Antibiotics Overused in Children With Asthma

Emma Hitt, PhD

May 31, 2011 — Antibiotics may be overprescribed for children with asthma, according to the findings of 2 new studies.

One study was led by Ian M. Paul, MD, from the departments of pediatrics and public health sciences, Penn State College of Medicine, Hershey, Pennsylvania, and the other was led by Kris De Boeck, MD, PHD, from the Department of Pediatric Pulmonology and Infectious Diseases at the University Hospital of Leuven in Belgium. Both studies were reported online May 23 and in the June print issue of Pediatrics.

According to Dr. Paul and colleagues, 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."

Macrolide and ketolide antibiotics are thought to have anti-inflammatory actions; however, the results from studies regarding their benefit in patients with asthma have been mixed, and "neither US nor international guidelines for asthma management currently recommend antibiotic treatment for asthma exacerbations," the authors write.

Dr. Paul and colleagues sought to determine how frequently US clinicians were prescribing antibiotics during pediatric asthma visits in the absence of a documented comorbidity. They evaluated data from both the National Ambulatory Medical Care Surveys and the National Hospital Ambulatory Medical Care Survey, collected from 1998 to 2007, pertaining to office and emergency department asthma visits made by children (aged < 18 years).

"An estimated 60.4 million visits occurred for asthma without another [International Classification of Diseases, Ninth Revision] code justifying antibiotic prescription," the authors write. In approximately 16% of these visits, however, patients were prescribed antibiotics.

The most commonly prescribed antibiotic was a macrolide (48.8%). In a multivariate analysis, factors associated with an increased likelihood of antibiotic prescription were concurrent systemic corticosteroid prescription (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.68 - 4.30) and treatment during the winter (OR, 1.92; 95% CI, 1.05 - 3.52).

In contrast, treatment in an emergency department was associated with decreased likelihood of antibiotic prescription (OR, 0.48; 95% CI, 0.26 0 0.89). In addition, during office-based visits, asthma education was associated with reduced antibiotic prescriptions (OR, 0.46; 95% CI, 0.24 - 0.86).

A second large study, led by Dr. De Boeck, examined a health insurance database involving the dispensing of antibiotics and asthma drugs during the course of a year in 892,841 Belgian children aged younger than 18 years.

Antibiotics were dispensed to 44.21% of children, whereas asthma drugs were dispensed to 16.04%. The greatest proportion of patients receiving either treatment was younger than 3 years of age.

Overall, an antibiotic was dispensed to 73.50% of children also receiving an asthma drug vs 38.62% of children receiving an antibiotic alone (P < .0001). Overall, regardless of age, children were about twice as likely to receive an antibiotic if they also received asthma treatment (OR, 1.90; 95% CI, 1.89 - 1.91; P < .0001). In more than a third of children receiving an asthma drug, an antibiotic was dispensed on the same day.

"A major strength of these studies is the sheer power of the data provided by their large data sets," noted the authors of a related commentary, Rita Mangione-Smith, MD, MPH, and Paul Krogstad, MD. Dr. Mangione-Smith is from the Department of Pediatrics at the University of Washington in Seattle, and Dr. Krogstad is from the departments of pediatrics and molecular and medical pharmacology at the David Geffen School of Medicine, University of California–Los Angeles.

According to the commentators, the "results suggest that Belgian and American physicians prescribe antibiotics for patients perceived to have a diagnosis of asthma or bronchospasm at a previously unsuspected level: as often as 1 in 6 visits for American children, which accounts for 1 million or more dubious prescriptions per year."

Some of the prescriptions may result from diagnostic uncertainty and medical-legal concerns, as well as pressure or influence from parents wanting an antibiotic prescription for their child, Dr. Mangione-Smith and Dr. Krogstad write.

"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," they add.

Neither of the studies was commercially funded. The researchers and commentators have disclosed no relevant financial relationships.

Pediatrics. 2011;127:1014-1021, 1022-1026 1174-1176. Paul article De Boeck article