined established quality indicators. All analyses were stratified by birth year and country.

RESULTS

In the 2016 birth cohorts, the median time to first antibiotic prescription was ~ 21 months in Denmark and ~ 28 in Germany; the rate of antibiotic treatment episodes per 1000 person-years was 537 in Denmark and 433 in Germany; the percentage of prescribed antibiotics with higher concerns regarding side effects and/or resistance potential was 6.2% in Denmark and 44.2% in Germany. In the 2016 birth cohorts, the age at first antibiotic prescription was 50-59% higher compared to the 2004 birth cohorts; the rate of antibiotic treatment episodes was 43-44% lower.

CONCLUSIONS

Infants in Denmark received antibiotics markedly earlier and more frequently than in Germany, while quality indicators of antibiotic prescribing were more favorable in Denmark. Although both countries experienced positive changes towards more rational antibiotic prescribing in early life, our findings suggest potential for further improvement. This particularly applies to prescribing antibiotics with a lower potential for side effects and/or resistance in Germany.

Opportunities to Improve Awareness of Antimicrobial Resistance Through Social Marketing: A Systematic Review of Interventions Targeting Parents and Children

Lack of knowledge from parents concerning the appropriate use of antimicrobials leads to poor treatment choices and mismanagement of antimicrobials for their children. Social marketing (SM) strategies have the potential to help parents access useful information on the appropriate use of antimicrobials. Still, its application in interventions targeting antimicrobial/antibiotic resistance awareness is minimal. This study explores the use of SM in antimicrobial/antibiotic awareness campaigns (AACs) to identify opportunities for SM approaches in developing future communication interventions targeting parents and children. We conduct a systematic review of interventions targeting parents and children between 2000 and 2022. Articles meeting the selection criteria were assessed against social marketing benchmark criteria (SMBC). We identified 6978 original records, 16 of which were included in the final review. None of the articles explicitly identified SM as part of their interventions. Twelve interventions (75%) included 1 to 4 (out of 8) benchmark criteria, while four (25%) had 5-8 benchmarks in their interventions. Of the interventions with less than four benchmark criteria, six studies (50%) reported a positive effect direction outcome, and six studies (50%) reported negative/no change direction on the outcome of interests. Meanwhile, all interventions with five or more SMBC resulted in a positive effect direction in their outcomes. In this review, the use of SM has shown promising results, indicating opportunities for future antimicrobial resistance (AMR) interventions that incorporate social marketing benchmark criteria to improve intervention outcomes.

Old Folks, Bad Boon: Antimicrobial Resistance in the Infant Gut Microbiome

The development of the intestinal microbiome in the neonate starts, mainly, at birth, when the infant receives its founding microbial inoculum from the mother. This microbiome contains genes conferring resistance to antibiotics since these are found in some of the microorganisms present in the intestine. Similarly to microbiota composition, the possession of antibiotic resistance genes is affected by different perinatal factors. Moreover, antibiotics are the most used drugs in early life, and the use of antibiotics in pediatrics covers a wide variety of possibilities and treatment options. The disruption in the early microbiota caused by antibiotics may be of great relevance, not just because it may limit colonization by beneficial microorganisms and increase that of potential pathogens, but also because it may increase the levels of antibiotic resistance genes. The increase in antibiotic-resistant microorganisms is one of the major public health threats that humanity has to face and, therefore, understanding the factors that determine the development of the resistome in early life is of relevance. Recent advancements in sequencing technologies have enabled the study of the microbiota and the resistome at unprecedent levels. These aspects are discussed in this review as well as some potential interventions aimed at reducing the possession of resistance genes.

Antimicrobial Resistance Genes (ARGs), the Gut Microbiome, and Infant Nutrition

The spread of antimicrobial resistance genes (ARGs) is a major public health crisis, with the ongoing spread of ARGs leading to reduced efficacy of antibiotic treatments. The gut microbiome is a key reservoir for ARGs, and because diet shapes the gut microbiome, diet also has the potential to shape the resistome. This diet-gut microbiome-resistome relationship may also be important in infants and young children. This narrative review examines what is known about the interaction between the infant gut microbiome, the infant resistome, and infant nutrition, including exploring the potential of diet to mitigate infant ARG carriage. While more research is needed, diet has the potential to reduce infant and toddler carriage of ARGs, an important goal as part of maintaining the efficacy of available antibiotics and preserving infant and toddler health.

Routine antibiotics for infants less than 6 months of age with growth failure/faltering: a systematic review

OBJECTIVE

This systematic review commissioned by WHO aimed to synthesise evidence from current literature on the effects of systematically given, routine use of antibiotics for infants under 6 months of age with growth failure/faltering.

SETTINGS

Low-income and middle-income countries.

PARTICIPANTS

The study population was infants less than 6 months of age with growth failure/faltering.

INTERVENTION

The intervention group was infants who received no antibiotics or antibiotics other than those recommended in 2013 guidelines by WHO to treat childhood severe acute malnutrition. The comparison group was infants who received antibiotics according to the aforementioned guidelines.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was all-cause mortality, and secondary outcomes: clinical deterioration, antimicrobial resistance, recovery from comorbidity, adverse events, markers of intestinal inflammation, markers of systemic inflammation, hospital-acquired infections and non-response. The Grading of Recommendations Assessment, Development and Evaluation approach was considered to report the overall evidence quality for an outcome.

RESULTS

We screened 5137 titles and abstracts and reviewed the full text of 157 studies. None of the studies from the literature search qualified to answer the question for this systematic review.

CONCLUSIONS

There is a paucity of evidence on the routine use of antibiotics for the treatment of malnutrition in infants less than 6 months of age. Future studies with adequate sample sizes are needed to assess the potential risks and benefits of antibiotics in malnourished infants under 6 months of age.

PROSPERO REGISTRATION NUMBER

CRD42021277073.

Psychological and cultural factors influencing antibiotic prescription

Humans have inundated the environment worldwide with antimicrobials for about one century, giving selective advantage to antibiotic-resistant bacteria. Therefore, antibiotic resistance has become a public health problem responsible for increased mortality and extended hospital stays because the efficacy of antibiotics has diminished. Hospitals and other clinical settings have implemented stewardship measures to reduce antibiotic administration and prescription. However, these measures demand multifactorial approaches, including multidisciplinary teams in clinical settings and the education of professionals and patients. Recent studies indicate that individual factors, such as mother-infant attachment and parenting styles, play a critical role in antibiotic use. Also, macrocontextual factors, such as economic, social, or cultural backgrounds, may impact antibiotic use rates. Therefore, research aiming to ameliorate stewardship measures must include psychologically and sociologically based research.

Impact of antibiotics on off-target infant gut microbiota and resistance genes in cohort studies

BACKGROUND

Young children are frequently exposed to antibiotics, with the potential for collateral consequences to the gut microbiome. The impact of antibiotic exposures to off-target microbes (i.e., bacteria not targeted by treatment) and antibiotic resistance genes (ARGs) is poorly understood.

