ירחון החברה הישראלית לפדיאטריה אמבולטורית (חיפ"א) גיליון 2019-1

34 Choosing Wisely: Do we give antibiotics for viral URIs? In this column, we continue to suggest “Choosing Wisely” strategies for best evidence-based medical care. Antibiotic resistance is a growing concern and the overuse of antibiotics is the most common culprit. In a cohort study from 123 clinics, Havers, et al, characterized antibiotic prescribing habits among outpatients with viral upper respiratory infections during the 201-2014 and 2014-2015 influenza seasons. 14,987 patients included in the study were of at least 6 months of age, had symptoms consistent with a URI and were swabbed for influenza. Diagnoses were stratified between Tier 1, for which antibiotics in indicated (such as, pneumonia); Tier 2, for which antibiotics is sometimes indicated (such as AOM, Pharyngitis, Sinusitis); and Tier 3, for which antibiotics is not indicated (such as URI, influenza, asthma). Antibiotic use was determined from medical, pharmacy and insurance records. In this review we will look at the pediatric data: 38% of the patients were <18 years old. Of the pediatric patients who were prescribed antibiotics, 25% had Tier 3 diagnoses. Among those diagnosed with influenza, 14% were prescribed antibiotics. The study did not fully evaluate the accuracy of Tier 2 diagnosis to determine appropriate antibiotic use. On a more positive side, pediatric patients were prescribed less antibiotics for Tier 3 diagnoses than adults or the elderly (25%, 46% and 65%, respectively) and pediatric patients were prescribed more narrow spectrum antibiotics. Nevertheless, this study demonstrates overuse of antibiotics including the pediatric population. The study has several limitations, including: appropriate use of antibiotics were based on ICD-9 codes. Prescriptions were based on history and not on those prescribed from these visits. Practice habits vary in different locations. The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey analyzed data from 1996-2014 for children diagnosed with pharyngitis. 60% of the children were prescribed antibiotics, whereas only 37% had streptococcus infections. Published in JAMA-Pediatrics, this study suggests that almost half of all antibiotic prescriptions for pharyngitis are futile. In informal discussions with physician administrators in kupat holim, I have heard similar conclusions. Overuse of antibiotics is a known and significant problem in healthcare. In addition to overprescribing, many prescribe broader-spectrum than necessary. Together, these