Assessing the appropriateness of paediatric antibiotic overuse in Australian children: a population-based sample survey

Evaluation of children's antibiotics use for outpatient pneumonia treatment in Vietnam

OBJECTIVE

Antibiotic resistance is increasing globally, associated with many failures in pneumonia treatment. This study aimed to evaluate antibiotic use in children treated for outpatient CAP (Community-Acquired Pneumonia).

METHODS

A cross-sectional descriptive retrospective study was conducted, focusing on data from outpatient prescriptions for pneumonia in patients aged 2‒192 months in 2019‒2021.

RESULTS

All antibiotic prescriptions are considered empiric as no documented bacterial and viral tests exist for children with non-severe CAP. Single antibiotic therapy (66%) had a 2-fold higher rate than combination therapy (34%). Amoxicillin/clavulanic acid (50.77%) and azithromycin (30.74%) were the most commonly prescribed in both single and combination therapies, thus determining antibiotic cost (80.15%). Besides, azithromycin (97.92%), cefuroxime (86.26%), and cefpodoxime (60.48%) were prescribed with high adherence to dose guidelines, except for amoxicillin (34.57%). These medicines are prescribed highly compliant (>83%) with dosing interval guidelines. Furthermore, significantly more brand-name antibiotics (56.5%) are prescribed than generic antibiotics (43.5%). In particular, antibiotic class, antibiotic origin, and antibiotic therapies showed significant association with rational antibiotic prescriptions for dose and dose interval (p < 0.05).

CONCLUSIONS

Amoxicillin/clavulanic acid is the most frequently prescribed medicine and the most inappropriate due to non-compliance with dose guidelines for CAP treatment. Generic antibiotic use for single therapy should be encouraged based on rapid and accurate diagnostic testing for viruses and bacteria to reduce antibiotic resistance in developing countries. Moreover, the study result has also shown that therapies and antibiotics (class and origin) exhibited significant association with rational prescriptions for CAP treatment for pediatrics.

Improving croup management at a pediatric emergency department

OBJECTIVES

Over-testing and over-treatment are common in children with croup at pediatric emergency departments (PED). The objective of the study was to improve care for children with croup.

METHODS

In this quality improvement (QI) initiative, all pediatric residents starting their rotation in the PED attended an informative presentation about croup and were provided reminders throughout their rotation. The primary outcome of this QI initiative was to reduce nebulized epinephrine (NE) use among children with mild croup by 50% over 7 months. The secondary outcome was to reduce X-rays by 50% over 7 months. Other outcomes included the administration of dexamethasone to all children with croup, reduction of antibiotics, laboratory tests, and revisits, and shortening the duration between physical examination to dexamethasone and NE treatments, and the length of stay (LOS) at the PED.

RESULTS

NE administration to patients with mild croup decreased from 80.2% to 36.3% (p < 0.001). The proportion of children with X-rays decreased from 37.4% to 17.1% (p < 0.001). There was a significant increase in dexamethasone administration, and significant decreases in laboratory blood tests, expanded viral PCR panel tests, and antibiotic prescription among all croup cases (p < 0.001). Revisit rates were not significantly different (p > 0.05). Time to dexamethasone and LOS shortened significantly (p < 0.001).

CONCLUSION

With this QI intervention, decreases in the rate of administration of NE to mild croup cases, antibiotic prescription, X-ray, laboratory blood and respiratory PCR panel tests in all croup cases were achieved without an increase in revisits. However, unnecessary NE, antibiotic, and X-ray rates are still high.

Overuse of Antibiotics: Who is to Blame? A Qualitative Study

Background

The irrational use of antibiotics seriously threatens global health. Clinicians undoubtedly play an essential role in consuming antibiotics in hospitals and communities, and their attitudes may help the health system's optimal treatment of antibiotics. In this study, we reported clinicians' experiences with antibiotics used in Isfahan, Iran.