METHODS

We used metagenomic sequencing data from paired stool samples collected prior to antibiotic exposure and at 1 year from over 200 infants and a difference-in-differences approach to assess the relationship between subsequent exposures and the abundance or compositional diversity of microbes and ARGs while adjusting for covariates.

RESULTS

By 1 year, the abundance of multiple species and ARGs differed by antibiotic exposure. Compared to infants never exposed to antibiotics, Bacteroides vulgatus relative abundance increased by 1.72% (95% CI: 0.19, 3.24) while Bacteroides fragilis decreased by 1.56% (95% CI: -4.32, 1.21). Bifidobacterium species also exhibited opposing trends. ARGs associated with exposure included class A beta-lactamase gene CfxA6. Among infants attending day care, Escherichia coli and ARG abundance were both positively associated with antibiotic use.

CONCLUSION

Novel findings, including the importance of day care attendance, were identified through considering microbiome data at baseline and post-intervention. Thus, our study design and approach have important implications for future studies evaluating the unintended impacts of antibiotics.

IMPACT

The impact of antibiotic exposure to off-target microbes and antibiotic resistance genes in the gut is poorly defined. We quantified these impacts in two cohort studies using a difference-in-differences approach. Novel to microbiome studies, we used pre/post-antibiotic data to emulate a randomized controlled trial. Compared to infants unexposed to antibiotics between baseline and 1 year, the relative abundance of multiple off-target species and antibiotic resistance genes was altered. Infants who attended day care and were exposed to antibiotics within the first year had a higher abundance of Escherichia coli and antibiotic resistance genes; a novel finding warranting further investigation.

Protocol for a systematic review on routine use of antibiotics for infants less than 6 months of age with growth failure/faltering

INTRODUCTION

Antibiotics have been used as an adjunct in treating children with severe acute malnutrition 6-59 months of age; however, the data for infants less than 6 months are scarce. The WHO recently started guideline development for preventing and treating wasting, including growth failure/faltering in infants less than 6 months. This systematic review commissioned by WHO aims to synthesise evidence from current literature on the effectiveness of antibiotics for infants less than 6 months of age with growth failure/faltering.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis for studies that assessed the effect of antibiotics in the treatment of infants with growth faltering. We will search multiple electronic databases. We will include randomised control trials and non-randomised studies with a control arm. The study population is infants less than 6 months of age with growth failure. The intervention group will be infants who received no antibiotics or antibiotics other than recommended in 2013 guidelines by WHO to treat severe acute malnutrition in children. The comparison group will be infants who received antibiotics according to the 2013 guideline by WHO. We will consider the following outcomes: mortality, clinical deterioration, antimicrobial resistance, recovery from comorbidity, adverse events, markers of intestinal inflammation, markers of systemic inflammation, hospital-acquired infections, non-response. We will use the meta-analysis to pool the studies where applicable. We will use the Grading of Recommendations Assessment, Development, and Evaluation approach to reporting the overall evidence quality for an outcome.

ETHICS AND DISSEMINATION

This is a systematic review and will not involve contact with a human subject. The findings of this review will be published in a peer-review journal and will guide the WHO's recommendation for the use of antibiotics in infants less than 6 months of age with growth failure.

PROSPERO REGISTRATION NUMBER

CRD42021277073.

Immune function in newborns with in-utero exposure to anti-TNFα therapy

BACKGROUND AND AIM

Anti-TNFα is measurable in infants exposed in utero up to 12 months of age. Data about the exposure effect on the infant's adaptive immunity are limited. We aimed to prospectively evaluate the distribution and function of T and B cells, in infants of females with inflammatory bowel disease, in utero exposed to anti-TNFα or azathioprine.

METHODS

A prospective multi-center study conducted 2014-2017. Anti-TNFα levels were measured in cord blood, and at 3 and 12 months. T-cell repertoire and function were analyzed at 3 and 12 months by flow-cytometry, expression of diverse T cell receptors (TCR) and T-cell receptor excision circles (TREC) quantification assay. Serum immunoglobulins and antibodies for inactivated vaccines were measured at 12 months. Baseline clinical data were retrieved, and 2-monthly telephonic interviews were performed regarding child infections and growth.

RESULTS

24 pregnant females, age 30.6 (IQR 26.5-34.5) years were recruited, 20 with anti-TNFα (infliximab 8, adalimumab 12), and 4 with azathioprine treatment. Cord blood anti-TNFα was higher than maternal blood levels [4.3 (IQR 2.3-9.2) vs. 2.5 (IQR 1.3-9.7) mcg/ml], declining at 3 and 12 months. All infants had normal number of B-cells (n = 17), adequate levels of immunoglobulins (n = 14), and protecting antibody levels to Tetanus, Diphtheria, Hemophilus influenza-B and hepatitis B (n = 17). All had normal CD4+, CD8+ T-cells, and TREC numbers. TCR repertoire was polyclonal in 18/20 and slightly skewed in 2/20 infants. No serious infections requiring hospitalization were recorded.

CONCLUSION

We found that T-cell and B-cell immunity is fully mature and immune function is normal in infants exposed in utero to anti-TNFα, as in those exposed to azathioprine. Untreated controls and large-scale studies are needed to confirm these results.

OUP accepted manuscript

Objectives

To investigate whether infants exposed to antimicrobials in hospital during the first 3 months of life had an increased risk of ambulatory antimicrobial use during the following year compared with infants not exposed to antimicrobials during the first 3 months of life.

Methods

Norwegian cohort study of infants less than 3 months consisting of one group exposed to antimicrobials recruited during hospitalization and one group not exposed to antimicrobials. Ten unexposed infants were matched with one exposed infant according to county of residence, birth year and month, and sex. The Norwegian Prescription Database was applied to register antimicrobial use from the month after discharge and 1 year onward. We defined comorbidity based on antimicrobials prescribed as reimbursable prescriptions due to underlying diseases.

Results

Of 95 infants exposed to antimicrobials during the first 3 months of life, 23% had recurrent use compared with 14% use in 950 unexposed infants [relative risk (RR) = 1.7 (95% CI = 1.1–2.5) and comorbidity-adjusted RR = 1.4 (95% CI = 0.9–2.2)]. The recurrence use rate in exposed term infants (≥37 weeks, n = 70) was 27% compared with 12% in their unexposed matches [RR 2.3 = (95% CI = 1.4–3.7) and comorbidity-adjusted RR = 1.9 (95% CI = 1.2–3.2). Of 25 exposed preterm infants, 3 (12%) had recurrent use. The total antimicrobial prescription rate was 674/1000 in the exposed group and 244/1000 in the unexposed group [incidence rate ratio = 2.8 (95% CI = 1.6–4.9)].

Conclusions

Infants exposed to antimicrobials during the first 3 months of life had an increased risk of recurrent use during the following year. This increased risk also appeared in term infants without infection-related comorbidity.

