Antibiotic prescription preferences in paediatric outpatient setting in Estonia and Sweden

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.

Factors associated with inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries: a systematic review and meta-analysis

BACKGROUND

Acutely ill children are at risk of unwarranted antibiotic prescribing. Data on the appropriateness of antibiotic prescriptions provide insights into potential tailored interventions to promote antibiotic stewardship.

OBJECTIVES

To examine factors associated with the inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries.

METHODS

On 8 September 2022, we systematically searched articles published since 2002 in MEDLINE, Embase, CENTRAL, Web of Science, and grey literature databases. We included studies with acutely ill children presenting to ambulatory care settings in high-income countries reporting on the appropriateness of antibiotic prescriptions. The quality of the studies was evaluated using the Appraisal tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale. Pooled ORs were calculated using random-effects models. Meta-regression, sensitivity and subgroup analysis were also performed.

RESULTS

We included 40 articles reporting on 30 different factors and their association with inappropriate antibiotic prescribing. 'Appropriateness' covered a wide range of definitions. The following factors were associated with increased inappropriate antibiotic prescribing: acute otitis media diagnosis [pooled OR (95% CI): 2.02 (0.54-7.48)], GP [pooled OR (95% CI) 1.38 (1.00-1.89)] and rural setting [pooled OR (95% CI) 1.47 (1.08-2.02)]. Older patient age and a respiratory tract infection diagnosis have a tendency to be positively associated with inappropriate antibiotic prescribing, but pooling of studies was not possible.

CONCLUSIONS

Prioritizing acute otitis media, GPs, rural areas, older children and respiratory tract infections within antimicrobial stewardship programmes plays a vital role in promoting responsible antibiotic prescribing. The implementation of a standardized definition of appropriateness is essential to evaluate such programmes.

The risk of respiratory tract infections and antibiotic use in a general population and among people with asthma

Aim

The aim of this study was to investigate occupational, environmental, early life and other risk factors associated with respiratory infections and antibiotics use in a general population and among asthmatic individuals.

Method

This study included 15 842 participants of the Respiratory Health in Northern Europe (RHINE) study aged 25–54 years from five Nordic countries, who answered a questionnaire covering respiratory outcomes, exposures, demographic characteristics and numbers of infections and courses of antibiotics in the last 12 months. Multiple logistic regression with and without adjustment for age, sex, smoking status, body mass index and centre were used to study the risk of infection and antibiotics in relation to asthma, and also the association between infection and antibiotics and occupations.

Results

In the whole population, 11.6% reported having three or more respiratory infections, and 14.7% had used antibiotics because of respiratory tract infections within the last year. Asthmatic participants reported tripled odds for such infections (adjusted OR 2.98, 95% CI 2.53–3.52) and antibiotics use (adjusted OR 3.67, 95% CI 3.18–4.24) as compared to non-asthmatic participants. Both in the general and the asthmatic population, female sex, obesity and exposure to building dampness were associated with respiratory infections. Female sex and current smoking and living in Tartu were associated with antibiotic use. The use of antibiotics was doubled in people hospitalised for severe respiratory infection in childhood.

Conclusion

In this study we identified several factors associated with increased respiratory infections and use of antibiotics in a general population and among asthmatic individuals. The frequency of respiratory infections and subsequent antibiotic treatment were increased among those with asthma.

The main findings of this study are that asthmatics reported three times higher odds for respiratory tract infections and more than three times higher odds for subsequent antibiotics than subjects without asthmahttps://bit.ly/3hwsH67

Pattern and appropriateness of antibiotic prescriptions for upper respiratory tract infections in primary care paediatric patients

OBJECTIVES

The aim of this cross-sectional study was to investigate the pattern of antibiotic prescriptions for upper respiratory tract infections (URTIs) in children seen by primary care paediatricians (PCPs).

METHODS

Data were collected from face-to-face interviews administered to a sample of parents of outpatient children aged 0-14 years in two regions in Southern Italy. To be eligible, children had to be diagnosed with sinusitis, pharyngotonsillitis, otitis media, bronchitis, influenza or a common cold. The presence of an indication of antibiotic therapy was evaluated according to national and international guidelines.

