Evidence for causal associations between prenatal and postnatal antibiotic exposure and asthma in children, England

Prevalence of systemic antibacterial use during pregnancy worldwide: A systematic review

OBJECTIVES

In this study, we aimed to systematically review the literature of the prevalence of systemic antibacterial use during pregnancy and to perform a descriptive analysis focused on methodological characteristics.

MATERIALS AND METHODS

This study was registered in PROSPERO under protocol number CRD42022376634. Medline, Embase, Scientific Electronic Library Online, Biblioteca Virtual em Saúde, Cumulative Index to Nursing and Allied Health Literature, and Web of Science databases were searched (published studies until November 3rd, 2022). Selected studies were population-based cross-sectional or cohort, carried out with pregnant women, and providing information about the prevalence of systemic antibacterial use at least in one trimester of pregnancy. Reviewers conducted in pairs the title and abstract screening, eligibility criteria check, and data extraction of selected studies. Quality appraisal was performed with an adapted version of the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Data of included studies were pooled into a graphical and tabular summary.

RESULTS

A total of 16,251,280 pregnant women and 5,169,959 pregnancy registers were identified. The prevalence estimates of systemic antibacterial use during pregnancy ranged from 2.0% (95%CI 2.0-2.0) to 64.3% (95%CI not reported) in the 79 included studies. The majority were performed in high-income countries (91.5%). Overall, the studies revealed considerable prevalence heterogeneity in terms of study type and dataset used. The 95% confidence intervals were not reported in 41% of studies.

CONCLUSION

The disparities in the prevalence of systemic antibacterial use during pregnancy can be related to methodological issues and different health policies. Lack of uniform databases and changes in data collection methods over time should be taken into account in public health strategy planning. The scarce evidence in low- and middle-income settings hampers the comprehensiveness of the global prevalence of antibacterial use during pregnancy.

Defining cases of asthma, eczema and allergic rhinitis using electronic health records in the Born in Bradford birth cohort

Key Messages • In electronic health records, the accuracy of diagnostic codes to define outcomes can be uncertain • The accuracy can vary in different settings, doctors and practices, even with validated codes • We recommend definitions combining codes previously described and other codes available in the records.

Duration of Neonatal Antibiotic Exposure in Preterm Infants in Association with Health and Developmental Outcomes in Early Childhood

Over 90% of preterm neonates are, often empirically, exposed to antibiotics as a potentially life-saving measure against sepsis. Long-term outcome in association with antibiotic exposure (NABE) has insufficiently been studied after preterm birth. We investigated the association of NABE-duration with early-childhood developmental and health outcomes in preterm-born children and additionally assessed the impact of GA on outcomes. Preterm children (GA < 30 weeks) participating in a multicenter cohort study were approached for follow-up. General expert-reviewed health questionnaires on respiratory, atopic and gastrointestinal symptoms were sent to parents of children > 24 months' corrected age (CA). Growth and developmental assessments (Bayley Scales of Infant and Toddler Development (BSID) III) were part of standard care assessment at 24 months' CA. Uni- and multivariate regressions were performed with NABE (per 5 days) and GA (per week) as independent variables. Odds ratios (OR) for health outcomes were adjusted (aOR) for confounders, where appropriate. Of 1079 infants whose parents were approached, 347 (32%) responded at a mean age of 4.6 years (SD 0.9). In children with NABE (97%), NABE duration decreased by 1.6 days (p < 0.001) per week of gestation. Below-average gross-motor development (BSID-III gross-motor score < 8) was associated with duration of NABE (aOR = 1.28; p = 0.04). The aOR for constipation was 0.81 (p = 0.04) per gestational week. Growth was inversely correlated with GA. Respiratory and atopic symptoms were not associated with NABE, nor GA. We observed that prolonged NABE after preterm birth was associated with below-average gross-motor development at 24 months' CA, while a low GA was associated with lower weight and stature Z-scores and higher odds for constipation.