The association between early life antibiotic exposure and the gut resistome of young children: a systematic review

Antimicrobial resistance is a growing public health burden, but little is known about the effects of antibiotic exposure on the gut resistome. As childhood (0-5 years) represents a sensitive window of microbiome development and a time of relatively high antibiotic use, the aims of this systematic review were to evaluate the effects of antibiotic exposure on the gut resistome of young children and identify knowledge gaps. We searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials. A PICO framework was developed to determine eligibility criteria. Our main outcomes were the mean or median difference in overall resistance gene load and resistome alpha diversity by antibiotic exposure groups. Bias assessment was completed using RoB 2 and ROBINS-I with quality of evidence assessed via the GRADE criteria. From 4885 records identified, 14 studies (3 randomized controlled trials and 11 observational studies) were included in the qualitative review. Eight studies that included information on antibiotic exposure and overall resistance gene load reported no or positive associations. Inconsistent associations were identified for the nine studies that assessed resistome alpha diversity. We identified three main groups of studies based on study design, location, participants, antibiotic exposures, and indication for antibiotics. Overall, the quality of evidence for our main outcomes was rated low or very low, mainly due to potential bias from the selective of reporting results and confounding. We found evidence that antibiotic exposure is associated with changes to the overall gut resistance gene load of children and may influence the diversity of antimicrobial resistance genes. Given the overall quality of the studies, more research is needed to assess how antibiotics impact the resistome of other populations. Nonetheless, this evidence indicates that the gut resistome is worthwhile to consider for antibiotic prescribing practices.

Model Based Evaluation of Hypersensitivity Adverse Drug Reactions to Antimicrobial Agents in Children

Drug use in children is-in most cases-supported by extrapolation of data generated from clinical trials in adult populations. This puts children at higher risk of developing adverse drug reactions (ADRs) due to "off-label" use of drugs and dosing issues. Major types of ADRs are drug hypersensitivity reactions, an idiosyncratic type of ADRs that are largely unpredictable and can cause high morbidity and mortality in a hard-to-identify specific population of patients. Lack of a complete understanding of the pathophysiology of DHRs and their unpredictive nature make them problematic in clinical practice and in drug development. In addition, ethical and legal obstacles hinder conducting large clinical trials in children, which in turn make children a "therapeutic orphan" where clear clinical guidelines are lacking, and practice is based largely on the personal experience of the clinician, hence making modeling desirable. This brief review summarizes the current knowledge of model-based evaluation of diagnosis and management of drug hypersensitivity reactions (DHRs) to antimicrobial drugs in the pediatric population. Ethical and legal aspects of drug research in children and the effect of different stages of child development and other factors on the risk of DHRs are discussed. The role of animal models, in vitro models and oral provocation test in management of DHRs are examined in the context of the current understanding of the pathophysiology of DHRs. Finally, recent changes in drug development legislations have been put forward to encourage drug developers to conduct trials in children clearly indicate the urgent need for evidence to support drug safety in children and for modeling to guide these clinical trials.

Risk factor analysis of allergic rhinitis in 6-8 year-old children in Taipei

The incidence of allergic rhinitis (AR) has increased rapidly in Taiwan during the past 30 years; however, potential risk factors of AR have yet to be examined. The purpose of this study is to explore the prevalence, personal and environmental risk factors of rhinitis. A cross-sectional survey was conducted in 26418 first graders (6–8 years old) in Taipei with a response rate of 94.6% (24999/26418). Modified International Study of Asthma and Allergies in Childhood (ISAAC) questionnaires were completed by their parents or main caregivers. Logistic regression was used to examine possible personal and environmental (in early life and current) factors related to rhinitis. The prevalence of rhinitis in the past 12 months was 42.8% in 6–8 years old children. Multivariate logistic regression analysis for both males and females revealed that male gender, antibiotic use in first year of life, bronchiolitis before the age of two years, diagnosed asthma, and diagnosed eczema, having a cat the first year of life were associated with an increased risk of rhinitis. Having older siblings, on the other hand, may reduce the risk of rhinitis. Based on the present study, we may recommend less use of antibiotics the first year of life and not having a cat in the home in the child’s first year of life as preventive measures to reduce the risk of rhinitis. From the subgroup analysis, we can take preventive measures for the different risk factors of rhinitis and the severity of rhinitis in each subgroup.

Respiratory Tract Infection Management and Antibiotic Prescription in Children: A Unique Study Comparing Three Levels of Healthcare in The Netherlands

BACKGROUND

Respiratory tract infections (RTIs) are common in children with febrile illness visiting the general practitioner (GP) or emergency department. We studied the management of children with fever and RTI at 3 different levels of healthcare in The Netherlands, focusing on antibiotic prescription.

METHODS

This prospective observational study is part of the Management and Outcome of Febrile children in Europe study. Data were used from face-to-face patient contacts of children with febrile illness in three healthcare settings in Nijmegen, The Netherlands during 2017. These settings were primary (GP), secondary (general hospital) and tertiary care (university hospital).

RESULTS

Of 892 cases with RTI without complex comorbidities, overall antibiotic prescription rates were 29% with no differences between the 3 levels of healthcare, leading to an absolute number of 5031 prescriptions per 100,000 children per year in primary care compared with 146 in secondary and tertiary care combined. The prescription rate in otitis media was similar in all levels: 60%. In cases with lower RTI who received nebulizations prescription rates varied between 19% and 55%.

CONCLUSIONS

Antibiotic prescription rates for RTIs in children were comparable between the 3 levels of healthcare, thus leading to a majority of antibiotics being prescribed in primary care. Relatively high prescription rates for all foci of RTIs were found, which was not in agreement with the national guidelines. Antibiotic stewardship needs improvement at all 3 levels of healthcare. Guidelines to prescribe small spectrum antibiotics for RTIs need to be better implemented in hospital care settings.

Lifetime antimicrobial use is associated with weight status in early adolescence-A register-based cohort study

BACKGROUND

Antimicrobial agents (AMs) are the most prescribed drugs to children. Early and repeated exposure to AMs in infancy is associated with increased risk of childhood overweight and obesity.

AIMS

We extended the investigation of AMs use, from birth to early adolescence, and evaluated their association with weight status.

MATERIALS & METHODS

A total of 10093 children from Finnish Health in Teens cohort (Fin-HIT) with register-based data on AMs purchases and measured weight status at the mean age of 11.2 y (SD 0.82) were included in the study. The key exposures were the number AM purchases at a given age or the sum of these during the entire follow-up time to describe lifetime exposure / use. Outcome was weight status in early adolescence defined with International Obesity Task Force cut-offs for the age- and sex-specific body mass index. Odds Ratio (OR) and 95% confidence intervals (CI) were estimated using Multinomial Logistic Regression.

