Are children carrying the burden of broad-spectrum antibiotics in general practice? Prescription pattern for paediatric outpatients with respiratory tract infections in Norway.

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by  Fossum, Guro Haugen

Open Access Research
Are children carrying the burden of
broad-spectrum antibiotics in general
practice? Prescription pattern for
paediatric outpatients with respiratory
tract infections in Norway
Guro Haugen Fossum,1,2 Morten Lindbæk,1 Svein Gjelstad,1 Ingvild Dalen,1
Kari J Kværner3,4
Tocite:FossumGH, ABSTRACT
ARTICLE SUMMARY
LindbækM,GjelstadS,etal. Objectives:Toinvestigatetheantibioticprescription
Arechildrencarryingthe patternandfactorsthatinfluencethephysicians’ Article focus
burdenofbroad-spectrum
antibioticsingeneral choiceofantibiotic. ▪ Scandinavia has a conservative prescription
practice?Prescriptionpattern Design:Observationalstudy. pattern for antibiotics in respiratory tract
forpaediatricoutpatientswith Setting:PrimaryhealthcareinNorway,December infections.
respiratorytractinfectionsin 2004throughNovember2005. ▪ Norwegian guidelines recommend the use of
Norway.BMJOpen2013;3: Participants:426 general practitioners, GPs, in phenoxymethylpenicillin in almost all upper
e002285.doi:10.1136/ Norway, giving 24888 respiratory tract infection respiratory tract infection in general practice
bmjopen-2012-002285 episodes with 19938 children aged 0–6years. (GP).
Outcome measures: Assess antibiotic ▪ Specific challenges apply when prescribing
▸ Prepublicationhistoryand prescription details and patient and GP drugstochildren.
additionalmaterialforthis characteristics associated with broad-spectrum and
paperareavailableonline.To Key messages
narrow-spectrum antibiotic use.
viewthesefilespleasevisit ▪ The general prescription rate for antibiotics in
Results: Of the 24888 episodes in the study,
thejournalonline respiratory tract infections is relatively low in
26.2% (95% CI 25.7% to 26.8%) included an
(http://dx.doi.org/10.1136/ Norway,buthigherinchildrenthanadults.
bmjopen-2012-002285). antibiotic prescription. Penicillin V accounted for ▪ Norwegian GPs tend to overprescribe macrolide
42% and macrolide antibiotics for 30%. The
antibioticstochildren.
Received30October2012 prescription rate varied among the physicians, with ▪ The national guidelines for antibiotics in GP are
Revised30October2012 a mean of 25.5% (95% CI 24.2% to 26.7%).
not followed in children diagnosed with bron-
Accepted3December2012 Acute tonsillitis gave the highest odds for a
chitis/bronchiolitis.
prescription, OR 33.6 (95% CI 25.7% to 43.9%),
Thisfinalarticleisavailable compared to ‘acute respiratory tract infections and Strengths and limitations of this study
foruseunderthetermsof
symptoms’ as a reference group. GPs with a ▪ Large data set with representative GPs from dif-
theCreativeCommons
AttributionNon-Commercial prescription rate of 33.3% or higher had the larger ferentpartsofNorwayparticipating.
2.0Licence;see probability for broad-spectrum antibiotic ▪ Analyses performed at the episode level, limiting
http://bmjopen.bmj.com prescriptions, OR 3.33 (95% CI 2.01% to 5.54%). theriskofincludingrevisitsforthesameillness.
Antibiotic prescriptions increased with increasing ▪ Data mainly from 2005; however, recent data
patient age. from the Norwegian Prescription Data base indi-
Conclusions: We found a low antibiotic cate that the prescription pattern has undergone
prescription rate for childhood respiratory tract fewchangessincethen.
infections. However, our figures indicate an overuse
of macrolide antibiotics and penicillins with
extended spectrum, more so than in the INTRODUCTION
corresponding study including the adult population. Almost 90% of antibiotics sold in Norway are
Palatability of antibiotic suspensions and other prescribed in the primary healthcare sector.1
administrative challenges affect medication Themostcommonantibioticsubtypeisphenox-
Fornumberedaffiliationssee
compliance in children. To help combat antibiotic ymethylpenicillin,followedbyerythromycin,piv-
endofarticle.
resistance, guidelines need to be followed, in mecillinam and doxycycline.2 Although the
particular for our youngest patients.
