Investigción originl / Physicins responsibility for ntibiotic use in infnts from periurbn Lim, Peru Lucie Ecker, 1 Liset Olrte, 2 Gustvo Vilchez, 1 Theres J. Ocho, 2 Isbel Amemiy, 1 An I. Gil, 1 nd Cludio F. Lnt 1 Suggested cittion Ecker L, Olrte L, Vilchez G, Ocho TJ, Amemiy I, Gil AI, et l. Physicins responsibility for ntibiotic use in infnts from periurbn Lim, Peru. Rev Pnm Slud Public. 11:(6):574 9 bstrct Key words Objective. To describe the use of ntibiotics in Peruvin children under 1 yer in setting where they re vilble without prescription. Methods. Dt were nlyzed from cohort study between September 6 nd December 7 of 1 23 children < 2 months old in periurbn Lim, Peru, followed until they were 1 yer old. Results. Seven hundred seventy of 1 23 (75.3%) children took 2 85 courses of ntibiotics. There were two courses per child per yer (rnge 12). Higher rtes of ntibiotic use were found in children 3 6 months old (37.2%). Antibiotics were given to children for 8.2% of common colds, 58.6% of ll phryngitis, 66.% of bronchitis,.7% of dirrhes, 22.8% of dermtitis, nd 12.% of bronchil obstructions. A physicin s prescription ws the most common reson for ntibiotic use (9.8%). Mediction use without prescription ws found in 6.9% of children, nd in 63.9% of them it ws preceded by physicin s prescription. Conclusions. Infnts re often exposed to ntibiotics in this setting. Overuse of ntibiotics is common for dignoses such s phryngitis, bronchitis, bronchil obstruction, nd dirrhe but is typiclly inpproprite (83.1% of courses) bsed on the most common etiologies for this ge group. Interventions to improve the use of ntibiotics should focus on physicins, since physicin s prescription ws the most common reson for ntibiotic use. Anti-bcteril gents; infnt; drug resistnce, microbil; inpproprite prescribing; Peru. Antibiotics re importnt wepons for fighting infections. Since they were discovered, they hve significntly reduced child mortlity nd incresed life expectncy. Worldwide, they re the most commonly prescribed drugs for children, especilly for cute respirtory illnesses nd dirrhe (1 4). Incresing ntibiotic resistnce is usully ttributed to overuse nd misuse of ntibiotics 1 Instituto de Investigción Nutricionl, Lim, Peru. Send correspondence to: Lucie Ecker, lecker@iin.sld.pe 2 Universidd Perun Cyetno Heredi, Lim, Peru. (5 7); it hs been estimted tht use is unnecessry in % 5% of the courses (8 ). Unfortuntely, misuse of ntibiotics is cusing the emergence of resistnt pthogens erly in life, especilly in the developing world where ntibiotics re vilble without prescriptions (3, 11 17). But misuse of ntibiotics nd the emergence of ntibiotic resistnce is not confined to developing countries; the increse in resistnt pthogens is spreding worldwide (11, 17, 18). Ptterns of greter resistnce to ntibiotics necessitte the use of newer nd more expensive drugs in order to control infections; this pttern increses helth cre inequlities (11) nd my contribute to higher risk of morbidity nd mortlity in smll infnts treted for serious infections in the developing world. In Peru, severl studies hve shown ptterns of high resistnce in respirtory bcteri nd enteropthogens in children, probbly due to buse nd misuse of ntibiotics (12, 13, 15, 19 21). Since the peditric popultion hs the highest rtes of ntibiotic prescribing in primry cre (1, 2), it is recognized trget group for inter- 574 Rev Pnm Slud Public (6), 11
ventions tht im to reduce unnecessry use of ntibiotics. In Peru, severl drugs, including ntibiotics, cn be bought without prescription in ll phrmcies. It hs been ssumed tht the vilbility of ntibiotics without prescription hs been the min cuse of ntibiotic misuse in the developing world (22 26). However, severl studies show high rtes of inpproprite medicl prescriptions s n importnt cuse of misuse of ntibiotics (16, 18, 27). Few dt re vilble on ntibiotic use in children from the developing world; there is scnt informtion on ntibiotic use in infnts in Peru. This study ims to describe the use of ntibiotics in Peruvin infnts, showing the dimensions nd chrcteristics of the problem in