RESULTS

An antibiotic prescription was indicated in 57 (10.1%) of the sampled patients, of whom 33.3% did not receive an antibiotic prescription; among the 508 patients for whom an antibiotic prescription was not indicated, 27.4% received a prescription. Of all PCP consultations, 72% were appropriate (an antibiotic was prescribed when indicated and not prescribed when not indicated), whilst an antibiotic prescription not indicated by guidelines was given to 24.6% of the participants, and 3.4% of the sample did not receive an antibiotic prescription when indicated. The most frequently prescribed antibiotic was amoxicillin with clavulanic acid. A rapid microbiological examination was performed in two patients.

CONCLUSIONS

The study findings highlight a high rate of sub-optimal antibiotic therapeutic profile. Over-prescription of antibiotic therapy and the use of broad-spectrum molecules are widespread in children with URTIs. Antibiotic under-prescription, which may deprive paediatric patients of an effective treatment when indicated, also occurs.

Impact of antibiotic consumption on the carriage of antibiotic-resistant bacteria by school children

BACKGROUND

Antibiotic consumption in the paediatric population is one of the key drivers of the emergence and spread of antimicrobial resistance, which is a serious global threat to public health and clinical medicine. The aims of this study were to investigate systemic antibiotic consumption in school children and to assess the associations among antibiotic consumption, carriage rate and resistance of respiratory pathogens residing in the upper respiratory tract mucosa.

METHODS

In this prospective study, throat and nasopharyngeal swabs from 450 school children, 6-15 years of age (225 healthy children and 225 patients who were ambulatory treated for upper respiratory tract infection), were processed in 2014 in Rijeka, Croatia, and clinical data were obtained via a questionnaire.

RESULTS

In total, 17% of the children had consumed an antibiotic in the previous 6 months, including 7% of the healthy children and 27% of the acutely ill patients. The most commonly prescribed antibiotics were amoxicillin (26%), amoxicillin with clavulanic acid (26%) and macrolides (18%). Respiratory pathogens were more frequently isolated from children who had consumed an antibiotic in the previous 6 months [odds ratio (OR) 3.67, P < 0.001]. Antibiotic-resistant bacteria were also more frequent in children who had been exposed to antibiotics (OR 5.44, P < 0.001).

CONCLUSIONS

Penicillins are the most frequently used antibiotics among school children. The results of this study demonstrate that antibiotic consumption is linked with higher carriage rates and resistance rates of respiratory tract pathogens. Therefore, rational use of antibiotics could prevent the emergence and spread of resistant bacteria.

Antibiotic prescribing trends in a pediatric population in Lithuania in 2003-2012: Observational study

The purpose of this study was to determine the trends in consumption of antibiotics and evaluate the antibiotic prescription rates in the pediatric population in Lithuania during 2003 to 2012.A cross-sectional study. Data of systemic antibiotic use in pediatric population for outpatient treatment was derived from National Health Insurance Fund database. Consumption was expressed as WHO ATC defined daily dose (DDD)/1000 children/day and as a number of prescriptions written in the general population per year. Statistical analysis was performed using the SPSS/W 20.0 software (Statistical Product and Service Solutions for Windows).Total utilization of antibiotics (expressed in DDD units) during study period increased by 8.40% (from 5.67 to 6.19 DDD/1000 children/day) and by 5.96% expressed in prescription rate (from 585.84 to 622.97 prescriptions/1000 children/year). The most popular antibiotic group was macrolides which showed the highest increase of utilization 5.9 times (from 0.27 DDD/1000 children/day in 2003 to 1.66 DDD/1000 children/day in 2012).The most common indications for antibiotic prescribing for children in 2012 were acute bronchitis (25.6%), acute tonsillitis (21.7%) and acute pharyngitis (14.6%). Amoxicillin had the highest probability to be chosen to treat acute tonsillitis (prob. [probability] = .2875) and acute pharyngitis (prob. = .5553). Clarithromycin had the highest probability to be chosen to treat acute bronchitis (prob. = .4222).Most of the diseases treated with antibiotics were viral infections. The most commonly prescribed antibiotics were broad-spectrum. The consumption of antibiotics was evenly increasing during 2003 to 2012 period, but the distribution of separate antibiotic group remained the same.

Too much? Mortality and health service utilisation among Danish children 1999-2016: A register-based study

OBJECTIVES

To describe the temporal development of mortality and health service utilisation defined as in- and outpatient hospital contacts, contacts with general practitioner and specialists, and prescribed dispensed medication among Danish children 0-5 years of age from 1999 to 2016.

DESIGN

Register-based descriptive study.

PARTICIPANTS

All children born in Denmark in the period 1994-2016 followed until 5 years of age.

