Antibiotics Over-prescribed for Strep

To prescribe or not to prescribe? About 50% of children who present with a sore throat receive antibiotics from their doctor- although at least two-thirds of the cases are likely to have a viral, rather than bacterial, origin, according to a new study.

Equally unsettling, only about half of physicians do a throat culture before giving children antibiotics for a sore throat, despite strong recommendations that children be tested for group A beta-hemolytic streptococci, according to a report by Jeffrey A Linder, MD, MPH, of Harvard Medical School and colleagues.

The report by Linder et al was published in the 9 November issue of the Journal of the American Medical Association and reported by MedPage Today on 9 November 2005.

The American Academy of Pediatrics, the Centers for Disease Control and Prevention (CDC), and the Infectious Disease Society of America recommend testing for group A beta-hemolytic streptococci, according to MedPage Today.
Study Results

In a review of data from national ambulatory care surveys conducted during the period 1995-2003, Dr Linder et al found that, during approximately 7.3 million annual visits for sore throat, doctors prescribed antibiotics in about 53% of cases. This percentage is considerably higher than the 15-36% prevalence of strep throat.

Moreover, about 50% of children who received antibiotics got the wrong drugs, or a non-recommended drug (27%). Recommended agents include amoxicillin, penicillin, first-generation cephalosporins and erythromycin.

Antibiotics not recommended but often prescribed include other cephalosporins, extended spectrum macrolides (e.g., Zithromax [azithromycin], Biaxin [clarithromycin]), Augmentin [amoxicillin-clavulanate]) or other agents.

"Encouragingly, we found a significant decrease in the proportion of patients receiving antibiotics over the study period," Dr Linder and colleagues wrote. "However, even at the end of the study period, the proportion of children prescribed an antibiotic still exceeded the maximum expected prevalence of group A beta-hemolytic streptococci among children with sore throat."

Doctors performed a group A beta-hemolytic streptococci test in 53% of visits, and in 51% of visits at which they prescribed an antibiotic. Group A beta-hemolytic streptococci testing was not associated with a lower prescribing rate of antibiotics (48% tested versus 51% not tested), but testing was associated with a lower antibiotic prescribing rate for children with a diagnosis of pharyngitis, tonsillitis and streptococcal sore throat (57% tested versus 73% not tested).

Interestingly, the clinical setting where the children were seen made a difference. Non-pediatrician, primary-care doctors and emergency department staff were about half as likely to test for group A beta-hemolytic streptococci as pediatricians, and they were about 60% more likely to prescribe an antibiotic. However, children seen in emergency departments were less likely to get a non-recommended drug.

The results of the study suggest that, although a downward trend in prescribing antibiotics exists, children are still needlessly receiving antibiotics, the authors contended.

"Perhaps unique among upper respiratory tract infections, clinicians have good, objective criteria in the form of group A beta-hemolytic streptococci testing to guide the antibiotic treatment of children with sore throat," Dr Linder and colleagues wrote. "Limiting antibiotic prescribing to children with a positive group A beta-hemolytic streptococci test result is a feasible goal for primary care physicians and an important step toward judicious use of antibiotics overall."

In accompanying editorial, J Todd Weber, MD, of the Office of Antimicrobial Resistance at the CDC's National Center for Infectious Diseases in Atlanta concurred with the researchers.

"To ensure appropriate use of antimicrobial drugs, the issue must be addressed across all diseases and all sectors of society," Dr Weber wrote. "Failure to do so will result in wasting the valuable resource of effective antimicrobial agents-a resource that still could be preserved for some time to come."