order to identify possible trgets for future interventions. METHODS Study design This descriptive cohort study used prospectively recorded dt from the clinicl records of 1 66 children prticipting in clinicl tril tht evluted the sfety of new hexvlent vccine 3 nd dt from pssive dirrhe surveillnce study of the sme cohort in Lim, Peru (28). Secondry dt were nlyzed by reviewing 1 23 medicl records of the 1 66 children who prticipted in the originl study. During the originl study 1 66 children < 2 months old were enrolled nd followed until they were 12 months old. At enrollment, previous drug use of the child ws recorded in the clinicl record. They hd scheduled visits nd could ttend the clinic when they were ill, nd the study physicin provided tretment dvice. This rrngement provided better ccess to medicl cre thn is vilble to the verge child in Lim, since it ws cost-free service. However, prents of children prticipting in the tril hd to buy the medictions s opposed to wht hppens t helth fcilities where mny receive them for free. The provision of ny drug during the 3 Mcis M, Lnt CF, Zmbrno B, Gil AI, Amemiy I, Mispiret M, et l. Sfety nd immunogenicity of n investigtionl fully liquid hexvlent DTP-IPV-Hep B-PRP-T vccine t 2, 4, 6 months of ge compred to licensed vccines in Ltin Americ [unpublished work]. 11. tril ws not considered benefit for the originl study. Six physicins worked during the study; ll of them were generl physicins. A history of children s previous illnesses nd drug use from birth to enrollment were recorded in the medicl record s well s detiled history of illness, prescribed drug use, nd tretment offered t home by the prents between scheduled visits. Anlysis Dignoses were grouped s upper respirtory trct infections (URTIs), including phryngitis, common colds, nd otitis, nd lower respirtory trct infections (LRTIs), which included bronchitis nd pneumoni. Anlyses used dt for ntibiotic courses, even if more thn one ntibiotic ws prescribed for some dignoses. For the purpose of nlysis nd ccording to the most likely etiologicl gents in this ge group (< 12 months old), use of ntibiotics ws considered inpproprite for the following dignoses: phryngitis, common colds, bronchitis, bronchil obstruction, dirrhe (excluding dysentery), nd dermtitis (29). Antibiotic use dt were nlyzed with STATA sttisticl pckges. Ethicl considertions The study ws presented nd pproved by the Ethicl Review Bord of the Instituto de Investigción Nutricionl (resolution number 281-9). As this study ws secondry dt nlysis study, which used dt from medicl records, informed consent ws not needed. RESULTS TABLE 1. Dignoses for which 2- to 12-monthold children received ntibiotic tretment, periurbn Lim, Peru, 6 7 Received ntibiotics Dignosis n No. % Conjunctivitis 1 6 96.4 Skin infection 8 72 9. Otitis medi 47 39 83. Pneumoni 36 24 66.7 Bronchitis 241 159 66. Urinry trct 36 22 61.1 infection Phryngitis 1 42 611 58.6 Dirrhe 1 96 446.7 Dermtitis 574 131 22.8 Bronchil 1 386 166 12. obstruction Common cold 2 528 8 8.2 Other 1 46 35 2.4 Not specified 822 1.1 All dignoses 8 636 2 23.4 Other dignoses include other skin diseses (12 cses), llergic rhinitis (9 cses), meconium spirtion (1 historicl cse), virl pneumoni (2 cses), externl otitis (2 cses), nonspecific symptoms (5 cses), meningitis (1 cse), bronchiolitis (1 cse), prsitosis (1 cse), nd sinusitis (1 cse). Between September 6 nd December 7, 1 23 children were followed from 2 to 12 months of ge. Fifty-five of the children were lost to follow-up nd their use of ntibiotics only during the period before they were lost to followup ws nlyzed. There were 15 344 medicl visits during the study period t the clinic. Of those visits, 5 886 (38.4%) were scheduled nd 8 636 (56.3%) were becuse the child ws ill. Of the 8 636 dignoses, 2 (23.4%) hd recorded use of ntibiotics; 58.6% of ll phryngitis, 66.