Variation in antibiotic prescription rates in febrile children presenting to emergency departments across Europe (MOFICHE): A multicentre observational study

Hagedoorn, Nienke N.; Borensztajn, Dorine M.; Nijman, Ruud; Balode, Anda; Both, Ulrich von; Carrol, Enitan D.; Eleftheriou, Irini; Emonts, Marieke; Flier, Michiel van der; Groot, Ronald de; Herberg, Jethro; Kohlmaier, Benno; Lim, Emma; Maconochie, Ian; Martinon-Torres, Federico; Nieboer, Daan; Pokorn, Marko; Strle, Franc; Tsolia, Maria; Yeung, Shunmay; Zavadska, Dace; Zenz, Werner; Vermont, Clementien; Levin, Michael und Moll, Henriette A. (2020): Variation in antibiotic prescription rates in febrile children presenting to emergency departments across Europe (MOFICHE): A multicentre observational study.
In: PLOS Medicine 17(8), e1003208

Abstract

Background: The prescription rate of antibiotics is high for febrile children visiting the emergency department (ED), contributing to antimicrobial resistance. Large studies at European EDs covering diversity in antibiotic and broad-spectrum prescriptions in all febrile children are lacking. A better understanding of variability in antibiotic prescriptions in EDs and its relation with viral or bacterial disease is essential for the development and implementation of interventions to optimise antibiotic use. As part of the PERFORM (Personalised Risk assessment in Febrile illness to Optimise Real-life Management across the European Union) project, the MOFICHE (Management and Outcome of Fever in Children in Europe) study aims to investigate variation and appropriateness of antibiotic prescription in febrile children visiting EDs in Europe. Methods and findings: Between January 2017 and April 2018, data were prospectively collected on febrile children aged 0-18 years presenting to 12 EDs in 8 European countries (Austria, Germany, Greece, Latvia, the Netherlands [n =3], Spain, Slovenia, United Kingdom [n =3]). These EDs were based in university hospitals (n =9) or large teaching hospitals (n =3). Main outcomes were (1) antibiotic prescription rate;(2) the proportion of antibiotics that were broad-spectrum antibiotics;(3) the proportion of antibiotics of appropriate indication (presumed bacterial), inappropriate indication (presumed viral), or inconclusive indication (unknown bacterial/viral or other);(4) the proportion of oral antibiotics of inappropriate duration;and (5) the proportion of antibiotics that were guideline-concordant in uncomplicated urinary and upper and lower respiratory tract infections (RTIs). We determined variation of antibiotic prescription and broad-spectrum prescription by calculating standardised prescription rates using multilevel logistic regression and adjusted for general characteristics (e.g., age, sex, comorbidity, referral), disease severity (e.g., triage level, fever duration, presence of alarming signs), use and result of diagnostics, and focus and cause of infection. In this analysis of 35,650 children (median age 2.8 years, 55% male), overall antibiotic prescription rate was 31.9% (range across EDs: 22.4%-41.6%), and among those prescriptions, the broad-spectrum antibiotic prescription rate was 52.1% (range across EDs: 33.0%-90.3%). After standardisation, differences in antibiotic prescriptions ranged from 0.8 to 1.4, and the ratio between broad-spectrum and narrow-spectrum prescriptions ranged from 0.7 to 1.8 across EDs. Standardised antibiotic prescription rates varied for presumed bacterial infections (0.9 to 1.1), presumed viral infections (0.1 to 3.3), and infections of unknown cause (0.1 to 1.8). In all febrile children, antibiotic prescriptions were appropriate in 65.0% of prescriptions, inappropriate in 12.5% (range across EDs: 0.6%-29.3%), and inconclusive in 22.5% (range across EDs: 0.4%-60.8%). Prescriptions were of inappropriate duration in 20% of oral prescriptions (range across EDs: 4.4%-59.0%). Oral prescriptions were not concordant with the local guideline in 22.3% (range across EDs: 11.8%-47.3%) of prescriptions in uncomplicated RTIs and in 45.1% (range across EDs: 11.1%-100%) of prescriptions in uncomplicated urinary tract infections. A limitation of our study is that the included EDs are not representative of all febrile children attending EDs in that country. Conclusions: In this study, we observed wide variation between European EDs in prescriptions of antibiotics and broad-spectrum antibiotics in febrile children. Overall, one-third of prescriptions were inappropriate or inconclusive, with marked variation between EDs. Until better diagnostics are available to accurately differentiate between bacterial and viral aetiologies, implementation of antimicrobial stewardship guidelines across Europe is necessary to limit antimicrobial resistance. Author summaryWhy was this study done? Respiratory infections, which are mainly caused by viruses, account for the majority of antibiotic use in children. In children with respiratory infections, antibiotic prescription rates vary across emergency departments (EDs) in Europe. In order to optimise antibiotic prescriptions, it is important to better understand variability and appropriateness in antibiotic prescriptions. What did the researchers do and find? In this prospective observational study, we included routine information of 35,650 children (median age 2.8 years) with fever attending 12 different EDs in Europe and calculated the proportion of antibiotic prescriptions and broad-spectrum antibiotic prescriptions. We adjusted for differences in population including age, comorbidity, disease severity, and focus and cause of infection. Across EDs, antibiotic prescription rates ranged between 22.4% and 41.6%, and of these prescriptions, broad-spectrum antibiotic rates ranged between 33.0% and 90.3%. Standardised antibiotic prescription rates ranged between 0.77 and 1.35, and standardised rates of broad-spectrum antibiotics ranged between 0.65 and 1.75. Prescriptions that were inappropriately indicated ranged from 0.6% to 29.3%, and inconclusive prescriptions ranged from 0.5% to 61.7%. The proportion of oral prescriptions with inappropriate duration ranged from 4.4% to 59.0%. What do these findings mean? In this study we found variation of prescription of antibiotics and broad-spectrum antibiotics between EDs in children with fever, even when correcting for age, comorbidity, disease severity, diagnostics, and focus and cause of infection. Variation was especially large in prescriptions for viral infections and infections of unknown cause. In this cohort of febrile children, one-third of prescriptions were of inappropriate or inconclusive indication, with variation between EDs. In addition, guideline concordance for respiratory and urinary infections varied widely across EDs. Generalisation of these results to all EDs in Europe should be undertaken with caution. Implementation of guidelines is needed to improve appropriate prescription of antibiotics, whilst new biomarkers will further improve antibiotic prescription.

• Dokumententyp: Zeitschriftenartikel
• Fakultät: Medizin
• Themengebiete: 600 Technik, Medizin, angewandte Wissenschaften > 610 Medizin und Gesundheit
• ISSN: 1549-1277
• Sprache: Englisch