A comparison of antibiotic use in children between Canada and Denmark

Outpatient antibacterial use and costs in children and adolescents: a nationwide register-based study in Finland, 2008-16

OBJECTIVES

To describe the prevalence of outpatient use and the costs of systemic antibacterials among children and adolescents in Finland during 2008-16 and to examine patterns of use by age and gender.

METHODS

Data were retrieved from the Finnish statistical database Kelasto, based on the Finnish Prescription Registry. Data included information on dispensed reimbursed prescriptions of antibacterials for systemic use in children aged 0-17 years during 2008-16. The prevalence of antibacterial prescriptions per 1000 children and costs per prescription were calculated.

RESULTS

The overall prevalence of antibacterial prescriptions decreased in the study period and was highest in 2010 (with 708 prescriptions per 1000 children) and lowest in 2016 (with 374 prescriptions per 1000 children). Children aged 1-2 years had the highest prevalence of antibacterial prescriptions. Furthermore, boys had slightly higher prevalences than girls. The 10 most commonly used antibacterial agents covered ∼97% of all prescriptions and broad-spectrum penicillins were the most commonly used antibacterials. The total costs of antibacterials decreased during the study period, but the costs per prescription increased.

CONCLUSIONS

This study showed a decreasing trend in the prescribing of antibacterial drugs, regardless of age or gender. Increasing awareness of antimicrobial resistance, reimbursement status changes and pneumococcal and influenza vaccinations are possible reasons for this. Some of the antibacterial oral solutions lost their reimbursement status, but their consumption did not decrease any faster than the consumption of the substances with continuous reimbursability. It is likely that removing the reimbursement status of antibacterials has placed an extra cost burden on families and increased costs per prescription.

Short- and long-term impacts of azithromycin treatment on the gut microbiota in children: A double-blind, randomized, placebo-controlled trial

Background

Macrolides are commonly prescribed for respiratory infections and asthma-like episodes in children. While their clinical benefits have been proved, concerns regarding the side-effects of their therapeutic use have been raised. Here we assess the short- and long-term impacts of azithromycin on the gut microbiota of young children.

Methods

We performed a randomized, double-blind, placebo-controlled trial in a group of children aged 12–36 months, diagnosed with recurrent asthma-like symptoms from the COPSAC₂₀₁₀ cohort. Each acute asthma-like episode was randomized to a 3-day course of azithromycin oral solution of 10 mg/kg per day or placebo. Azithromycin reduced episode duration by half, which was the primary end-point and reported previously. The assessment of gut microbiota after treatment was the secondary end-point and reported in this study. Fecal samples were collected 14 days after randomization (N = 59, short-term) and again at age 4 years (N = 49, long-term, of whom N = 18 were placebo treated) and investigated by 16S rRNA gene amplicon sequencing.

Findings

Short-term, azithromycin caused a 23% reduction in observed richness and 13% reduction in Shannon diversity. Microbiota composition was shifted primarily in the Actinobacteria phylum, especially a reduction of abundance in the genus Bifidobacterium. Long-term (13–39 months after treatment), we did not observe any differences between the azithromycin and placebo recipients in their gut microbiota composition.

Interpretation

Azithromycin treatment induced a perturbation in the gut microbiota 14 days after randomization but did not have long-lasting effects on the gut microbiota composition. However, it should be noted that our analyses included a limited number of fecal samples for the placebo treated group at age 4 years.

Fund

Lundbeck Foundation, Danish Ministry of Health, Danish Council for Strategic Research, Capital Region Research Foundation, China Scholarship Council.

High Diversity of CTX-M Extended-Spectrum β-Lactamases in Municipal Wastewater and Urban Wetlands

The CTX-M-type extended-spectrum β-lactamases (ESBLs) present a serious public health threat as they have become nearly ubiquitous among clinical gram-negative pathogens, particularly the enterobacteria. To aid in the understanding and eventual control of the spread of such resistance genes, we sought to determine the diversity of CTX-M ESBLs not among clinical isolates, but in the environment, where weaker and more diverse selective pressures may allow greater enzyme diversification. This was done by examining the CTX-M diversity in municipal wastewater and urban coastal wetlands in southern California, United States, by Sanger sequencing of polymerase chain reaction amplicons. Of the five known CTX-M phylogroups (1, 2, 8, 9, and 25), only genes from groups 1 and 2 were detected in both wastewater treatment plants (WWTPs), and group 1 genes were also detected in one of the two wetlands after a winter rain. The highest relative abundance of blaCTX-M group 1 genes was in the sludge of one WWTP (2.1 × 10(-4) blaCTX-M copies/16S rRNA gene copy). Gene libraries revealed surprisingly high nucleotide sequence diversity, with 157 new variants not found in GenBank, representing 99 novel amino acid sequences. Our results indicate that the resistomes of WWTPs and urban wetlands contain diverse blaCTX-M ESBLs, which may constitute a mobile reservoir of clinically relevant resistance genes.

