Antibiotics prescribed during 21% of pediatric ambulatory visits; 50% were broad-spectrum

Antibiotics are commonly prescribed for children with conditions for which they provide no benefit, including viral respiratory infections.

The researchers used the National Ambulatory and National Hospital Ambulatory Medical Care surveys from 2006 to 2008, which are representative of ambulatory care visits in the United States.

Antibiotics were prescribed during 21% of pediatric ambulatory visits; 50% were broad-spectrum, most commonly macrolides. Respiratory conditions accounted for >70% of visits in which antibiotics were prescribed.

The authors concluded that broad-spectrum antibiotic prescribing in ambulatory pediatrics is extremely common and frequently inappropriate.

Cough is one of the common reasons for unnecessary antibiotic prescription. As you can see from the diagram below, the differential diagnosis of chronic cough is broad and includes asthma and other conditions in which antibiotics are ineffective:



Differential diagnosis of cough, a simple mnemonic is GREAT BAD CAT TOM. Click here to enlarge the image: (GERD (reflux), Laryngopharyngeal Reflux (LPR), Rhinitis (both allergic and non-allergic) with post-nasal drip (upper airway cough syndrome), Embolism, e.g. PE in adults, Asthma, TB (tuberculosis), Bronchitis, pneumonia, pertussis, Aspiration, e.g foreign body in children, Drugs, e.g. ACE inhibitor, CF in children, Cardiogenic, e.g. mitral stenosis in adults, Achalasia in adults, Thyroid enlargement, e.g. goiter, "Thoughts" (psychogenic), Other causes, Malignancy, e.g. lung cancer in adults).

References:

Antibiotic Prescribing in Ambulatory Pediatrics in the United States. Adam L. Hersh, MD, PhDa, Daniel J. Shapiro, BAb, Andrew T. Pavia, MDa, Samir S. Shah, MD, MSCE. Pediatrics Vol. 128 No. 6 December 1, 2011, pp. 1053 -1061, (doi: 10.1542/peds.2011-1337).

Image source: Wikipedia, GNU Free Documentation License.

Acute bronchitis: Many patients expect to be treated with antibiotics and cough meds but this differs from guidelines

Mind map of differential diagnosis of cough. See more Allergy and Immunology mind maps here.

Cough is the most common symptom bringing patients to the primary care physician's office. The most common diagnosis in these patients is acute bronchitis, according to a recent review in the official journal of AFP, American Family Physician.

Acute bronchitis should be differentiated from other common causes of cough such as pneumonia and asthma - because the therapies are clearly different.

Symptoms of acute bronchitis typically last 3 weeks. As we already know, the presence of colored (e.g., yellow or green) sputum does not reliably differentiate between bacterial and viral lower respiratory tract infections. This conclusion was contradicted by a recent study: Green or yellow phlegm likely to be bacterial - confirming beliefs by doctors and patients alike (http://goo.gl/zff8X and http://goo.gl/cwKGs).

Viruses cause more than 90% of acute bronchitis, and therefore, antibiotics are generally not indicated. They should be used only if pertussis is suspected to reduce transmission or if the patient is at increased risk of developing pneumonia (e.g., patients 65 years or older).

The typical therapies that have been traditionally used for managing acute bronchitis symptoms have been shown to be ineffective. The U.S. Food and Drug Administration recommends against using cough and cold preparations in children younger than 6 years.

The supplement pelargonium may help reduce symptom severity in adults.

Many patients expect to be treated with antibiotics and cough medications but this differs from evidence-based recommendations.

The CNN video below tries to decipher what hides behind the names of common cough and cold medications:

References:

Diagnosis and treatment of acute bronchitis. Albert RH. Am Fam Physician. 2010 Dec 1;82(11):1345-50.