Scandinavian prescription pattern is conserva-
Correspondenceto Trial registration number (clinicaltrials.org):
tive, the European trend of increased use of
DrGuroHaugenFossum;
NCT00272155.
[email protected] broad-spectrum penicillins and macrolide
FossumGH,LindbækM,GjelstadS,etal.BMJOpen2013;3:e002285.doi:10.1136/bmjopen-2012-002285 1
Are children carrying the burden of broad-spectrum antibiotics?
antibiotics is also found in Norway.2–4 Recent figures from RTIs and prescription drugs for the elderly.22 As part of
both Holland and the USA from 1998 to 2004 confirmed theRx-PADstudy,a1-yearsamplingofbaselinedatafrom
thetendency.56 441 GPs were performed (December 2004 through
The use of antibiotics in Norwegian children aged November 2005); the material of the present study. All
0–4years was approximately 30% in 2005/2006, com- RTIdiagnoseswereincluded, basedon theInternational
pared to anaverageofabout 24% inthegeneralpopula- Classification of Primary Care (ICPC-2) coding system.23
tion.1 Users per 1000 aged 0–9years were 220 in 2005 Data were extracted from the doctors’ computer systems
and 227 in 2011.7 Most prescriptions for children in usingsoftwaredevelopedbyMediataAS.
primary healthcare are results of common airway infec- Of the 441 GPs in the project, 12 GPs with less than
tions. A Norwegian study from 1989 found that 80% of 10 registered episodes, 72 episodes where patient
general practice (GP) contacts for children aged 0– gender was missing and 3 GPs in rural practices with an
12years with the diagnoses tonsillitis, sinusitis, acute over-the-counter delivery of antibiotics were excluded.
bronchitis,bronchiolitis andpneumoniawereprescribed The total number of episodes available for analysis were
antibiotics, with phenoxymethylpenicillin as the drug of 24888, including 19938 patientsand 426GPs (figure 1).
choice.8 The Rx-PAD database was merged with the Norwegian
When prescription rates are considered, it is import- National Prescription Database (NorPD). Informations
ant to keep in mind that several studies from GP show included in the database are the drug-specific anatom-
that consultations for upper respiratory tract infections ical therapeutic chemical codes, name, strength, admin-
(RTIs) are decreasing, while the proportion of antibiotic istration form, compound size and the date of
prescriptions remains constant.9–12 Variations in phys- withdrawal by the patient.24
ician seeking behaviour and changing prescription The outcome of interest for the present study was anti-
pattern among GPs are suggested explanations. biotic prescription details from the GPs. The following
Adequate and rational use of antibiotics is one needed diagnoseswereincluded according totheICPC-2classifi-
action to prevent and combat antibiotic resistance,13 14 cation system: acute RTIs and symptoms (R01–29, 74,
hence several surveillance systems monitor the use of 80), acute bronchiolitis/bronchitis (R78), pneumonia
antibiotics on national and European levels.15–17 The (R81), acute otitis media and ear pain (H01,71, 72, 74),
proportion of pneumococcus airway isolates with acute tonsillitis (R72, 76) and other RTIs including
reduced penicillin sensitivity was 3.3% in 2007 and sinusitis, laryngitis and asthma (R71, 75, 77, 79, 83, 95,
shows an increasing tendency.16 Erythromycin resistance 96).23
in pneumococcus airway isolates increased from 2% in Consultations with preschool children, aged 0–6years,
2000 to 12.4% in 2006 but decreased to 9.4% in were extracted from the Rx-PAD baseline data to form a
2007.16 18 Resistance to macrolide antibiotics is of par- distinct database in SPSS. Consultations within 30days of
ticular importance in children. Studies have shown each other were combined to form one episode, of
resistant strains in their oral flora in 17% of patients which the first antibiotic prescription of the episode was
6weeks following treatment with erythromycin, and 85% selected for furtheranalysis. Analyses wereperformed by
forazithromycin.19 episode; one patient may be included more than once.