RESULTS

Of children, 73.7% were normal weight, 11.1% thin and 15.2% overweight/obese. AMs use was highest during the second year of life, when 65% of all children used AMs, but thereafter decreased with age. The highest mean purchases and prevalence at any given age along with the highest lifetime use were consistently seen among overweight children. Each episode of AMs use throughout life increased the risk of being overweight in adolescence [OR = 1.02 (1.02-1.03)]. However, there was an inverse association between AMs use and thinness [OR = 0.98 (0.97-0.99)].

DISCUSSION

Despite a high prevalence of AMs use during the early years, lifetime-use was associated with weight status in early adolescence in a dose response manner.

CONCLUSION

Future studies should address mechanisms underlying the relationship between AM use and weight.

Marked reductions in outpatient antibiotic prescriptions for children and adolescents - a population-based study covering 83% of the paediatric population, Germany, 2010 to 2018

BackgroundPrescribing of systemic antibiotics in general and of cephalosporins in particular in German paediatric outpatients has previously been reported to be higher than in other European countries.AimOur objective was to assess recent trends in antibiotic prescribing in German children.MethodsThis study was conducted as consecutive annual cross-sectional analyses and included all children aged 0-14 years (n = 9,389,183 in 2018) covered by statutory health insurance in Germany. Annual antibiotic prescription rates from 2010 to 2018 were calculated for the age groups 0-1, 2-5, 6-9 and 10-14 years. Poisson regression was used to estimate trends of prescription rates by age group and antibiotic subgroup.ResultsOverall, the age-standardised antibiotic prescription rate decreased significantly by 43% from 746 prescriptions per 1,000 persons in 2010 to 428 per 1,000 in 2018 (p < 0.001). Reductions were most pronounced in the age groups 0-1 year (-50%) and 2-5 years (-44%). The age group 2-5 years exhibited the highest prescription rate with 683 per 1,000 in 2018 (0-1 year: 320/1,000; 6-9 years: 417/1,000; 10-14 years: 273/1,000). Cephalosporins (second and third generation) accounted for 32% of prescribed antibiotics.ConclusionsMarked reductions in antibiotic prescribing during the last decade indicate a change towards more judicious paediatric prescribing habits. Compared with other European countries, however, prescribing of second- and third-generation cephalosporins remains high in Germany, suggesting frequent first-line use of these substances for common respiratory infections. Considerable regional variations underline the need for regionally targeted interventions.

Antibiotic use for Australian Aboriginal children in three remote Northern Territory communities

OBJECTIVE

To describe antibiotic prescription rates for Australian Aboriginal children aged <2 years living in three remote Northern Territory communities.

DESIGN

A retrospective cohort study using electronic health records.

SETTING

Three primary health care centres located in the Katherine East region.

PARTICIPANTS

Consent was obtained from 149 mothers to extract data from 196 child records. There were 124 children born between January 2010 and July 2014 who resided in one of the three chosen communities and had electronic health records for their first two years of life.

MAIN OUTCOME MEASURES

Antibiotic prescription rates, factors associated with antibiotic prescription and factors associated with appropriate antibiotic prescription.

RESULTS

There were 5,675 Primary Health Care (PHC) encounters for 124 children (median 41, IQR 25.5, 64). Of the 5,675 PHC encounters, 1,542 (27%) recorded at least one infection (total 1,777) and 1,330 (23%) had at least one antibiotic prescription recorded (total 1,468). Children had a median five (IQR 2, 9) prescriptions in both their first and second year of life, with a prescription rate of 5.99/person year (95% CI 5.35, 6.63). Acute otitis media was the most common infection (683 records, 38%) and Amoxycillin was the most commonly prescribed antibiotic (797 prescriptions, 54%). Of the 1,468 recorded prescriptions, 398 (27%) had no infection recorded and 116 (8%) with an infection recorded were not aligned with local treatment guidelines.

CONCLUSION

Prescription rates for Australian Aboriginal children in these communities are significantly higher than that reported nationally for non-Aboriginal Australians. Prescriptions predominantly aligned with treatment guidelines in this setting where there is a high burden of infectious disease.

Survey of antibiotic use among hospitalised children in a hospital in Northeast China over a 4-year period

PURPOSE

We investigated the usage of antibiotic utilisation rate (AUR) among Chinese hospitalised children over a 4-year period to determine clinical characteristics.

DESIGN AND METHODS

AUR, antibiotic type and antibiotic use in combination were analysed among hospitalised children of the affiliated hospital of Beihua University in Northeast China from January 2015 to December 2018. The linear prediction was used to investigate the trends of antibiotics use in combination and AUR, and autoregressive integrated moving average model was used to predict AUR in 2019.

RESULTS

A total of 2,981 inpatients were admitted to the hospital during the study period. The AUR from 2015 to 2018 was 91.51%, 92.67%, 91.30%, and 93.00%, respectively. AUR was associated with season (p < .01), the peak period was found to be from November to January in 2019 (R²  = 0.802). The etiological delivery rate had increased (p < .01). Pneumonia was the main disease in children for which they received antibiotics. The combination of multidrug (≥3 agents used) had increased (p < .01) over the study period.

PRACTICE IMPLICATIONS

AUR was stable among hospitalised children in a hospital. Cephalosporin and macrolide antibiotics were the main antibiotic types, and the combination of multidrug had increased, more attention should be paid to the use of antibiotics in hospitalised children.

Antimicrobial use in an Indonesian community cohort 0-18 months of age

BACKGROUND

Antimicrobial resistance has become a global health emergency and is contributed to by inappropriate antibiotic use in community clinical settings. The aim of this study was to evaluate the antimicrobial use pattern in infants from birth until 18 months of age in Indonesia.

METHODS

A post-hoc analysis was conducted in 1621 participants from the RV3BB Phase IIb trial conducted in Indonesia from January 2013 through July 2016. Any health events were documented in the trial as adverse events. Concomitant medication surveillance recorded all medications, including antibiotics during the 18 months of follow-up. Information included the frequency, duration of usage, formulation, classes, and their indications, including prophylactic antibiotic and perinatal use.

RESULTS

Of 1621 participants, 551 (33.99%) received at least one antibiotic for treatment of infections during the 18 months observation period. Additionally, during the perinatal period, prophylactic antibiotics were used in 1244 (76.74%) participants and antibiotics consumed in 235 mothers of participants (14.50%). A total of 956 antibiotic consumptions were recorded for 18 months follow up, 67 (7.01%) as part of antimicrobial combinations. The average duration of antibiotic course was 4.92 days. Penicillin and sulfonamides were the most common antibiotic classes consumed (38.81% and 24.48%, respectively).

CONCLUSIONS

Despite the low community consumption rate, the overuse of antibiotic in URTIs and non-bloody diarrhea in our setting represents a major opportunity for antimicrobial stewardship, particularly in early life.

What Can We Do About Antimicrobial Resistance?

Antimicrobial resistance is of global concern, and preserving the ability of many antimicrobials to kill disease-causing bacteria is likely to become more challenging over time. However, we are speeding up this process dramatically by using antibiotics too much or in the wrong way. Respecting simple key principles of optimal antibiotic prescribing together with commitment to further research in this area from the pediatric community is essential to extend the lifeline of antibiotics for the most vulnerable patients without limiting access to antibiotics for those children who require treatment.