Methods

In a qualitative study conducted from October 2020 to March 2021, the experiences of 13 clinicians with different clinical specialties were collected through one-to-one interviews. Participants were selected through purposive sampling until data saturation; data collection was conducted through semi-structured interviews. Conventional content analysis was used to analyze the transcribed interviews. The main category was recognized and subcategorized and coded by three researchers.

Results

Eight women and five men with a mean work experience of 12.54 ± 10.047 years participated in the study. All of them worried about the overuse of antibiotics and antibiotic resistance. Clinicians believe that the antimicrobial stewardship committee is not active in our country. Laboratory challenges, healthcare providers, the poor performance of the health system, and marketing and business were the main categories of the study. Subcategrories of main categories included inefficiency in the function of laboratories, harmful profit, challenges in medical education, ups and downs of disease treatment, the unacceptable performance of hospitals, failure to upgrade the health system, threats and opportunities, and jobbery.

Conclusions

The participants of this study believed that excessive use of antibiotics is a serious challenge in our country. Physicians were concerned about antibiotic resistance and believed that the pattern of antibiotic resistance was not routinely reported. Therefore, in our region, we should make more efforts to collect data in this field and provide this information to physicians. Also, this study confirmed many obstacles to implementing the antimicrobial stewardship program, and the infrastructure needs strengthening. There is also a need for cultural changes and the views of physicians.

Usage and parental knowledge of antibiotics in children undergoing (adeno) tonsillectomy in northern Tanzania

Introduction

Antimicrobial Resistance (AMR) is a growing concern globally, mostly being contributed by a limited understanding of antibiotic utilization as a result of inappropriate acquisition and prescription. Parental awareness is essential in optimizing their usage and preserving the effectiveness of these crucial medications. The current study investigates the usage and parental knowledge of antibiotics in children undergoing (adeno) tonsillectomy ((A)TE) in Northern Tanzania.

Methods

a cross-sectional survey was conducted among parents/caregivers of children who underwent (A)TE in Northern Tanzania. A modified and well-structured questionnaire, which was adapted from a World Health Organization (WHO) questionnaire and used to assess the parents´ knowledge of antibiotics and antibiotic use.

Results

the study included 157 participants. About 54% of the children under the age of 5 years. As of 88% of children had already received antibiotics prior to surgery, 92% of the used antibiotics were prescribed by a clinician, and 5% of parents to used leftovers antibiotics for their children. While 88% of the parents reported adhering to prescriptions, 8% of reported buying the same antibiotic (as prescribed before) without consulting a clinician again when their children are sick.

Conclusion

the use of antibiotics, including broad-spectrum antibiotics, was found to be high in our study group. Parents demonstrate a relatively good understanding of antibiotic usage. It is plausible to speculate that a higher prevalence of non-insured, unemployed, and less educated parents may lead to an increased incidence of misuse and misinterpretation of antibiotics.

Nudge interventions to reduce unnecessary antibiotic prescribing in primary care: a systematic review

OBJECTIVES

Antibiotic prescribing in primary care contributes significantly to antibiotic overuse. Nudge interventions alter the decision-making environment to achieve behaviour change without restricting options. Our objectives were to conduct a systematic review to describe the types of nudge interventions used to reduce unnecessary antibiotic prescribing in primary care, their key features, and their effects on antibiotic prescribing overall.

METHODS

Medline, Embase and grey literature were searched for randomised trials or regression discontinuity studies in April 2021. Risk of bias was assessed independently by two researchers using the Cochrane Effective Practice and Organisation of Care group's tool. Results were synthesised to report the percentage of studies demonstrating a reduction in overall antibiotic prescribing for different types of nudges. Effects of social norm nudges were examined for features that may enhance effectiveness.

