Antibiotic Prescribing for Children May Be Leveling Off

Larry Hand

February 04, 2014

A downward trend in outpatient antibiotic prescribing for children may have reached a plateau, according to an article published online February 2 in Pediatrics. In fact, in some areas, prescribing rates may have started inching back up.

Louise Elaine Vaz, MD, from the Division of Infectious Diseases and Department of Laboratory Medicine, Boston Children's Hospital, Massachusetts, and colleagues analyzed pharmacy and outpatient claims from September 2000 to August 2010 for 3 regional US health plans: a commercial health insurer in New England, an integrated healthcare delivery system in the Mountain West, and an integrated health system with affiliated network practices in the Midwest.

The researchers calculated rates of antibiotic dispensing per person-year for children between 3 months and 18 years of age and then calculated differences in rates per year, diagnosis, and health plan. They analyzed data by 4 age groups: from 3 to fewer than 24 months, 2 to fewer than 6 years, 6 to fewer than 12 years, and 12 to fewer than 18 years.

The researchers found statistically significant variation (P < .001) among the 3 health plans, with the Mountain West region having consistently lower rates of antibiotic dispensing than New England and the Midwest for each age group.

Variation by Area and Age

Overall antibiotic dispensing rates declined from 2000 to 2010, going from 2.27 (New England), 1.40 (Mountain West), and 2.23 (Midwest) antibiotics per person-year in 2000-2001 to 1.62, 0.91, and 1.70, respectively, in 2009-2010. The youngest patients, aged 3 to fewer than 24 months, had the highest rates of antibiotic prescriptions during all years.

However, using Poisson regression modeling, the researchers found that downward trend slopes changed at different times during the period, depending on age group and site.

For the youngest children, the group with the greatest decline, the early yearly declines ranged from 5.0% to 9.3% among the 3 plans. However, after an inflection year (2004-2005 for New England and 2003-2004 for the other 2 plans), annual declines dropped to less than 3% for the New England and Mountain West plans and to almost zero for the Midwest plan.

Moreover, the researchers observed a 5% increase in dispensing for the youngest age group from 2008-2009 to 2009-2010 (0.59 - 0.62; P < .001) for the Mountain West region.

Variation by Diagnosis and Antibiotic

Respiratory tract infections accounted for most (>75%) of all antibiotic prescribing for children younger than 12 years. For children younger than 6 years, and particularly for the youngest children, otitis media (OM) was the most common diagnosis for prescribing antibiotics. However, the prescribing rate for OM declined for all plans from 2000 to 2010 (New England went from 1.40 to 1.05, Mountain West went from 0.93 to 0.64, and Midwest went from 1.44 to 1.04; P < .001).

Most antibiotics prescribed for children younger than 12 years were penicillins, cephalosporins, and second-generation macrolides, although tetracyclines followed penicillins closely for adolescents, coinciding with healthcare visits for acne.

Prescribing of broad-spectrum, third-generation cephalosporins increased during the period, often for OM diagnoses in children younger than 12 years and for sinusitis in adolescents.

Guidelines and Education

The decline in prescribing antibiotics for OM may be a result of "guidelines and education aimed at narrowing the diagnostic criteria for acute OM, as well as use of the conjugated pneumococcal vaccine," the researchers write. Overall, identifying best practices in low-prescribing areas could improve "judicious antibiotic use," they add.

"Our data suggest that the downward trend in antibiotic use for children, observed for more than a decade, is coming to an end. This finding seems to be true across all pediatric age groups," the researchers conclude. "However, because the highest rates of antibiotic use continue to be in young children, decreasing broad-spectrum use for common conditions such as OM will need to be a continuing focus for intervention."

What Next? 3 Suggestions

In an accompanying commentary, Ateev Mehrotra, MD, from the Department of Health Care Policy, Harvard Medical School, Boston, writes that the new study provides an opportunity to review why prescribing decreased and to consider next steps.

"One striking finding in the article by Vaz et al is that 1 health system's antibiotic prescribing rate was almost one-half that of the other 2 sites," he writes. "Given that ongoing efforts appear to be no longer working, the question is what next."

He put forth 3 suggestions, including efforts to focus attention on limiting inappropriate prescribing over the telephone, be more "intrusive on providers to curb antibiotic" prescribing for conditions such as viral upper respiratory tract infections, and educate parents on how to " 'self-triage' and therefore completely avoid physician office visits."

This research was supported by the National Institutes of Health. Dr. Mehrotra received funding from the National Institute of Allergy and Infectious Diseases. The authors and Dr. Mehrotra have disclosed no other relevant financial relationships.

Pediatrics. Published online February 2, 2014. Article full text, Commentary full text


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