Children Overprescribed Antibiotics
Clinicians prescribe antibiotics for more than half of children with sore throat, exceeding the expected prevalence of strep throat, and used nonrecommended antibiotics for 27 percent of children who received an antibiotic prescription, according to a study in the November 9 issue of JAMA.
Pharyngitis (inflammation of the throat) accounts for 6 percent of visits by children to family medicine clinicians and pediatricians, according to background information in the article. The most common manifestation of acute pharyngitis is sore throat. The main bacterial cause of sore throat and the only common cause of sore throat warranting antibiotic treatment is group A beta-hemolytic streptococci (GABHS). GABHS are cultured from 15 percent to 36 percent of children with sore throat. To improve diagnostic accuracy and reduce unnecessary antibiotic treatment, it is recommended that a GABHS test be conducted prior to treating children with an antibiotic. Penicillin is the recommended antibiotic, but acceptable alternatives include amoxicillin, erythromycin (for penicillin-allergic patients), and first-generation cephalosporins.
Jeffrey A. Linder, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, Boston, and his colleagues conducted a study to determine the change in the rate and type of antibiotics prescribed to children with a chief complaint of sore throat, and the frequency of GABHS testing.
The scientists used data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1995 to 2003. The study included an analysis of visits by children aged 3 to 17 years with sore throat to office-based clinicians, hospital outpatient departments, and emergency departments (n = 4,158), and of a subset of visits with GABHS testing data (n = 2,797).
The scientists found that clinicians prescribed antibiotics in 53 percent of an estimated 7.3 million annual visits for sore throat and nonrecommended antibiotics to 27 percent of children who received an antibiotic. Antibiotic prescribing decreased from 66 percent of visits in 1995 to 54 percent of visits in 2003. This decrease was attributable to a decrease in the prescribing of recommended antibiotics (49 percent to 38 percent). Clinicians performed a GABHS test in 53 percent of visits and in 51 percent of visits at which an antibiotic was prescribed. GABHS testing was not associated with a lower antibiotic prescribing rate overall (48 percent tested vs. 51 percent not tested), but testing was associated with a lower antibiotic prescribing rate for children with diagnosis codes for pharyngitis, tonsillitis, and streptococcal sore throat (57 percent tested vs. 73 percent not tested).
"In conclusion, we found that clinicians prescribed antibiotics less frequently over time to children with sore throat. However, the overall antibiotic prescribing rate continues to exceed the expected prevalence of GABHS, and clinicians continue to select unnecessarily broad-spectrum antibiotics. Unnecessary antibiotic prescriptions are not non-malignant: they increase the prevalence of antibiotic-resistant bacteria, expose patients to adverse drug events, and increase costs. Perhaps unique among upper respiratory tract infections, physicians have good, objective criteria in the form of GABHS testing to guide the antibiotic treatment of children with sore throat. Limiting antibiotic prescribing to children with a positive GABHS test result is a feasible goal for primary care clinicians and an important step toward judicious use of antibiotics overall," the authors write.
(JAMA. 2005;294:2315-2322. Available pre-embargo to the media at www.jamamedia.org).
Editor's Note: This study was supported by the Agency for Healthcare Research and Quality through a Career Development Award to Dr. Linder. Co-author Grace M. Lee, M.D., M.P.H., is supported by an Agency for Healthcare Research and Quality Career Development Award.