Appropriate Use of Antibiotic and Principles of Antimicrobial Stewardship in Children

Antibiotics account for over 10% of the overall drug expense of the National Health System in Italy in 2021. Their use in children is of particular interest on one side, because acute infections are very common in children, while they build their immunologic library of competence; on the other side, although many acute infections are expected and turn out to be of viral origin, caregivers will often ask the family doctor or primary care attending to reassure them by prescribing antibiotic treatment, although it may often be unnecessary. The inappropriate prescription of antibiotics in children may likely be a source not only of undue economic burden for the public health system but also of increasing development of antimicrobial resistance (AMR). Based on those issues, the inappropriate use of antibiotics in children should be avoided to reduce the risks of unnecessary toxicity, increase in health costs, lifelong effects, and selection of resistant organisms causing undue deaths. Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure an optimal use of antimicrobials to improve patient outcomes while limiting the risk of adverse events including AMR. The aim of this paper is to spread some concept of good use of antibiotics for pediatricians or every other physician involved in the choice to prescribe, or not, antibiotics in children. Several actions could be of help in this process, including the following: (1) identify patients with high probability of bacterial infection; (2) collect samples for culture study before starting antibiotic treatment if invasive bacterial infection is suspected; (3) select the appropriate antibiotic molecule based on local resistance and narrow spectrum for the suspected pathogen(s); avoid multi-antibiotic association; prescribe correct dosage; (4) choose the best route of administration (oral vs. parenteral) and the best schedule of administration for every prescription (i.e., multiple administration for beta lactam); (5) schedule clinical and laboratory re-evaluation with the aim to consider therapeutic de-escalation; (6) stop antibiotic administration as soon as possible, avoiding the application of "antibiotic course".

Strategies to Prevent Early and Late-Onset Group B Streptococcal Infection via Interventions in Pregnancy

Group B Streptococcus is a Gram-positive bacterium that typically colonizes 10-30% of pregnant women, causing chorioamnionitis, preterm birth, and stillbirth, as well as neonatal sepsis and meningitis with early-onset disease (EOD) or late-onset disease (LOD) due to ascending infection or transmission during delivery. While there are some differences between EOD and LOD in terms of route of transmission, risk factors, and serotypes, the only preventive approach currently is maternal intrapartum antibiotic prophylaxis (IAP) which will not be able to fully address the burden of the disease since this has no impact on LOD. Probiotics and immunization in pregnancy may be more effective than IAP for both EOD and LOD. There is mixed evidence of probiotic effects on the prevention of GBS colonization, and the data from completed and ongoing clinical trials investigating different GBS vaccines are promising. Current vaccine candidates target bacterial proteins or the polysaccharide capsule and include trivalent, tetravalent, and hexavalent protein-polysaccharide conjugate vaccines. Some challenges in developing novel GBS vaccines include the lack of a correlate of protection, the potential for serotype switching, a need to understand interactions with other vaccines, and optimal timing of administration in pregnancy to maximize protection for both term and preterm infants.

Relationships between antibiotic exposure and asthma in adults in the United States: results of the National Health and Nutrition Examination Survey between 1999 and 2018

Objectives

To investigate the relationship between antibiotic exposure and asthma in adults in the United States.

Methods

Data was obtained from the National Health and Nutrition Examination Survey (NHANES) conducted between 1999 and 2018. A total of 51,124 participants were included, excluding those who were aged < 20 years, female participants who were pregnant, and individuals who did not complete the prescription medications questionnaire and the medical conditions questionnaire regarding asthma status. Antibiotic exposure was defined as the utilization of antibiotics within the past 30 days, categorized based on the Multum Lexicon Plus therapeutic classification system. Asthma was defined as having a history of asthma or having an asthma attack or wheezing symptoms in the past year.

