Dynamics of antibiotic prescribing for children.

Abstract

THE DYNAMICS THAT INFLUENCE ANTIBIOTIC PRESCRIBing by office-based physicians in the United States are complex. Physicians have been receiving repeated messages to curtail antibiotic use from the biomedical literature, medical and public media, health insurance companies, key opinion leaders, alternative medicine advocates, and some patients. The message has been consistent, frequent, and loud, so it cannot have been missed. The crescendo of research during the past decade has established that (1) antibiotic overuse is a major public health problem; (2) approximately 50% of prescriptions for children written by community-based practitioners are unnecessary, and (3) the single most important factor in the emergence of antibiotic resistance among respiratory bacterial pathogens is selection pressure from antimicrobial agents. Thus, as a public health policy, there seems little doubt that overzealous prescribing habits and inappropriate use of antibiotics should be reduced on a community-wide basis. This all sounds good, but what about the individual patient seeking care? Faced with an ill-appearing, febrile child or adolescent, anxious parents, a busy office schedule, a potential insurance company audit of medical records, and the omnipresent concern for malpractice litigation, the physician must consider a different dynamic. Considerations when making treatment decisions for the individual patient include diagnostic uncertainty; sociocultural and economic pressures; meeting parent/patient and insurance company expectations; and taking defensive action in case of litigation. Occasionally, some bacterial infections that are preceded by viral illness have a rapid course, and patients may not always return to see the physician if the illness worsens or persists. Thus, the inclination is to err on the side of prescribing antibiotics even if the chance of a bacterial infection is low. The perceived risk for the individual patient to have an illness evolve with significant consequences often seems more important than the risks of dealing with an antibiotic-resistant organism later. In this issue of THE JOURNAL, McCaig and colleagues assess trends in antibiotic prescribing from 1989-1990 through 1999-2000 for US children and adolescents younger than 15 years. The authors used data from standardized office visit record forms completed by nationally representative samples of office-based physicians, who participated in annual National Ambulatory Medical Care Surveys (NAMCSs), to calculate populationand visit-based antibiotic prescribing rates. This study is a follow-up to a prior analysis of NAMCS data, which demonstrated increasing annual population-based rates of antibiotic prescribing in outpatient settings for pediatric patients from 1980 through 1992. The take-home message of the current study is that antibiotic prescribing appears to have decreased overall and for common respiratory tract infections among children. That is good news, if true. Several factors other than appropriate use, however, might explain the observed decline in antibiotic prescribing. Some of the decline might be accounted for by a decreasing secular trend in physician visits over the study period. Perhaps the worried well and patients with milder illness are simply not visiting physicians as often. The NAMCS only captures drugs dispensed at a physician visit, so if physician visits decline, antibiotic prescriptions will decline at a population level. Visit-based rates, however, which do not depend on the number of office visits, also declined overall and for respiratory tract infections. Increased telephone dispensing of antibiotics might be another variable to explain the observed trends. McCaig et al used urinary tract infections as an indicator condition for changes in telephone prescribing. However, physicians might regard urinary tract infections quite differently than respiratory tract infections in terms of the need for in-office evaluations. The pattern of care and use of telephone triage for respiratory tract infections may not be the same as for urinary tract infections. Patient self-administration of leftover antibiotic prescriptions might also be occurring. One study suggests that up to 66% of children arriving for outpatient care have already been self-administering antibiotics. For otitis media and bronchitis, McCaig et al noted decreases in the population-based antibiotic prescribing rate, but not in the visit-based prescribing rate. The authors speculate that only patients with more serious infections came to physician offices; that diagnosis may have been more accurate; or that the incidence of otitis media and bronchitis may