Bacterial Prevalence and Antimicrobial Prescribing Trends for Acute Respiratory Tract Infections

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Many pediatric acute respiratory tract infections (ARTI) are viral and do not require antimicrobial treatment. Recent estimates of antimicrobial overprescribing for these infections, defined based on the published bacterial disease prevalence among all ARTI, are not available. WHAT THIS STUDY ADDS:Based on the published bacterial prevalence rates for pediatric ARTI, antimicrobial agents are prescribed almost twice as often as expected to outpatients nationally, amounting to an estimated 11.4 million potentially preventable antimicrobial prescriptions annually. abstract BACKGROUND AND OBJECTIVES: Antimicrobials are frequently prescribed for acute respiratory tract infections (ARTI), although many are viral. We aimed to determine bacterial prevalence rates for 5 common childhood ARTI -acute otitis media (AOM), sinusitis, bronchitis, upper respiratory tract infection, and pharyngitis-and to compare these rates to nationally representative antimicrobial prescription rates for these ARTI. METHODS:We performed (1) a meta-analysis of English language pediatric studies published between 2000 and 2011 in Medline, Embase, and the Cochrane library to determine ARTI bacterial prevalence rates; and (2) a retrospective cohort analysis of children age ,18 years evaluated in ambulatory clinics sampled by the 2000-2010 National Ambulatory Medical Care Survey (NAMCS) to determine estimated US ARTI antimicrobial prescribing rates. RESULTS:From the meta-analysis, the AOM bacterial prevalence was 64.7% (95% confidence interval [CI], 50.5%-77.7%); Streptococcus pyogenes prevalence during pharyngitis was 20.2% (95% CI, 15.9%-25.2%). No URI or bronchitis studies met inclusion criteria, and 1 sinusitis study met inclusion criteria, identifying bacteria in 78% of subjects. Based on these condition-specific bacterial prevalence rates, the expected antimicrobial rescribing rate for ARTI overall was 27.4% (95% CI, 26.5%-28.3%). However, antimicrobial agents were prescribed in NAMCS during 56.9% (95% CI, 50.8%-63.1%) of ARTI encounters, representing an estimated 11.4 million potentially preventable antimicrobial prescriptions annually.

Communication Practices and Antibiotic Use for Acute Respiratory Tract Infections in Children

“…3,32 On the other hand, bacterial diagnoses were given in only 34% of study visits (400/1,194), which is relatively close to the 27% bacterial prevalence rate expected for pediatric ARTIs and substantially below the 49% national rate of assigning bacterial diagnoses in pediatric ARTI visits. 3 While the Hawthorne effect may explain some of the presumed overdiagnosis of bacterial illness, 15 we hypothesize 2 additional reasons this might have occurred: diagnostic uncertainty and perceived parental pressure to prescribe antibiotics. In cases where the provider is faced with diagnostic uncertainty, use of a contingency plan may allow for the child's illness to evolve and be more clearly classified as viral or bacterial over the ensuing 2 to 3 days.…”

“…[1][2][3] In the outpatient setting, more than 50% of children diagnosed with ARTIs receive antibiotic prescriptions. 1,3 Considering that the estimated US prevalence of pediatric bacterial ARTIs is 27%, 3 this represents substantial antibiotic overuse nationwide. Unwarranted use of antibiotics is associated with increased resistance among bacteria that commonly cause ARTIs, posing risks to both individuals and communities.…”

Antibiotic Exposure and Juvenile Idiopathic Arthritis: A Case–Control Study

“…This public health finding is potentially important, considering that approximately onequarter of antibiotics prescribed for children, and an estimated one-half of antibiotics for acute respiratory infections, may be unnecessary and potentially avoidable. 31,32 The human microbiome plays important roles in immune regulation and self-tolerance. 33 Disturbance of the intestinal microbiome has been linked to several autoimmune diseases, including IBD, 34,35 rheumatoid arthritis, [36][37][38][39][40] and at least 1 category of JIA.…”

Identifying and treating group A streptococcal pharyngitis in children

“…Given that most sore throats are caused by viruses, giving treatment to all patients would result in unnecessary antibiotic use in an era of increasing antimicrobial resistance. 3 Having all patients undergo testing will reduce antibiotic exposure, but may be less desirable to physicians who have to follow-up with patients after their appointments to provide results or call in prescriptions. This strategy also involves higher cost and may lead to increased symptom duration.…”

“…1 Most of these infections are caused by viruses, but about 20%-40% of cases in children are due to group A streptococcal infection. 2,3 Differentiating between streptococcal and viral causes has proven difficult, because individual signs and symptoms are not sufficiently discerning. 4 Thus, some expert guidelines recommend microbiologic testing.…”