Evaluation of children's antibiotics use for outpatient pneumonia treatment in Vietnam

Thi, Tuong Vi Le; Pham, Em Canh; Dang-Nguyen, Doan-Trang

doi:10.1016/j.bjid.2024.103839

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Brazilian Journal of Infectious Diseases

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Original Article • Braz J Infect Dis 28 (4) • 2024 • https://doi.org/10.1016/j.bjid.2024.103839 copy

Evaluation of children's antibiotics use for outpatient pneumonia treatment in Vietnam

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

Antibiotic resistance is increasing globally, associated with many failures in pneumonia treatment. This study aimed to evaluate antibiotic use in children treated for outpatient CAP (Community-Acquired Pneumonia).

Methods

A cross-sectional descriptive retrospective study was conducted, focusing on data from outpatient prescriptions for pneumonia in patients aged 2‒192 months in 2019‒2021.

Results

All antibiotic prescriptions are considered empiric as no documented bacterial and viral tests exist for children with non-severe CAP. Single antibiotic therapy (66%) had a 2-fold higher rate than combination therapy (34%). Amoxicillin/clavulanic acid (50.77%) and azithromycin (30.74%) were the most commonly prescribed in both single and combination therapies, thus determining antibiotic cost (80.15%). Besides, azithromycin (97.92%), cefuroxime (86.26%), and cefpodoxime (60.48%) were prescribed with high adherence to dose guidelines, except for amoxicillin (34.57%). These medicines are prescribed highly compliant (>83%) with dosing interval guidelines. Furthermore, significantly more brand-name antibiotics (56.5%) are prescribed than generic antibiotics (43.5%). In particular, antibiotic class, antibiotic origin, and antibiotic therapies showed significant association with rational antibiotic prescriptions for dose and dose interval (p < 0.05).

Conclusions

Amoxicillin/clavulanic acid is the most frequently prescribed medicine and the most inappropriate due to non-compliance with dose guidelines for CAP treatment. Generic antibiotic use for single therapy should be encouraged based on rapid and accurate diagnostic testing for viruses and bacteria to reduce antibiotic resistance in developing countries. Moreover, the study result has also shown that therapies and antibiotics (class and origin) exhibited significant association with rational prescriptions for CAP treatment for pediatrics.

Keywords
Antibiotic; Outpatient pneumonia; Children; Prescription; CAP

Antibiotic	Dose (mg/kg/day)	Dose interval (time/day)	Ref
Amoxicillin	90	2	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Amoxicillin/Clavulanic acid	80‒90	2	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Amoxicillin/Sulbactam	100	2	^* ⁎ According to the drug leaflet.
Cefuroxime	20‒30	2	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Cefaclor	20‒40	2‒3	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Cefdinir	14	1‒2	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Cefditoren	9	3	^* ⁎ According to the drug leaflet.
Cefixime	8	1‒2	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Cefpodoxime	10	2	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Azithromycin	5‒10	1	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Clarithromycin	15	2	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Erythromycin	40‒50	3-4	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Clindamycin	10‒25	3	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Ciprofloxacin	20‒40	2	¹⁰10 American Academy of Pediatrics (AAP). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021.
Levofloxacin	16‒20^a a Aged 6-months to 5-years.	2^a a Aged 6-months to 5-years.	¹¹11 Pediatric Infectious Diseases Society and the Infectious Diseases Society of America, Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:e25-76.
Levofloxacin	10^b b Older than 5-years.	1^b b Older than 5-years.

Antibiotic		2019	2020	2021	Total^a a Average of 3-years.
Group	Name	n (%)	n (%)	n (%)	%	%	%
Penicillin	Amoxicillin	34 (1.26)	18 (1.27)	10 (1.56)	1.37	1.37	52.96
Penicillin/β-lactamase inhibitor	Amoxicillin/Clavulanic acid	1387 (51.24)	731 (51.77)	315 (49.30)	50.77	51.59
Penicillin/β-lactamase inhibitor	Amoxicillin/Sulbactam	30 (1.12)	19 (1.35)	0 (0.00)	0.82	51.59
2^nd generation Cephalosporin	Cefuroxime	282 (10.44)	162 (11.47)	36 (5.63)	9.18	9.35	14.69
2^nd generation Cephalosporin	Cefaclor	2 (0.05)	0 (0.00)	3 (0.47)	0.17	9.35
3^rd generation Cephalosporin	Cefdinir	0 (0.00)	0 (0.00)	1 (0.16)	0.05	5.34
	Cefpodoxime	90 (3.32)	41 (2.90)	50 (7.82)	4.68
	Cefditoren	5 (0.20)	3 (0.21)	6 (0.94)	0.45
	Cefixime	7 (0.24)	1 (0.07)	1 (0.16)	0.16
Macrolide	Azithromycin	826 (30.52)	427 (30.24)	201 (31.46)	30.74	32.28	32.28
	Clarithromycin	22 (0.83)	5 (0.35)	10 (1.56)	0.91
	Erythromycin	16 (0.59)	5 (0.35)	6 (0.94)	0.63
Fluoroquinolone	Ciprofloxacin	4 (0.15)	0 (0.00)	0 (0.00)	0.05	0.07	0.07
Fluoroquinolone	Levofloxacin	2 (0.05)	0 (0.00)	0 (0.00)	0.02	0.07	0.07
Lincosamide	Clindamycin	0 (0.00)	0 (0.00)	0 (0.00)	0.00	0.00	0.00
Total		2707 (100)	1412 (100)	639 (100)	100	100	100

