26/12/2016

BroadSpectrumAntibioticTreatmentandSubsequentChildhoodType1Diabetes:ANationwideDanishCohortStudy

Broad-Spectrum Antibiotic Treatment and Subsequent

Childhood Type 1 Diabetes: A Nationwide Danish Cohort
Study
TineD.Clausen

, ThomasBergholt, OlivierBouaziz, MagnusArpi, FrankEriksson, SteenRasmussen, NielsKeiding,

EllenC.Lkkegaard
Published:August25,2016

http://dx.doi.org/10.1371/journal.pone.0161654

Abstract
Background

Studieslinkantibiotictreatmentanddeliverybycesareansectionwithincreasedriskofchronicdiseasesthroughchangesofthe
gutmicrobiota.Weaimedtoevaluatetheassociationofbroadspectrumantibiotictreatmentduringthefirsttwoyearsoflifewith
subsequentonsetofchildhoodtype1diabetesandthepotentialeffectmodificationbymodeofdelivery.
MaterialsandMethods

ADanishnationwidecohortstudyincludingallsingletonsbornduring19972010.EndoffollowupbyDecember2012.Four
nationalregistersprovidedinformationonantibioticredemptions,outcomeandconfounders.Redemptionsofantibiotic
prescriptionsduringthefirsttwoyearsoflifewasclassifiedintonarrowspectrumorbroadspectrumantibiotics.Childrenwere
followedfromagetwotofourteen,bothinclusive.Theriskoftype1diabeteswithonsetbeforetheageof15yearswasassessed
byCoxregression.Atotalof858,201singletonscontributed5,906,069personyears,duringwhich1,503childrendevelopedtype1
diabetes.
Results

Redemptionofbroadspectrumantibioticsduringthefirsttwoyearsoflifewasassociatedwithanincreasedrateoftype1diabetes
duringthefollowing13yearsoflife(HR1.1395%CI1.02to1.25),however,theratewasmodifiedbymodeofdelivery.Broad
spectrumantibioticswereassociatedwithanincreasedrateoftype1diabetesinchildrendeliveredbyeitherintrapartumcesarean
section(HR1.7095%CI1.15to2.51)orprelaborcesareansection(HR1.6395%CI1.11to2.39),butnotinvaginallydelivered
children.Numberneededtoharmwas433and562,respectively.Theassociationwithbroadspectrumantibioticswasnotmodified
byparity,geneticpredispositionormaternalredemptionofantibioticsduringpregnancyorlactation.
Conclusions

Redemptionofbroadspectrumantibioticsduringinfancyisassociatedwithanincreasedriskofchildhoodtype1diabetesin
childrendeliveredbycesareansection.
Citation:ClausenTD,BergholtT,BouazizO,ArpiM,ErikssonF,RasmussenS,etal.(2016)BroadSpectrumAntibiotic
TreatmentandSubsequentChildhoodType1Diabetes:ANationwideDanishCohortStudy.PLoSONE11(8):e0161654.
doi:10.1371/journal.pone.0161654
Editor:AbderrezakBouchama,KingAbdullahInternationalMedicalResearchCenter,SAUDIARABIA
Received:April1,2016Accepted:August9,2016Published:August25,2016
Copyright:2016Clausenetal.ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommons
AttributionLicense,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalauthor
andsourcearecredited.
DataAvailability:Dataunderlyingthefindingsreportedhavetoberequestedfromathirdparty(StatisticsDenmark).Dueto
legalrestrictionsanddatasecurityregardingprocessingofpersonaldata,itiscompulsorytoapplyfordataaccessthrough
TheDanishDataProtectionAgency,whichcouldbecontactedthroughEmail:dt@datatilsynet.dk.Furthermore,asdata
includesinformationonprescriptionmedicine,analyseshastobeperformedthroughtheserversofStatisticsDenmark,which
requiresindividualpermission.StatisticsDenmarkcouldbecontactedthrough,Email:dst@dst.dk.
Funding:TDCreceivedfundingfromNordsjllandsHospital,Hillerd,Denmark,Grantnumber473
(https://www.nordsjaellandshospital.dk/).Thefundershadnoroleinstudydesign,datacollectionandanalysis,decisionto
publish,orpreparationofthemanuscript.
Competinginterests:Theauthorshavedeclaredthatnocompetinginterestsexist.