% of bronchitis, nd.7% of dirrhes were treted with ntibiotics (Tble 1). Seven hundred seventy children (75.3%) took t lest one course of ntibiotics during their first yer of life: 243 children took only one course of ntibiotics (31.6%), 194 took two courses (25.2%), 142 took three courses (18.4%), nd 191 (24.8%) took more thn four courses of ntibiotics before they were 12 months old. The incidence of ntibiotic use in the first yer of life ws two courses per child per yer (rnge 12). Children took totl of 2 85 courses of ntibiotics (Tble 2). A physicin s prescription ws the most common reson for ntibiotic use (9.8%). Physicins were responsible for 1 894 courses (9.8%) of ntibiotics. Mediction provided by prents ws documented in only 6.9% (Tble 2), where no record of prescription from nurse or phrmcist ws found in the medicl records. From 144 courses of prentprovided ntibiotics, 92 (63.9%) were preceded by n ntibiotic prescription from physicin; 44 of those children (.6%) received the sme ntibiotic they hd tken previously. Prents used ntibiotics without prescription minly for dignoses like common colds (32.6%) nd dirrhe (.8%), while physicins prescribed ntibiotics minly for children with phryngitis (31.1%) nd dirrhe (21.1%) (Tble 2). Children strted ntibiotic use s erly s 9 dys of ge. The men ge of us- Rev Pnm Slud Public (6), 11 575
TABLE 2. Number of ntibiotic courses used due to physicin s prescription nd without medicl dvice in 2- to 12-month-old children from periurbn Lim, Peru, 6 7 Responsible for prescription Physicin Prents Unknown Dignosis n No. % No. % No. % Common cold 214 159 74.3 47 22. 8 3.7 Phryngitis 616 589 95.6 22 3.6 5.8 Otitis medi 39 37 94.9 2 5.1. Bronchitis 166 157 94.6 8 4.8 1.6 Bronchil obstruction 166 138 83.1 19 11.4 9 5.4 Pneumoni 33 32 97. 1 3.. Dirrhe 464 418 9.1 6.5 16 3.4 Urinry trct infection 24 23 95.8. 1 4.2 Skin Infection 8 77 96.3 2 2.5 1 1.3 Dermtitis 132 126 95.5 5 3.8 1.8 Conjunctivitis 1 b 6 96.4 1.9 3 2.7 Other c 32 8. 6 15. 2 5. Unknown 1. 1.. All dignoses 2 85 1 894 9.8 144 6.9 47 2.3 Topicl route of dministrtion 86.6%. b Topicl route of dministrtion 81.%. c Other ntibiotic courses by dignoses include other skin diseses (12 courses), llergic rhinitis (9 courses), virl pneumoni (3 courses), nonspecific symptoms (5 courses), externl otitis (3 courses), meningitis (3 courses), meconium spirtion (2 historicl courses), bronchiolitis (1 course), prsitosis (1 course), nd sinusitis (1 course). ge ws 6.5 months. Higher rtes of ntibiotic use were found in children 3 6 months old (776 courses, 37.2%) nd 6 9 months old (645 courses,.9%). Lower rtes of use were found in children younger thn 3 months of ge (215 courses,.3%) nd older thn 9 months of ge (449 courses, 21.5%). The leding dignoses ccounting for ntibiotic use in children < 3 months of ge were URTI (.5%) nd other dignosis (34.%) (with 39.7% of them for dermtitis nd 34.2% for conjunctivitis). In children > 3 months of ge, the most common dignoses tht received n ntibiotic were URTI nd dirrhe (3 6 months, 43.8% nd 21.8%, respectively; 6 9 months, 39.7% nd 27.3%, respectively; nd older thn 9 months, 41.4% nd.9%, respectively). The most frequently used ntibiotics re shown in Tble 3. (687 courses, 33.%) were most commonly used, followed by mcrolides (488 courses, 23.4%), prticulrly erythromycin (64.5%) nd zitromycin (31.4%); trimethoprim-sulfmethoxzole (TMP- SMX) ws used in 15.1% of courses. (38.6%) were used most commonly in children < 3 months old, nd mcrolides (.5%) were used most commonly in children > 9 months old (Figure 1). URTI nd LRTI were treted preferentilly with penicillins (56.4% nd 48.7%, respectively), mcrolides (19.2% nd 21.6%, respectively), nd (19.8% nd 14.6%, respectively). Dirrhe ws treted minly with mcrolides (49.6%), nitrofurns (24.8%), nd (17.2%) (Figure 2). Antibiotic usge rtes were significntly higher in mles (56.4%, P =.1). Events ssocited with ntibiotic use were mostly mild (89.2%); events of moderte nd severe intensity were rre (8.8% nd 1.8%, respectively), nd three events hd no registered intensity. Route of dministrtion ws minly orl (84.4%); less frequently used routes were topicl (12.2%) nd intrvenous or intrmusculr (3.4%). Topicl routes included derml (59.2%), ophthlmic (.4%), nd otic (.4%). In 477 courses of ntibiotic use, dt were vilble for totl dys of use. Men durtion of ntibiotic