Antibiotics
Sonya Collins
In the United States, nearly one in three outpatient pediatric antibiotic prescriptions is inappropriate. New research published in JAMA suggests that the costs and adverse events associated with inappropriate prescribing of pediatric antibiotics have been underestimated.
In the study of more than 2.8 million insured children with common infections treated in an outpatient setting, those who were prescribed antibiotics inappropriately were more likely to experience adverse events, and their 30-day health care costs were higher.
“Pharmacists are in a unique position to educate their colleagues and patients about the harms—both clinical and economic—of inappropriate antibiotic prescribing,” said Anne Mobley Butler, PhD, assistant professor of medicine in the Division of Infectious Diseases at Washington University School of Medicine in St. Louis and lead author of the study. “Inappropriate antibiotics are a prime target for reducing health care expenditures and wasted resources, as antibiotics are the most commonly prescribed medication among children.”
Study findings
Researchers analyzed health and cost data for 2,804,254 children ages 6 months to 17 years who had bacterial (e.g., suppurative otitis media, pharyngitis, and sinusitis) or viral (influenza, viral upper respiratory infection, bronchiolitis, bronchitis, and nonsuppurative otitis media) infections, commonly diagnosed in the outpatient setting.
As many as 36% of the children in the cohort received inappropriate antibiotics for bacterial infections. Up to 70% were inappropriately prescribed antibiotics for viral infections.
Children who received inappropriate antibiotics for viral infections or nonrecommended antibiotics for bacterial infections were more likely to have severe adverse drug events, including C. difficile infections and severe allergic reactions, than the children who received appropriate treatment.
The 30-day health care costs of children in this group were generally higher, too. The average costs for those with bacterial infections ranged from $21 to $56. For children with viral infections, costs were up to $97, according to the analysis. Suppurative otitis media racked up the highest costs with an estimated national annual expenditure of $25.3 million, followed by pharyngitis at $21.3 million and viral upper respiratory infection at $19.1 million.
“Previous studies have focused on drug costs or emergency department visits to quantify antibiotic expenditures and adverse drug reactions from antibiotics, but these methods underestimate the full impact of inappropriate use by failing to account for all settings and downstream effects of antibiotics,” Butler said. “Our study of inappropriate antibiotic prescribing extends beyond the index prescription and incorporates downstream expenditures, and does so across all outpatient health care settings, including office visits, urgent care, and the emergency department.”
A role for pharmacists
The study findings, said Meredith Oliver, PharmD, “are a call for outpatient antimicrobial stewardship.” Oliver is a pediatric antimicrobial stewardship and infectious diseases pharmacist at M Health Fairview Masonic Children’s Hospital in Minneapolis, MN, who has not involved in the study.
Oliver suggests that the 4 most costly infections could be the primary targets of outpatient antibiotic stewardship programs.
“If you were to start an outpatient stewardship program, you could home in on improving prescribing for suppurative otitis media followed by the others,” she said.
CDC offers detailed guidance on how to create and implement an outpatient antimicrobial stewardship program, including specific resources on pediatric acute otitis media, acute sinusitis, pharyngitis, and upper respiratory infections. Among CDC’s recommendations are the following key points:
Identify a “point person” in charge of antimicrobial stewardship.
Implement at least one policy or practice to improve antimicrobial stewardship.
Track and report outcomes since implementation of the new policy or practice.
Offer regular feedback to clinicians.
“From a sustainability perspective, implementing a policy, tracking outcomes, and offering regular feedback is the best way to educate,” Oliver said. ■