Results

The risk of asthma was found to be 2.557 (95% CI: 1.811, 3.612), 1.547 (95% CI: 1.190, 2.011) and 2.053 (95% CI: 1.344, 3.137) times greater in participants who had used macrolide derivatives, penicillin and quinolones in the past 30 days, respectively, compared with those not using antibiotics. After adjusting for demographic covariates and asthma-related factors, only macrolides derivatives were significantly associated with asthma in the 20-40 and 40-60 age groups. For individuals over 60 years old, quinolones were significantly associated with asthma. The effect of different types of antibiotic with asthma varied in male and female populations. Moreover, higher socioeconomic status, greater BMI, younger age, smoking habits, history of infection, chronic bronchitis, emphysema, and family history of asthma were all identified as risk factors for asthma.

Conclusion

Our study indicated that three types of antibiotics were significantly associated with asthma in different subgroups of the population. Therefore, the use of antibiotics should be more strictly regulated.

Early life environmental antibiotic exposure and preschool allergic diseases: A biomonitoring-based prospective study in eastern China

Background

Globally, the prevalence of allergic diseases remains high, as does the level of environmental antibiotics. It has been found that clinical antibiotic application may increase preschool allergy risk. However, few biomonitoring studies have been conducted about the association between early life environmental trace dose antibiotic exposure and preschool allergy.

Objective

To analyze the association between prenatal environmental antibiotic levels and allergic diseases using logistic regression models.

Methods

A total of 743 pregnant women and their offspring from the Shanghai Allergy Birth Cohort completed five years follow-up, and 251 mother-infant pairs were finally included. Maternal urine samples were collected for 15 antibiotic quantitative measurements using liquid chromatography-tandem mass spectrometry. The high-antibiotic group was defined as having at least half of antibiotics exceeding the median concentration. Allergic diseases were assessed by clinicians through clinical history, standardized questionnaires, and annual physical examinations until the age of five. Skin-prick-test (SPT) was performed at 5 years old.

Results

The incidence of allergic diseases was generally higher in the high-antibiotic than that in the low-antibiotic group. Compared to the low-comprehensive antibiotic group, children in the high-antibiotic group were weakly associated with allergic diseases but had a 6-fold increased risk of food allergens sensitivity (OR: 7.09, 95% CI: 1.59, 31.74). Association of above-median single prenatal antibiotic concentration exposure and allergic diseases was also observed (azithromycin and asthma, OR: 2.72, 95% CI: 1.15, 6.42; enrofloxacin and wheeze, OR: 2.22, 95% CI: 1.22, 4.05; trimethoprim and atopic dermatitis, OR: 2.00, 95% CI: 1.08, 3.71). Moreover, children with higher prenatal norfloxacin levels were more sensitive to food allergens (OR: 5.52, 95%CI: 1.54, 19.71).

Conclusion

Early-life environmental antibiotic exposure may be correlated with an increased risk of asthma, wheeze, atopic dermatitis, and SPT positivity for food allergens in 5-year-old children.

Maternal antibiotic use and infections during pregnancy and offspring asthma: the Norwegian Mother, Father and Child Cohort Study and a nationwide register cohort

Maternal antibiotic use during pregnancy has been linked to asthma risk in children, but the role of underlying infections remains unclear. We investigated the association of maternal antibiotic use and infections during pregnancy with offspring risk of asthma. We used two population-based cohorts: the Norwegian Mother, Father and Child Cohort Study (MoBa) (n = 53 417) and a register-based cohort (n = 417 548). Asthma was defined based on dispensed asthma medications at 7 and 13 years from the Norwegian Prescription Database. Self-reported information on antibiotic use and infections during pregnancy was available in MoBa, while registrations of dispensed prescriptions were used to classify use of antibiotics in the register-based cohort. Maternal antibiotic use during pregnancy was associated with asthma at 7 in both cohorts (adjusted risk ratio (aRR) 1.23, 95% CI 1.11-1.37 in MoBa and 1.21, 1.16-1.25 in the register cohort) and asthma at 13 in the register cohort (1.13, 1.03-1.23) after adjusting for maternal characteristics. In MoBa, the estimate was attenuated after adjusting for infections during pregnancy. Maternal lower and upper respiratory tract infections (aRR 1.30, 95% CI 1.07-1.57 and 1.19, 1.09-1.30, respectively) and urinary tract infections (1.26, 1.11-1.42) showed associations with asthma at 7. Register cohort also showed an increased risk of asthma in relation to maternal antibiotics before and after pregnancy. Our findings suggest that both maternal antibiotics and infections during pregnancy have a role in the risk of offspring asthma. However, results from the register cohort suggest that the effect of antibiotics may reflect the shared underlying susceptibility.