use ws 5.7 dys (stndrd devition 2.1 dys). According to the dignoses present nd the most common etiologies for this ge group (< 12 months old), 83.1% of the ntibiotics prescribed were inpproprite. Antibiotics re inexpensive in this setting. The verge totl cost ws bout $1 798 (U.S. dollrs), or $1.8 per child per yer during the first yer of life. DISCUSSION This study offers strong evidence of ntibiotic overuse in smll children, showing tht infnts from periurbn Lim re commonly exposed to ntibiotics. Among children < 12 months old, 75.3% received t lest one ntibiotic course, which is much higher thn the proportion of children < 5 yers old mking mbultory cre visits in the United Sttes of Americ, Cnd, North Centrl Europe, nd Itly, where preschool children hd reported prevlence of ntibiotic therpy of 72% (18). The ntibiotic prescription rte reched two courses per child per yer in children < 1 yer old; this rte ppers to be higher thn tht reported in the United Sttes (.9 course per child per yer in TABLE 3. ge of ntibiotics used, by dignosis, in 2- to 12-month-old children from periurbn Lim, Peru, 6 7 Antibiotic URTI (n = 869) LRTI (n = 199) Dirrhe (n = 464) Bronchil obstruction (n = 166) Other (n = 387) All dignoses (n = 2 85) 56.4 48.7 1.9 44.6 4.4 33. Cephlosporins 3.7.1.7 11.5 5.7 4.6 Mcrolides 19.2 21.6 49.6 25.3 1.6 23.4.1 3. 2.6. 58.9 b 11.9.1. 2.6.6 2.8 1.2 Nitrofurns.4. 24.8. 1. 5.9 19.8 14.6 17.2 17.5 1.3 15.1 Other ntibiotics c.4 2..7.6 24.3 5. Note: URTI: upper respirtory trct infection, LRTI: lower respirtory trct infection, : trimethoprim-sulfmethoxzole. Other dignoses included urinry trct infection (n = 24), skin infection (n = 8), dermtitis (n = 132), conjunctivitis (n = 1), other skin diseses (n = 12), llergic rhinitis (n = 9), virl pneumoni (n = 3), nonspecific symptoms (n = 5), externl otitis (n = 3), meningitis (n = 3), meconium spirtion (n = 2, historicl courses), bronchiolitis (n = 1), prsitosis (n = 1), sinusitis (n = 1), nd not specified dignosis (n = 1). b 94.7% used topiclly to tret skin diseses nd conjunctivitis. c Other ntibiotics include oxcillin nd dicloxcillin (62 courses), neomycin (23 courses), oxytetrcycline (5 courses), metronidzole (4 courses), chlormphenicol (4 courses), clindmycin (2 courses), sulfcetmide (2 courses), sulfdizine (1 course), lincomycin (1 course), nd vncomycin (1 course). 576 Rev Pnm Slud Public (6), 11
FIGURE 1. ge of ntibiotics used in 2- to 12-month-old children, periurbn Lim, Peru, 6 7 ( 3 months, n = 215 courses; 3 6 months, n = 776 courses; 6 9 months, n = 645 courses; nd 9 months, n = 449 courses) 45 35 25 15 5 3 3 6 6 9 9 Age (months) children 3 18 months old) nd in Sweden nd Germny (.8 course per child per yer in children < 6 yers old) (18). Mcrolides Nitrofurns Trimethoprim-sulfmethoxzole These rtes my be higher becuse of the younger ge selection compred with the cited studies. If this trend continues, the development of resistnt pthogens t erly ges is serious risk. In mny countries in the developing world, like Peru, ntibiotics re sold in phrmcies without need for medicl prescription (26). Generlly, it hs been ssumed tht the vilbility of ntibiotics without medicl prescription leds to higher rtes of self-mediction (23 26). However, physicins were responsible for lmost ll the ntibiotic use in this setting (9.8% of ntibiotic use), s in the developed world (1, 6, 7, 18), nd dt show tht ntibiotic use without prescription ws preceded by n ntibiotic prescription from physicin in 63.9% of the cses. This rte is higher thn tht found in the urbn community of Yurimgus in the Amzonin re of Peru, where ntibiotics used were prescribed by physicins in 7% of the cses (16). In other developing countries of South Americ, physicins recommended 54% of these ntibiotics (24). The uthors strongly believe FIGURE 2. ge of ntibiotic clsses used to tret 2- to 12-month-old children from periurbn Lim, Peru, 6 7, for upper respirtory trct infection (A) (n = 869), lower respirtory trct infection (n = 199) (B), dirrhe (n = 464) (C), nd bronchil obstruction (n = 166) (D) 6 56.4 A 6 B 5 5 48.7 3.7 Cephlosporins 19.2 19.8.1.1.4 Mcrolides Nitrofurns.1 Cephlosporins 21.6 3. Mcrolides.. Nitrofurns 14.6 6 5 49.6 C 5 45 44.6 D 1.9.7 Cephlosporins Mcrolides 2.6 2.6 24.8 Nitrofurns 17.2 35 25 15 5 11.5 Cephlosporins 25.3..6 Mcrolides. Nitrofurns 17.5 = trimethoprim-sulfmethoxzole. Rev Pnm Slud Public (6), 11 577
