Antibiotics prescribed for young children fell when COVID‐19 restrictions were in place

Many large register studies from different countries have reported reductions in both children's respiratory tract infections and antibiotic prescriptions after COVID‐19 was declared a pandemic in March 2020. ¹ , ² , ³ , ⁴ Restrictive measures that aimed to limit the spread of the virus ranged from recommending social distancing to full national lockdowns. These restrictions were the main reasons for fewer respiratory infections and antibiotic prescriptions.

Until now, the studies published on the influence of the COVID‐19 pandemic have compared pre‐pandemic data with the first year of the pandemic. I am only aware of one paediatric study that continued during the first months of the second year of the pandemic, when restrictive measures were eased. ⁴ This was an American retrospective observational study that was carried out in 27 paediatric primary care practices. It compared about 69 000 pre‐pandemic antibiotic prescriptions for children with respiratory tract infections from April to December 2019 with about 19 000 prescriptions during the same pandemic months in 2020. In 2020, antibiotic prescriptions decreased by 80%, followed by a non‐significant increase of antibiotic prescriptions in April to June 2021. ⁴

Finland went into lockdown in March 2020, and the restrictions included closing schools and day‐care centres. The restrictions were eased in May 2020, when the numbers of COVID‐19 infections decreased. However, the restrictions were reinstated for some of the autumn months in 2020 and 2021, when the numbers of COVID‐19 infections increased. They were then reinstated in January 2022, when the Omicron variant became an issue. However, schools and day‐care centres were not closed after the first lockdown at the beginning of the pandemic.

In this issue of Acta Paediatrica, Kuitunen and Renko publish the interesting results of a nationwide study on antibiotic prescriptions for children during various COVID‐19 pandemic phases. ⁵ All pharmacies in Finland are legally required to submit online data on antibiotic purchases to the national register run by the Social Insurance Institute. That was the database used in the study. The data comprised all prescriptions for ambulatory antibiotics issued by primary and secondary care staff working in public and private health organisations. The data were collected separately for children aged 0–5 and 6–12 years and were limited to orally administered beta‐lactams, including cephalosporins and macrolides. ⁵ The periods used for the comparisons were the 2019 pre‐pandemic year and the first and second pandemic years, namely 2020 and 2021, which were further divided into 3‐month periods. The variables used for the comparisons were prescription rates per 1000 children in the age‐specific population. ⁵

More than 300 000 prescriptions were included in the analyses: 90% were for beta‐lactams, and 69% were given to children aged 0–5 years. ⁵ Both beta‐lactam and macrolide consumptions decreased rapidly in this age group during the first pandemic year (2020) and the reduction was as high as 90% during the first 3 months. Consumption increased to the pre‐pandemic level during the second pandemic year (2021) and the consumption of beta‐lactams was 33% higher during autumn 2021 than autumn 2019. ⁵ In winter 2022, when restrictions returned, but schools and day‐care centres remained open, the consumption of both beta‐lactams and macrolides almost halved again. ⁵ Antibiotic prescriptions for children aged 6–12 years decreased by 82% during the first 3 months of the pandemic. However, unlike the data for younger children, they remained lower than pre‐pandemic rates during the two pandemic years. ⁵

The study by Kuitunen and Renko ⁵ reports that antibiotic prescription rates varied during the COVID‐19 pandemic, depending on what restrictions were in place. An important conclusion can also be drawn from the background material gathered by the study. Putting restrictions in place, particularly closing schools and day‐care centres, and then reducing restrictions, appeared to modify the epidemiology of respiratory viral infections. There were no respiratory syncytial virus and influenza virus epidemics during the autumn and winter season in 2020–2021. However, there was an exceptional parainfluenza virus epidemic in summer 2021 ⁶ and an unusually early high‐peak respiratory syncytial virus epidemic in autumn 2021. ⁷ Viral infections pave the way for bacterial infections in the airways and the numbers of viral respiratory infections and subsequent visits to doctors are the main factors that influence antibiotic prescriptions for children.

We need to reduce the numbers of unnecessary antibiotic prescriptions for children with respiratory tract infections, as they often recover spontaneously. Several national and international evidence‐based best practice and current care guidelines have detailed the indications for appropriate antibiotic treatments. However, the immediate influence that such guidelines have had been minor. In the long run, beneficial effects can be seen, but they are adopted slowly, and information needs to be repeated. Two studies published in 2022 used nationwide antibiotic prescription data from the largest private health care company in Finland, with about 250 000 annual paediatric visits around the country. One study documented a constant, but slow, decrease in antibiotic consumption for upper respiratory tract infections, from 18% in 2014 to 12% in 2019. ⁸ The other reported that prescription for lower respiratory tract infections fell from 37% to 25% during the same periods. ⁹ The national current care guidelines for children's respiratory tract infections, which were published in 2014, were in use during the studies and information about the guidelines was repeatedly provided by the company. The consumption of antibiotics further decreased in 2020, to 9% in upper and to 20% in lower respiratory tract infections. ⁸ , ⁹ This means that the COVID‐19 pandemic did not change the beneficial trend. The nationwide American safety programme for improving antibiotic use in ambulatory care reported similar findings. ¹⁰ It comprised 292 practices, who submitted complete data on 6.5 million visits to 5500 clinicians by children and adults from December 2019 to November 2020. There was an overall 24% reduction in acute respiratory tract infection visits to practices between December 2019 and May 2020, but a 74% increase between May 2020 and November 2020. Antibiotic prescribing for respiratory tract infections decreased from 39% of visits in December 2019 to 25% in November 2020. ¹⁰

As Kuitunen and Renko concluded, ⁵ the initial social restrictions at the start of the COVID‐19 pandemic in spring 2020 led to a rapid decrease in antibiotic prescriptions in Finland. This was followed by an increase after restrictions were relaxed and a new decrease in winter 2022 when restrictions partially returned, but schools and day‐care centres remained open. The reductions were more prominent in children aged 0–5 years than 6–12 years. These observations raise questions about whether some of these restrictions could be applied, in a more targeted form, to prevent the harmful consequences of future respiratory syncytial virus and influenza virus epidemics. These could also reduce antibiotic prescriptions for young children. Restrictions, such as breaks in institutional day care, smaller or rotating teaching groups in schools or using face masks on public transport or in public buildings, should be limited to the peaks of the epidemics. These should focus on reducing viral exposures in children who are at risk due to their young age or an underlying illness.

The paper by Kuitunen and Renko ⁵ in this issue of the journal adds useful data to the ongoing debate.

CONFLICT OF INTEREST

The author has no conflicts of interest to declare.