Introduction

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161654

1/9

26/12/2016

BroadSpectrumAntibioticTreatmentandSubsequentChildhoodType1Diabetes:ANationwideDanishCohortStudy

Infectiousmorbidityandmortalityhavebeenreduceddramaticallysincetheintroductionofpenicillinandotherantibiotics.However,
expandinguseofantibioticshasunwantedecologicalsideeffects.Recentstudiesindicatethatantibiotictreatmentmayinfluence
thehumanorganisminalongtermperspectiveandincreasetheriskofchronicdiseases.[13]Itissuggestedthatthedisease
causingeffectofantibioticsworksthroughchangesofthegutmicrobiota,andbroadspectrumantibioticsarethoughttohavethe
mostprominenteffect.[2]
Since1997,theincidencerateoftype1diabetesin04yearoldchildreninDenmarkhasstabilizedat14newcasesper100,000
personyears,whereastheincidenceratesamong59and1014yearoldchildrenhavebeensteadilyincreasing.[4]Studieshave
linkedmicrobiomicchangestoanincreasedriskoftype1diabetes,throughacomplexdisturbanceofthematurationoftheimmune
systemandanincreasedvulnerabilitytoenvironmentaltriggersofautoimmunity.[25]Asthemicrobiotaisaffectedforseveral
monthsfollowingabroadspectrumantibiotictreatment,[6]ithasbeenintriguingtolinktheincreasingincidenceofchildhoodtype1
diabetestotherisinguseofbroadspectrumantibiotics.Publishedstudiesshowinconsistentresults.[5711]Modeofdeliveryhas
alsobeenlinkedtoanincreasedriskoftype1diabetes,possiblyduetomicrobiomicchanges,butfindingsfromstudiesare
conflicting.[41215]Accordingtothehygienehypothesisexposuretomicrobes,includingthoseinthegenitaltractduringbirth,
increasesthemicrobialbiodiversityandisthoughttobebeneficialfortheimmunesystemmaturationandprotectiveforlater
developmentofavarietyofdiseases.Therefore,harmfuleffectsofbroadspectrumantibioticswouldbeexpectedtobemost
pronouncedamongchildrendeliveredbyprelaborcesareansection,whomhadnotbeenexposedtothematernalvaginalflora.[12]
Weevaluatedtheassociationofbroadspectrumantibiotictreatmentduringthefirsttwoyearsoflifewithsubsequentonsetof
childhoodtype1diabetesandexploredpotentialeffectmodificationbymodeofdelivery.

MaterialsandMethods
WeestablishedadatabasebasedonfourDanishnationwideregisters:theMedicalBirthRegistry(1997to2010),[16]theFertility
Database(1997to2010),[17]theNationalPatientRegistry(1977to2011),[18]theRegisterofMedicinalProductStatistics(1997to
2012)[19]andadditionalinformationfromStatisticsDenmark(1997to2012).
Byauniquepersonalidentificationnumber,linkagebetweenregistersandbetweenchildrenandtheirparentswaspossible.[20]
TheDanishDataProtectionAgencyapprovedthestudy(Journalnumber:2012580004).Afterlinkagedataweredeidentifiedto
ensuredatasafety.
TheMedicalBirthRegistryprovideddataondateofbirth,vitalstatusatbirth,modeofdelivery,parity,multiplebirths,birthweight
andgestationalageatbirth.
TheFertilityDatabaselinkedchildrentotheirparentsandprovideddataonoffspringsex,anddateofbirthfortheparents.
TheNationalPatientRegistry,deliveredhospitaladmissiondates,dischargediagnosesfordiabetesinthechild,motherandfather,
andcodesfordiagnosesandsurgicalproceduresrelatedtomodeofdelivery.
TheRegisterofMedicinalProductStatistics,validontheindividuallevelsince1997,capturedredeemedprescriptionson
insulin/insulinanaloguesandoralantidiabeticsforthechild,motherandfatherandonantibioticsforthechildandthemother.
TherelevantcodesandchangesovertimefordiagnosesandproceduresarelistedinS1Table.
StatisticsDenmarkprovidedinformationonvitalstatus,emigrationandparentaleducationalstatus.
Studypopulation

AlllivebornchildreninDenmarkfrom1January1997through31December2010(n=912,797)wereidentifiedintheMedicalBirth
Registry.Weexcluded38,218childrenfrommultiplepregnancies(n=37,895)andpregnancieswitherrorsinthepersonal
identificationnumber(n=323).Furthermore,weexcluded16,378childrenwitheventsbeforetheirtwoyearsbirthdayduetoeither
death(n=3,412),emigration(n=12,790)ordiagnosisoftype1diabetes(n=176).Thefinalpopulationincluded858,201liveborn
singletonchildrenbornto527,927mothers.
Thechildrenwerefollowedfromagetwountiltheirfifteenthbirthday(n=60,934),thedateoftype1diabetesdiagnosis(n=1,503),
death(n=618),firstemigration(n=21,787)orendoffollowupbyDecember2012(n=773,359),whichevercamefirst(Fig1).

Fig1.Inclusion,exclusionanddatacensoring.