MAIN OUTCOME MEASURES

Annual incidence rates of mortality and health service utilisation outcomes, and incidence rate ratios compared to the reference calendar year 1999. The new measure of post-discharge mortality is presented.

RESULTS

Post-discharge mortality decreased from 1999 to 2016, IRR2016 = 0.49 (95% CI: 0.36 to 0.66). Total contacts did not change much over time, IRR2016 = 1.02 (1.02 to 1.03), but increased among neonates, IRR2016 = 3.69 (3.63 to 3.75), and decreased among children with chronic disease IRR2016 = 0.94 (0.93 to 0.94). In- and out-patient hospitalisations increased, IRR2016 = 1.26 (1.24-1.27) resp. IRR2016 = 1.62 (1.60-1.63), contacts with medical specialists increased, IRR2016 = 1.43 (1.42 to 1.43), whilst contacts with general practitioner decreased, IRR2016 = 0.91 (0.91 to 0.91). Medication use decreased, IRR2016 = 0.82 (0.82 to 0.82).

CONCLUSIONS

Our measure of post-discharge mortality was halved during the study period indicating improved health. Overall health service utilisation did not change much, but the type of utilisation changed, and the development over time differed between subgroups defined by age and chronic disease status. Our findings call for considerations about the benefit of increased specialisation and increased use of health services among 'healthy' children not suffering from chronic disease.

Estimating global trends in total and childhood antibiotic consumption, 2011-2015

INTRODUCTION

Understanding patterns of antibiotic consumption is essential to ensure access to appropriate antibiotics when needed and to minimise overuse, which can lead to antibiotic resistance. We aimed to describe changes in global antibiotic consumption between 2011 and 2015.

METHODS

We analysed wholesale data on total antibiotic sales and antibiotics sold as child-appropriate formulations (CAFs), stratified by country income level (low/middle-income and high-income countries (LMICs and HICs)). The volume of antibiotics sold per year was recorded for 36 LMICs and 39 HICs, measured in standard units (SU: 1 SU is equivalent to a single tablet, capsule or 5 mL ampoule/vial/oral suspension) and SU per person, overall and as CAFs. Changes over time were quantified as percentage changes and compound annual growth rates in consumption per person. Analyses were conducted separately for total sales, sales of antibiotics in the Access and Watch groups of the WHO's Essential Medicines List for children 2017, for amoxicillin and amoxicillin with clavulanic acid.

RESULTS

Antibiotic consumption increased slightly between 2011 and 2015, from 6.85×1010 SU to 7.44×1010 SU overall and from 1.66×1010 SU to 1.78×1010 SU for CAFs. However, trends differed between countries and for specific antibiotics; for example, consumption of amoxicillin as CAFs changed little in LMICs and HICs, but that of amoxicillin with clavulanic acid increased by 6.8% per year in LMICs and decreased by 1.0% per year in HICs.

CONCLUSIONS

As measured in standard units in sales data, the rate of increase in global antibiotic consumption may be slowing. However, the trends appear to differ between countries and drugs. In the absence of routine surveillance of antibiotic use in many countries, these data provide important indicators of trends in consumption which should be confirmed in national and local studies of prescribing.

Antibiotic prescription and clinical management of common infections among general practitioners in Latvia, Lithuania, and Sweden: a pilot survey with a simple protocol

Comparative information on diagnosis-related antibiotic prescribing patterns are scarce from primary care within and between countries. To describe and compare antibiotic prescription and routine management of infections in primary care in Latvia (LV), Lithuania (LT) and two study sites in Sweden (SE), a cross-sectional observational study on patients who consulted due to sypmtoms compatible with infection was undetraken. Infection and treatment was detected and recorded by physicians only. Data was collected from altogether 8786 consecutive patients with infections in the three countries. Although the overall proportion of patients receiving an antibiotic prescription was similar in all three countries (LV and LT 42%, SE 38%), there were differences in the rate of prescription between the countries depending on the respective diagnoses. While penicillins dominated among prescriptions (LV 58%, LT 67%, SE 70%), phenoxymethylpenicillin was most commonly prescribed in Sweden (57% of all penicillins), while it was amoxicillin with or without clavulanic acid in Latvia (99%) and Lithuania (85%) respectively. Pivmecillinam and flucloxacillin, which accounted for 29% of penicillins in Sweden, were available neither in Latvia nor in Lithuania. The applied methodology was simple, and provided useful information on differences in treatment of common infections in ambulatory care in the absence of available computerized diagnosis-prescription data. Despite some limitations, the method can be used for assessment of intention to treat and compliance to treatment guidelines and benchmarking locally, nationally, or internationally, just as the point prevalence surveys (PPS) protocols have been used in hospitals all over Europe.

