Currently there is very limited information on antimicrobial consumption and antibiotic resistance for children in Europe. Existing European surveillance schemes such as ESAC (European Surveillance of Antimicrobial Consumption), and EARSS (European Antimicrobial Resistance Surveillance System) have limited age-specific data. There is also a wide variation or absence of antibiotic prescribing guidelines in many countries in Europe. Some countries have robust evidence-based guidance, which aim to reduce the use of antibiotics for minor viral upper respiratory tract infection. In the other countries there are either no guidelines in place, or guidelines advocate the use of very broad spectrum antibiotics. There is also only limited data on the impact of immunisation campaigns on EU wide antibiotic prescribing for specific clinical indications and rates of antimicrobial resistance.
The aim of this study will build on existing paediatric infectious diseases networks, including PENTA, ESPID and TEDDY. The project will use established methodologies from ESAC and EARSS and existing community prescribing databases to develop a prospective surveillance system to monitor rates of antibiotic prescribing and resistance in European children. The project working with Prof Miriam Sturkenboom of Erasmus University, will determine the variation in drug, dose and indications for community and hospital antibiotic prescribing for common childhood infections between EU countries and changes in the reported disease incidence for specific infections, including otitis media and pneumonia. For community paediatric prescribing the variation in both overall and antibiotic class-specific rates will be determined between countries. The analysis of community prescribing of antibiotics will use existing databases. Using EU childhood population data as the denominator, data can be used to determine rates for prescribing per 1,000 children per year, where possible linked to clinical indications using ICD 10 codes. Data will be obtained from the IMS database which has been used previously to compare the prescribing of psychotropic drugs in children from 10 different countries. (IMS collects total antibiotic use without indication in most countries, which can act as a check for other data sources. Data will also be obtained from the PEDIANET database (which provides paediatric electronic medical records from 150 paediatricians in Italy) and the Integrated Primary Care Information (IPCI) database, which stores adult and paediatric electronic medical records from more than 400 doctors since 1996 in the Netherlands. The feasibility of using other country-specific primary care databases (eg. Estonia) will be explored. Using these databases, person time follow up for each child can be stratified by calendar year and age group. Person-time accumulated in calendar years will be used as the denominator to calculate prevalence rates.
There are even less data available for comparative rates of antibiotic prescribing in children admitted to hospital. The programme will produce a novel paediatric defined daily dose (DDD) methodology and conduct an EU wide point prevalence survey to compare antibiotic use in children in hospital. The paediatric point prevalence study (PPS) will be performed in collaboration with ESAC and Prof Herman Goossens’ team at Antwerp University, developing novel PPS forms for children’s wards and neonatal units. The paediatric PPS data will include the name and dose of the drug, clinical indication, weight of the child, and route of administration. The neonatal form will also include gestational age, birth weight and post-natal age. A standardised methodology for measuring paediatric and neonatal bed utilisation will be developed. A PPS will then be conducted in partner hospitals during a defined 2 month period each year and entered onto a web based centralised database for analysis. This project would have the additional benefit of developing and then validating a paediatric methodology for PPS which could be used across Europe and also internationally.
Using established EARSS methodology information on bacteraemia rates and antimicrobial susceptibility patterns for selected common pathogens in Europe will be collected for major children’s hospitals in partner countries and where available, regional or national databases. This will include the prevalence of penicillin-resistant pneumococci (where the impact of the varied uptake and schedules of conjugate pneumococcal vaccination has not been systematically studied) and gram-negative bacteria (as extended-spectrum beta-lactamases are an increasing problem in high-risk areas like Neonatal Intensive Care Units). The project will collect data from different countries on blood culture isolates for
Streptococcus pneumoniae
,
Haemophilus influenzae
,
Staphylococcus aureus
,
Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae
and
Pseudomonas aeruginosa
. Standardised definitions of resistance will be used based on EARSS methodology. Local and regional data will be obtained and entered into a central data base for analysis with denominator data where possible to provide age specific incidence rates.
We will also collate all existing community and hospital antimicrobial guidelines from participating countries. Local and national antibiotic guidelines will be collected, collated and entered into a central web based register. Consistency between country specific guidelines and actual medicines used will be explored. A web based training programme on optimal antibiotic prescribing will be developed based on existing ESPID and PENTA training modules, and this will be disseminated through ESPID and the EAP.
ARPEC will feed back the project results through regional meetings and use an established web based methodology to develop a new ESPID educational training programme on prudent prescribing. The study will aim to set early benchmarks for prescribing and resistance rates, working through ESPID clinical experts and opinion leaders to encourage the development of more unified EU wide prudent treatment guidelines.