Antibiotic Use in Children — a Cross-national Analysis

A cross-national analysis of seven pediatric cohorts in six countries (Germany, Italy, South Korea, Norway, Spain, and the United States) was performed looking at data from 2008-2012. Data of 74,744,302 person-years were analyzed. The highest rate of antibiotic prescribing in children was seen in Korea, with 3.41 prescribed courses per child-year during the first two years of life. The corresponding rates were 1.6 in the Lazio, Italy cohort, 1.4 in the Pedianet, Italy cohort, 1.5 in Spain, 1.1 in the United States, 1.0 in Germany, and 0.5 in Norway. In Norway, 64.8% of prescriptions were for first-line penicillins (ampicillin, amoxicillin, dicloxacillin, oxacillin, penicillin V potassium) vs. 38.2% in Germany, 31.8% in the United States, 27.7% in Spain, 25.1% in Italy/Pedianet, 9.8% in Korea, and 8.5% in Italy/Lazio. Second-line penicillins (amoxicillin-clavulanate) were the most commonly prescribed antibiotics in Korea (44.8%) vs. 40.9% in Italy/Lazio, 30.6% in Italy/Pedianet, 35.1% in Spain, 8.5% in the United States, 2.2% in Germany, and 0.1% in Norway. Second-generation macrolides (azithromycin, clarithromycin, roxithromycin) made up 25% of U.S. prescriptions, 24.1% in Italy/Lazio, 21.3% in Italy/Pedianet, 18.6% in Spain, and 17.5% of Korean prescriptions. Cephalosporins were used in 35.2% of German prescriptions, 24.6% in the United States, 26.2% in Korea, 25.8% Italy/Lazio, 21.3% Italy/Pedianet, 20.1% in Spain, and only 1.7% in Norway.

COMMENTARY

This cohort study showed amazingly large country-to-country differences in the rates of antibiotic prescriptions, with South Korean toddlers and younger children receiving 3.41 antibiotic prescriptions on average each year, a rate that was 7.5 times the rate that antibiotics were prescribed to children in Norway. This extremely high antibiotic utilization in Korean children was in line with previously reported high rates of antibiotic prescribing seen in earlier observational studies in Korean adults¹ and elsewhere in East Asia.^2,3 Not only the magnitude of overuse of antibiotics in Korea, but the widespread usage of amoxicillin-clavulanate (vs. first-line penicillins) also may be driving the high rate of antibiotic resistance seen in Korea.^4,5

While overuse of antibiotics in children was not as prevalent in the United States as it was in Korea, the particular overuse of second-generation macrolides (particularly azithromycin) in the United States should be noted. The Germans and the Norwegians clearly are doing much better than the rest of us by being much more judicious in the prescription of antibiotics to children. When they are prescribed antibiotics, German and Norwegian children more often receive narrower spectrum first-line penicillins, which are generally the preferred agents recommended in guidelines for treatment of most childhood bacterial infections.

REFERENCES

1. Lee YS, Kwon JW, Oh OH, Sohn HS. Temporal decrease in overall antibiotic consumption accompanying antibiotic prescribing rate disclosure policy: Evidence from analysis of national health insurance claims data in South Korea. Arch Pharm Res 2014;37:1295-1300.
2. Iqbal U, Syed-Abdul S, Nguyen PA, et al. Physicians’ antibiotics prescribing behavior in Taiwan, 1998-2001. Clin Infect Dis 2015;60:1439-1441.
3. Wang J, Wang P, Wang X, et al. Use and prescription of antibiotics in primary health care settings in China. JAMA Intern Med 2014;174:1914-1920.
4. Lee S, Lee K, Kang Y, Bae S. Prevalence of serotype and multidrug-resistance of Streptococcus pneumoniae respiratory tract isolates in 265 adults and 36 children in Korea, 2002-2005. Microb Drug Resist 2010;16:135-142.
5. Cho SY, Baek JY, Kang CI, et al. Extensively drug-resistant Streptococcus pneumoniae, South Korea, 2011-2012. Emerg Infect Dis 2014;20:869-871.