A study has shown that in the United States 25% of children under 2 years of age with bronchiolitis are prescribed in emergency room antibiotic therapy. Greater adherence to international guidelines and policies for quality improvement in emergency departments could lower the percentage to 6%, as demonstrated by an action plan developed in some hospitals.
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Acute viral bronchiolitis is a major health problem worldwide. This is the most common lower respiratory tract infection among children under 2 years of age. In the United States, bronchiolitis is the leading cause of hospitalization in the first year of life.
Several evidence-based guidelines for bronchiolitis have been published, underlining the need to avoid unnecessary treatment and investigation. Because children with bronchiolitis have a low risk (<1%) of invasive bacterial infection, the American Academy of Pediatrics (AAP) guidelines, published in 2006 and revised in 2014, recommend that routine antibiotic treatments should not be performed in children without documented bacterial infection.
A recent study has attempted to evaluate the proportion of pediatric diagnosis of bronchiolitis prescribed with antibiotics between 2007 and 2015. The data were collected by the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national statistical survey that takes place annually on about 300,000 visits in 300 randomly selected emergency departments. The study included all children aged <2 years with a diagnosis of bronchiolitis The average age was 8 months. Most of these patients have been evaluated in non-university and non-pediatric hospitals.
An antibiotic was prescribed for 25.6% of patients. Penicillins (37.9%) and macrolides (37.7%) were the most commonly prescribed classes of antibiotics. The use of antibiotics for bronchiolitis is presumably motivated by concern about a concomitant bacterial infection. However, in this large representative sample, two-thirds of the patients who were given antibiotics did not have a diagnosis of associated bacterial infection. Even more surprising is that among infants with bronchiolitis who were not clinically compromised, to the point that they could be sent home from the emergency room with an antibiotic prescription, more than 70% did not have a documented bacterial co-infection. Since the risk of invasive bacterial infection is well below 1% among children with viral syndromes, such as bronchiolitis, overprescription can be safely reduced.
The unnecessary use of antibiotics remains a major problem. Due to the risks associated with adverse pharmacological events, alterations in the host microbiome and the emergence of bacterial resistance, the reduction of excessive use of antibiotics for the treatment of bronchiolitis should be a priority. According to the research team, multi-component quality improvement initiatives are needed, particularly in non-university and non-pediatric hospitals.
Papenburg J, Fontela PS, Freitas RR, Burstein B. Inappropriate Antibiotic Prescribing for Acute Bronchiolitis in US Emergency Departments, 2007-2015. J Pediatric Infect Dis Soc. 2019 Jan 17. Doi: 10.1093/jpids/piy131.