Prophylactic Broad-Spectrum Antibiotics Common in Pediatric Hospitals

Ricki Lewis, PhD

April 03, 2018

Nearly one third (32.9%) of hospitalized children received antibiotics prophylactically, and 51.8% of those children were given broad-spectrum antibiotics, according to findings published online March 22 in the Journal of the Pediatric Infectious Diseases Society.

"Although the appropriate selection and administration of antibiotics certainly saves lives, their widespread overuse — especially of broad-spectrum antibiotics — has also contributed to significant increases in antimicrobial resistance," Markus Hufnagel, MD, director of pediatric rheumatology and deputy director of pediatric infectious diseases at the University Children's Hospital in Freiburg, Germany, and colleagues write.

They examined the variation in prescription practices for systemic antibiotics used prophylactically in pediatric patients at 226 pediatric hospitals in 41 countries in October and November 2012. They identify combination prescriptions, widespread use of broad-spectrum antibiotics, and prolonged duration of surgical prophylaxis as targets for minimizing antimicrobial use.

Data used in the comprehensive study included patient age, sex, current weight, diagnoses, and whether prophylaxis was surgical or medical. The investigators recorded duration of surgical prophylaxis as single dose, 24 hours, or more than 24 hours.

The researchers used the cross-sectional Antibiotic Resistance and Prescribing in European Children Point Prevalence Survey to assess 17,693 patients, of whom 6499 (36.7%) received antibiotics.

Medical Prophylaxis

Medical prophylaxis was the reason for 83.5% of antimicrobial prescriptions (24.9% of all antimicrobials) given to children younger than 30 days and 70.4% (19.9% of all antimicrobials) of those prescribed for children aged 30 days or older.

For medical prophylaxis, the three most common antimicrobials prescribed for children aged 30 days or older were trimethoprim/sulfonamides, antifungals, and antivirals. Use of narrow-spectrum penicillins was equal around the world, but prescribing rates were higher in northern Europe than the rest of the continent. In North America, prescribing practices favored macrolides and lincosamides. Asian hospitals tended to use more third- or fourth-generation cephalosporins and fewer trimethoprim/sulfonamides.

"Guidelines for medical antibiotic prophylaxis can only be found for a few specific medical conditions, such as congenital heart anomalies, vesicoureteral reflux, acute rheumatic fever, asplenia and sickle cell disease, meningococcal and pertussis exposure, Pneumocystis pneumonia prophylaxis, and latent tuberculosis infection," the researchers write.

Surgical Prophylaxis

Surgical prophylaxis accounted for 16.5% (4.9% of all antimicrobials) of antimicrobials prescribed for children younger than 30 days and 29.6% (8.3% of all antimicrobials) of those prescribed for children aged 30 days or older.

"Because pediatric-specific surgical prophylaxis data are sparse, pediatric recommendations have been extrapolated from adult data," the authors explain.

At least 80% of children who received surgical prophylaxis were given antibiotics for longer than a day.

For children younger than 30 days, the four most common classes of antimicrobials prescribed for surgical prophylaxis were aminoglycosides, narrow-spectrum penicillins, imidazole derivates, and glycopeptides.

For surgical prophylaxis among the children aged 30 days or older, first-generation cephalosporins, narrow-spectrum penicillins, second-generation cephalosporins, and third- or fourth-generation cephalosporins were most commonly prescribed. First-generation cephalosporins were more commonly prescribed in North America and Australia, whereas narrow-spectrum penicillins were more commonly prescribed in northern Europe. Second-generation cephalosporins were more often used in Western Europe. Asia favored third- or fourth-generation cephalosporins and fluoroquinolones.

Use of Multiple Antimicrobials Common

Nearly half (1656 of the 3400, or 48.7%) of the prescriptions were for patients receiving at least two antimicrobials. Broad-spectrum drugs made up 1761 of the 3400 prophylactically prescribed drugs (51.8%).

Of the 2242 patients who received prophylactic antibiotics, 1420 (63.3%) received one drug, 576 (25.7%) received two drugs, and 246 (11.0%) received three or more drugs. Prescription of two or more drugs was more prevalent for medical prophylaxis (615 of 1582, or 38.9%) than surgical prophylaxis (183 of 636, or 28.8%; risk ratio, 1.391; 95% confidence interval, 1.199 - 1.613).

Underlying Conditions

Among 619 infants younger than 30 days, the most common underlying condition was respiratory distress (138, or 22.3%), followed by premature rupture of membranes (110, or 17.8%), and surgical disease (74, or 12.0%). No underlying disease was noted for 88 (14.2%) of the younger group.

For the 1623 children aged 30 days or older receiving prophylactic antimicrobials, the most common reported underlying condition was cancer (536, or 33.0%), followed by surgery (316, or 19.5%), and chronic heart condition (107, or 6.6%). No underlying disease was known for 203 (12.5%) of the children aged 30 days or older.

Limitations of the investigation include the cross-sectional design that provides a "snapshot" of prescribing practices, possible participation bias, lack of a consensus definition of medical prophylaxis, overrepresentation of tertiary care facilities, uneven representation of geographical regions, and not knowing the specific indications for prophylaxis, just the underlying diagnoses.

"We conclude that the following interventions are needed: (1) reduce the high rate of antimicrobial combination prescriptions, especially in medical prophylaxis; (2) limit the high rate of broad-spectrum antibiotic usage; and (3) combat the extended duration of surgical prophylaxis," the researchers write.

The authors have disclosed no relevant financial relationships.

J Pediatric Infect Dis Soc. Published online March 22, 2018. Abstract

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