A prospective study of the use of antibiotics in the Emergency Department of a Chinese University Hospital

Antibiotics are one of the most widely misused group of medicines. The aim of this study was to investigate the use of antibiotics in one of the paediatric emergency departments in China.


Introduction
Antibacterial drugs are one of the most widely used group of medicines in both general and paediatric patients. Higher country-level rates of antibiotic resistance have been shown to be associated with higher antibiotic use. [1] A review of the use of antibiotics in paediatric outpatients in Canada, the USA, Australia and six European countries showed a fourfold variation in the prevalence of prescribed antibiotics. In total, 14% of children in the UK received antibiotics, whereas 52% of children in Italy received antibiotics. [2] In China, the rate of antibiotic use in paediatric outpatients was found to be considerably higher (85%). [3] It has been suggested that 50% of paediatric antimicrobial prescriptions are inappropriate. [4] Inappropriate use results in bacterial resistance and additionally is a waste of health resources. [5,6] Concern has previously been raised regarding the antibiotic resistance in children caused by overuse of antibiotics in China. [7,8] We performed a prospective, cross-sectional study of antibiotic use in the paediatric emergency room in one Chinese hospital to assess the rationality of antibiotic use.

Setting
The setting was the West China Second University Hospital (WCSUH) emergency department. This hospital follows the national policy of antibiotic management. This hospital has a prescribing policy which classifies antibiotics as for unrestricted use, restricted use and special use.

Subjects
The subjects were 500 consecutive paediatric patients (0-18 years old) attending the emergency department (ED) between 25 March to 3 April 2013.
This study was approved by the Institutional Review Board of West China Second University Hospital.

Data collection
Patient and medication information was collected by clinical pharmacists. To avoid influence on drug use behaviour, doctors were not informed of the aim of the study. Children were classified into four groups: newborn infants (0-27 days), infants and toddlers (28 days to 23 months), children (2-11 years) and adolescents (12-18 years).

Evaluation of antimicrobial use
Antibacterial agents were classified into 13 groups according to the Anatomical Therapeutic Chemical (ATC) classification system of World Health Organization (WHO). The evaluation was based on two levels. On the hospital level, prescribing indicators were assessed according to How to Investigate Antimicrobial Use in Hospitals: Selected Indicators. [9] On the prescription level, the rational use of antibiotics was assessed in relation to indication, medicine selection, formulation or route of administration, dose, drug combination, compatibility and allergy testing. [10][11][12][13][14][15][16][17][18] Data management Data were entered into an Excel spreadsheet by one researcher (Die Hu). Categorical data were described by frequency and proportion, while continuous data were described by mean and standard deviation (SD) or median and range. Chi-square test was conducted to test for associations between rates of antibacterial use and impact factors.

Patients
Of the 500 patients, 289 were male, and 211 were female. The median age was 2 years 2 months. There were 239 (48%) infants and toddlers and 255 (51%) children. There were only 6 adolescents and no neonates (Table 1).

Antimicrobial use
Overall, 311 children (62%) received antibiotics ( Table 2). The mean number of antimicrobials prescribed per patient was 1.2, and the mean cost was 80.6 yuan (12.1 US dollars). More than one antibiotic was used in 51 patients. The four most common conditions seen in the ED were wheezy bronchitis, URTI, tonsillitis and pneumonia. A total of 120 of the 149 children with wheezy bronchitis received antibiotics (Table 3). In total, 76 of the 91 children (87%) with tonsillitis and 29 of the 91 children (25%) with an URTI also received antibiotics ( Table 3). The antibiotics prescribed were predominantly cephalosporins and penicillins (75.3%, 22%). No quinolones were prescribed.
Sex of patients did not influence antibiotic use (P = 0.57), but the rate of antibiotics was significantly different between age groups. Children (67.8%) received more antibiotics than adolescents (16.7%), infants and toddlers (57.8%) (P = 0.01).

Discussion
Over half the children attending the emergency department received antibiotics. Of particular concern was the high rates of antibiotic use for children with wheezy bronchitis and tonsillitis. Over 80% of children with either of these conditions received antibiotics. Antibiotic use for children with an URTI or tonsillitis was greater than the 20% maximum recommended by the ESAC. [19]  The main strengths of this study were that data were collected prospectively and focused on the most widely used medicines, that is antibiotics. The main limitations were that it was a single-centre study and interviews were not performed with the doctors as to their reasons for prescribing antibiotics.
Many of the previous studies are over 10 years old. [20,21] A recent study in Italy showed that the introduction of guidelines on the use of antibiotics for acute otitis media did not reduce the use of antibiotics for this condition in children. [22] A Spanish study of drug use in children in the ED focused on labelling, but suggested that over 10% prescriptions were for systemic antiinfectives. [23] Inappropriate antibiotic use is a major component of irrational drug prescribing in children. Our studies suggest that education about the rational use of antibiotics is required for health professionals within the paediatric emergency department setting.

Acknowledgements
We would like to thank Program for Yangtze River Scholars and Innovative Research Team in University (No. IRT0935) and Group of People with Highest Risk of Drug Exposure of International Network for the Rational Use of Drugs,China, for their support.

Authors' contributions
Linan Zeng performed research design, research execution and manuscript preparation. Die Hu performed research execution, data analysis and manuscript preparation. Imti Choonara performed research design and manuscript preparation. De Zhimu performed research design. Lingli Zhang performed research design. Xihong Li performed data analysis. Zuojie Zhang performed data analysis and manuscript preparation.