Norwegian guidelines present phenoxymethylpenicil- Less common antibiotics were grouped. Antibiotics
lin asthe drug of choice in almost all upper RTIs if anti- common for urinary tract infections and rarely in use
biotics are required.20 The level of resistance is low, and for respiratory infections (nitrofurantoin, trimethoprim,
the only reasons for second-choice antibiotics are peni- pivmecillinam and methenamine) were coded as no
cillin allergy or treatment failure. Compliance is an antibioticprescription.
important issue when antibiotic suspensions are sub- Descriptive statistics were estimated in IBM SPSS
scribed, palatability being onedeterminant.21 Statistics V.19. Logistic regression models were used to
The aim of the study was to investigate the prescrip- identify predictors of antibiotic prescription and predic-
tion pattern of antibiotics for RTIs in Norwegian tors of broad-spectrum antibiotic prescription in Stata
primary healthcare in preschool children; estimate the IC/11.2 for Windows. The results from logistic regres-
prescription rate and assess factors affecting the GP’s sion analyses were adjusted for clustering by means of
prescription pattern. multilevel modelling with random intercept at the group
and doctor level, and random slope at diagnoses for
doctors.
MATERIAL ANDMETHODS
The Prescription Peer Academic Detailing (Rx-PAD)
Study was initiated in 2004 at the University of Oslo to RESULTS
provide structured training in the use of prescription GP characteristics areshown in table 1.
drugs for GPs. Eighty GP training groups including A total of 426 GPs were included in the study, 31.5%
approximately 450 physicians from different parts of the and 68.5% females and males, respectively. A total of
country were recruited with the purpose of raising 86% of the physicians were authorised GP specialists.
awareness and improving GP’s prescription patterns in Most GPs worked ina group practice.
2 FossumGH,LindbækM,GjelstadS,etal.BMJOpen2013;3:e002285.doi:10.1136/bmjopen-2012-002285
Are children carrying the burden of broad-spectrum antibiotics?
Figure1 Selectionprocessafter
datafrom441general
practitioners(GPs)and25093
respiratorytractinfection
episodesfor1year(December
2004throughNovember2005)
werecollected.
The prescription pattern among GPs varied consider-
Table1 Characteristicsof426participatinggeneral
practitioners(GPs) ably,withameanof25.5(95%CI24.2to26.7)antibiotic
prescriptions per 100 episodes. For broad-spectrum anti-
Characteristic
biotic proportion, the corresponding figure was 53.7
(n=426) Number %(95%CI)
(95% CI 50.7 to 56.7). Among the latter, more than 50
Gender
doctorsprescribed broad-spectrum antibiotics every time
Female 135 31.7(27.3to36.1)
(figure2).
Male 291 68.3(63.9to72.7)
Respiratory infections were most common among
Grouppractice
2-year-olds to 3-year-olds, 41% experienced infections
Yes 394 92.5(90.0to95.0)
No 32 7.5(5.0to10.0) and fewer episodes were found in June, July and August.
GPspecialist Of the 24888 episodes, 53% were boys and 47% were
Yes 365 85.7(82.4to89.0) girls. The three most common diagnoses were acute
No 61 14.3(11.0to17.6) upper RTI (R74), cough (R05) and acute otitis media
Practicelocation (H71), 27%, 18% and 16%, respectively. A total of 20%
City 233 54.7(50.0to59.4) of the episodesarerepeating visits.
Rural 193 45.3(40.6to50.0)
An antibiotic prescription was registered in 26.2%
Mean Median(range)
(6525) of all episodes. Penicillin V was prescribed most
Age(years) 49 50(28to67)
frequently, followed by macrolide/lincosamide antibio-
Yearssince 19 20(0to41)
tics. In the latter group, lincosamides accounted foronly
authorisation
1.3%; the group is therefore referred to as macrolides.25
Numberoflisted 1328 1316(0to3385)
patients Few registered prescriptions of tetracyclines and cepha-
Consultationsperyear 3095 3029(309to11252) losporins for RTIs were found. Episodes with acute ton-
sillitis resulted in a prescription in 77%, and more than
FossumGH,LindbækM,GjelstadS,etal.BMJOpen2013;3:e002285.doi:10.1136/bmjopen-2012-002285 3
Are children carrying the burden of broad-spectrum antibiotics?
childrenbelowage1(n=1552),whereonly10%received
an antibiotic prescription.