Out-of-hours antibiotic prescription after screening with C reactive protein: a randomised controlled study

OBJECTIVE

To evaluate the effect of preconsultation C reactive protein (CRP) screening on antibiotic prescribing and referral to hospital in Norwegian primary care settings with low prevalence of serious infections.

DESIGN

Randomised controlled observational study at out-of-hours services in Norway.

SETTING

Primary care.

PARTICIPANTS

401 children (0-6 years) with fever and/or respiratory symptoms were recruited from 5 different out-of-hours services (including 1 paediatric emergency clinic) in 2013-2015.

INTERVENTION

Data were collected from questionnaires and clinical examination results. Every third child was randomised to a CRP test before the consultation; for the rest, the doctor ordered a CRP test if considered necessary.

OUTCOME MEASURES

Main outcome variables were prescription of antibiotics and referral to hospital.

RESULTS

In the group pretested with CRP, the antibiotic prescription rate was 26%, compared with 22% in the control group. In the group pretested with CRP, 5% were admitted to hospital, compared with 9% in the control group. These differences were not statistically significant. The main predictors for ordering a CRP test were parents' assessment of seriousness of the illness and the child's temperature. Paediatricians ordered CRP tests less frequently than did other doctors (9% vs 56%, p<0.001).

CONCLUSIONS

Preconsultation screening with CRP of children presenting to out-of-hours services with fever and/or respiratory symptoms does not significantly affect the prescription of antibiotics or referral to hospital.

TRIAL REGISTRATION NUMBER

NCT02496559; Results.

Ambulatory Care Visits to Pediatricians in Taiwan: A Nationwide Analysis

Pediatricians play a key role in the healthy development of children. Nevertheless, the practice patterns of pediatricians have seldom been investigated. The current study analyzed the nationwide profiles of ambulatory visits to pediatricians in Taiwan, using the National Health Insurance Research Database. From a dataset that was randomly sampled one out of every 500 records among a total of 309,880,000 visits in 2012 in the country, 9.8% (n = 60,717) of the visits were found paid to pediatricians. Children and adolescents accounted for only 69.3% of the visits to pediatricians. Male pediatricians provided 80.5% of the services and the main workforces were those aged 40-49 years. The most frequent diagnoses were respiratory tract diseases (64.7%) and anti-histamine agents were prescribed in 48.8% of the visits to pediatricians. Our detailed results could contribute to evidence-based discussions on health policymaking.

Use of antibiotics in paediatric primary care settings in Serbia

OBJECTIVE

The aim of the study was to compare the quality of antibiotic use among children in primary settings with the internationally developed disease-specific quality indicators and with National Guidelines.

DESIGN

Prescriptions of systemic antibiotics to the paediatric population (<18 years) at the primary level of healthcare for the period between 2011 and 2013 were analysed by using the National Health Insurance Fund's outpatient reimbursement database.

RESULTS

The mean annual number of antibiotic prescriptions was 1.887.615, while the mean annual number of children receiving antibiotics was 728.285. The prescription rate slightly decreased by 10% from 1.516 antibiotic prescriptions per 1000 persons per year in 2011 to 1.365 in 2013. The highest percentage of prescribed antibiotics was observed in the group of children aged 2-23 months. The mean annual prevalence of antibiotic prescriptions was 54%. The percentage of patients prescribed an antibiotic for acute upper respiratory tract infections, acute tonsillitis and acute otitis media (AOM) was above the proposed range (≤ 20), 87% -96%. These three diagnoses represent more than 69% of all indications for prescribing antibiotics. The percentage of patients prescribed a recommended antibiotic was below the proposed range (≥ 80%), 1% -17%, while the adherence rate to National Guidelines was low, 19%-28%. The percentage of patients prescribed quinolones was above the proposed range for AOM (≤ 5%), 7%. There were no significant differences in indicators value at the regional level in Serbia.

CONCLUSIONS

Antibiotic use among children in Serbia is extremely high compared with that in most other European countries. Major problems are frequent use of antibiotics for indications that usually receive no benefit from this treatment and the use of broad-spectrum antibiotics.