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Nyquist A, Gonzales R, Steiner JF, Sande MA. Antibiotic Prescribing for Children With Colds, Upper Respiratory Tract Infections, and Bronchitis. JAMA. 1998;279(11):875–877. doi:10.1001/jama.279.11.875
From the Division of Infectious Diseases, Department of Pediatrics (Dr Nyquist), Division of General Internal Medicine (Drs Gonzales and Steiner), and the Department of Preventive Medicine and Biometrics (Drs Nyquist, Gonzales, and Steiner), University of Colorado Health Sciences Center, Denver; and the Department of Medicine, University of Utah, Salt Lake City (Dr Sande).
Context.— The spread of antibiotic-resistant bacteria is associated with antibiotic
use. Children receive a significant proportion of the antibiotics prescribed
each year and represent an important target group for efforts aimed at reducing
unnecessary antibiotic use.
Objective.— To evaluate antibiotic-prescribing practices for children younger than
18 years who had received a diagnosis of cold, upper respiratory tract infection
(URI), or bronchitis in the United States.
Design.— Representative national survey of practicing physicians participating
in the National Ambulatory Medical Care Survey conducted in 1992 with a response
rate of 73%.
Setting.— Office-based physician practices.
Participants.— Physicians completing patient record forms for patients younger than
Main Outcome Measures.— Principal diagnoses and antibiotic prescriptions.
Results.— A total of 531 pediatric office visits were recorded that included a
principal diagnosis of cold, URI, or bronchitis. Antibiotics were prescribed
to 44% of patients with common colds, 46% with URIs, and 75% with bronchitis.
Extrapolating to the United States, 6.5 million prescriptions (12% of all
prescriptions for children) were written for children diagnosed as having
a URI or nasopharyngitis (common cold), and 4.7 million (9% of all prescriptions
for children) were written for children diagnosed as having bronchitis. After
controlling for confounding factors, antibiotics were prescribed more often
for children aged 5 to 11 years than for younger children (odds ratio [OR],
1.94; 95% confidence interval [CI], 1.13-3.33) and rates were lower for pediatricians
than for nonpediatricians (OR, 0.57; 95% CI, 0.35-0.92). Children aged 0 to
4 years received 53% of all antibiotic prescriptions, and otitis media was
the most frequent diagnosis for which antibiotics were prescribed (30% of
Conclusions.— Antibiotic prescribing for children diagnosed as having colds, URIs,
and bronchitis, conditions that typically do not benefit from antibiotics,
represents a substantial proportion of total antibiotic prescriptions to children
in the United States each year.
INCREASING rates of antibiotic resistance in community pathogens have
focused the attention of researchers and clinicians on this public health
problem.1 Prior to 1980, more than 99% of all Streptococcus pneumoniae cases were susceptible to penicillin.
In the past decade, however, up to 40% of clinical isolates have demonstrated
intermediate- and high-level resistance to penicillins and cephalosporins
Pediatric populations are important targets for efforts aimed at reducing
unnecessary antibiotic use. Environments unique to children, such as day care
and school, enhance the transmission and spread of drug-resistant S pneumoniae.2,3 The frequency
and duration of prior antibiotic exposure are strongly associated with the
spread of drug-resistant S pneumoniae, and children
receive a significant proportion of the total antibiotics prescribed each
Reducing unnecessary antibiotic use in children requires identification
of conditions for which antibiotics are overprescribed. McCaig and Hughes7 reported that upper respiratory tract infections (URIs)
and bronchitis ranked second and third among conditions associated with antibiotic
prescriptions by US ambulatory physicians in 1992. Further characterization
of this antibiotic-prescribing practice in pediatric populations is needed.
The goals of this study were to identify the conditions for which clinicians
prescribe antibiotics most frequently in children and to characterize the
antibiotic-prescribing practices for conditions that do not typically benefit
from antibiotics (colds, URIs, and bronchitis).8-10
The National Ambulatory Medical Care Survey (NAMCS), conducted annually
by the National Center for Health Statistics, provides national estimates
of reasons people seek medical attention and the diagnoses and prescriptions
they receive from a representative sample of US ambulatory care physicians.11 An analysis of antibiotic prescribing for adults
has been previously reported by our group.12
For the current study, we evaluated antibiotic prescriptions from the
1992 survey for patients younger than 18 years with the principal diagnoses
of acute nasopharyngitis (common cold, International Classification
of Diseases, Ninth Revision, Clinical Modification13
[ICD-9-CM] code 460), acute URIs (ICD-9-CM code 465) of multiple or unspecified sites, acute bronchitis
or bronchiolitis (ICD-9-CM code 466), and bronchitis,
not otherwise specified (ICD-9-CM code 490). Office
visits were sampled equally throughout the year. We excluded patients with
underlying lung diseases such as asthma (ICD-9 code
493) and chronic bronchitis (ICD-9 code 491) to eliminate
subsets of patients for whom antibiotic therapy might be justified. We aggregated
colds, URIs, and bronchitis to identify common factors associated with antibiotic
use for these conditions. Antibiotic prescriptions for each visit were counted
only if entered as the primary medication related to the office visit on the
patient record form. The final study group (n=531) represented 9% of pediatric
office visits in the 1992 NAMCS and comprised 62% pediatricians, 20% family
practitioners, 11% general practitioners, 4% internists, and 3% other (mostly
Our statistical analysis of the NAMCS 1992 database12
was previously described. χ2 Tests were used to measure the
unadjusted association between predictor variables (age, race, ethnicity,
method of payment, practice location, physician specialty) and antibiotic
prescriptions for colds, URIs, and bronchitis in children. Multivariate logistic
regression analysis further tested the independence of associations using
a model that included all predictor variables. Results are presented as odds
ratios (ORs) with 95% confidence intervals (CIs).
