Antibiotics overused in children with asthma exacerbations

Article Outline

• Question
• Design
• Setting
• Participants
• Outcomes
• Main Results
• Conclusions
• Commentary
• Reference
• Copyright

De Boeck K, Vermeulen F, Meyts I, Hutsebaut L, Franckaert D, Proesmans M. Coprescription of Antibiotics and Asthma Drugs in Children. Pediatrics 2011;127:1022-6.

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Question 

Among children with asthma exacerbations, how often are antibiotics prescribed and is this beneficial?

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Design 

Health insurance database analysis.

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Setting 

Belgium.

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Participants 

The insurance database covers 44% of the Belgian population. The population selected for this study included 892,841 Belgian children aged <18 years.

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Outcomes 

Codispensing of antibiotics, calculated as the percentage of subjects with an asthma drug dispensed who had an antibiotic dispensed on the same day, as well as throughout the same year.

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Main Results 

For a 1-year period, an antibiotic was dispensed to 44.21% of children: 73.05% aged <3 years; 49.62% aged 3 to 7 years; and 34.21% aged 8 to <18 years. An asthma drug was dispensed to 16.04% of children: 44.81% aged <3 years; 17.90% aged 3 to 7 years; and 7.64% aged 8 to <18 years. Overall, an antibiotic was dispensed without an asthma drug to 38.62% of children versus with an asthma drug to 73.50% of children (P<.0001). More frequent dispensing of antibiotics to children who received an asthma drug (odds ratio: 1.90; 95% confidence interval: 1.89 –1.91) occurred in all age categories (P<.0001). In 35.64% of children with an asthma drug dispensed, an antibiotic was dispensed on the same day.

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Conclusions 

In all age groups, dispensing of antibiotics is more likely in children who have an asthma drug dispensed in the same year, and codispensing of antibiotics and asthma drugs is a common practice. Efforts to decrease antibiotic use in children could be improved by focusing on children who are being treated with asthma drugs.

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Commentary 

Over the past 10 years, there has been a national focus on reducing unnecessary antibiotic use in children with upper respiratory infections and otitis media. This robust study by De Boeck et al highlights a new area of potential antibiotic overuse — patients with asthma exacerbations. In this large study from Belgium, children who were prescribed an asthma drug were twice as likely to have also been prescribed an antibiotic, compared with those who were not prescribed an asthma drug. This discrepancy in antibiotic prescriptions was seen across all age groups. Importantly, 35% of children in the study were prescribed an asthma drug and antibiotic on the same day. Although the study, which was based on insurance data, was not able to investigate patient symptoms or the decision-making process of the physician, this large difference in antibiotic prescribing is of concern. It is well known that the majority of infections causing asthma exacerbations are due to viral infections, and bacterial superinfection is uncommon. Mangione-Smith and Krogstad examine potential reasons for the antibiotic overuse in patients with asthma in an accompanying commentary.¹ One of the most likely reasons is diagnostic uncertainty. Physicians may be worried about possibility of a concomitant pneumonia or other bacterial infection in patients, especially those with more severe asthma exacerbations. Although it may be difficult to differentiate between asthma and a bacterial infection in very young children, it gets easier after children are of school-age. Thus, the authors of this study advocate for increased education of physicians and of patients with asthma and their families as a way to decrease overuse and potentially inappropriate use of antibiotics. It may also be worthwhile employing a “watchful waiting” approach, similar to that used in some cases for otitis media.¹

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Reference 

1. Mangione-Smith R, Krogstad P. Antibiotic prescription with asthma medications: Why is it so common?. Pediatrics. 2011;127:1174–1176
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