Antibiotics overused in children with asthma

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Nearly one-in-six children who visit a pediatric ambulatory care center for asthma are prescribed an unnecessary antibiotic, new study results indicate.

“Additional education and interventions are needed to prevent unnecessary antibiotic prescribing for asthma,” Ian M. Paul, MD, MSc, of the departments of pediatrics and public health sciences at Penn State College of Medicine in Hershey, Penn., and colleagues wrote online first in Pediatrics.

Prior studies that have investigated the role of antibiotics with anti-inflammatory properties in asthma therapy have yielded mixed results, and current National Asthma Education and Prevention Program guidelines advise against prescribing antibiotics for chronic or acute asthma exacerbations unless a comorbid bacterial infection is present.

To investigate the prevalence of inappropriate antibiotic prescribing practices during U.S. ambulatory care pediatric asthma visits the researchers analyzed data from two national surveys – the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey – from 1998 to 2007.

International Classification of Diseases, Ninth Revision codes (ICD-9) were used to determine the presence of coexisting conditions that could warrant an antibiotic.

A total of 60.4 million visits for asthma without another ICD-9 code occurred during the study period, the researchers found, and antibiotic prescriptions occurring during 15.6% of these visits.

“This equates to an estimate of about one million pediatric ambulatory visits per year in the United States for asthma during which antibiotics may be inappropriately prescribed,” the researchers wrote.

Macrolides were the most commonly prescribed antibiotic, accounting for 48.8%, followed by aminopenicillins at 26.3% and cephalosporins at 20.6%.

Bivariate analyses revealed a seasonal trend for prescription behaviors (P=.08). The researchers found that prescriptions peaking in the fall and winter, with 18.5% prescribed during September through November and 20.3% prescribed from December through January. Prescriptions waned in the spring and summer months accounting for about 12% of all written.

The researchers determined that systemic corticosteroid use was independently associated with the choice to prescribe an antibiotic, occurring in 26.3% vs. 13.1% (P=.0007) of antibiotic prescriptions. Clinicians were also more likely to choose a macrolide over another antibiotic when corticosteroids were prescribed (68.9% vs. 38.1%; P=.004),

“The finding that overall antibiotic use and specifically macrolide antibiotic use, occurs more commonly when systemic corticosteroids are jointly prescribed is in agreement with studies that have reported that disease severity has some influence on this choice,” the researchers wrote.

Antibiotics were prescribed more often to children with private insurance vs. those without (54.9% vs. 37.6%; P=.06), whereas those treated in an emergency department had a decreased likelihood of receiving an antibiotic (OR: 0.48; 95% CI: 0.26-0.89).

Asthma education during the office-based visits was associated with reduced antibiotic prescriptions (OR=0.46; 95% CI: 0.24-0.84), data from a second multivariate analysis indicated.

“Patient asthma education is increasing being viewed as an important marker of quality care in the ambulatory care setting,” the researchers wrote. “The results from this finding suggest other potential benefits for asthma education, as it seems to be associated with more judicious use of antibiotics by providers.”

In an accompanying editorial, Rita Mangione-Smith, MD, MPH, of the department of pediatrics at the University of Washington in Seattle, and Paul Krostad, MS, MD, of the David Geffen School of Medicine in Los Angeles, suggest an automated quality improvement program to reduce antibiotic overuse.

They suggested a Web-based application that could be incorporated into electronic medical records that would contain “decision support,” including information on appropriate use of broad-spectrum antibiotics, the consequences of overuse and provider performance feedback.

The battle to reduce inappropriate antibiotic prescribing for children diagnosed with viral upper respiratory infections has largely been won,” they wrote. “The new battle for curbing unjustified antibiotic use in the pediatric outpatient setting requires that we focus on reducing inappropriate bacterial diagnoses and decreasing the use of broad spectrum agents.”

Paul IM. Pediatrics. 2011;DOI:10.1542/peds.2011-0218.

Mangione-Smith R, Krostad P. Pediatrics. 2011:DOI:10.1542/peds.2011-0894.

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