January 08, 2019
By Will Boggs MD
NEW YORK (Reuters Health) - In U.S. emergency departments (EDs), especially non-pediatric EDs, children often receive antibiotics inappropriately, a retrospective study suggests.
"The most striking result of this report shows that each year, over 2 million courses of antibiotics prescribed to children in EDs nationally are unnecessary," Dr. Nicole M. Poole of the University of Washington and Seattle Children's Research Institute told Reuters Health by email. "There is an urgent need to improve the quality of antibiotic prescribing for children in both pediatric and general EDs nationwide."
Previous studies have estimated that 15-20% of children in EDs receive antibiotics and that nearly a third of antibiotics prescribed to children in ambulatory settings are not in accordance with national guidelines.
Dr. Poole's team used National Hospital Ambulatory Medical Care Survey ED data from 2009 to 2014 to characterize ambulatory antibiotic prescribing for children in U.S. pediatric and nonpediatric EDs.
During this interval, 23% of ED visits by children resulted in an antibiotic prescription, with significantly higher rates in nonpediatric EDs (24%) than in pediatric EDs (20%), the researchers report in Pediatrics, online January 8.
Diagnoses most commonly associated with antibiotic prescriptions included acute respiratory tract infections (55%), skin and soft tissue infections (9%) and urinary tract infection (7%).
Just under one-third (32%) of antibiotic visits for children in the EDs nationally were for conditions for which antibiotics were generally not indicated. Again, the proportion of these visits was higher at nonpediatric EDs (33%) than at pediatric EDs (26%).
Macrolides like azithromycin were prescribed far more commonly in nonpediatric EDs (18% of antibiotics prescribed) than in pediatric EDs (8%), and 44% of all ED macrolide prescriptions to children were for diagnoses for which antibiotics are generally not indicated.
"Azithromycin is prescribed inappropriately to children in EDs both for illnesses for which antibiotics shouldn't be used, like colds and bronchitis, and for illnesses for which another antibiotic is recommended, like ear infections," Dr. Poole said.
Among children with acute otitis media, sinusitis, or pharyngitis, the proportion of antibiotic visits during which they received first-line, guideline-concordant therapy was significantly higher in pediatric EDs (87%) than in nonpediatric EDs (77%).
"Like other outpatient clinicians, ED clinicians are often worried about patient and parent satisfaction and expectations for antibiotics, which in combination with the time constraints of a busy Emergency Department, may drive them to prescribe antibiotics when they aren't needed," Dr. Poole said.
"Methods that can improve antibiotic prescribing in EDs include the use of standardized clinical pathways and clinical decision support tools, as well as clinical justification for non-recommended antibiotic use and communication training for clinicians," she said. "Use of these interventions can also streamline patient work flow and decrease the length of patient visits in the ED. CDC's Core Elements of Outpatient Antibiotic Stewardship provide a framework that EDs can use to implement antibiotic stewardship, which is the effort to measure and improve antibiotic use."
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