Data show significant antibiotic overprescribing for kids in ERs

A new study has found that children receive more than 2 million unnecessary antibiotic prescriptions a year in US emergency departments (EDs), with most inappropriate prescribing occurring in nonpediatric EDs. The findings appeared yesterday in the journal Pediatrics.

The study also found that nonpediatric ED clinicians are more likely to prescribe macrolide antibiotics for children and less likely to follow national prescribing guidelines for common pediatric respiratory infections. While these findings were not necessarily surprising, given the amount of antibiotic overprescribing that goes on in pediatric outpatient clinics, the authors say they highlight a significant gap in efforts to promote more judicious use of antibiotics in children.

"There's over 2 million courses of antibiotics prescribed to children in emergency departments that we know are not necessary," lead study author Nicole Poole, MD, MPH, a pediatric infectious disease specialist at Seattle Children's Hospital, told CIDRAP News. "So we need to be thinking about the guidelines that are more relevant to outpatient diagnoses in the emergency department, and how to improve the number of prescriptions that are going out to children from these settings."

Higher inappropriate prescribing in nonpediatric EDs

The retrospective study used data from the National Ambulatory Medical Care Survey, which is given annually to a nationwide selection of emergency departments. Using data from 2009 through 2014, the researchers estimated the number of ED visits by children ages 0 to 17, the proportion of visits that resulted in an antibiotic prescription, which types of antibiotic children received, and for what diagnosis.

Each diagnosis was assigned to one of three categories—conditions for which antibiotics are (1) almost always indicated, (2) may be indicated, or (3) generally not indicated.

The researchers also looked at what type of emergency room was visited (pediatric or nonpediatric), and whether clinicians were following national prescribing guidelines for three common acute respiratory infections—acute otitis media (AOM, or ear infection), sinusitis, and pharyngitis. These conditions account for the majority antibiotic prescribing in children.

The analysis found that over the 5-year period, there were an average of 29 million annual ED visits by children, resulting in 6.7 million antibiotic prescriptions (23%) per year. Only 14% of those visits were to pediatric EDs. The percentage of ED visits resulting in an antibiotic prescription was significantly higher in nonpediatric EDs (24%) than in pediatric EDs (20%).

Overall, 32% of those prescriptions (2.1 million per year) were for illnesses for which antibiotics are generally not indicated, such as bronchitis, and 44% were for broad-spectrum antibiotics. Antibiotic prescribing for these conditions was significantly higher in nonpediatric EDs than it was at pediatric EDs (33% vs. 24%).

"Antibiotic prescribing for these conditions provides no benefits to patients, puts them at unnecessary risk for adverse events, and should be targeted for quality improvement in EDs nationally, particularly nonpediatric EDs," Poole and her co-authors write.

While there was no significant difference in broad-spectrum antibiotic prescribing between pediatric and nonpediatric EDs, the analysis showed that macrolides, particularly azithromycin, were more frequently prescribed at nonpediatric EDs (18%) compared with pediatric EDs (8%). In addition, first-line, guideline-concordant antibiotic therapy for children with AOM, sinusitis, and pharyngitis was lower in nonpediatric EDs (77%) than pediatric EDs (87%). Clinicians at pediatric EDs were twice as likely follow prescribing guidelines (adjusted odds ratio, 2.01; 95% confidence interval, 1.38 to 2.92)

Poole and her colleagues note that the findings on macrolide use add to a growing body of literature that shows nonpediatric healthcare centers and clinicians more frequently prescribe macrolides to children. "Azithromycin is an antibiotic that classically is thought of as easy to prescribe," Poole explained, and likely appeals to clinicians and parents of young children because of the fact that it only has to be taken once a day over 5 days. "It is, I would imagine, a more attractive choice, in terms of ease of administration."

Azithromycin is also a broad-spectrum antibiotic, so it could potentially cover a range of infections in the event there's uncertainty in the diagnosis.

But Poole noted that azithromycin isn't always a great choice for the most common pediatric bacterial infections.  Take AOM, for which macrolides were the most commonly prescribed antibiotic. Azithromycin is a suboptimal choice for AOM because most cases are caused by Streptococcus pneumoniae, and nearly a third of all invasive S pneumoniae isolates are macrolide resistant. In addition, Poole said, azithromycin is also more likely to cause side effects, such as diarrhea, than first-line options like amoxicillin.

"I'm hoping that, by bringing attention to azithromycin use, physicians in emergency departments will reflect on why an individual might prescribe more azithromycin…and really weigh the risks and benefits, and whether it's really going to provide any benefit for the diagnosis that they're giving," she said.

More stewardship needed in emergency settings

So what's going on? Poole and her colleagues suggest that training plays a significant role. Pediatric-trained clinicians, they note, are more likely to work in pediatric EDs and be familiar with (and follow) pediatric-specific antibiotic prescribing guidelines. There's also the issue of patient pressure and how clinicians perceive that pressure, issues that come into play in antibiotic prescribing in all settings.

"We know that sometimes parents expect antibiotics, and sometimes they don't," Poole said. "But we also know that clinicians are not perfect in understanding when a parent wants an antibiotic, and when they do not. So there's often misperception of parent pressure at times."

Poole and her colleagues suggest that exposing emergency medicine specialists to pediatric-focused guidelines and antibiotic stewardship initiatives could help improve prescribing in nonpediatric EDs.

An accompanying commentary written by pediatric and emergency medicine specialists also argues that EDs in general are a setting in which inappropriate antibiotic prescribing is well-established and stewardship is difficult because of high volumes of patients and rapid patient turnover. Beyond exposing emergency medicine providers to pediatric prescribing guidelines, they argue what's needed is generalizable, ED-based antibiotic stewardship programs that could be implemented in all emergency settings.

"ASP and ED experts must continue to collaborate and formulate thoughtful solutions to this important patient-safety and public-health issue," the authors write.  

See also:

Jan 8 Pediatrics study

Jan 8 Pediatrics commentary

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