Predictors for antibiotic prescriptions are shown in
table 3. Tonsillitis and pneumonia gave the highest OR
for antibiotics among the diagnostic groups, with ORs of
33.6 (95% CI 25.7 to 43.9) and 16.5 (95% CI 12.7 to
21.4), respectively. Older children had an increased
probability for antibiotics compared to the age group
0–1years (table 3). Gender or GP characteristics did not
predict antibiotic prescriptions, except for GPs with a
high work load (measured by annual consultations),
which were more frequent prescribers. Bivariate analysis
found increased ORs for antibiotic prescriptions among
GPs in single practice and non-specialists, but these dif-
ferences did not remain significant afteradjustment.
Regression analysis on predictors for broad-spectrum
antibiotics showed a similar pattern (table 4). The diag-
Figure2 Antibioticprescriptionratesforrespiratorytract
noses giving the highest ORs were the group of other
infectionepisodesandproportionbroad-spectrumantibiotic
respiratory infections and bronchitis, ORs of 3.04 (95%
prescriptionsamongthe426participatinggeneral
practitioners. CI 2.28 to 4.05) and 2.71 (95% CI 1.91 to 3.86), respect-
ively gave the highest ORs compared to the reference
group of acute RTIs. The probability for broad-spectrum
67% of the prescriptions were penicillin V. As shown in
antibiotics was low for tonsillitis, and increasing age
table 2, a high antibiotic rate for acute bronchitis was
lowered the probability (table 4). Predictors of broad-
found, 40%, with macrolide antibiotics as the choice of
spectrum antibiotics with regard to the GP gave higher
preference. When patients were diagnosed ‘other RTIs’, ORs for specialist GPs. The most significantly increased
only 12% of the episodes resulted in antibiotic prescrip-
OR was seen in high prescribers, OR 3.33 (95% CI 2.01
tions. In the latter, 52% of the episodes resulted in to 5.54), for GPs withprescription rates of33.3–77.8%.
macrolide antibiotics and 22% in penicillins with
extended spectrum. In the otitis media group where
antibiotics were prescribed, penicillin V and penicillins DISCUSSION
with extended spectrum were provided in 46% and Our results showed frequent use of broad-spectrum anti-
33%, respectively. A lower prescription rate was found in biotics for RTIs in children, but a low overall
Table2 Antibioticprescriptionsof426GPsfor24888RTIepisodesfor1year(December2004throughNovember2005)
accordingtoICPC-2diagnosesandtypeofantibiotic
ICPC-2 Episodes Prescriptionrate
Diagnoses codes N (%)(95%CI) PcVn(%) Pc-Extn(%) Macn(%) OtherJ01n(%)
Acuteupper R01–29, 6806 13.5(12.7to14.3) 388(42) 245(27) 272(30) 17(2)
respiratorytract 74,80
infectionsand
symptoms
Otherrespiratory R71,75, 8758 12.4(11.7to13.1) 271(25) 236(22) 562(52) 17(2)
tractinfections 77,79,
(including 83,95
sinusitisand
laryngitis)
Acute R78 1481 40.2(37.7to42.7) 141(24) 138(23) 309(52) 8(1)
bronchiolitis/
bronchitis
Pneumonia R81 606 67.0(63.3to70.7) 127(31) 97(24) 178(44) 4(1)
Acuteotitisand H01,71, 5961 42.5(41.2to43.8) 1174(46) 832(33) 477(19) 53(2)
earpain 72,74
Acutetonsillitis R72,76 1276 76.7(74.4to79.0) 654(67) 137(14) 176(18) 12(1)
Total 24888 26.2(25.7to26.7) 2755(42) 1685(26) 1974(30) 111(2)
GPs,generalpractitioners;ICPC-2,InternationalClassificationofPrimaryCare;Mac,macrolideandlincosamideantibiotics;OtherJ01,
cephalosporins,co-trimoxazoleandtetracyclins;PcExt,penicillinswithextendedspectrum(non-penicillinV);PcV,penicillinV;RTI,respiratory
tractinfection.
4 FossumGH,LindbækM,GjelstadS,etal.BMJOpen2013;3:e002285.doi:10.1136/bmjopen-2012-002285
Are children carrying the burden of broad-spectrum antibiotics?
