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Health and medicine

Many kids face an antibiotic overload

A study shows many American children get unneeded antibiotics. Doctors worry that could help spawn "superbugs."

By LISA GREENE
Published November 9, 2005

Amid a sea of sniffly noses and wheezing coughs, children with sore throats are supposed to be pediatricians' easy cases.

Test for strep throat. If they test positive, give penicillin or a similar antibiotic.

A negative test, and no antibiotic will help.

But that's not what really happens, says a major new study. Even with a clear-cut choice and a rapid test, legions of American children are getting antibiotics when they don't need them.

The study is a blow for health officials who have been waging a public campaign to cut down on unnecessary antibiotic use. Such prescriptions only encourage the spread of "superbugs" - bacteria that become resistant to common antibiotic drugs and can't be killed by them.

"We did this study because with sore throats and kids, there's a good test available," said Dr. Jeffrey A. Linder. "We expected that, if doctors were doing well anywhere, we would hope it would be here. We were surprised that the antibiotic rate was as high as it was."

Linder, lead author of the study published in today's Journal of the American Medical Association, is an instructor at Harvard Medical School and associate physician at Brigham and Women's Hospital. The journal also published a second study and an editorial focusing on unneeded antibiotics.

Sore throats are a common childhood problem, accounting for 6 percent of doctor visits - about 7.3-million in the United States each year.

When these children are tested for strep, 15 to 36 percent generally test positive. The others generally have a virus, which can't be treated with antibiotics.

But the study found that far more children, about 53 percent, were given antibiotics.

What's more, only about half those with sore throats were even tested for strep.

More than a quarter of the children getting antibiotics got drugs that aren't recommended for treating strep, further encouraging the development of resistant bacteria.

"Many people feel that one potential future is that in 10 to 15 years, antibiotic resistance will be the norm," said Dr. Matthew Samore, lead author of the second JAMA study. As a result, illness, and even deaths, will increase, he said.

In the Tampa Bay area, doctors said they were disappointed but not entirely surprised.

"It is impossible to look at someone's throat and tell if they have strep," said Tampa pediatrician Fred Lipschutz. "Even the most experienced clinicians can't tell."

But doctors pointed to reasons why some doctors might skip tests. Some of the newest, most accurate strep tests require doctors to get a certification before using them, said Dr. Juan Dumois, infectious disease chairman at All Children's Hospital in St. Petersburg.

Then there's the pressure from expectations. "The doctor is always charged to make a diagnosis right there and prescribe something to cure them right away," Dumois said. "There are certain clinical conditions where a virus or a bacteria could cause the same symptoms, and without a test you can't make a diagnosis."

But some patients don't like test delays - or at least, doctors say they don't. Doctors complain of patients who insist on antibiotics, no matter what.

"It's almost like the two sides aren't talking to each other," Samore said. "Doctors perceive patient demand (for antibiotics), but they're often not very good at identifying which patients are actually asking for them. On the patient side, patients have some misconceptions about what's a virus and what's a (bacterial) infection."

The study reviewed databases with more than 700,000 patient records to look at 4,158 children who visited doctors for sore throats from 1995 to 2003. Of those, 2,797 got strep tests.

When children got antibiotics, Linder said, most should have gotten penicillin or a related drug. Penicillin is cheap and effective and strep hardly ever resists it. Children should get a different drug, erythromycin, only if they're allergic to penicillin.

But instead, Linder and his colleagues found 27 percent got other drugs - often newer, more expensive "broad spectrum" drugs designed to treat many different conditions. Such drugs include Zithromax and Biaxin.

Many children think erythromycin tastes bad, Lipschutz said, so some doctors might choose a different drug.

"If you prescribe something to a child who's not going to take it, it's not going to do much good," he said. "But we still have a long way to go to do this right."

Dumois said he's especially worried about the newer drugs being overused.

"There's no need to use these stronger, more expensive drugs," he said. "We're seeing more and more resistance (to those) from strep and staph. Those are no longer as useful as they were 10 years ago."

The study included one bright spot: Antibiotic prescriptions for sore throats have dropped, going from 66 percent of such children in 1995 to 54 percent in 2003.

"It's going down, but not a lot," said Dr. Todd J. Weber, director of the Office of Antimicrobial Resistance with the federal Centers for Disease Control and Prevention. "We still have to help prescribers understand what diagnoses are likely to be viral."

Weber wrote the editorial in today's JAMA, urging doctors not to overprescribe and stressing the need for health officials, drug companies and doctors to work on ways to improve antibiotic use.

One way to help doctors prescribe more carefully would be a system of guided questions. In the study led by Samore, doctors found such a system could cut antibiotic prescriptions by about 10 percent for upper respiratory infections.

Doctors could use the system on paper or electronically, with a hand-held computer. The system asks questions, and recommends whether to prescribe an antibiotic based on the answers. For example, a doctor seeing a patient with a sore throat would be asked if the patient has a fever or a runny nose, and if the soreness started suddenly. Depending on the answers, the system would say whether the patient should be tested for strep.

"The other purpose of this is to try to do the teaching and ingraining of new habits," Samore said. "A lot of what is done is based on patterns of previous experience."

[Last modified November 9, 2005, 00:40:17]