Does the timing of antibiotic exposure in pregnancy impact the risk of development of pediatric asthma?: A systematic review and meta-analysis

OBJECTIVE

Maternal exposure to antibiotics has been linked to the development of pediatric asthma. However, the impact of the timing of exposure is unclear. We aimed to explore if the risk of pediatric asthma varies with trimester-specific exposure to antibiotics through a systematic review and meta-analysis.

METHODS

PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases were searched for studies reporting an association between trimester-specific maternal exposure to antibiotics and risk of asthma in the offspring.

RESULTS

Eleven studies were included. The total sample size of the included studies was 2,160,216. Meta-analysis revealed a statistically significant increased risk of asthma with first (RR: 1.13 95% CI: 1.10, 1.17 I² = 59% p < 0.00001), second (RR: 1.14 95% CI: 1.07, 1.21 I² = 92% p < 0.0001), and third (RR: 1.14 95% CI: 1.08, 1.20 I²=86% p < 0.00001) trimester exposure of antibiotics. The results were stable on sensitivity analysis. On subgroup analysis, we noted that the association for the first and second trimester was significant for studies on children >5 years but not for those on children <5 years of age. The certainty of evidence based on GRADE was low.

CONCLUSION

Our results indicate that antibiotics administered during any trimester of pregnancy lead to an increased risk of childhood asthma. The overall risk is small and could be due to confounding. Further studies rigorously adjusting for important confounding variables are needed for stronger evidence.

Factors predicting amoxicillin prescribing in primary care among children: a cohort study

BACKGROUND

Antibiotic prescribing during childhood, most commonly for respiratory tract infections (RTIs), contributes to antimicrobial resistance, which is a major public health concern.

AIM

To identify factors associated with amoxicillin prescribing and RTI consultation attendance in young children in primary care.

DESIGN AND SETTING

Cohort study in Bradford spanning pregnancy to age 24 months, collected 2007-2013, linked to electronic primary care and air pollution data.

METHOD

Amoxicillin prescribing and RTI consultation rates/1000 child-years were calculated. Mixed-effects logistic regression models were fitted with general practice (GP) surgery as the random effect.

RESULTS

The amoxicillin prescribing rate among 2493 children was 710/1000 child-years during year 1 (95% confidence interval [CI] = 677 to 744) and 780/1000 (95% CI = 745 to 816) during year 2. During year 1, odds of amoxicillin prescribing were higher for boys (adjusted odds ratio [aOR] 1.36, 95% CI = 1.14 to 1.61), infants from socioeconomically deprived households (aOR 1.36, 95% CI = 1.00 to 1.86), and infants with a Pakistani ethnic background (with mothers born in the UK [aOR 1.44, 95% CI = 1.06 to 1.94] and outside [aOR 1.42, 95% CI = 1.07 to 1.90]). During year 2, odds of amoxicillin prescribing were higher for infants with a Pakistani ethnic background (with mothers born in the UK [aOR 1.46, 95% CI = 1.10 to 1.94] and outside [aOR 1.56, 95% CI = 1.19 to 2.04]) and those born <39 weeks gestation (aOR 1.20, 95% CI = 1.00 to 1.45). Additional risk factors included caesarean delivery, congenital anomalies, overcrowding, birth season, and childcare attendance, with GP surgery explaining 7%-9% of variation.

CONCLUSION

Socioeconomic status and ethnic background were associated with amoxicillin prescribing during childhood. Efforts to reduce RTI spread in household and childcare settings may reduce antibiotic prescribing in primary care.