Use of antibiotics in paediatric primary care settings in Serbia

OBJECTIVE

The aim of the study was to compare the quality of antibiotic use among children in primary settings with the internationally developed disease-specific quality indicators and with National Guidelines.

DESIGN

Prescriptions of systemic antibiotics to the paediatric population (<18 years) at the primary level of healthcare for the period between 2011 and 2013 were analysed by using the National Health Insurance Fund's outpatient reimbursement database.

RESULTS

The mean annual number of antibiotic prescriptions was 1.887.615, while the mean annual number of children receiving antibiotics was 728.285. The prescription rate slightly decreased by 10% from 1.516 antibiotic prescriptions per 1000 persons per year in 2011 to 1.365 in 2013. The highest percentage of prescribed antibiotics was observed in the group of children aged 2-23 months. The mean annual prevalence of antibiotic prescriptions was 54%. The percentage of patients prescribed an antibiotic for acute upper respiratory tract infections, acute tonsillitis and acute otitis media (AOM) was above the proposed range (≤ 20), 87% -96%. These three diagnoses represent more than 69% of all indications for prescribing antibiotics. The percentage of patients prescribed a recommended antibiotic was below the proposed range (≥ 80%), 1% -17%, while the adherence rate to National Guidelines was low, 19%-28%. The percentage of patients prescribed quinolones was above the proposed range for AOM (≤ 5%), 7%. There were no significant differences in indicators value at the regional level in Serbia.

CONCLUSIONS

Antibiotic use among children in Serbia is extremely high compared with that in most other European countries. Major problems are frequent use of antibiotics for indications that usually receive no benefit from this treatment and the use of broad-spectrum antibiotics.

Clostridium difficile infection seasonality: patterns across hemispheres and continents - a systematic review

Background

Studies have demonstrated seasonal variability in rates of Clostridium difficile infection (CDI). Synthesising all available information on seasonality is a necessary step in identifying large-scale epidemiological patterns and elucidating underlying causes.

Methods

Three medical and life sciences publication databases were searched from inception to October 2014 for longitudinal epidemiological studies written in English, Spanish or Portuguese that reported the incidence of CDI. The monthly frequency of CDI were extracted, standardized and weighted according to the number of follow-up months. Cross correlation coefficients (XCORR) were calculated to examine the correlation and lag between the year-month frequencies of reported CDI across hemispheres and continents.

Results

The search identified 13, 5 and 2 studies from North America, Europe, and Oceania, respectively that met the inclusion criteria. CDI had a similar seasonal pattern in the Northern and Southern Hemisphere characterized by a peak in spring and lower frequencies of CDI in summer/autumn with a lag of 8 months (XCORR = 0.60) between hemispheres. There was no difference between the seasonal patterns across European and North American countries.

Conclusion

CDI demonstrates a distinct seasonal pattern that is consistent across North America, Europe and Oceania. Further studies are required to identify the driving factors of the observed seasonality.

Use of antibiotics in children: a Danish nationwide drug utilization study

BACKGROUND

We aimed to describe the use of systemic antibiotics among children in Denmark.

METHODS

National data on drug use in Denmark were extracted from the Danish National Prescription Database. We used prescription data for all children in Denmark aged 0 to 11 years from January 1, 2000 to December 31, 2012.

RESULTS

We obtained data on 5,884,301 prescriptions for systemic antibiotics issued to 1,206,107 children. The most used single substances were phenoxymethylpenicillin (45%), amoxicillin (34%) and erythromycin (6%). The highest incidence rate of antibiotic treatment episodes was observed among children younger than 2 at 827 per 1000 children in 2012. Incidence rates were relatively stable throughout the study period. One-year prevalences in 2012 were 485, 363 and 190 per 1000 children among children aged 0-1, 2-4 and 5-11, respectively. A gradual shift from narrow-spectrum penicillin V to the broader-spectrum amoxicillin was found among children younger than 5. The use of macrolides decreased slightly, especially among those aged 0-1. Minor regional differences were noted, with somewhat higher use in the Capital Region. Skewness in use was most notable among those aged 0-1. There was little evidence of heavy users.

CONCLUSION

Prescribing rate of antibiotics to children in Denmark remained stable at a high level from 2000 to 2012. An increase in the use of broad-spectrum beta-lactam penicillin was noted, but otherwise the prescribing pattern adhered well to National guidelines with respect to choice of antibiotics.