Table3 Multiplelogisticregressionanalysisshowingfactorsindependentlyassociatedwith426generalpractitioners’(GPs)
antibioticprescriptionsfor24888respiratorytractinfectionepisodesduring1year(December2004throughNovember
2005)
n(episodes) AdjustedOR(95%CI)
Patientfactors
Patient’sgender
Male(ref) 13214 1
Female 11674 0.97(0.90to1.04)
Groupofdiagnoses
Acuteupperrespiratorytractinfectionsandsymptoms(ref) 6806 1
Otherrespiratorytractinfections 8758 0.76(0.67to0.87)
Acutebronchitis 1481 4.35(3.53to5.35)
Pneumonia 606 16.5(12.7to21.4)
Acuteotitisandearpain 5961 5.16(4.55to5.85)
Acutetonsillitis 1276 33.6(25.7to43.9)
Patientage
<2years(ref) 7909 1
3–4years 10118 1.34(1.24to1.46)
5–6years 6861 1.41(1.28to1.54)
Doctorfactors
Doctor’sgender
Male(ref) 16281 1
Female 8607 1.06(0.88to1.28)
Practicelocation
City(ref) 14009 1
Rural 10879 1.00(0.84to1.18)
Practicetype
Group(ref) 23207 1
Single 1681 1.10(0.81to1.49)
Educationallevel
GPspecialist (ref) 21798 1
Notspecialist 3090 1.38(1.06to1.81)
Doctor’sage
28–43(ref) 7096 1
44–49 7544 1.19(0.94to1.52)
50–54 5833 1.05(0.82to1.36)
55–67 4415 1.12(0.86to1.44)
Patientcontactsperyear
309–2302(ref) 4025 1
2303–3028 5495 1.16(0.91to1.47)
3029–3711 7060 1.27(0.99to1.62)
3712–11252 8308 1.54(1.20to1.97)
Significantvaluesinbold,p<0.05.
prescription rate. Overprescription was found for bron- suspected atypical pneumonia or penicillin allergy. In
chitis and in busy GPs. our study they have been used for other diagnoses as
Although penicillin V was the most frequent preferred well. One explanation may, at least in part, be adminis-
choice of antibiotic in 42% of childhood diagnoses, a trative convenience and a more preferential taste com-
high percentage of broader spectrum antibiotics, espe- pared to the bitter-tasting penicillin V. It has been found
cially macrolides, was found. An overall 30% macrolide that tolerability, taste and administrative frequency
use is seen in the present study. A proportion of 52% for are of importance in paediatric populations.21 28 29
bronchitis differs from a bronchitis macrolide propor- When Hoppe and co-workers tested paediatric
tion of 32% in the corresponding study whereadult data compliance in oral antibiotics, acompliance of 94% and
also are included.26 The use of penicillin with extended 90% was found for clarithromycin and erythromycin.
spectrum is recommended prior to the use of macro- Correspondingly, penicillin V suspensions had a compli-
lides due to resistance issues.16 18 19 Macrolides, accord- ance rate of 62% and 56%.30 Hinnerskov et al31 have
ing to the Norwegian guidelines for antibiotic use in highlighted a similar problem of macrolide overuse in
primary care,20 27 are first choice of preference only in Denmark.
FossumGH,LindbækM,GjelstadS,etal.BMJOpen2013;3:e002285.doi:10.1136/bmjopen-2012-002285 5
Are children carrying the burden of broad-spectrum antibiotics?
Table4 Multiplelogisticregressionanalysisshowingfactorsindependentlyassociatedwith426generalpractitioners’(GPs)
proportionofbroad-spectrumantibiotics(non-penicillinV)for6525respiratorytractinfectionepisodeswithprescribed
antibioticfor1year(December2004throughNovember2005)
n(episodes) AdjustedOR(95%CI)
Patientfactors
Patient’sgender
Male(ref) 3490 1
Female 3035 1.04(0.91to1.19)
Groupofdiagnoses
Acuteupperrespiratorytractinfectionsandsymptoms(ref) 922 1
Otherrespiratorytractinfections 1086 3.04(2.28to4.05)
Acutebronchitis 596 2.71(1.91to3.86)
Pneumonia 406 2.10(1.46to3.02)
Acuteotitisandearpain 2536 1.11(0.87to1.43)
Acutetonsillitis 979 0.24(0.18to0.33)
Patientage
<2years(ref) 1533 1
3–4years 2888 1.13(0.94to1.35)
5–6years 2104 0.79(0.66to0.96)
Doctorfactors
Doctor’sgender
Male(ref) 4310 1
Female 2215 0.83(0.56to1.24)
Practicelocation
City(ref) 3689 1
Rural 2836 1.07(0.72to1.59)
Practicetype
Group(ref) 6038 1
Single 487 1.21(0.61to2.34)
Educationallevel
GPspecialist (ref) 5658 1
Notspecialist 867 0.53(0.30to0.94)
Doctor’sage
28–43(ref) 1878 1
44–49 1927 0.71(0.43to1.19)
50–54 1489 1.06(0.62to1.80)
55–67 1231 0.85(0.49to1.49)
Patientcontactsperyear
309–2302(ref) 955 1
2303–3028 1367 1.48(0.90to2.44)
3029–3711 1889 1.23(0.74to2.06)
3712–11252 2314 1.44(0.85to2.46)
Antibioticprescriptionrate(%)
0–15.60(ref) 580 1
15.61–23.64 1236 1.15(0.69to1.90)
23.65–33.33 1942 1.37(0.84to2.23)
33.34–77.78 2767 3.33(2.01to5.54)
Significantvaluesinbold,p<0.05.
