Prescriptions inappropriées d’antibiotiques chez l’enfant en médecine de ville : raisons et conséquences

RésuméContexteLa prescription d’antibiotiques dans les infections courantes de l’enfant demeure élevée en France.ObjectifÉtudier chez les enfants hospitalisés dans les suites d’une antibiothérapie prescrite en ville, la nature de l’antibiothérapie initiale, ses motivations et l’évolution ultérieure de ces enfants.Patients et méthodesÉtude menée sur une période de 6 mois sur une cohorte de 52 enfants. Le motif de consultation aux urgences pédiatriques devait être la persistance ou l’apparition de nouveaux symptômes à plus de 48 h de la prescription d’antibiotiques en ville.RésultatsSoixante-quinze pour cent des prescriptions d’antibiotiques ont été considérées comme inappropriés. Elles n’étaient pas indiquées ou inadaptées dans 60 % et 15 % des cas respectivement. Seulement 25 % des enfants avaient eu des examens complémentaires prescrits en ville alors que ceux-ci ont permis de poser un diagnostic à l’hôpital pour 71 % des enfants. Quinze pour cent des enfants présentaient des effets secondaires de l’antibiothérapie à l’admission. Les principales raisons pour lesquelles les praticiens de ville avaient estimé nécessaire d’avoir recours à une prescription « hors recommandation » étaient la difficulté de réévaluation à 48 h (84 %), le terrain fragilisé (71 %) et la pression parentale importante (33 %).DiscussionSi certaines contraintes propres à la médecine de ville sont à prendre en compte, une meilleure utilisation des examens paracliniques dans ce mode d’exercice pourrait contribuer à la réduction des prescriptions inappropriées d’antibiotiques.ConclusionNotre étude confirme la nécessité d’une meilleure compréhension des pratiques afin de cibler les mesures de contrôle de la prescription d’antibiotiques.

SummaryContextThe judicious prescription of antibiotics has become a central focus of professional and public-health measures to combat the spread of resistant organisms. It also seems important to consider the other impacts and determinants of antibiotic misuse.ObjectiveEvaluating the ambulatory antibiotic prescription for common infections in patients secondarily hospitalized as well as the consequences and determinants of this prescription.Patients and methodsStudy conducted over a period of 6 months between May and November 2008, during which 52 children aged between 3 months and 15 years, hospitalized in the pediatric hospital of Aix-en-Provence, were recruited. The reason for the pediatric emergency department visit was persistent symptoms or new symptoms over 48 h of ambulatory antibiotic prescription. The ambulatory antibiotic prescription was compared with current practice guidelines, and clinical progression after hospitalization was also analyzed. Afterwards, the determinants of this overprescription in ambulatory practice were investigated through a telephone questionnaire.ResultsSeventy-five percent of the antibiotic prescriptions were inappropriate, 60 % of which could potentially have been avoided with had an adequate and recommended practices been followed. Only 25 % of the children were prescribed ambulatory diagnostic exams, whereas these exams confirmed the diagnosis at the hospital for 71 % of them. In addition, 15 % of the children presented secondary effects of the antibiotics at their admission. Among practitioners, 84 % recognized having difficulties on reevaluation of the antibiotic prescription at 48 h. A high proportion of them (71 %) believe that antibiotics should be initiated precociously in patients with underlying conditions such as diabetes. Furthermore, 33 % recognized that the perceived parents’ expectation could be a determinant of prescription. Otherwise, 22 % of them had attended an antibiotic prescription educational program during the past year.DiscussionAntibiotic prescription for children's common infections remains a difficult decision for practitioners. This could partly be explained by atypical clinical symptoms and the risk of rapid progression in pediatric medicine. However, the rate of inappropriate prescription of antibiotics is high in this population. Among the main consequences of this practice, one may note the appearance of antibiotic resistance, the occurrence of side effects, and delayed diagnoses as well as preventable hospitalizations. Although certain considerations, such as the problems re-evaluating the patient after 48 h, must be taken into account, better use of paraclinical examinations in general practice could help to reduce inappropriate antibiotic prescriptions. Further large-scale, prospective studies should be conducted on the existing practices and beliefs concerning ambulatory antibiotic prescription in order to adjust prevention strategies.