Systemic antibiotic prescribing to paediatric outpatients in 5 European countries: a population-based cohort study

Background

To describe the utilisation of antibiotics in children and adolescents across 5 European countries based on the same drug utilisation measures and age groups. Special attention was given to age-group-specific distributions of antibiotic subgroups, since comparison in this regard between countries is lacking so far.

Methods

Outpatient paediatric prescriptions of systemic antibiotics during the years 2005-2008 were analysed using health care databases from the UK, the Netherlands, Denmark, Italy and Germany. Annual antibiotic prescription rates per 1,000 person years were estimated for each database and stratified by age (≤4, 5-9, 10-14, 15-18 years). Age-group-specific distributions of antibiotic subgroups were calculated for 2008.

Results

With 957 prescriptions per 1000 person years, the highest annual prescription rate in the year 2008 was found in the Italian region Emilia Romagna followed by Germany (561), the UK (555), Denmark (481) and the Netherlands (294). Seasonal peaks during winter months were most pronounced in countries with high utilisation. Age-group-specific use varied substantially between countries with regard to total prescribing and distributions of antibiotic subgroups. However, prescription rates were highest among children in the age group ≤4 years in all countries, predominantly due to high use of broad spectrum penicillins.

Conclusions

Strong increases of antibiotic prescriptions in winter months in high utilising countries most likely result from frequent antibiotic treatment of mostly viral infections. This and strong variations of overall and age-group-specific distributions of antibiotic subgroups across countries, suggests that antibiotics are inappropriately used to a large extent.

Differences in outpatient antibiotic use between a Spanish region and a Nordic country

INTRODUCTION

Antibiotic use and misuse are linked to pathogen resistance and, as such, both constitute a public health issue with local, national, and global dimensions. Early studies have shown striking variations in the use of these drugs between Nordic and Mediterranean countries. The aim of the present study was to describe and compare antibiotic prescribing in Primary Care in Denmark and Aragón (a North-eastern Spanish region).

METHODS

Outpatient antibiotic prescription data (2010) were obtained from the National Institute for Health Data and Disease Control (Denmark), and the Information System on Medication Consumption in Aragón. The consumption of antibiotics (ATC J01) was analyzed from the prescription rates and the number of defined daily dose (DDD) per 1000 inhabitants/day (DID).

RESULTS

The rate of antibiotic prescription in 2010 in Aragón was greater than in Denmark (407 compared to 315 exposed individuals/1000 inhabitants). There were significant differences as regards overall consumption of antibiotics (23.2 DID in Aragón and 17.0 DID in Denmark), as well as the therapeutic group selection. There was an elevated use of broad spectrum penicillins, quinolones and cephalosporins in the Spanish region while, in Denmark, the most-consumed antibiotic was narrow spectrum penicillin.

CONCLUSION

The use of antibiotics in the Spanish region is very high, and there are marked differences in the choice of drug between this region and Denmark. Interventions are needed that promote the rational use of these drugs to reduce potential bacterial resistance, and to avoid unnecessary risks to patients.

Systemic antibiotic use among children and adolescents in Germany: a population-based study

The aim of the study was to comprehensively describe antibiotic use among children and young adolescents in Germany. Outpatient prescriptions of systemic antibiotics to children (<15 years) were analysed using data from four German statutory health insurances for the years 2004 to 2006. Annual prevalence of antibiotic prescriptions was determined using the average number of insured children during the respective year as reference population. Annual antibiotic prescription rates were calculated per 1,000 person years. Both figures were stratified by age (0-4, 5-9 and 10-14 years) and sex. Frequent indications for prescribing were analysed. Annual prevalence of antibiotic prescriptions rose from 35.68 % [95 % confidence intervals (CI), 35.62-35.75] in 2004 to 37.79 % [95 % CI, 37.72-37.86] in 2006. Prescription rates slightly increased by 6.01 % from 668.54 [95 % CI, 667.34-669.72] antibiotic prescriptions per 1,000 person years in 2004 to 708.71 [95 % CI, 707.47-709.95] in 2006. In 2006, prescriptions of broad-spectrum penicillins (25.09 %), second-generation cephalosporins (18.11 %) and narrow-spectrum penicillins (16.45 %) were most frequent. The most common indication for antibiotic prescribing was tonsillitis followed by bronchitis, otitis media, acute upper respiratory infections and scarlet fever.

CONCLUSION

In contrast to other northern European countries, paediatric prescription rates are high in Germany. This and the frequent prescribing of broad spectrum agents for the treatment of mostly viral self-limiting conditions indicate limited adherence to evidence-based practice guidelines in antibiotic prescribing in the German outpatient setting.

