By Shalmali Pa
Pediatric asthma patients are nearly twice as likely to be prescribed an unnecessary antibiotic, compared with other pediatric patients, during an office or emergency department visit, recent studies revealed.
Two studies, one conducted in the U.S. over a 10-year period, and one in Belgium done over a two-year period, examined pediatric asthma encounters, with results published in the June issue of Pediatrics.
Antibiotics are prescribed in nearly one of six U.S. pediatric ambulatory care visits for asthma patients, which represents one million prescriptions annually, according to Ian M. Paul, MD, of Penn State College of Medicine in Hershey, Pa., and colleagues. This occurs even though the National Asthma Education and Prevention Program guidelines specify that antibiotics should not be used as part of chronic asthma therapy or for acute exacerbations, with the exception of patients with comorbid bacterial infections such as pneumonia or sinusitis, the authors noted.
The results of the study imply that "additional education and interventions are needed to prevent unnecessary antibiotic prescribing for asthma," the researchers said.
The multi-institutional team analyzed office and emergency-department asthma visits by children from 1998 to 2007 based on data from the National Ambulatory Medical Care Surveys (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS).
They looked for the frequency of antibiotic prescriptions.
The cohort of 5,198 ambulatory care visits, representing an estimated 60.5 million visits in the U.S., also was evaluated for ICD-9 codes that could determine whether a comorbid secondary condition existed to justify an antibiotic prescription.
These secondary conditions included acute respiratory tract, skin, or urinary tract infections.
"During 15.6% of these visits, an antibiotic was prescribed without a coexisting diagnosis to justify such a treatment course," the researchers wrote.
"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," they wrote.
The authors noted that when antibiotics were prescribed, macrolides were most commonly chosen, at 48.8%, followed by aminopenicillins at 26.3% and cephalosporins at 20.6%. The remaining prescriptions were comprised of all other classes of antibiotics.
They also found that corticosteroids played an important role in whether or not antibiotics were also prescribed. When systemic corticosteroids (oral, intramuscular, or intravenous) were prescribed, antibiotics were also prescribed in 26.3% of the visits, compared with 13.1% of the visits when no corticosteroids were prescribed (P=0.0007).
The researchers noted that their study was limited by the data available, observing that undocumented conditions may well have existed that justified antibiotic prescribing. In addition, ICD-9 codes do not allow the determination of whether the asthma visit was for an exacerbation of the disease or for other nonacute reasons related to asthma.
"Despite these limitations, the current study demonstrates that clinicians are prescribing antibiotics as part of asthma treatment in a fashion that conflicts with U.S. and international guidelines," they stated.
Inappropriate and Expensive
The problem of unnecessary antibiotic prescribing for pediatric asthma patients is not limited to the U.S. In a two-year study of nearly one million children in Belgium, Kris De Boeck, MD, and colleagues found that the codispensing of antibiotics and asthma drugs was common practice.
The researchers analyzed drug dispensing data for 892,841 children from October 2005 through September 2006. A second study year included data from 880,969 children and was used for internal validation. All data was obtained from Christelijke Mutualiteiten, a healthcare insurer covering 44% of the Belgian population.
Each child was tracked over the year in order to calculate the number and percentage of children who had an antibiotic or asthma drug dispensed. Codispensing was calculated as patients prescribed an asthma drug who then had an antibiotic dispensed on the same day or throughout the year.
The researchers found that among children who had an asthma drug dispensed, the odds that they had also been given an antibiotic were 1.90 (95% CI: 1.89 to 1.91; P<.0001).
They found that penicillin antibiotics were the most prescribed (64.4%), followed by macrolides at 14.2% and cephalosporins at 12.2%.
The researchers also found a sharp decrease in both asthma drug and antibiotic prescribing among older children.
For children less than 3 years of age, asthma drug dispensing was 44.81%, but dropped to 7.64% in children ages 8 to 18. For the same under-3 population, antibiotic dispensing was at 73.05%, then slid to 34.21% in the older age group.
They noted that their analysis was limited by being cross-sectional and by the lack of diagnostic data for drug dispensation decisions. As with their counterparts in the U.S., they observed that some of the antibiotic prescriptions to asthma patients were undoubtedly for appropriate indications.
The yearly cost of the antibiotics dispensed to the study population amounted to about 7 million Euros ($9.9 million), the researchers stated. "Because of the lack of efficacy and high cost of coprescription of antibiotics and asthma drugs, the negative aspects of the 'coprescription habit' should become a focus of health education."
Patient, Physician Education
The studies highlight the need for patient asthma education to address inappropriate antibiotic prescribing in the pediatric outpatient setting," said Rita Mangione-Smith, MD, of the University of Washington in Seattle, and Paul Krogstad, MD, of the University of California at Los Angeles, in an accompanying commentary.
They noted that in one study, patient asthma education during an office-based visit led to a greater than 50% reduction in unnecessary antibiotic prescriptions.
The commentators also recommend watchful waiting if a child presents with an acute exacerbation of asthma, and there is a low suspicion for bacterial illness.
"In such cases, a child would be treated with appropriate asthma medications and, if the child is not improving in one to two days or getting worse, be reevaluated," they wrote.
They also said that Web-based quality improvement programs can play an important role in disseminating information throughout the pediatric outpatient provider population and can result in a decrease in inappropriate antibiotic prescribing.
"The battle to reduce inappropriate antibiotic prescribing for children diagnosed with viral upper respiratory infections has largely been won," they stated. "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."
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