Early childhood antibiotics use and autism spectrum disorders: a population-based cohort study

Background

Changes in microbiota composition as a result of antibiotics use in early life has been proposed as a possible contributor in the aetiology of autism spectrum disorders (ASD). We aimed to examine the association between early life antibiotic exposure and risk of ASD.

Methods

This was a population-based cohort study which included all live births in Manitoba, Canada, between 1 April 1998 and 31 March 2016. We used administrative health data from the Manitoba Population Research Data Repository. Exposure was defined as having filled one or more antibiotic prescription during the first year of life. The main outcome was ASD diagnosis. Cox proportional hazards regression models were used to estimate the risk of developing ASD in the overall population and in a sibling cohort.

Results

Of all subjects in the cohort (n = 214 834), 94 024 (43.8%) filled an antibiotic prescription during the first year of life. During follow-up, 2965 children received an ASD diagnosis. Compared with children who did not use antibiotics during the first year of life, those who received antibiotics had a reduced risk of ASD [adjusted hazardz ratio (HR) 0.91, 95% confidence interval (CI) 0.84-0.99). Number of treatment courses and cumulative duration of antibiotic exposure were not associated with ASD. In the sibling-controlled analysis, early life antibiotic exposure was not associated with ASD (adjusted HR 1.03, 95% CI 0.86-1.23).

Conclusions

Our findings suggested no clinically significant association between early life antibiotics exposure and risk of autism spectrum disorders, and should provide reassurance to concerned prescribers and parents.

The prevalence and risk factors of atopic dermatitis in 6-8 year-old first graders in Taipei

BACKGROUND

Despite the advance in the understanding of etiology, pathophysiology and diagnosis of atopic dermatitis (AD), its prevalence has increased annually in Taiwan.

PURPOSES

The purpose of this study is to explore the prevalence, and personal and environmental risk factors of AD.

METHODS

A cross-sectional survey was conducted via health centers of elementary schools in Taipei city. We used the Chinese version of ISAAC questionnaire to examine possible personal and environmental risk factors of AD. Questionnaires were completed by parents or guardians of first graders (6-8 year-old) who agreed to participate in this study. Logistic regression was conducted to examine possible personal and environmental factors related to AD (in early life and currently).

RESULTS

The 12-month prevalence of AD (in the past 12 months) was 10.7% (2683/24,999) among 6- to 8-year-old first graders in Taipei. Forty-five percent of first graders with AD had their first episode of AD symptoms before the age of two. Children with asthma history were 1.65 times (95% CI: 1.51-1.79, p < 0.001) and children with rhinitis were 2.57 times (95% CI: 2.34-2.84, p < 0.001) more likely to have AD than those without the conditions. Compare to their counterarts, children who used antibiotics during their first year of life (OR = 1.37, 95% CI: 1.22-1.53, p < 0.001) and who had bronchiolitis before the age of two (OR = 1.47, 95% CI: 1.33-1.63, p < 0.001) had a higher chance to have AD during the last 12 months of the study. However, receiving breastfeeding for less than 4 months (OR = 0.75, 95% CI: 0.67-0.83, p < 0.001) and having older siblings (OR = 0.83, 95% CI: 0.76-0.92, p < 0.001) had 25% and 17% reduced risks for AD in the 12 months before this study, respectively.

CONCLUSION

Our study verified personal and environmental risk factors of AD in children in Taiwan. Based on the results, we propose that avoiding bronchiolitis before the age of two, using antibiotics properly in babies, and providing diet counseling for breastfeeding mothers may be good prevention strategies of AD.

Prescription of Antibacterial Drugs for HIV-Exposed, Uninfected Infants, Malawi, 2004-2010

Antimicrobial drug resistance is a serious health hazard driven by overuse. Administration of antimicrobial drugs to HIV-exposed, uninfected infants, a population that is growing and at high risk for infection, is poorly studied. We therefore analyzed factors associated with antibacterial drug administration to HIV-exposed, uninfected infants during their first year of life. Our study population was 2,152 HIV-exposed, uninfected infants enrolled in the Breastfeeding, Antiretrovirals and Nutrition study in Lilongwe, Malawi, during 2004-2010. All infants were breastfed through 28 weeks of age. Antibacterial drugs were prescribed frequently (to 80% of infants), and most (67%) of the 5,329 prescriptions were for respiratory indications. Most commonly prescribed were penicillins (43%) and sulfonamides (23%). Factors associated with lower hazard for antibacterial drug prescription included receipt of cotrimoxazole preventive therapy, receipt of antiretroviral drugs, and increased age. Thus, cotrimoxazole preventive therapy may lead to fewer prescriptions for antibacterial drugs for these infants.

Outpatient antibiotic use in Dutch infants after 10-valent pneumococcal vaccine introduction: a time-series analysis

OBJECTIVE

This population-based cohort study assesses the impact of switching from a 7-valent pneumococcal conjugate vaccine (PCV) to a 10-valent PCV on outpatient antibiotic use in Dutch infants, and whether geographical vaccination coverage modifies this association.

SETTING AND PARTICIPANTS

We extracted 2006-2013 anonymised antibiotic purchase data of 255 154 Dutch infants aged below 2 years from Achmea Health, a health insurance fund covering 28% of the national population.

DESIGN AND MAIN OUTCOME MEASURE

Changes in monthly antibiotic use from 2006-2011 (PCV7) to 2011-2013 (PCV10) were estimated using time-series analysis accounting for seasonality and autocorrelation. Interaction terms for vaccination coverage (categorised into seven groups) and period were added to the model to test whether this association was vaccination coverage-dependent.

RESULTS

275 337 antibiotic courses were used by 119 078 infants (461 352 person-years). PCV10 introduction was associated with a modest 1.6% overall reduction in antibiotic use (purchase rate ratio: 0.98, 95% CI: 0.98 to 0.99). Our model showed a significant difference in time trend in antibiotic use after PCV10 introduction (p=0.0084) with an increase in prescriptions in the PCV7 period (slope: 0.0023/month, 95% CI: -0.0001 to 0.0047) versus a decline in the PCV10 period (slope: -0.0089/month, 95% CI: -0.0150 to -0.0029). There was no evidence that PCV vaccination coverage affected this association, but since the largest rate ratios were observed in municipalities with the lowest vaccine coverage and had very wide accompanying CIs, our study might have insufficient power to detect such an association.

CONCLUSIONS

Switching from PCV7 to PCV10 was associated with a modest decline in outpatient antibiotic use in Dutch infants.

Triclosan and triclocarban exposure, infectious disease symptoms and antibiotic prescription in infants-A community-based randomized intervention

Background

Triclosan and triclocarban (TCs) are broad-spectrum antimicrobials that, until recently, were found in a wide variety of household and personal wash products. Popular with consumers, TCs have not been shown to protect against infectious diseases.

