Antibiotic prescribing in children in SG can still be improved, study says

A closer look at antibiotic prescribing practices for childhood illnesses in Singapore uncovers opportunities for improvement, even when overall rates seem appropriate.

In a study involving 831,669 paediatric patient visits across six public primary care clinics between 2018 and 2021, oral and topical antibiotics were prescribed for 2.3 percent and 2.5 percent of visits, respectively. A sharp decline in antibiotic prescriptions per month was observed during the COVID-19 pandemic years of 2020–2021, with a mean difference of 458.3 prescriptions per month (95 percent confidence interval [CI], 365.9–550.7) compared with the prepandemic years of 2018–2019. [Antibiotics (Basel) 2024;13:695]

According to the 2021 World Health Organization (WHO) AWaRe classification, a tool used to rationalize antibiotic use, most prescriptions (95.8 percent) for acute conditions fell within the “Access” group or antibiotics used in the first- or second-line treatment of common infections that should be widely accessible. Only 4.2 percent of prescriptions were within the “Watch” group or antibiotics that should be restricted to a limited group of well-defined syndromes. None of the prescriptions were under the “Reserve” group or antibiotics that should be only used as a last resort to treat multi- or extensively drug-resistant bacteria.

In the “Watch” group, most antibiotics were prescribed for gastrointestinal respiratory conditions (n=562, 6.1 percent), with clarithromycin (n=524, 5.6 percent) being the most common. Furthermore, “Watch” antibiotics comprised one-fifth of those prescribed for gastrointestinal conditions (n=63, 20.1 percent), with ciprofloxacin (n=48, 15.3 percent) as the most often used. Gastroenteritis was the most frequent gastrointestinal condition for which antibiotics were prescribed (52.6 percent).

Less than ideal

In terms of the overall quality of primary care antibiotic prescriptions, as benchmarked against the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) quality indicators, oral antibiotic prescriptions for otitis media were excessively high at 55.2 percent relative to the ESAC-Net acceptable range for receiving antibiotics of 0–20 percent. On the other hand, prescriptions for acute respiratory infections were within the acceptable range (4.3 percent).

However, only around half of the prescribed antibiotics for both otitis media (49.4 percent) and acute respiratory infections (51.3 percent) were recommended by the National Institute for Health and Care Excellence guidelines, falling below the EASC-Net acceptable range for receiving recommended antibiotics of 80–100 percent.

Amoxicillin/clavulanate was the most prescribed antibiotic for otitis media (n=179, 45.4 percent) and acute respiratory infections (n=3,550, 39.6 percent), despite not being recommended for these conditions.

Meanwhile, the use of quinolones, which are “Watch” antibiotics, in otitis media (0.3 percent) and acute respiratory infections (0.1 percent) was within the EASC-Net acceptable range of 0–5 percent.

Gaps in antibiotic use for children

“This study showcases the prevalence and appropriateness of antibiotic prescriptions for children within a segment of public primary care in Singapore,” with gaps identified in antibiotic prescription for otitis media and choice of antibiotic for acute respiratory infections, otitis media, and gastrointestinal conditions, according to the study authors.

“These findings pave the way for further research to identify the reasons behind these gaps and lay the foundation for adapting antimicrobial guidelines and stewardship programmes to [the local] primary care setting,” they added.

The findings offer a snapshot of antibiotic prescription in children in the western cluster of Singapore’s public primary care institutions, and it is unclear whether these prescribing patterns hold true for other public primary care clusters or in private primary care settings, as the authors pointed out.

“However, given that Singapore’s primary care physicians have mostly trained locally, and the country offers relatively uniform levels of medical training across its three medical schools, the findings likely highlight broader gaps, for instance, regarding antibiotic prescription for otitis media and choice of antibiotic for acute respiratory infections, otitis media, and gastrointestinal conditions,” they said.