Children With Asthma Prescribed Antibiotics Unnecessarily

Ingrid Hein

September 11, 2017

MILAN — Children presenting with asthma are 1.6 times more likely than children without asthma to be prescribed antibiotics by primary care practitioners, new research shows, despite the fact that antibiotics should not be used to treat asthma.

"We compared the UK primary care database with a Dutch database because we know that the Netherlands has one of the lowest antibiotic prescription rates in the world," said investigator Esmé Baan, MD, from the Department of Medical Informatics at Erasmus University in Rotterdam, the Netherlands.

Although antibiotic prescriptions overall were higher in the United Kingdom than in the Netherlands, the rate of prescriptions written by primary care practitioners for children with asthma were similar in the two places, she told Medscape Medical News.

For their study, Dr Baan and her colleagues identified 1,591,036 children 5 years or older in the British database, and 330,726 in the Dutch database.

An asthma disease code plus the use of at least two prescriptions for asthma drugs in a 1-year period were considered to indicate a diagnosis of asthma. "This would include salbutamol and inhaled corticosteroids," Dr Baan said here at the European Respiratory Society International Congress 2017.

The team cross-referenced antibiotic codes with codes for a diagnosis of asthma to determine how often antibiotics were prescribed.

After adjustment for age, sex, and calendar year, antibiotic use was significantly higher in children with asthma than in those without in the United Kingdom (374 vs 250 per 1000 patient-years) and in the Netherlands (197 vs 126 per 1000 patient-years). The rate of prescription was 60% higher in children with asthma than in those without asthma in the United Kingdom, and 65% higher in the Netherlands.

Children with asthma have a lot of respiratory symptoms, and when they are coughing or presenting with symptoms of infection, it is difficult to differentiate between an asthma exacerbation and infection, Dr Baan explained. It is possible that general practitioners are prescribing antibiotics because they "just want to be on the safe side."

Infection Not Always Easy to Identify

"If you've seen one bad pneumonia in a child, you want to give treatment on time," she said. "It's not a good excuse, but I understand it."

Parents who are quick to ask for antibiotics could also be a contributing factor, "but it's the role of the doctor to say no," she pointed out.

The prescription of antibiotics for asthma has been associated with increased microbial resistance, which puts the individual and the population at risk. "We have to make physicians and the population more aware," she said.

"The use of antibiotics is really too high in all countries," added Francesco Blasi, MD, from the University of Milan.

"Children are exposed to a lot of antibiotics and they get a lot of respiratory tract infections," he acknowledged, but antibiotic use in children needs to be reduced.

In a new program in the United Kingdom, patients are asked to wait a few days before filling antibiotic prescriptions, he reported. "This could be a good idea for children — delayed use."

The finding that most surprised Dr Baan and her colleagues was the prevalence of antibiotic prescriptions for asthma exacerbation only. This was the case in 3% of the British records and 14% of the Dutch records.

"I thought that if a doctor wasn't sure about a diagnosis, we would find a double diagnosis; for example, one for bronchitis and one for asthma," Dr Baan said. "But that wasn't the case. What we often saw was indication of asthmatic exacerbation only."

For children without asthma, the most common indication for antibiotics — lower respiratory tract infection — was documented in 21% of the records in the United Kingdom and 28% in the Netherlands. For children with asthma, the rates were 12% and 14%, respectively.

When the researchers looked at quality indicators for the prescription of antibiotics, they found that narrow-spectrum antibiotics were prescribed more often in the United Kingdom than in the Netherlands.

In the United Kingdom, ratios of amoxicillin use (indicating better quality) to broad-spectrum antibiotic use (indicating worse quality) were 7.6 for children with asthma and 8.6 for those without. In the Netherlands, ratios were 1.2 and 1.3, respectively.

Evidence of Change

Some of this difference is likely related to country-specific antibiotic guidelines. For example, Dr Baan explained, the prescription of first-generation cephalosporin, a narrow-spectrum antibiotic, was much higher in the United Kingdom than in the Netherlands, and "narrow-spectrum cephalosporin does better in quality scores." However, in Dutch guidelines, the use of cephalosporin is reserved for secondary care providers, like hospitals.

Despite high overall rates of antibiotic prescription in both countries, over the 4-year study period, there was a decrease of about 1% each year, overall, in the prescription of antibiotics for asthma, Dr Baan reported.

"We actually investigated the influence of time and saw, in both databases, a small but significant decrease of antibiotic use, so there is hope for change," she added.

Dr Baan has disclosed no relevant financial relationships. Dr Blasi is a consultant for GSK and Zambon, and has financial relationships with AstraZeneca, Bayer, Chiesi, Dompè, Guidotti-Malesci, Menarini, Novartis, Pfizer, Teva, and Thermofisher.

European Respiratory Society (ERS) International Congress 2017: Abstract OA3449. Presented September 12, 2017.

Follow Medscape Pulmonary Medicine on Twitter @MedscapeLung and Ingrid Hein @ingridhein

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