Critical Need to Reduce Pediatric Prophylactic Antimicrobial Prescriptions Worldwide

High proportions of hospitalized children received prophylactic broad-spectrum antibiotics (BSA) during their stay, according to research in the Journal of the Pediatric Infectious Disease Society.¹ This finding represents an area for improvement in reducing BSA prescribing, use, and prolonged prescription.

A cross-sectional point-prevalence survey was conducted at 226 pediatric hospitals in 41 countries in order to assess prescription practices for systemic antimicrobial agents used for prophylaxis.

Of 17,693 pediatric patients surveyed, 36.7% received antibiotics. Of 6818 inpatient children surveyed, 32.9% received at least one prophylactic antimicrobial. Prophylaxis for medical diseases was reported in 73.4% of 3400 cases while 26.6% were for surgical diseases. In 48.7% of cases a combination of at least 2 antimicrobials was prescribed.

BSAs, including tetracyclines, macrolides, lincosamides, and sulfonamides/trimethoprim, were used in 51.8% of the cases. This practice of BSA use for medical prophylaxis was more common in Asia (risk ratio [RR] 1.322; 95% CI, 1.202-1.653) and more restricted in Australia (RR 0.619; 95% CI, 0.521-0.736).  Also, 79.7% of 905 surgical patients received prophylaxis for longer than 1 day.

The data collected here provided a snapshot of antibiotic prescription practices that may be biased as participation was voluntary. There was also no clear consensus on the definition of medical prophylaxis, meaning the study protocols also lacked this information. Further limitations of the study were a lack of in-person training for data collectors, overrepresentation of tertiary care hospitals, and underrepresentation of areas outside of Europe. 

This survey identified several areas for improvement in prophylactic prescribing practices. The overuse of combination prescriptions in adults has shown no substantial benefits in lowering the rates of postoperative surgical infections and can cause harmful drug interaction complications.^2,3 Also, the high rate of use of BSAs worldwide for medical and surgical prophylaxis was concerning; specifically in Asia for both conditions and in Western Europe for surgical cases.  Finally, the duration of surgical prophylactic treatment >24 hours was common despite the World Health Organization’s guidelines recommending this be considered only in a limited set of surgeries.

Despite the limitations, a large number of participants were included and the standardized protocol facilitates comparison across hospitals and regions. This study represents the first look at prophylactic prescription practices for pediatric patients worldwide and revealed several specific areas of improvement: “reduce the high rate of antimicrobial combination prescriptions, especially in medical prophylaxis, limit the high rate of broad-spectrum antibiotic usage, and combat the extended duration of surgical prophylaxis.”

References

1. Hufnagel M, Versporten A, Bielicki J, Drapier N, Sharland M, Goossens H; for the ARPEC Project Group. High rates of prescribing antimicrobials for prophylaxis in children and neonates: results from the antibiotic resistance and prescribing in European children point prevalence survey [published online March 22, 2018]. J Pediatric Infect Dis Soc. doi: 10.1093/jpids/piy019
2. Bratzler DW, Dellinger EP, Olsen KM, et al; American Society of Health-System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195-283.
3. National Institute for Health and Care Excellence. Surgical site infection: prevention and treatment of surgical site infection. Updated February 2017. Accessed April 17, 2018.