Antibiotic Prescribing During Pediatric Ambulatory Care Visits for Asthma

Abstract

OBJECTIVE: National guidelines do not recommend antibiotics as an asthma therapy. We sought to examine the frequency of inappropriate antibiotic prescribing during US ambulatory care pediatric asthma visits as well as the patient, provider, and systemic variables associated with such practice. PATIENTS AND METHODS: Data from the National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Survey were examined to assess office and emergency-department asthma visits made by children (aged <18 years) for frequencies of antibiotic prescription. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to assess the presence of coexisting conditions warranting antibiotics. Multivariable logistic regression models assessed associations with the prescription of antibiotics. RESULTS: From 1998 to 2007, an estimated 60.4 million visits occurred for asthma without another ICD-9 code justifying antibiotic prescription. Antibiotics were prescribed during 16% of these visits, most commonly macrolides (48.8%). In multivariate analysis, controlling for patient age, gender, race, insurance type, region, and controller medication use, systemic corticosteroid prescription (odds ratio [OR]: 2.69 [95% confidence interval (CI): 1.68–4.30]) and treatment during the winter (OR: 1.92 [95% CI: 1.05–3.52]) were associated with an increased likelihood of antibiotic prescription, whereas treatment in an emergency department was associated with decreased likelihood (OR: 0.48 [95% CI: 0.26–0.89]). A second multivariate analysis of only office-based visits demonstrated that asthma education during the visits was associated with reduced antibiotic prescriptions (OR: 0.46 [95% CI: 0.24–0.86]). CONCLUSIONS: Antibiotics are prescribed during nearly 1 in 6 US pediatric ambulatory care visits for asthma, ∼1 million prescriptions annually, when antibiotic need is undocumented. Additional education and interventions are needed to prevent unnecessary antibiotic prescribing for asthma.

Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial

“…Although one could argue that medical practices differ between private clinics and family practice teaching units, 30 we believe that the difference in outcomes observed at baseline can be attributed to a seasonal effect (baseline recruitment in late fall and winter in the pilot study v. summer and early fall in the current trial); this has been observed in other studies. 31 The seasonal effect might also explain the 13% increase in prescriptions in the control group between baseline (recruitment in the summer) and after the intervention (recruitment in the winter).…”

“…• 99 of 144 eligible physicians and 210 patients; median practice size = 40 physicians, range [29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] Clusters analyzed n = 4 units…”

Establishing Benchmarks for the Hospitalized Care of Children With Asthma, Bronchiolitis, and Pneumonia

“…18 In 2011, nearly 1 in 6 pediatric ambulatory care visits for asthma ended with a prescription for an antibiotic without another ICD-9 code to justify its use, raising the concern for unnecessary antibiotic use. 19 With concern about antibiotic overutilization for asthma, along with previous reports of antibiotic use in asthmatic subjects of ∼20%, an ABC of 6.6% seems to be an appropriate goal. We also demonstrated an ABC of 24.5% for CXR use in asthma management, which is consistent with literature that supports the belief that CXR is not routinely indicated for asthma exacerbations but only in circumstances with clinical suspicion for alternate diagnosis (eg, pneumothorax, foreign body, pneumonia).…”

Race, Otitis Media, and Antibiotic Selection

“…Patients were excluded from the analysis of antibiotic prescribing for OM if a diagnosis of another condition warranting antibiotics was made concomitantly (eg, mastoiditis, acute pharyngitis, acute tonsillitis, nonviral pneumonia, streptococcal sore throat or scarlet fever, acute sinusitis, peritonsillar abscess, urinary tract infection, or skin and soft tissue infection). 15 Narrowspectrum antibiotics consisted of penicillins (including amoxicillin), firstgeneration cephalosporins, tetracyclines, and sulfonamides. 16 Broad-spectrum antibiotics included macrolides (eg, azithromycin), quinolones, broad-spectrum penicillins (eg, b-lactam/b-lactamase inhibitor combinations), lincomycin derivatives (clindamycin), and broad-spectrum (second-or third-generation) cephalosporins.…”