The overall prescription rate of only 26% for RTIs in a prescription rate of only 26% shows a decreasing ten-
children aged 0–6years in our study was rather low com- dency. In 1998, antibiotics were the rule rather than the
pared to the corresponding data including the adult exceptionforchildrenvisitingGPsforotitismedia,tonsil-
population.26 Although a low rate in preschool children litis,sinusitis,bronchitis/bronchiolitisandpneumonia.8
of 24% was found of the latter, a high proportion was Antibiotic prescriptions by diagnosis showed a similar
broad-spectrum antibiotics.26 Blix et al1 reported popula- distribution pattern to that of the corresponding dataset
tion prevalence for all antibiotic prescriptions of 24% including adults, but a higher rate for otitis media and a
andforchildren0–4yearsabout30%in2005/2006.Our lower rate for symptom diagnoses and bronchitis.26
selection only included RTIs, and is, accordingly, some- SubstantialefforthasbeenperformedinNorwaythepast
what lower. Compared to a Norwegian study from 1998,8 decade to decrease the prescription rate of antibiotics.
6 FossumGH,LindbækM,GjelstadS,etal.BMJOpen2013;3:e002285.doi:10.1136/bmjopen-2012-002285
Are children carrying the burden of broad-spectrum antibiotics?
Our data indicate that these efforts are about to pay off. comprised a complete year, including all seasonal varia-
For instance, we found a low antibiotic prescription rate tions. GPs from most parts of the Southern Norway
inpatientswithotitismedia,42.5%.Thisisinaccordance participated; urban as well as rural areas. We believe it is
withcurrentNorwegianguidelines.20Comparablefigures likely that our data represent the prescription pattern
frompreviousstudiesonantibioticprescriptionsforRTIs for RTIs well and that our findings are generalisable to
in children in several countries revealed an average pre- Norwegian GPs. We have chosen to analyse by infectious
scription rate of 47%. Among the 14 study populations episodes, with a cut-off at 30days, well aware that a few
included in the study, Italy and Canada have high levels new episodes may represent revisits due to treatment
of42and57%,respectively.HollandandUKhavecorres- failure and follow-up visits by the same patient. Previous
pondinglylowlevelsof14%and21%.32 studies havebeenperformedbasedonconsultationsand
by infectious episodes.32 36 The consultations in the
Predictors of antibiotic prescriptions present studyonly represent GPs’regularofficework, no
The prescription rate of 40% for bronchitis/bronchio- out-of-hour emergency visits are included. In most of
litis was worryingly high. This figure is lower than the Norway, the same office GPs also are on duty taking care
former study from 1998,8 but not in correspondence of emergency cases during evenings and nights. A study
with current Norwegian guidelines.20 Considerable byFagan39showedthatNorwegianGPs’prescriptionpat-
improvement in prescription routines is needed. terns are identical when regular office consultations are
Cochrane reviews have shown no evidence for treating compared to emergency visits forotitis media and tonsil-
acute bronchiolitis in children with antibiotics, and only litis. Our data are mainly from 2005; however, figures
a modest beneficial effect when treating patients from NorPD indicate similar patterns of antibiotic use
8–65.33 34 No obvious explanation to the high prescrip- nowin2011.7
tion rate for bronchitis is evident, but one reason may In conclusion, a low antibiotic prescription rate for
be a perceived patient or parental demand for prescrip- childhood RTIs was found. However, the GPs tend
tion, as reported by Little et al.35 We also suspect that to choose macrolide antibiotics and penicillins with
some diagnoses may be registered based on symptom extended spectrum more often than the guidelines
findings, although the GP suspected more serious illness recommend. We recognise the specific challenges that
and subsequently prescribed antibiotics. C reactive are related to medication compliance in children.