Objectives

To determine whether use of TC-containing wash products reduces incidence of infection in children less than one year of age.

Methods

Starting in 2011, we nested a randomized intervention of wash products with and without TCs within a multiethnic birth cohort. Maternal reports of infectious disease symptoms and antibiotic use were collected weekly by automated survey; household visits occurred every four months. Antibiotic prescriptions were identified by medical chart review. Urinary triclosan levels were measured in a participant subset. Differences by intervention group in reported infectious disease (primary outcome) and antibiotic use (secondary outcome) were assessed using mixed effects logistic regression and Fisher’s Exact tests, respectively.

Results

Infectious illness occurred in 6% of weeks, with upper respiratory illness the predominant syndrome. Among 60 (45%) TC-exposed and 73 (55%) non-TC-exposed babies, infectious disease reports did not differ in frequency between groups (likelihood ratio test: p = 0.88). Medical visits with antibiotic prescriptions were less common in the TC group than in the non-TC group (7.8% vs. 16.6%, respectively; p = 0.02).

Conclusions

Although randomization to TC-containing wash products was not associated with decreased infectious disease reports by mothers, TCs were associated with decreased antibiotic prescriptions, suggesting a benefit against bacterial infection. The recent removal of TCs from consumer wash products makes further elucidation of benefits and risks impracticable.

Prevalence and determinants of antibiotic exposure in infants: A population-derived Australian birth cohort study

AIM

The aim of this study was to describe antibiotic exposure in Australian infants during the first year of life, focusing on antibiotic class, indication, risk factors associated with exposure and comparison with international counterparts.

METHODS

The Barwon Infant Study is a birth cohort study (n = 1074) with an unselected antenatal sampling frame from a large regional centre in Victoria, Australia. Longitudinal data on infection and medication were collected at 1, 3, 6, 9 and 12 months by parental questionnaire and from general practitioner and hospital records. Predictors of questionnaire non-completion were identified. A total of 660 infants with complete serial data were comprehensively examined. Antibiotic exposure was calculated as (i) antibiotic prescriptions and (ii) antibiotic days-exposed per person-year.

RESULTS

Mean antibiotic prescription rate was 0.92 prescriptions (95% confidence interval (CI), 0.83-1.02) per person-year, with the highest rates in those aged <1 month (1.50 (95% CI, 1.09-1.91) per person-year). A total of 50.0% of infants were exposed to at least one antibiotic in their first year of life. Increasing number of siblings was associated with increased antibiotic exposure. Penicillin with extended spectrum (365 of 661 antibiotic prescriptions, 52.6%) and cephalosporins (12.0%) were the most frequently prescribed antibiotics. One fifth of antibiotics were prescribed for respiratory tract infections and bronchiolitis.

CONCLUSION

Australian infants in this large population-based study are exposed to considerably more antibiotics than the majority of their international counterparts. Interventions aimed at addressing avoidable prescribing by medical practitioners and modifiable risk factors associated with antibiotic exposure may reduce antibiotic use.

Trends in Antibiotic Use by Birth Season and Birth Year

OBJECTIVES

We examined 2 birth cohort effects on antibiotic prescribing during the first year of life (henceforth, infancy) in Denmark: (1) the birth season effect on timing and overall occurrence of antibiotic prescribing, and (2) the birth year effect amid emerging nationwide pneumococcal vaccination programs and changing prescribing guidelines.

METHODS

We linked data for all live births in Denmark from 2004 to 2012 (N = 561 729) across the National Health Service Prescription Database, Medical Birth Registry, and Civil Registration System. Across birth season and birth year cohorts, we estimated 1-year risk, rate, and burden of redeemed antibiotic prescriptions during infancy. We used interrupted time series methods to assess prescribing trends across birth year cohorts. Graphical displays of all birth cohort effect data are included.

RESULTS

The 1-year risk of having at least 1 redeemed antibiotic prescription during infancy was 39.5% (99% confidence interval [CI]: 39.3% to 39.6%). The hazard of a first prescription increased with age throughout infancy and varied by season; subsequently, Kaplan-Meier-derived risk functions varied by birth season cohort. After rollout of a first vaccination program and new antibiotic prescribing guidelines, 1-year risk decreased by 4.4% over 14 months (99% CI: 3.4% to 5.5%); it decreased again after rollout of a second vaccination program by 6.9% over 3 years (99% CI: 4.4% to 9.3%).

CONCLUSIONS

In Denmark, birth season and birth year cohort effects influenced timing and risk of antibiotic prescribing during infancy. Future studies of antibiotic stewardship, effectiveness, and safety in children should consider these cohort effects, which may render some children inherently more susceptible than others to downstream antibiotic effects.

Antibiotic Use in Children - A Cross-National Analysis of 6 Countries

OBJECTIVES

To describe the rates of pediatric antibiotic use across 6 countries on 3 continents.

STUDY DESIGN

Cross-national analysis of 7 pediatric cohorts in 6 countries (Germany, Italy, South Korea, Norway, Spain, and the US) was performed for 2008-2012. Antibiotic dispensings were identified and grouped into subclasses. We calculated the rates of antimicrobial prescriptions per person-year specific to each age group, comparing the rates across different countries.

RESULTS

A total of 74 744 302 person-years from all participating centers were included in this analysis. Infants in South Korea had the highest rate of antimicrobial consumption, with 3.41 prescribed courses per child-year during the first 2 years of life. This compares with 1.6 in Lazio, Italy; 1.4 in Pedianet, Italy; 1.5 in Spain; 1.1 in the US; 1.0 in Germany; and 0.5 courses per child-year in Norway. Of antimicrobial prescriptions written in Norway, 64.8% were for first-line penicillins, compared with 38.2% in Germany, 31.8% in the US, 27.7% in Spain, 25.1% in the Italian Pedianet population, 9.8% in South Korea, and 8% in the Italian Lazio population.

CONCLUSIONS

We found substantial differences of up to 7.5-fold in pediatric antimicrobial use across several industrialized countries from Europe, Asia, and North America. These data reinforce the need to develop strategies to decrease the unnecessary use of antimicrobial agents.

The burden of community-managed acute respiratory infections in the first 2-years of life

BACKGROUND

Contemporary information on acute respiratory infections (ARIs) in children is based on hospital cohorts, primary healthcare presentations, and high-risk birth cohort studies. We describe the burden and determinants of symptomatic episodes of ARIs in unselected healthy infants in the first 2-years of life.

METHODS

One hundred and fifty-four infants from subtropical Brisbane, Australia participated in a longitudinal, community-based birth cohort study. A daily tick-box diary captured pre-defined respiratory symptoms. Parents also completed a burden diary, recording family physician and hospital visits, and antibiotic use.

