Antibiotic-Related Adverse Events Tied to 70,000 ED Visits by Kids Each Year

Roxanne Nelson, BSN, RN

August 23, 2018

Antibiotic use was associated with nearly 70,000 emergency department (ED) visits by children each between 2011 and 2015, according to a new analysis published in the Journal of the Pediatric Infectious Diseases Society.

Most ED visit were for allergic reactions, which varied in severity from a rash to anaphylaxis, and these events disproportionately affected young children.

"For parents and other caregivers of children, these findings are a reminder that while antibiotics save lives when used appropriately, antibiotics also can harm children and should only be used when needed," said lead author Maribeth C. Lovegrove, MPH, from the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention, in a statement. "For health care providers, these findings are a reminder that adverse effects from antibiotics are common and can be clinically significant and consequential for pediatric patients."

Antibiotics are among the most commonly prescribed medications for children, and the authors note that in 2011, antibiotics accounted for nearly 74 million prescriptions among patients aged 19 years and younger.

Efforts to reduce antimicrobial resistance have focused largely on reducing inappropriate prescribing, yet researchers estimate that approximately one third of outpatient pediatric antibiotic prescriptions are unnecessary, and more are likely to be inappropriate in terms of antibiotic selection, dosing, or duration.

Data on the individual short-term risks for antibiotic-related adverse events (AEs) could help clinicians and parents weigh the risks and benefits of antibiotic treatment.

In the current study, Lovegrove and colleagues analyzed data from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project and retail pharmacy dispensing data from QuintilesIMS (2011 - 2015) to identify the antibiotics that caused the highest rates of ED visits related to adverse events, as well as the children at the highest risk.

Based on 6542 surveillance cases, the researchers estimate that antibiotic AEs led to 69,464 ED visits per year among patients age 19 years or younger. Only a small percentage (3.0%) of these ED visits resulted in hospitalization.

Antibiotic-related AEs accounted for 46.2% of all ED visits for AEs from a systemic medication in this population. Among children 2 years of age and younger, antibiotics accounted for 63.9% of ED visits for AEs from a systemic medication. Among children aged 10 to 19 years, antibiotics accounted for just 32.4% of AEs related to a systemic medication.

For nearly all pediatric ED visits (95.9%), a single class of oral antibiotics was implicated. Only 2.2% involved two antibiotics from different classes, and 1.9% were attributed to only an injectable antibiotic.

When looking at specific drug classes, the researchers found that oral penicillins were involved in about 38,680 ED visits annually, or 55.7% of antibiotic-related ED visits.  Oral cephalosporins (11.9%) were the second most frequently implicated class, followed by sulfonamides (11.1%) alone. Overall, oral sulfonamides and clindamycin resulted in the highest rates of ED visits after accounting for estimates of prescriptions from retail pharmacies (18.0 and 16.6 ED visits per 10,000 dispensed prescriptions, respectively).

Most AEs were mild allergic reactions, such as rash or pruritus, and ranged from half of the visits that involved an oral quinolone alone (51.4%) to four fifths of the visits involving penicillins (81.0%) or a sulfonamide (80.9%) alone.

A moderate-to-severe allergic reaction, such as anaphylaxis or angioedema, occurred in 30.0% of patients from an oral quinolone alone and 19.8% from a tetracycline alone. Oral sulfonamides and clindamycin were associated with the lowest incidence of mild reactions (1 in 688 and 1 in 856 dispensed prescriptions, respectively), and for moderate-to-severe allergic reaction, oral quinolones were the lowest (1 in 2525 dispensed prescriptions).

The rates of ED visits for antibiotic AEs decreased as patient age increased for all antibiotics except for sulfamethoxazole-trimethoprim. Amoxicillin was associated with the highest rate of ED visits for children aged 9 years or younger, while sulfamethoxazole-trimethoprim use had the highest rate of AEs among those aged 10 to 19 years (29.9 and 24.2 ED visits per 10,000 dispensed prescriptions, respectively).

"By considering available data on the immediate risks to individual patients, clinicians, and parents and caregivers can better weigh the risks and benefits of antibiotic treatment," Lovegrove said.

The authors note several study limitations, including that only AEs resulting in presentation to an ED were included. AEs that are more likely dealt with elsewhere, such as Clostridium difficile infection, or were not severe enough to require emergency attention were not included. Thus, the overall incidence is an underestimate of antibiotic-related AEs.

The study was funded by the Centers for Disease Control and Prevention. All authors are employees of the Centers for Disease Control and Prevention and disclosed no relevant financial relationships.

J Pediatr Infect Dis Soc. Published online August 23, 2018. Full text

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