protein (CRP), CRP-testing, is usually performed follow- Administrative simplifications, such as the availability to
ing clinical examination, and after the ICPC-2 coding. oral penicillin suspensions during meals, may help shift
Elevated CRP may cause a prescription without a corre- the trend away from broad-spectrum antibiotics.40
sponding change in the initial ICPC-2 code. In the Palatability may also affect compliance, taking penicillin
present study, 12–14% received antibiotics based on V’s bitter taste into account. Differences between GPs
symptom diagnoses only. Jansen et al report similar can be targeted by more individual and specified means.
results from Holland, with a symptom diagnose prescrip- We recommend that GPs replace narrow spectered peni-
tion rate of 12–15% for preschool children.36 Such cillins with extended spectered penicillins rather than
infections are likely to have viral pathology. A corres- macrolidesas second-choice antibiotic in RTIs.
pondingly low prescription rate is expected.
Children aged 5–6years had the highest probability Authoraffiliations
for antibiotic prescriptions, children below age 2 the 1DepartmentofGeneralPractice,InstituteofHealthandSociety,Universityof
Oslo,Oslo,Norway
lowest. An opposite pattern was seen in the prescription
2DivisionofSurgeryandClinicalNeuroscience,Departmentfor
pattern for broad-spectrum antibiotics. Another factor
Otorhinolaryngology,HeadandNeckSurgery,OsloUniversityHospital,Oslo,
influencing antibiotic prescription was related to GP Norway
experience, as GP non-specialists were more likely to 3Research,InnovationandEducationUnit,OsloUniversityHospital,Oslo,
prescribe antibiotics. A high number of patient contacts Norway
4DepartmentofHealthManagementandHealthEconomics,Universityof
per year increased prescription likelihood. High anti-
Oslo,Oslo,Norway
biotic prescription rates increased the probability for
broad-spectrum antibiotics. Slightly surprising, GP spe- Contributors GHF,MLandSGconceivedtheideaofthestudyandwere
cialiststend to use more broad-spectrum antibiotics than responsibleforthedesignofthestudy.GHF,SGandIDwereresponsiblefor
those without the specialist authorisation. Similar results thedataanalysesandproducedthetablesandgraphs.IDdesignedthemodel
arepresentedbyClavennaetal,suggestingthatphysician usedformultilevelanalysis.Allauthorsprovidedinputintothedataanalysis
andtotheinterpretationoftheresults.Theinitialdraftofthemanuscriptwas
attitude may play a role obtaining prudent antibiotic
preparedbyGHF,MLandKJKandthencirculatedrepeatedlyamongall
prescriptions37. Antibiotic overuse may also be affected authorsforcriticalrevision.
by an existing gap between perceived and real determi-
Funding TheRx-PADstudywascarriedoutwithgrantsfromtheNorwegian
nantsof antibiotic prescription.38
MinistryofHealthandtheNorwegianMedicalAssociation.Thepresentstudy
isfundedaspartofaPhD-projectbytheAntibioticCenterforPrimaryCare.
Strengths and limitations
Competinginterests ICMEJformsaresubmittedforallauthors.SGis
The major strength of this study is the large number of workingparttimeandhasownershipinthecompanythatproducedsoftware
infectious episodes in the data set. The study period fordataextractioninthisstudy.Otherauthorsnonetodeclare.
FossumGH,LindbækM,GjelstadS,etal.BMJOpen2013;3:e002285.doi:10.1136/bmjopen-2012-002285 7
Are children carrying the burden of broad-spectrum antibiotics?
Ethicsapproval TheRx-PAD-study,mergedwiththedatafromNorPDwas 19. KastnerU,GuggenbichlerJP.Influenceofmacrolideantibioticson
approvedbytheregionalethicscommittee,theNorwegiandatainspectorate promotionofresistanceintheoralfloraofchildren.Infection
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