The leading ambulatory care diagnoses accounting for antibiotic prescriptions
in children younger than 18 years are presented in Table 1. Otitis media was the leading condition, accounting for
30% of the total antibiotic prescriptions to children in ambulatory practice
in 1992. Diagnoses of URI (including the common cold), pharyngitis, and bronchitis
accounted for 12%, 10%, and 9% of total antibiotic prescriptions, respectively.
Antibiotics were prescribed in 44% of cases diagnosed as the common
cold, 46% of URIs, 72% of acute bronchitis, and 76% of bronchitis, not otherwise
specified (total for bronchitis overall, 75%). Antibiotic prescription rates
were significantly lower for URIs than for bronchitis (χ2test, P<.001) (Figure 1).
Antibiotic prescription rates for colds, URIs, and bronchitis, as a
group, were stratified by patient-specific factors (age group, gender, race,
ethnicity), practice demographics (geographic region, US Census standardized
metropolitan statistical area), method of payment, and physician specialty
(Table 2). Factors significantly
associated with greater antibiotic prescription rates in the bivariate analyses
(unadjusted ORs) included patients aged 5 to 11 years (OR, 2.24; 95% CI, 1.34-3.73)
and patients aged 12 to 17 years (OR, 2.17; 95% CI, 1.15-4.08). Pediatricians
had lower antibiotic prescription rates (OR, 0.51; 95% CI, 0.33-0.77) than
physicians in other specialties.
After controlling for variations due to gender, race, payment source,
physician specialty, and practice location, significant independent associations
persisted for children aged 5 to 11 years (compared with those aged 0 to 4
years) and pediatricians (compared with nonpediatricians). Children aged 5
to 11 years were 1.94 times as likely to receive an antibiotic prescription
at an office visit related to colds, URIs, and bronchitis as children aged
0 to 4 years. Pediatricians were 0.57 times less likely to prescribe antibiotics
for these conditions than nonpediatricians. These associations persisted within
disease categories and were not affected by excluding office visits for which
secondary diagnoses of otitis media, sinusitis, and pharyngitis were reported
(present in 12% of the study sample) (data not shown).
Table 2 also displays the
percentage of total antibiotic use in each group. Despite a lower antibiotic
prescription rate, children aged 0 to 4 years received 53% of all antibiotic
prescriptions to pediatric populations. Pediatricians, while prescribing less
frequently than nonpediatricians, accounted for approximately half of all
Colds, URIs, and bronchitis accounted for over 20% of all antibiotic
prescriptions provided by US ambulatory physicians to children (<18 years)
in 1992, despite the lack of evidence that antibiotics improve outcomes in
Our finding that antibiotics were prescribed for the common cold in 44% of
visits and for URIs in 46% of visits corroborates other smaller studies of
antibiotic-prescribing practices in children.14,15
Controlling for all other factors, we found that patient age (age 5
to 11 years) and physician specialty were independent predictors of antibiotic
use for these respiratory illnesses. There was also suggestive evidence that
antibiotic prescribing was more common in visits for children aged 12 to 17
years and by physicians practicing in the South (90% CIs excluded 1.0).
Physicians who provide care for children and are not trained as pediatricians
were more likely to prescribe antibiotics for colds, URIs, and bronchitis
than pediatricians. This finding could be due to differential distribution
among physician specialties of a number of factors that have been reported
to influence the treatment of children with acute respiratory illnesses, including
parental pressure, patient volume, and the physician's desire to act or to
validate the office visit.16-20
For example, parents whose children are seen by pediatricians may have different
expectations regarding antibiotic prescribing. It is also possible that pediatricians
use different clinical criteria for deciding when to prescribe an antibiotic
for children with URIs. For example, they may place less weight on the purulence
of secretions than nonpediatricians, a factor that seems to increase the likelihood
for antibiotic treatment of URIs.21
Office visits for school-aged children were more likely to result in
an antibiotic prescription than visits for younger children (although younger
children, aged 0 to 4 years, still account for 53% of the total antibiotic
burden in pediatric populations). This finding could also reflect differences
in parental pressure. Since parents of school-aged children often do not have
mechanisms in place to care for their child at home, they may perceive antibiotic
treatment as reassurance that "everything possible is being done" and feel
more comfortable returning the child with a respiratory illness back to school.
The NAMCS provides important information about antibiotic-prescribing
practices in the United States because of its representativeness, standardized
data collection methods, and the ability to avoid ascertainment bias related
to study hypotheses. Despite this, our study was limited because physicians
may have reported diagnoses in a biased manner to justify antibiotic treatment.
However, this occurrence would likely lead to an underestimation of antibiotic
prescribing for colds, URIs, and bronchitis. To decrease the potential for
misclassification, we included only those office visits in the study in which
cold, URI, or bronchitis were listed as the principal diagnosis and an antibiotic
was listed as the principal drug therapy.
Antibiotics are frequently prescribed for children with colds, URIs,
and bronchitis, despite recommendations to the contrary. This study confirms
that the overuse of antibiotics for these conditions is widespread, prevalent
in all medical specialties, and not dramatically influenced by patient demographics
or methods of payment. Understanding why physicians prescribe antibiotics
for conditions not helped by antibiotics will require broadly based studies
of physician decision making and patient health-seeking behavior. Efforts
to improve antibiotic-prescribing practices should target all physicians and
parents who care for children and teenagers.