RESULTS

Participants contributed 88,032 child-days (78.2% of expected), of which 17,316 (19.7%) days were symptomatic during 1,651 ARI episodes: incidence rate 0.56 ARIs per child-month (95%CI: 0.54, 0.59). Runny nose (14,220 days; 6.0-days median duration) and dry cough (6,880 days; 4.0-days median duration) were reported most frequently. Overall, 955 burden diaries recorded 455 family physician visits (1-8 visits per ARI) and 48 hospital presentations, including six hospital admissions. Antibiotics were prescribed on 209 occasions (21.9% of ARI episodes where burden diary submitted). Increasing age, non-summer seasons, and attendance at childcare were associated with an increased risk of ARI.

CONCLUSIONS

ARIs are a common cause of morbidity in the first 2-years of life, with children experiencing 13 discrete ARI episodes and almost 5-months of respiratory symptoms. Most ARIs are managed in the community by parents and family physicians. Antibiotic prescribing remains common for ARIs in young children. Secular societal changes, including greater use of childcare in early childhood, may have maintained the high ARI incidence in this age-group. Pediatr Pulmonol. 2016;51:1336-1346. © 2016 Wiley Periodicals, Inc.

Clostridium difficile infection in children: epidemiology and risk of recurrence in a low-prevalence country

Clostridium difficile infection (CDI) is increasingly found in children worldwide, but limited data are available from children living in southern Europe. A 6-year retrospective study was performed to investigate the epidemiology, clinical features, treatment, and risk of recurrence in Italy. Data of children with community- and hospital-acquired CDI (CA-CDI and HA-CDI, respectively) seen at seven pediatric referral centers in Italy were recorded retrospectively. Annual infection rates/10,000 hospital admissions were calculated. Logistic regression was used to investigate risk factors for recurrence. A total of 177 CDI episodes was reported in 148 children (83 males, median age 55.3 months), with a cumulative infection rate of 2.25/10,000 admissions, with no significant variability over time. The majority of children (60.8 %) had CA-CDI. Children with HA-CDI (39.2 %) had a longer duration of symptoms and hospitalization (p = 0.003) and a more common previous use of antibiotics (p = 0.0001). Metronidazole was used in 70.7 % of cases (87/123) and vancomycin in 29.3 % (36/123), with similar success rates. Recurrence occurred in 16 children (10.8 %), and 3 (2 %) of them presented a further treatment failure. The use of metronidazole was associated with a 5-fold increase in the risk of recurrence [odds ratio (OR) 5.18, 95 % confidence interval (CI) 1.1-23.8, p = 0.03]. Short bowel syndrome was the only underlying condition associated with treatment failure (OR 5.29, 95 % CI 1.17-23.8, p = 0.03). The incidence of pediatric CDI in Italy is low and substantially stable. In this setting, there is a limited risk of recurrence, which mainly concerns children treated with oral metronidazole and those with short bowel syndrome.

Antibiotic Prescriptions and Prophylaxis in Italian Children. Is It Time to Change? Data from the ARPEC Project

BACKGROUND

Antimicrobials are the most commonly prescribed drugs. Many studies have evaluated antibiotic prescriptions in the paediatric outpatient but few studies describing the real antibiotic consumption in Italian children's hospitals have been published. Point-prevalence survey (PPS) has been shown to be a simple, feasible and reliable standardized method for antimicrobials surveillance in children and neonates admitted to the hospital. In this paper, we presented data from a PPS on antimicrobial prescriptions carried out in 7 large Italian paediatric institutions.

METHODS

A 1-day PPS on antibiotic use in hospitalized neonates and children was performed in Italy between October and December 2012 as part of the Antibiotic Resistance and Prescribing in European Children project (ARPEC). Seven institutions in seven Italian cities were involved. The survey included all admitted patients less than 18 years of age present in the ward at 8:00 am on the day of the survey, who had at least one on-going antibiotic prescription. For all patients data about age, weight, underlying disease, antimicrobial agent, dose and indication for treatment were collected.

RESULTS

The PPS was performed in 61 wards within 7 Italian institutions. A total of 899 patients were eligible and 349 (38.9%) had an on-going prescription for one or more antibiotics, with variable rates among the hospitals (25.7% - 53.8%). We describe antibiotic prescriptions separately in neonates (<30 days old) and children (> = 30 days to <18 years old). In the neonatal cohort, 62.8% received antibiotics for prophylaxis and only 37.2% on those on antibiotics were treated for infection. Penicillins and aminoglycosides were the most prescribed antibiotic classes. In the paediatric cohort, 64.4% of patients were receiving antibiotics for treatment of infections and 35.5% for prophylaxis. Third generation cephalosporins and penicillin plus inhibitors were the top two antibiotic classes. The main reason for prescribing antibiotic therapy in children was lower respiratory tract infections (LRTI), followed by febrile neutropenia/fever in oncologic patients, while, in neonates, sepsis was the most common indication for treatment. Focusing on prescriptions for LRTI, 43.3% of patients were treated with 3rd generation cephalosporins, followed by macrolides (26.9%), quinolones (16.4%) and carbapenems (14.9%) and 50.1% of LRTI cases were receiving more than one antibiotic. For neutropenic fever/fever in oncologic patients, the preferred antibiotics were penicillins with inhibitors (47.8%), followed by carbapenems (34.8%), aminoglycosides (26.1%) and glycopeptides (26.1%). Overall, the 60.9% of patients were treated with a combination therapy.

CONCLUSIONS

Our study provides insight on the Italian situation in terms of antibiotic prescriptions in hospitalized neonates and children. An over-use of third generation cephalosporins both for prophylaxis and treatment was the most worrisome finding. A misuse and abuse of carbapenems and quinolones was also noted. Antibiotic stewardship programs should immediately identify feasible targets to monitor and modify the prescription patterns in children's hospital, also considering the continuous and alarming emergence of MDR bacteria.

[Pharmacist interventions on antibiotic prescriptions in outpatient pediatric unit in a teaching hospital of Côte d'Ivoire]

OBJECTIVES

The objectives of our study were to analyse the prescriptions of antibiotics and assessing the relevance of pharmacist interventions (PI) in outpatient consultations in a pediatric unit of a Teaching Hospital of Abidjan, Côte d'Ivoire.

METHODS

We conducted a cross-sectional descriptive study from May to December 2013. The analysis of antibiotic prescriptions was documented. The tool of PI classification validated by the French Society of Clinical Pharmacy was used. The PI rating was made by prescribers. This rating evolved from PI0 to PI3 depending on the severity of the clinical impact of the problem and to the severity of clinical consequences avoided by the PI. The relevance was evaluated by the PI acceptance rate by physicians and clinical evaluation of their impact.

RESULTS

Our study included 150 patients with a mean age of 11.75 months and a sex ratio (M/F) of 2. The amoxicillin-clavulanic acid (27.2 %) and amoxicillin (22.3 %) were the most prescribed antibiotics. Sixty-three drug-related problems (DRPs) were detected on the antibiotic prescriptions. They were non-optimal drug administration plan (88.9 %) and underdose (11.1 %). The amoxicillin-clavulanic acid (61.9 %) and josamycin (17.4 %) were the most affected by these DRPs. PI were related to the precision of modes of drug administration (88.9 %) and dose adjustments (11.1 %). The prescribers accepted 93.7 % of PIs. All accepted PIs was rated PI1 (significant clinical impact).