Antibiotic	2019		2020		2021		Total^b b Average of 3-years.
	Dose	Dose interval	Dose	Dose interval	Dose	Dose interval	Dose	Dose interval
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	%	%
Amoxicillin^a a Amoxicillin or Amoxicillin/Clavulanic acid or Amoxicillin/Sulbactam.	570 (39.28)	1450 (99.93)	268 (34.90)	767 (99.87)	96 (29.54)	325 (100.00)	34.57	99.93
Cefuroxime	231 (81.91)	227 (80.50)	138 (85.19)	130 (80.25)	33 (91.67)	32 (88.89)	86.26	83.21
Cefaclor	2 (100.00)	2 (100.00)	‒	‒	3 (100.00)	3 (100.00)	100.00	100.00
Cefdinir	‒	‒	‒	‒	0 (0.00)	0 (0.00)	‒	‒
Cefditoren	0 (0.00)	4 (80.00)	1 (33.33)	2 (66.67)	3 (50.00)	6 (100.00)	27.78	82.22
Cefixime	2 (28.57)	6 (85.71)	1 (100.00)	1 (100.00)	0 (0.00)	1 (100.00)	42.86	95.24
Cefpodoxime	52 (57.78)	74 (82.22)	22 (53.66)	37 (90.24)	35 (70.00)	49 (98.00)	60.48	90.15
Azithromycin	802 (97.09)	814 (98.55)	417 (97.66)	421 (98.59)	199 (99.00)	200 (99.50)	97.92	98.88
Clarithromycin	13 (59.09)	22 (100.00)	3 (60.00)	5 (100.00)	4 (40.00)	9 (90.00)	53.03	96.67
Erythromycin	13 (81.25)	4 (25.00)	5 (100.00)	1 (20.00)	6 (100.00)	2 (33.33)	93.75	26.11
Ciprofloxacin	4 (100.00)	4 (100.00)	‒	‒	‒	‒	100.00	100.00
Levofloxacin	0 (0.00)	2 (100.00)	‒	‒	‒	‒	0.00	100.00
Clindamycin	‒	‒	‒	‒	‒	‒	‒	‒

		Antibiotic treatment		p-value^d d Using the χ2 test.	Drug substance			p-value^d d Using the χ2 test.	Origin of medicine		p-value^d d Using the χ2 test.
Characteristics		One	Two	p-value^d d Using the χ2 test.	Lactam	Macrolide	Other	p-value^d d Using the χ2 test.	Generic	Brand-name	p-value^d d Using the χ2 test.
Gender	Male	1307	634	0.116	1759	817	3	0.793	1250	1329	0.622
Gender	Female	1045	569	0.116	1475	701	3	0.793	1040	1138	0.622
Age ^a a Aged month, 0- Guideline non-adherence, 1- Guideline adherence, Total- Compliance - agreed on both dose and dose interval guidelines for all antibiotics in each prescription.	2 to <60	2213	1075	0.238	3017	1347	5	0.000	2055	2314	0.000
	≥60	139	128	0.238	217	171	1	0.000	234	154	0.000
Place of residence	City^b b Ho Chi Minh City.	1172	502	0.714	1518	665	2	0.113	1139	1047	0.000
	Other	1180	701		1716	853	4		1152	1421
		Dose		p-value	Dose interval		p-value	Total		p-value
		0	1	p-value	0	1	p-value	0	1	p-value
Gender	Male	1207	737	0.371	106	1838	0.284	1254	690	0.334
Gender	Female	976	634	0.371	75	1535	0.284	1014	597	0.334
Age ^a a Aged month, 0- Guideline non-adherence, 1- Guideline adherence, Total- Compliance - agreed on both dose and dose interval guidelines for all antibiotics in each prescription.	2 to <60	2007	1285	0.047	165	3127	0.438	2085	1208	0.034
	≥60	176	86	0.047	16	246	0.438	183	79	0.034
Place of residence	City^b b Ho Chi Minh City.	1055	626	0.121	84	1597	0.806	1090	591	0.220
Place of residence	Other	1128	745	0.121	97	1776	0.806	1178	696	0.220
Antibiotic treatment	One	1385	967	0.000	104	2248	0.004	1439	913	0.000
Antibiotic treatment	Two	805	398	0.000	80	1123	0.004	837	366	0.000
Drug substance ^c c Calculated in antibiotic units.	Lactam	1777	1457	0.000	118	3116	0.007	‒	‒
	Macrolide	56	1462		40	1478		‒	‒
	Other	2	4		0	6		‒	‒
Origin of medicine	Generic	974	692	0.001	133	1533	0.000	1032	635	0.028
Origin of medicine	Brand-name	1209	679	0.001	48	1840	0.000	1236	652	0.028

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[1] ⁎ Corresponding author. E-mail address:canhem112009@gmail.com (E. Canh Pham), trang.dnd@ump.edu.vn (D.-T. Dang-Nguyen).