Antibiotic prescription preferences in paediatric outpatient setting in Estonia and Sweden

Aims of the study were to compare the paediatric outpatient antibiotic use in two countries with low overall antibiotic consumption and antibacterial resistance levels - Sweden and Estonia - and to describe the adherence to Estonian treatment guideline. All prescriptions for systemic antibiotics for children less than 18 years during 2007 from the Swedish Prescribed Drug Register and Estonian Health Insurance Fund database were identified to conduct a descriptive drug utilisation study. The total paediatric antibiotic use was 616 and 353 per 1000 in Estonia and Sweden, respectively. The greatest between country differences occurred in the age group 2 to 6 years -Estonian children received 1184 and Swedish children 528 prescriptions per 1000. Extended spectrum penicillin amoxicillin (189 per 1000) or its combination with beta-lactamase inhibitor (81 per 1000) and a newer macrolide clarithromycin (127 per 1000) were prescribed most often in Estonia whereas narrow spectrum penicillin phenoxymethylpenicillin (169 per 1000) and older generation macrolide erythromycin (21 per 1000) predominated in Sweden. For acute bronchitis, 17 different antibiotics (most commonly clarithromycin) were prescribed in Estonia despite the guideline recommendation not to use antibiotics. The higher rate of antibiotic use especially of extended spectrum antibiotics in Estonia compared to Sweden emphasizes the need for national activities to promote appropriate use of antibiotics while treating children, even when the overall antibiotic consumption is low.

Antibiotic consumption in children prior to diagnosis of asthma

BACKGROUND

Asthma is difficult to diagnose in children and at times misdiagnosis of an infection can occur. However, little is known about the magnitude and patterns of antibiotic consumption in children with asthma relative to those without asthma.

METHODS

Using population-based data, 128,872 children were identified with at least 6 years of follow-up. The adjusted rate-ratio (RR) of antibiotics dispensed to asthmatic as compared to non-asthmatic children was determined.

RESULTS

At age six, the RR of antibiotic consumption for asthmatics compared to non-asthmatics varied between, 1.66 to 2.32, depending on the year of asthma diagnosis. Of the 18,864 children with asthma at ages 2-8, 52% (n = 9,841) had antibiotics dispensed in the 6 months prior to their index date of asthma diagnosis. The RR of antibiotic consumption in the 1 month prior to asthma diagnosis compared to 5 months prior was 1.66 (95% CI 1.60-1.71). The RR was lower in males compared to females (1.58 vs 1.77), and lower in those who received antibiotics in the first year of life relative to those that did not (1.60 vs. 1.76).

CONCLUSIONS

There is higher antibiotic consumption in children with asthma compared to those without asthma. The pattern of antibiotic use suggests that diagnosis guidelines are difficult to follow in young children leading to misdiagnosis and over treatment with antibiotics.

Prescribing habits and caregiver satisfaction with resources for dosing children: rationale for more informative dosing guidance

Background

Physicians, nurses and hospital pharmacists were surveyed to assess attitudes of hospital-based pediatric caregivers regarding the dosing of medicine to children. Our objectives were to gauge how current resources are utilized to guide the management of pediatric pharmacotherapy, assess drugs and drug classes where guidance is most critical and examine the prevalence and practice of dose adjustment in pediatric patients.

Methods

Questionnaire categories included demographics, pharmacotherapy resources, dosing adjustment and modification, and valuation of additional tools to provide improved pharmacotherapy guidance. The questionnaire was developed in collaboration with representative nurse, pharmacist and physician team members using the SurveyMonkey.com site and survey tool. The survey link was distributed to caregivers via email. The questionnaire results of 303 respondents were collected into MS Excel and imported into SAS for data summarization.

Results

A total of 313 responses were obtained. Physician and nurse practitioner groups comprised the majority of the responses. Approximately 80% of the responders considered dosing adjustment important in pediatric pharmacotherapy. While there was general satisfaction with available resources, nearly 75% responded in support of access to predictive tools that facilitate individualized patient pharmacotherapy. The majority of respondents (> 65%) indicated that dosing outside standard practice occurs in 1-20% of their patients, while still a substantial number of respondents (a range of 8 to 20% reflecting the resident and fellow categories) estimated between 20 and 50% of their patients required adjustments outside the standard practice.

Conclusions

Differences in prescribing habits based on caregiver role, specialty and location were small and likely require further exploration. Existing resources are generally viewed as helpful but inadequate to guide recommendations for individual patients. Decision support systems connected to hospital-based electronic medical records offer the promise of informative and individualized pharmacotherapy guidance.

