Antibiotic Prescribing to Kids — Down, But Still Too Much

In the CDC’s weekly bulletin today, there’s a report: 58 percent of the antibiotic prescriptions given to kids and pre-teens during medical office visits are for conditions for which antibiotics are not necessary.

And that’s an improvement.

It’s a sign of how difficult it has become to change the trend of over-use of antibiotics in human medicine, which — along with overuse in agriculture — is one of the main drivers of the emergence of antibiotic resistance worldwide.

Full details: The numbers come from an analysis of data from the annual National Ambulatory Medical Care Survey. The analysis compares data for physician office visits from the years 1993-94 and 2007-08. It looks specifically at prescribing to children and teens who are 14 years old or less. It slices the data by rate compared to the population, by office visit, and by prescriptions for the five most common acute respiratory infections: pharyngitis (sore throat), otitis media (ear infection), bronchitis, sinusitis and nonspecific upper respiratory infection (common colds).

Within the report, there is some good news:

  • prescribing per visit decreased 24 percent from 300 antibiotic courses per 1,000 office visits in 1993-94 to 229 in 2007-08
  • prescribing measured against population decreased 10 percent, from 655 per 1,000 persons aged ≤14 years in 1993-94 to 592 in 2007-08.

But further analysis reveals the picture to be less positive. To make sense of this, it’s important to understand that the five respiratory infections called out in the analysis tend to be caused by viruses, which antibiotics do not affect. (NB, this is for acute — rapid onset — infections, as in: Your child goes to sleep healthy but wakes up with a sore throat. There are bacterial infections of the sinuses, the ear, etc., but they tend to be slower to develop, and may be a secondary infection to some other condition.) So antibiotics for them are  inappropriate, because  the drugs will not address the infection, and may foster the emergence of resistant bacteria unrelated to the acute illness. And:

  • prescribing for pharyngitis decreased 26 percent
  • prescribing for colds decreased 19 percent
  • prescribing for ear infection, bronchitis and sinus infection did not change at all
  • and of all the prescriptions written for office visits in this age group, 58 percent were for those five conditions which should not require antibiotics at all. (Modest improvement: In 1993-94, the inappropriate proportion was 69 percent.)

This inappropriate prescribing persists despite repeated guidance from major medical associations saying that antibiotics should not be used (such as these 2004 guidelines from the American Association of Pediatrics on otitis media treatment) and despite years of public education campaigns from the CDC. The research project Extending the Cure has published two excellent briefs that illustrate how intractable this problem is, examining (here and here) how antibiotic prescribing rises during flu seasons — periods when the dominant illness is definitively viral. (Some cases of flu are followed by secondary bacterial pneumonia, but only  1-2 percent — far less than would account for the surge in antibiotic use.)

Why is antibiotic use for viral illnesses so sticky?

When I was reporting my book Superbug, I had a lot of conversations with health care workers and parents about this issue. What I heard, over and over, was that many of these prescriptions weren’t driven by medical need, but by the influence of external factors. For many parents, that was “just in case” uncertainty; for parents of children in daycare, it was knowing that a sniffly kid wouldn’t be accepted by the daycare without proof that an antibiotic had been prescribed. For tightly scheduled physicians, it was time constraints: Coaching a parent in how to conduct “watchful waiting” takes longer than writing out a scrip. And for both sides, it was the unfortunate reality that we’ve trained people, as a society, to recognize the proffering of a prescription as the signal that something has been accomplished in a medical office visit. So far, we have not happened upon any other action that confers on the encounter the same sense of accomplishment and closure.

There’s a hint in today’s CDC analysis, though, that some other actions might serve as proof that something has been done. The condition for which there was the greatest decline in inappropriate prescribing was pharyngitis. One significant change in office diagnosis of pharyngitis during the period of the study was the development of a rapid test for group A Streptococcus, AKA strep throat — a bacterial infection, and a diagnosis for which an antibiotic prescription would be appropriate.

There is no way to know, in the confines of this data, whether the administration of strep rapid tests caused the decline in misapplied prescriptions for pharyngitis. But it’s certainly tempting to speculate that a physician who has a negative strep-test result in hand might be better equipped to convince a worried parent that her child does not need a prescription. If that’s the case, then it makes me wonder what other roles affordable point-of-care diagnostics might play in extending the life of antibiotics that are increasingly scarce, and that we all need.

I’m interested in any thoughts about why inappropriate prescribing exists.  Comments?

Cite: CDC MMWR. Office-Related Antibiotic Prescribing for Persons Aged ≤14 Years — United States, 1993–1994 to 2007–2008. Sept. 2, 2011 / 60(34);1153-1156

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