Antibiotic Prescribing Patterns in Children Vary with Country and Age

In a recent study published in The Pediatric Infectious Disease Journal, researchers use two new pediatric-specific quality indicators (QIs) to describe patterns of antibiotic use in pediatric primary care in three European countries.

The research team found that antibiotic prescribing remains moderately high in the United Kingdom; however, although overall antibiotic use and amoxicillin use has reduced only slightly over time, prescribing of broad-spectrum antibiotics is low. Conversely, in the Netherlands, antibiotic use is low and stable, but prescribing of broad-spectrum antibiotics is increasing compared with that of narrow-spectrum agents. Finally, in Italy, broad-spectrum agents dominate antibiotic prescribing patterns.

Sandra de Bie, MD, PhD, from the Erasmus University Medical Center, Rotterdam, the Netherlands, and colleagues, wrote, “The pediatric-specific QIs combined with the total prevalence rate of use provide a clear picture of the trends of community childhood antibiotic prescribing, allowing monitoring of the impact of policy interventions.”

Although evidence has shown that antibiotic overuse contributes to the mounting problem of antibiotic resistance, antibiotic prescribing rates remain high in Europe, with a north-south gradient in prescribing patterns.

Clinicians frequently prescribe antibiotics to children, in particular, especially in the first years of life. However, studies to evaluate the quality of outpatient antibiotic prescribing in children have, so far, been lacking.

With this in mind, Dr. de Bie and colleagues performed a study to examine antibiotic prescribing patterns in children in primary care settings. They also applied two new QIs of pediatric community-based antibiotic prescribing, the amoxicillin index (AI; the proportion of amoxicillin users) and the ratio between users of amoxicillin to broad-spectrum penicillins, cephalosporins, and macrolides (A/B ratio).

In their study, the researchers included more than 2 million children under 18 who contributed more than 12 million person-years (PYs) of follow-up over the course of 10 to 16 years.

They found that the overall annual prevalence of antibiotic prescriptions was 18.0% in the Netherlands, 36.2% in the United Kingdom, and 52.0% in Italy. In all three countries, antibiotic prescribing was highest in the first years of life, and slightly decreased over time; the number of antibiotics that accounted for 90% of antibiotic prescriptions was also similar, and amoxicillin was the most commonly prescribed antibiotic.

According to the authors, prescribing of broad-spectrum antibiotics increased in all three countries throughout the course of the study, and was highest in Italy. The ratio of broad- to narrow-spectrum antibiotic use varied widely from 0.3 to 74.7, and was highest in the youngest children.

The AI was highest in the Netherlands and the United Kingdom (50% to 60%) and lowest in Italy (30%), and worsened over time in all three countries. This reflects “the much higher annual exposure of Italian children to macrolides, to penicillins with beta-lactamase inhibitors, and to 3^rd or 4th generation cephalosporins,” the authors explained.

The A/B ratio was highest in the United Kingdom (5.4), followed by the Netherlands (1.7) and Italy (0.3), showing an increased preference for prescribing narrower-spectrum antibiotics, such as beta lactamase-susceptible penicillins, in the United Kingdom than in the Netherlands or Italy.

As a consequence, although overall antibiotic prescribing in the Netherlands is lower than in the United Kingdom, children there are more likely to receive broader-spectrum agents than they are in the United Kingdom. The A/B ratio is reversed in Italy, the authors said, highlighting that broad-spectrum antibiotics are more commonly prescribed than amoxicillin is.

“Crucially, total antibiotic prevalence of use and the 2 new pediatric-specific QIs may inform the evaluation of existing national interventions to reduce and improve antibiotic prescribing and, most importantly, may help to adequately design future interventions in this area,” the authors concluded.

​Dr. Parry graduated from the University of Liverpool, England in 1997 and is a board-certified veterinary pathologist. After 13 years working in academia, she founded Midwest Veterinary Pathology, LLC where she now works as a private consultant. She is passionate about veterinary education and serves on the Indiana Veterinary Medical Association’s Continuing Education Committee. She regularly writes continuing education articles for veterinary organizations and journals, and has also served on the American College of Veterinary Pathologists’ Examination Committee and Education Committee.