Secular trends of antibacterial prescribing in UK paediatric primary care

BACKGROUND

Resistance to antibacterial drugs can be contained by judicious prescribing. In particular, the use of these drugs in children requires ongoing surveillance. While there was a decline in antibacterial prescribing in the UK during the 1990s, recent trends are less well known.

OBJECTIVES

To describe antibiotic prescribing patterns and time trends in children in the UK over the last two decades.

METHODS

We identified all children ages 0-19 years from 1993 to 2007 and their antibiotic prescriptions from the General Practice Research Database. We used Poisson regression to estimate prescription rates considering the children's age and gender, calendar year and practice.

RESULTS

The cohort included 1 751 645 children with 5 835 891 antibacterial prescriptions. The average prescription rate was 511 prescriptions per 1000 person-years [95% confidence interval (CI) 509-513]. As of 1995, the rate decreased to 419/1000 person-years (95% CI 411-426) in 2000, then increased to 568/1000 person-years (95% CI 559-577) in 2007. Between 2000 and 2007, rates increased on average by 4.3% (95% CI 3.7-5.0%) annually, amounting to an increase of 40.7% (95% CI 34.5-47.2%) for all children. Rates were generally higher in girls, except for boys <5 years. Broad-spectrum penicillins were most frequently prescribed; their rate increased on average by 4.6% annually (95% CI 4.0-5.3%) after 2000. This trend was similar in most classes of antibacterials.

CONCLUSIONS

Antibacterial prescribing to outpatient children in the UK has been steadily increasing since 2000, consistently for boys and girls, across all ages and antibacterial classes.

Antibiotic prescribing in paediatric populations: a comparison between Viareggio, Italy and Funen, Denmark

BACKGROUND

High rates of antibiotic prescribing in paediatric populations represent a major issue because of the problem of antibiotic resistance. North European countries reported an appropriate use of antibiotics in general population; few studies on this issue have been conducted until now, especially in Italy. Therefore a comparison concerning paediatric antibiotic prescribing rates between an Italian administrative area in Tuscany (Viareggio) and the county of Funen (Denmark) was conducted.

METHODS

Reimbursement data from 2003 were gathered from the Tuscany Health Authority database and from the database containing pharmacy dispensing data from the Danish Medicines Agency. All data were converted to Defined Daily Doses (DDD) per 1000 inhabitants per day (DDD/TID). Data were broken down by age, identifying four age groups: 0-4, 5-9, 10-14, 15-19 years.

RESULTS

The overall prescription of antibiotics to paediatric patients from 0 to 19 years of age was higher in Viareggio (67 DDD/TID) than in Funen (35 DDD/TID). In Viareggio amoxicillin and amoxicillin plus enzyme inhibitors ranked in the first two places as the most frequently prescribed antibiotics in the whole population. Cephalosporins were also heavily used in Viareggio with cefaclor being the third most frequently prescribed antibiotic, especially in the 0-4 and 5- to 9-year-old age groups. In Funen, phenoxymethylpenicillin was the most commonly used antibiotic in all age groups, representing almost one-third of prescriptions, followed by amoxicillin.

CONCLUSIONS

The paediatric antibiotic prescription rate is substantially higher in Viareggio compared with Funen. These data confirm possible overuse and misuse of antibiotics in the Italian paediatric population.

Databases for pediatric medicine research in Europe--assessment and critical appraisal

PURPOSE

To identify and describe European health care databases that can be used for pediatric pharmacoepidemiological research.

METHODS

A web-based survey was conducted among all European databases that were listed on the website of the International Society of Pharmacoepidemiology (ISPE) and/or known by an expert group. The survey comprised of questions regarding (a) the nature of the database, (b) database size, (c) demographic, clinical and drug related data provided, (d) cost, and (e) accessibility of the database.

RESULTS

A total of 25 data sources from 12 European countries were identified and invited to participate in the survey. Responses were obtained from 21 (84%) databases located in 10 different European countries. Seventeen databases were included in the assessment comprising a total of at least 9 million children aged 0-18 years. The majority of databases are based on outpatient data and all keep either prescription or drug dispensing data. Ten databases are based on electronic patient records from primary care physicians and five databases are predominantly claims oriented. Three databases do not belong to either of the above mentioned categories. Almost all of the databases can be used for pediatric drug utilization studies. For drug safety studies it is more appropriate to use electronic patient record databases because of the available clinical information and the potential to obtain additional information.

CONCLUSIONS

There are many European healthcare databases providing an enormous potential for pediatric pharmacoepidemiological research. Future research should focus on methods to bring data from different databases together to use the full capacity effectively.