Nancy A. Melville

May 28, 2012

May 28, 2012 (Thessaloniki, Greece) — Despite strict policies regarding the use of antibiotics in treating sore throats in pediatric patients, emergency department physicians commonly prescribe the drugs, particularly to patients younger than 5 years or if the prescribing physician is on a night shift, according to a Belgian study presented here at the European Society of Paediatric Infectious Diseases (ESPID) 30th Annual Meeting.

With antibiotic resistance a pressing concern, policies are in place around the world to try to curb overuse, and Belgium is no exception, said lead author Inge Roggen, MD, of the Universitair Ziekenhuis Brussels Department of Emergency Medicine, Belgium.

"Every government has different guidelines, but in Belgium, our policy is that if the child is healthy with no other comorbidities, we don't give antibiotics if it is just a sore throat," she said.

Dr. Roggen and her team conducted the prospective study in an effort to evaluate adherence to the guidelines. They analyzed all medical records of patients younger than 16 years who were diagnosed in the emergency department with sore throat between 2009 and 2010. After those with chronic disease and existing antibiotic treatment were excluded, 1345 out of 33,152 met the study criteria.

The results showed that children younger than 5 years were more commonly prescribed antibiotics (38% vs 28%; P = .0006), yet the incidence of infection with β-hemolytic group A Streptococcus (GAS) is lower in this group (23% vs 41%; P = .0002).

Other distinctions included the fact that white children received antibiotic prescriptions less frequently than children of other ethnicities (32% vs 37%; P = .03) and that more antibiotics were prescribed during night shifts (39% vs 32%; P = .008).

"We were shocked to see that 1 in 3 children received antibiotic prescriptions," Dr. Roggen said. "We searched the literature, but we found no clinical or medical reason to correlate with the prescription rate," she said.

"It was also shocking to see that children below the age of 5 received significantly more antibiotics, since we all know that the incidence of group A Streptococcus under the age of 5 is much lower than in the cohorts from 5 to 15 years old, which were also in our group."

Under Belgian law, emergency department residents are required to be equally divided to include 50% Belgian residents and 50% Dutch; the findings also showed that physicians with a Belgian degree prescribed antibiotics less frequently than physicians who studied in the Netherlands (23% vs 46%; P < .0001).

"This, too, was surprising to us because the Dutch and the Germans are known to have very strict antibiotic policies," Dr. Roggen said.

According to Jason G. Newland, MD, director of the Antibiotic Stewardship Program and the Office of Evidence Base Practice at the University of Missouri School of Medicine, in Kansas City, the trend of overprescribing antibiotics to patients younger than 5 years extends well beyond Belgium. In the United States, part of the problem is a cultural tendency to expect easy fixes.

"In the US, we have a culture based around doing things — you go to a hospital or a clinic and you want something identified and done. It's not enough for some people if the doctor simply says the patient has a virus, go home and it will be okay."

"It is of course justified to give the antibiotic if the patient has the clinical condition that's specific, but I don't think the situation in Belgium is all that unusual," Dr. Newland said

A big component in cases of sore throat in children younger than 5 years is the unnecessary ordering of rapid group A strep testing, he noted.

"There are plenty of children under the age of 5 or under even 3 who are tested for group A strep when they shouldn't be," Dr. Newland said.

"I'm speculating, but what I think likely happens is the rapid strep test is an easy test to do, and so when a patient presents...the clinician may say, 'Oh, lets just do the rapid test, and then if it's positive, I'll have my answer.' It's easy and can allow them to quickly move on to the next patient."

Dr. Roggen and and Dr. Newland have disclosed no relevant financial relationships.

European Society for Paediatric Infectious Diseases (ESPID) 30th Annual Meeting. Abstract 514. Presented May 11, 2012.


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