EDs Too Often Give Antibiotics for Infant Viral Lung Infections

Recommendations to avoid antibiotics in infants treated for bronchiolitis issued more than a decade ago are being widely ignored in U.S. emergency departments, according to a nationally representative survey of hospital visit data.

An estimated one in four patients with bronchiolitis seen in U.S. emergency departments (EDs) from 2007 to 2015 received antibiotics, even though 70% of cases had no documented bacterial coinfection.

The study findings suggest that antibiotic use in emergency departments did not decrease significantly after national guidelines recommending against their routine use were first published by the American Academy of Pediatrics (AAP) in 2006.

Bronchiolitis is the leading cause of hospitalization among children in the U.S. during their first year of life. The condition occurs when the small airways become congested, usually due to viral infection.

The study, published Jan. 17 in the Journal of the Pediatric Infectious Disease Society, highlighted a concerning trend in failing to translate evidence-based guidelines into clinical practice, said researcher Brett Burstein, MD, PhD, of the McGill University Health Centre in Montreal.

In an interview with MedPage Today, Burstein cited his team’s earlier research published last October in JAMA, showing that half of infants diagnosed with bronchiolitis in the same study population also received chest x-rays despite recommendations against their use in the same AAP guidelines.

“The steady elevated rate of chest radiography and antibiotic use demonstrates the well-established challenge of translating guidelines into practice,” Burstein said. “Knowledge translation of health research has been reported to take an estimated average of 17 years to enter day-to-day clinical practice. Unfortunately, there is no consensus on how to precisely measure these translational delays nor how they can be reduced.”

Young children with bronchiolitis have a less than 1% risk of invasive bacterial infection. This, along with initiative to reduce antibiotic overuse and bacterial resistance in children led to the AAP guidelines, which were first published in 2006 and revised in 2014.

The researchers conducted a cross-sectional analysis of data from the CDC’s National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007 to 2015, which represented approximately 30,000 ED visits to 300 randomly selected hospital EDs.

Burstein and colleagues used a multistage probability sampling design in an effort to generate unbiased population-level estimates. The study population included children under the age of 2 years with a discharge diagnosis of bronchiolitis.

The primary outcome was the proportion of children with bronchiolitis with no concomitant bacterial infection prescribed antibiotics in the ED. Additional covariates considered in the analysis included patient demographics including age, sex, race, and insurance provider; visit characteristics, such as triage acuity level, admission/discharge, and radiography use; and ED characteristics of pediatric and teaching status.

During the 9-year study period, 612 patients met the inclusion criteria, representing an estimated 2.92 million (95% CI, 2.43 million-3.41 million) ED visits for bronchiolitis among children under the age of 2 years.

The median age at ED visit was 8 months of age, and the majority of patients were treated at non-teaching (86.9%) and non-pediatric (76.6%) hospitals.

At least one additional diagnosis consistent with bacterial infection occurred in 11.9% of cases.

The antibiotic data revealed that:

• 25.6% of patients received antibiotics, an estimated about 83,000 prescriptions annually

• No significant change occurred in the annual proportion prescribed antibiotics during the study period (P for trend, 0.18)

• Antibiotic prescribing between the admitted and non-admitted patients was not statistically different (19.2% vs 26.3%, respectively; P=0.30)

• 69.9% of young children treated with antibiotics (95% CI, 59.7%–78.5%) had no documented concomitant bacterial infection

Factors significantly associated with increased antibiotic prescribing on multivariable logistic regression analysis adjusted for patient- and ED-level covariates were:

• Age of 12 to 23 months (adjusted odds ratio [aOR], 2.64 [95% CI, 1.06–6.59])
• Use of radiography (aOR, 3.37 [95% CI, 1.55–7.32])
• Treatment in a non-teaching (aOR, 3.03 [95% CI, 1.04–9.77]) or non-pediatric (aOR, 3.32 [95% CI, 1.07–11.36]) hospital

Since 2013, reducing unnecessary antibiotic prescribing for bronchiolitis and similar viral illnesses has been a major stated goal of the AAP’s “Choosing Wisely” campaign.

Burstein said targeted interventions will be necessary to translate the AAP guidelines into practice, particularly among non-academic hospitals where most infants with bronchiolitis are treated.

He cited findings from a multi-site collaborative published last February in Pediatrics with the goal of improving delivery of evidence-based management of bronchiolitis at 35 pediatric and non-pediatric hospitals, as well as teaching and non-teaching hospitals from across the U.S.

While ED antibiotic use did not decrease during the year-long intervention, it was steady at an already low 5% with an achievable benchmark defined at 0.7%. ED chest imaging was 23% during the intervention with an achievable benchmark of 4%.

“Multi-modal, multi-site interventions such as these are likely needed to move the dial,” Burstein said, “as are national campaigns such as Choosing Wisely, to inform the lay public regarding viral illness and the importance of avoiding unnecessary antibiotic use when possible.”