CONCLUSIONS

PIs performed on antibiotic prescription were relevant with a high rate of acceptance and a significant clinical impact.

Prevalence of antibiotic use for pediatric acute upper respiratory tract infections in Korea

This study was conducted to estimate the prevalence of antimicrobial prescribing for acute upper respiratory tract infections (URI) among pediatric outpatients and to identify the national patterns of its use from 2009 to 2011 in Korea. Using National Patients Sample database from 2009 to 2011, we estimated the frequency of antibiotics prescribing for URI in pediatric outpatients with diagnoses of acute nasopharyngitis (common cold), acute sinusitis, acute pharyngitis, acute tonsillitis, acute laryngitis/tracheitis, acute obstructive laryngitis/epiglottitis, and acute upper respiratory infections of multiple and unspecified sites. The proportions of each antibiotic class were calculated by year and absolute and relative differences were estimated. Also, we investigated daily amount of prescribed antibiotics per defined population according to the type of medical care institution, physician specialty, and geographic region. The overall antibiotic prescribing proportion was 58.7% and its annual proportion slightly decreased (55.4% in 2011 vs. 60.5% in 2009; adjusted odds ratio, 0.82; 95% confidence interval, 0.82-0.83). Variations by the type of medical care institution were observed. Tertiary hospitals (45.0%) were less likely to prescribe antibiotics than primary care clinics (59.4%), hospitals (59.0%), and general hospitals (61.2%); they showed different tendencies in choosing antibiotics. Variations by physician specialty and region were also observed. Prevalence of antimicrobial prescribing for pediatric URI is still considered higher than that of western countries and varies by the type of medical care institution, physician specialty, and geographic region.

Parent-reported symptoms of acute otitis media during the first year of life: what is beneath the surface?

Background

Most estimates of the incidence of acute otitis media (AOM) are based on general practitioner (GP) or pediatrician diagnoses. It is likely that these figures underestimate the community incidence of AOM since parents do not visit their doctor every time their child suffers from acute ear symptoms. The impact of these symptom episodes may be substantial since they affect the child’s quality of life and parents’ productivity.

Methods

To determine AOM symptoms in the community, we measured parent-reported AOM symptoms daily for 12 consecutive months in 1,260 children participating in a prospective birth cohort in the Netherlands. The mean age of these children was at study enrollment 0.9 months (standard deviation 0.6). A parent-reported AOM symptom episode was defined as fever (temperature 38˚C or above) plus at least one of the following symptoms: ear pain and ear discharge. These febrile AOM symptom episodes were linked to GP-consultations and diagnoses in the GP electronic health records.

Results

With an estimated 624 parent-reported symptom episodes per 1,000 child-years (95% CI: 577 to 674) incidence of febrile AOM symptoms during the child’s first year is high. The GP was consulted in half of these symptom episodes and AOM was diagnosed in 49% of these consultations.

Conclusions and Relevance

The incidence of febrile AOM symptoms in the first year of life is high in Dutch children and leads to a GP-consultation in only half of the cases. This suggests that AOM symptomatology in the community is underestimated when focusing on GP-diagnosed AOM episodes alone, since a considerable proportion of febrile AOM symptom episodes are treated symptomatically by parents at home and do not come to the attention of the GP. Having data on community AOM symptomatology available for each country is important when the potential impact of preventive and therapeutic interventions for AOM are studied.

Infant antibiotic exposure and the development of childhood overweight and central adiposity

BACKGROUND

Obesity has been associated with disruption of the gut microbiota, which is established during infancy and vulnerable to disruption by antibiotics.

OBJECTIVES

To investigate the association between early-life antibiotic exposure and subsequent development of overweight and central adiposity.

METHODS

Provincial health-care records were linked to clinical and survey data from a Canadian longitudinal birth cohort study. Antibiotic exposure during the first year of life was documented from prescription records. Overweight and central adiposity were determined from anthropometric measurements at ages 9 (n=616) and 12 (n=431). Associations were determined by multiple logistic regression.

RESULTS

Infants receiving antibiotics in the first year of life were more likely to be overweight later in childhood compared with those who were unexposed (32.4 versus 18.2% at age 12, P=0.002). Following adjustment for birth weight, breastfeeding, maternal overweight and other potential confounders, this association persisted in boys (aOR 5.35, 95% confidence interval (CI) 1.94-14.72) but not in girls (aOR 1.13, CI 0.46-2.81). Similar gender-specific associations were found for overweight at age 9 (aOR 2.19, CI 1.06-4.54 for boys; aOR 1.20, CI 0.53-2.70 for girls) and for high central adiposity at age 12 (aOR 2.85, CI 1.24-6.51 for boys; aOR 1.59, CI 0.68-3.68 for girls).

CONCLUSIONS

Among boys, antibiotic exposure during the first year of life was associated with an increased risk of overweight and central adiposity in preadolescence, indicating that antibiotic stewardship is particularly important during infancy. Given the current epidemic of childhood obesity and the high prevalence of infant antibiotic exposure, further studies are necessary to determine the mechanisms underlying this association, to identify the long-term health consequences, and to develop strategies for mitigating these effects when antibiotic exposure cannot be avoided.

Paediatric drug use with focus on off-label prescriptions in Lombardy and implications for therapeutic approaches

The persistent lack of information on the paediatric use of most medicinal products is a major hindrance towards an optimal treatment of paediatric patients. Several studies have documented the high prevalence of off-label use in paediatric population. No comprehensive studies, however, exist that analyse in full all prescriptions for all dispensed drugs, especially in view of the recent intervention by the European Medicine Agency to tackle this issue. We have assessed the drug prescription pattern in the paediatric outpatient population of Lombardy, which has a reliable record of such prescriptions focusing on off-label drug use. We analysed all dispensed outpatient prescriptions to children aged 0-18 years and the proportion of off-label drug use in 2011, using data from the regional administrative prescriptions database. A total of 4,027,119 prescriptions were dispensed, of which 133,619 (3.3 %) were off-label. The anatomical therapeutic chemical classes most involved in off-label prescriptions were antibiotics for systemic use (33,629), alimentary tract and metabolism (31,739) and respiratory tract (31,458). The highest rate (8 %) of off-label drug prescriptions was observed in the age range 0-1. The study revealed also an inappropriate prescription pattern for fluoroquinolones and drugs targeting the cardiovascular and musculoskeletal systems. We identified inappropriate prescriptions for specific drug classes, highlighting the need of increasing pharmacological studies in the paediatric patients and specific critical drugs/drug classes in which such studies are particularly urgent. Depending on the region, inappropriate paediatric drug prescriptions may affect different drug classes, indicating the need of tailoring specific programmes of information.