RESULTS

Nineteen studies were included, testing 23 nudge interventions. Four studies were rated as having a high risk of bias, nine as moderate risk of bias and six as at low risk. Overall, 78.3% (n=18, 95% CI 58.1 to 90.3) of the nudges evaluated resulted in a reduction in overall antibiotic prescribing. Social norm feedback was the most frequently applied nudge (n=17), with 76.5% (n=13; 95% CI 52.7 to 90.4) of these studies reporting a reduction. Other nudges applied were changing option consequences (n=3; with 2 reporting a reduction), providing reminders (n=2; 2 reporting a reduction) and facilitating commitment (n=1; reporting a reduction). Successful social norm nudges typically either included an injunctive norm, compared prescribing to physicians with the lowest prescribers or targeted high prescribers.

CONCLUSIONS

Nudge interventions are effective for improving antibiotic prescribing in primary care. Expanding the use of nudge interventions beyond social norm nudges could reap further improvements in antibiotic prescribing practices. Policy-makers and managers need to be mindful of how social norm nudges are implemented to enhance intervention effects.

Antibiotic Prescribing Patterns for Outpatient Pediatrics at a Private Hospital in Abu Dhabi: A Clinical Audit Study

BACKGROUND

Antibiotics are commonly used in pediatrics. The aim and objectives were to evaluate the antibiotic prescribing patterns of pediatric outpatients at a private hospital in Abu Dhabi, UAE.

METHODS

A retrospective drug utilization review was conducted for pediatric patients aged 1-18 between June and December 2018. The prescriptions with inclusion criteria were reviewed and evaluated by using the WHO indicators.

RESULTS

419 encounters included were female (50.1%). Most pediatrics were aged 4-6 years (35.3%). The average number of drugs per prescription were 4.9 drugs. The percentage of parenteral medication prescriptions was 16.9%, and with antibiotic prescriptions was 43.0%, where cefaclor was the most prescribed antibiotic (31.1%). The average consultation time was 14 min, while the average dispensing time was 9.6 min. The most common diagnosis where antibiotics were prescribed was acute pharyngitis (33.4%). There were about 60.6% with lab investigation.

CONCLUSION

As per the WHO indicators, the pediatric outpatient department has a high rate of antibiotic use and polypharmacy, but adherence to the drug formulary and prescribing medicines using generic names was appropriate. The average time for consultation and dispensing were suitable. Irrational antibiotic use for inappropriate diagnoses such as acute otitis media and bronchiolitis were found.

Early life antibiotics and childhood gastrointestinal disorders: a systematic review

BACKGROUND

In adults, there is increasing evidence for an association between antibiotic use and gastrointestinal (GI) disorders but in children, the evidence is scarce.

OBJECTIVE

Assess the association between exposure to antibiotics in the first 2 years of life in term born children and the presence of chronic GI disorders later in childhood.

DESIGN

For this systematic review the MEDLINE, Embase, WHO trial register and Web of Science were systematically searched from inception to 8 June 2020. Title and abstract screening (n=12 219), full-text screening (n=132) as well as the quality assessment with the Newcastle-Ottawa Scale were independently performed by two researchers.

MAIN OUTCOME MEASURES

The association between antibiotics and inflammatory bowel disease (IBD) (n=6), eosinophilic oesophagitis (EoE) (n=5), coeliac disease (CeD) (n=6), infantile colics (n=3), functional constipation (n=2), recurrent abdominal pain, regurgitation, functional diarrhoea and infant dyschezia were examined.

RESULTS

Twenty-two studies were included, 11 cohort and 11 case-control studies. A best evidence synthesis showed strong evidence for an association between antibiotic exposure in the first 2 years of life and the presence of IBD, and CeD during childhood. Moderate evidence was found for an association with EoE and no association with functional constipation in the first year of life. There was insufficient evidence for the other studied disorders.

CONCLUSIONS

The use of antibiotics in early life may increase the risk of GI disorders later in life. Further studies are necessary to unravel the underlying mechanisms and determine potential preventive measures. Meanwhile judicious use of antibiotics in early childhood is highly warranted.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019132631.