tht physicins hve the responsibility to explin why ntibiotics re not needed, nd this study shows tht prents follow physicin s recommendtion for ntibiotic use; however, they re lso lerning how to reuse ntibiotic prescriptions for their children t very erly ges. This fct gives responsibility for ntibiotic use to physicins, probbly due to deficient explntion of ntibiotic usge. As in other studies, the most frequently used ntibiotics were penicillins (32.9%) (2, 18, 27). The second most commonly used ntibiotics were mcrolides (23.4%). (15.1%) ws next most common, in contrst to dt from other studies in the developing world but following the trend of ntibiotic use in developing countries (18). Mcrolides were used more frequently in children > 9 months old nd in children with dirrhe, which is probbly due to higher dirrhel rtes mong older children. Proper use of ntibiotics ws found in dignoses like skin infections, pneumonis, otitis medi, nd urinry trct infections. Only 8.5% of ll common cold dignoses received ntibiotic tretment. According to dignoses nd usul etiologies in this ge group, 83.1% of the ntibiotics prescribed were inpproprite (29), leding to unnecessry erly exposure of children to drugs. The fct tht physicins mde dignoses tht re rre mong infnts, like bronchitis nd phryngitis, speks to their inexperience with children. Sttistics of the Ministry of Helth confirm tht > 93% of peditric primry cre units hve only generl physicins in these settings (, 31). Antimicrobil resistnce is gret chllenge, nd it is relted to the high intke of ntibiotics, to the use of inpproprite doses, nd to the inpproprite choice of n ntibiotic for given infection. Severl studies show tht recent ntibiotic use rises the risk for developing infection or coloniztion with resistnt bcteril pthogens (7, 32, 33). This study shows excessive nd inpproprite use of ntimicrobils for infections tht hve minly virl etiologies, which probbly ws prt of the cuse of the high ntibiotic resistnce found in dirrhegenic Escherichi coli from stool smples in this study (19); the dirrhegenic E. coli s group showed resistnce to mpicillin, cotrimoxzole, tetrcycline, nd gentmicin. Thirteen percent of strins showed intermedite resistnce to nitrofurntoin mong dirrhel smples. Multidrug resistnce (resistnce to three or more ntibiotics) ws common in dirrhel (63%) nd control smples (51%). Mny studies hve ddressed ntibiotic use, but few studies hve recorded ntibiotic use dt within cohort (24). This cohort study ssembled detiled dt on ntibiotic use during the first yer of life of lrge number of prticipnts. However, this study is limited becuse findings cnnot be generlized to ll children in this periurbn community. Even though dt were gthered on ntibiotic prescriptions outside the study, most tretments were t the study clinic, limiting the study to one clinic with few physicins. One cn only infer tht physicins t the study clinic cted similrly to others in the study re. Since the study children clerly hd better ccess to medicl cre thn the verge child in this poor setting round Lim, it is impossible to ssess how mny prents would hve purchsed n ntibiotic if they hd to py for the visit. However, round 5% of the children hd free ccess to stte helth fcilities becuse of their finncil condition nd round 13% hd free ccess to insurnce helth fcilities. Medicl visits in these settings cn cost round $2., which is ffordble for most residents. Prents my hve underreported ntibiotic use without prescription, since no ctive surveillnce t home ws performed. Physicins my hve reported dignoses in bised mnner, which would likely led to wrong estimtion of ntibiotic prescribing dignoses. Moreover, no dt were recorded on the dvice of phrmcists or reltives for ntibiotic use in the medicl records of the children studied. Specific informtion bout