Antibiotic use in ambulatory care for acutely ill children in high income countries: a systematic review and meta-analysis

Ruben Burvenich, Hannelore Dillen, Nhung Trinh, Joseph Freer, Laure Wynants, Stefan Heytens, An De Sutter, Jan Y Verbakel

Keywords: Anti-Bacterial Agents, Antimicrobial resistance, Drug Prescriptions, Primary Health Care, Outpatients, Ambulatory Care, General Practice, General Practitioners, Peadiatrics, Emergency Medicine

Background:

Childhood infections are common. Inappropriate antibiotic prescribing leads to antimicrobial resistance with associated healthcare costs.

Research questions:

To determine the rate and appropriateness of antibiotic prescribing for acutely ill children in ambulatory care in high-income countries.

Method:

On 10 February 2021, we systematically searched articles published since 2000 in MEDLINE, Embase, CENTRAL, Web-Of-Science, and grey literature databases. We included cross-sectional and longitudinal studies, time series analyses, randomised controlled trials and non-randomised studies of interventions with acutely ill children up to and including 12 years of age in ambulatory care settings in high-income countries. Pooled antibiotic prescribing and appropriateness rates were calculated using random-effects models. Meta-regression was performed to describe the relationship between the antibiotic prescribing rate and study-level covariates.

Results:

We included 86 studies comprising 11,114,863 children. We found a pooled antibiotic prescribing rate of 45.4% (95% confidence interval [CI] 38.2 to 52.8) for all acutely ill children, and 85.6% (95% CI 73.3 to 92.9) for acute otitis media, 37.4% (95% CI 30.9 to 44.3) for respiratory tract infections, and 40.4% (95% CI 29.9 to 51.9) for other diagnoses. Considerable heterogeneity can only partly be explained by differences in diagnoses. The overall pooled appropriateness rate is 68.5% (95% CI 55.8 to 78.9, I²=99.8%; 19 studies, 119,995 participants). 38.3% of all prescribed antibiotics were aminopenicillins.

Conclusions:

Antibiotic prescribing rates for acutely ill children in ambulatory care in high-income countries remain high. Large differences in prescription rates between studies can only partly be explained by differences in diagnoses. Better registration and further research are needed to investigate patient-level data on diagnosis and appropriateness.

Points for discussion:

How can we generate less heterogeneous data in the future?

Why does (inappropriate) antibiotic prescribing for acutely ill children presenting to ambulatory care in high income countries remain high despite the many interventions?

Which methods exist to determine the appropriateness of antibiotic prescribing and which are preferred?

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