Drug utilisation in outpatient children. A comparison among Tenerife, Valencia, and Barcelona (Spain), Toulouse (France), Sofia (Bulgaria), Bratislava (Slovakia) and Smolensk (Russia)

INTRODUCTION

Scarce information about comparative diagnostic and therapeutic patterns in paediatric outpatients of different countries is found in the literature.

OBJECTIVE

To describe the similarities and differences observed in diagnosis and therapeutic patterns of paediatric patients of seven locations in different countries.

DESIGN

Cross-sectional, prospective, international comparative, descriptive study.

PATIENTS AND METHODS

A randomly selected sample of 12,264 paediatric outpatients seen in consultation rooms of urban and rural areas and attended by paediatricians or general practitioners of the participating locations. Data on patient demographic information, diagnosis and pharmacological treatment were collected using pre-designed forms. Diagnoses were coded using the ICD-9 and drugs according to the ATC classification.

RESULTS

Among the ten most common diagnoses, upper respiratory tract infections are in the first position in all locations; asthma prevalence is highest in Tenerife (8.4%). Tonsillitis, otitis, bronchitis and dermatological affections are the most common diagnoses in all locations. Pneumonia is only reported in Sofia (3.8%) and Smolensk (2.3%). The average number of drugs prescribed per child varied from 1.3 in Barcelona to 2.9 in Smolensk. There are no great differences in the profile of pharmacological groups prescribed, but a considerable range of variations in antibiotic therapy is observed: prescription of cephalosporins is low in Smolensk (0.7%) and higher in the other locations, from 16.5% (Bratislava) to 28% (Tenerife). Macrolides prescriptions range from 12.6% (Toulouse) to 24.7% (Smolensk), except in Sofia where they drop to 5.6%. Trimethoprim and its combinations are used in Smolensk (23.3%), Sofia (11.8%) and Bratislava (8.7%). Check-up consultations are not recorded in Smolensk and Bratislava, whereas in Toulouse these visits account for 16.2% of all consultations and in the other locations the percentage varies from 6.1% (Tenerife) to 1.9% (Sofia). Homeopathic treatments are registered only in Toulouse.

CONCLUSION

Except in asthma prevalence, there are no great differences in diagnostic maps among locations. Significant variations in the number of drugs prescribed per child and antibiotic therapies are observed. Areas for improvement have been identified.

Pharmacological treatment of acute otitis media in children. A comparison among seven locations: Tenerife, Barcelona and Valencia (Spain), Toulouse (France), Smolensk (Russia), Bratislava (Slovakia) and Sofia (Bulgaria)

OBJECTIVE

To describe patterns observed in the treatment of acute otitis media (AOM) in several locations of five countries.

PATIENTS AND METHODS

Cross-sectional, descriptive study. Random sample of 12,264 paediatric outpatients seen by paediatricians or general practitioners (GPs). Data on patient demographics, diagnoses and treatment were collected. Diagnoses were coded by ICD-9 and drugs by ATC classification. Patients diagnosed with AOM (ICD-9 codes: 381 and 382) were selected for analysis.

RESULTS

Cases of AOM (873) accounted for 7.1% of the sample. There is a clear variation in the percentage of children diagnosed with AOM and treated with antibiotics in the different locations, antibiotic prescriptions being higher in Barcelona (93% of children), and lowest in Smolensk (56.4 % of children were treated without antibiotics). The antibiotics used varied widely: ampicillin use is almost limited to Smolensk (26.7%) and Bratislava (13.8%), whereas amoxicillin plus clavulanic acid is the choice in Toulouse (33.8%), Valencia (30.2%) and Barcelona (28.9%), and cephalosporins are more frequently prescribed in Tenerife (51.7%). Finally, macrolides are used in Barcelona (18.3%), Valencia (17.5%) and Tenerife (13.6%), but not prescribed in Toulouse or Sofia. Prescriptions of anti-inflammatory drugs were only relevant in Valencia (31.7%), Tenerife (27.2%) and Toulouse (17.4%) and of otological preparations in Sofia, where almost each child received ear drops (91.9%). Nasal preparations are commonly used only in Sofia (41.9%), Bratislava (65.5%) and Smolensk (68.6%).

CONCLUSION

Despite the general agreement of most guidelines, wide differences in the treatment of uncomplicated AOM in children are observed. Non-antibiotic therapy for AOM and the use of first-choice antibiotics should be more actively encouraged in the primary care centres. Studies to measure prevailing rates of antibiotic resistance in these populations are needed.

[Drug-induced hepatotoxicity in children. Where we are and where we are going]

Childhood is characterized by continuous growth and development during which the organs and systems gradually mature. Because drug pharmacokinetics and pharmacodynamics in children differ from those in adults, pediatric patients are highly susceptible to adverse drug reactions. Surprisingly, very few studies have been designed to study the efficacy and safety of drugs in this population and consequently dosage regimens are based on the assumption that children are small adults. We present a detailed review of these controversial aspects and propose the establishment of a multicenter, multidisciplinary network to monitor drug-induced liver disease in children. This project represents the integration of an epidemiological approach into routine clinical care. A protocol agreed by consensus for the collection of data on cases of hepatotoxicity with uniform and internationally accepted criteria for causality assessment and the classification of drug-induced liver injuries is proposed.

The antioxidant role of bile pigments evaluated by chemical tests

Bilirubin, biliverdin and their serum albumin complexes were tested as oxyradical scavengers (superoxide generated by the xanthine/xanthine oxidase system and peroxyl radical-trapping antioxidant ability). As superoxide scavengers the free bile pigments showed activities near to that of serum albumin, higher than the water soluble vitamin E analog Trolox and lower than ascorbic acid. The peroxyl radical-trapping antioxidant abilities of the tested bile pigments were much higher than those of the serum albumin and of the same order as their serum albumin complexes. This interaction with peroxyl radicals showed different stoichiometric factors for bilirubin (approximately 2) and biliverdin (approximately 4).