prescriptions by nondoctors (medicl students, phrmcists, nd reltives or friends) is lso lcking. A complementry investigtion in community nd primry helth fcilities is needed to dd to this ssessment. In summry, children in this setting receive erly nd frequent ntibiotics. Inpproprite use of ntibiotics in children < 12 months old is very common, especilly for respirtory infections nd dirrhe, with risk for the development of resistnt pthogens. The type of ntibiotics used follows the trend of ntibiotic use in developing countries. It seems tht prents seek medicl dvice before using ntibiotics without prescription nd physicins were responsible for ntibiotic use in these children more often thn in other studies from the developing world. This study offers strong evidence tht prents follow physicins recommendtions for ntibiotic use in their children, nd this finding suggests tht interventions need to focus on physicin eduction in order to reduce inpproprite ntibiotic use. Acknowledgments. The uthors thnk the study prticipnts nd their prents s well s stff t the Instituto de Investigción Nutricionl who prticipted in the cohort study. This study ws prtilly funded by C. Lnt s institutionl reserch funds nd by Snofi Psteur. REFERENCES 1. Nyquist AC, Gonzles R, Steiner JF, Snde MA. Antibiotic prescribing for children with colds, upper respirtory trct infections, nd bronchitis. JAMA. 1998;279(11):875 7. 2. Wtson RL, Dowell SF, Jyrmn M, Keyserling H, Kolczk M, Schwrtz B. Anti microbil use for peditric upper respirtory infections: reported prctice, ctul prctice, nd prent beliefs. Peditrics. 1999;4(6):1251 7. 3. Bojlil R, Clv JJ. Antibiotic misuse in dirrhe. A household survey in Mexicn community. 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Avilble from: http://www.dislimsur.gob.pe/disa_contenido.spx?opcm=74 Accessed 3 October. 32. Vnden Eng J, Mrcus R, Hdler JL, Imhoff B, Vugi DJ, Cieslk PR, et l. Consumer ttitudes nd use of ntibiotics. Emerg Infect Dis. 3;9(9):1128 35. 33. Rogues AM, Dumrtin C, Amdeo B, Venier AG, Mrty N, Prneix P, et l. Reltionship between rtes of ntimicrobil consumption nd the incidence of ntimicrobil resistnce in Stphylococcus ureus nd Pseudomons eruginos isoltes from 47 French hospitls. Infect Control Hosp Epidemiol. 7;28(12):1389 95. Mnuscript received on 7 Mrch 11. Revised version ccepted for publiction on 26 October 11. resumen Responsbilidd del médico en el uso de ntibióticos en niños menores de 1 ño de zons periurbns de Lim, Perú Plbrs clve Objetivo. Describir el uso de ntibióticos en niños de 2 12 meses de edd en entornos donde estos medicmentos se pueden obtener sin prescripción. Métodos. Se nlizron los dtos de un estudio de cohorte efectudo entre septiembre del 6 y diciembre del 7 en 1 23 niños menores de 2 meses de l zon periurbn de Lim, Perú, cuyo seguimiento se relizó hst el ño de edd. Resultdos. De los 1 23 niños, 77 (75,3%) tomron 2 85 tnds de trtmiento ntibiótico. Se registrron dos tnds por niño por ño (rngo 12). Ls tss más elevds de uso de ntibióticos se encontrron en los niños de 3 6 meses (37,2%). Los niños recibieron ntibióticos pr 8,2% de los resfridos comunes, 58,6% de ls fringitis, 66,% de ls bronquitis,,7% de ls dirres, 22,8% de ls dermtitis y 12,% de ls obstrucciones bronquiles. L prescripción de un médico fue l rzón más frecuente pr el uso de ntibióticos (9,8%). Se comprobó el uso de medicmentos sin prescripción en 6,9% de los niños, y en 63,9% de ellos este fue precedido por un prescripción médic. Conclusiones. En el entorno estudido, los niños menores de 1 ño menudo están expuestos los ntibióticos. El buso de los ntibióticos es frecuente nte enfermeddes como fringitis, bronquitis, obstrucción bronquil y dirre, pero por lo generl es indecudo (83,1% de ls tnds de trtmiento ntibiótico) según ls etiologís más comunes en este grupo etrio. Ls intervenciones dirigids mejorr el uso de los ntibióticos deben concentrrse en los médicos, y que l prescripción médic fue l rzón más común pr el uso de ntibióticos. Agentes ntibcterinos; lctnte; resistenci medicmentos; prescripción indecud; Perú. Rev Pnm Slud Public (6), 11 579