Shownarethenumberofchildrenwhomettheexclusioncriteria,thenumberofeventsandthedistributionofantibiotics
redemptionanddiagnosisofchildhoodtype1diabetes.
http://dx.doi.org/10.1371/journal.pone.0161654.g001
Exposure

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161654

2/9

26/12/2016

BroadSpectrumAntibioticTreatmentandSubsequentChildhoodType1Diabetes:ANationwideDanishCohortStudy

Outpatientredemptionsofantibioticprescriptionsforthechildduringthefirsttwoyearsoflifewereclassifiedintoeither:anytypeof
antibiotics(yesorno),narrowspectrumantibiotics(yesorno)orbroadspectrumantibiotics(yesorno),classifiedinaccordance
withtheDanishIntegratedAntimicrobialMonitoringandResearchProgram2013(S2Table).[21]Consequently,childrenexposedto
bothnarrowandbroadspectrumantibiotics,wouldbeclassifiedasexposedinallanalysesevaluatingeffectsofanytype,narrow
spectrumorbroadspectrumantibiotics,respectively,whereaschildrentreatedwithonlybroadspectrumantibiotics,wouldbe
includedintheexposedgroupinanalysesevaluatingeffectsofanytypeandbroadspectrumantibioticsbutintheunexposed
group,whenevaluatingtheeffectofnarrowspectrumantibiotics.Theclassificationintothethreedifferentexposuregroupswere
usedinseparateanalyses.
Outcomevariable

Wefollowedchildrenduring13yearsfromagetwotofourteen,bothinclusive,contributing5,906,069personyearsatriskandan
averagedurationoffollowupof6.9years.Wedefinedchildhoodtype1diabetesinchildrenwhobeforetheageoffifteenfulfilled
oneoftwoofthefollowingcriteriaorboth.Eithertheyweredischargedfromahospitalwithadiabetesdiagnosis(type1or
unspecified)ortheyhadredeemedatleasttwoprescriptionsoninsulin/insulinanalogueswithinoneyear.Childrenwhoadditionally
redeemedtwoprescriptionsonoralantidiabeticswithinoneyearwereconsideredhavingtype2diabetes.Thedateofonsetof
type1diabeteswasdefinedasthefirstofeitherthedateofthefirstdiabetesrelatedhospitaladmissionorthedateforthesecond
redemptionofinsulin/insulinanalogues(S1Table).
Confoundersandothercovariates

Webasedselectionofpossibleconfoundersonknowledgefrompreviousstudiesonriskfactorsfortype1diabetes,aswellason
theoreticalconsiderationsregardingfactorsknowntobeassociatedwithboththeuseofantibioticsandriskoftype1diabetes.[22]
Confounderscomprisedbirthyear(19972010),sex(maleorfemale),parity(primiparousormultiparous)andmodeofdelivery
(vaginaldelivery,intrapartumcesareansectionorprelaborcesareansection)(S1Table).
Includedparentalconfoundersweregeneticpredispositionmeasuredasmaternalorpaternaldiabetesstatusatchildbirth,aswell
asmaternalandpaternaleducationallevelandage(<25,2530or>30years)atchildbirth.Maternalandpaternaltype1diabetes
wasdefinedinparentsdischargedsince1977withadiabetesdiagnosis(type1orunspecific).Parentswithtwoprescriptionson
oralantidiabeticswithinoneyearwereinterpretedashavingtype2diabetes.Theonsetdateoftype1diabeteswasdefinedasthe
dateforthefirstdiabetesrelatedhospitaladmission.Thevariablewasclassifiedintotwocategories(type1diabetesdiagnosed
beforechildbirth:yesorno).Educationwasrecordedasthehighestlevelofongoingorfinishededucationandclassifiedintothree
categories(elementaryschool/highschool,shorteducation/skilledworkerormedium/longeducation).Indicators(yesorno)on
maternalredemptionofantibioticsduringpregnancy(Trimester1,2or3)andduringthefirstsixmonthsafterdeliverywerederived
forany,narrowspectrumorbroadspectrumantibiotics.
Birthweight(<2,500,2,5004,000or>4,000grams)andgestationalage(<34,3436,3740or>40weeksgestation)were
available.
Dataanalysis

Weestimatedchildhoodtype1diabeteshazardratios(HRs)forredemptionofantibioticsusingaCoxproportionalhazardsmodel,
usingthesurvivalpackage(version2.377)inR(version3.0.2).TheproportionalhazardsassumptionoftheCoxregressionmodel
impliesthattheassociationwithantibioticsdoesnotchangewithage.Toexaminethevalidityofthisassumption,wefittedmodels
whereweallowedtheassociationtochangeinthreeyearintervals.Thesemodelsvalidatedthattheproportionalhazards
assumptionwasmet.
Robust(sandwich)standarderrorswereusedtoadjustformultiplebirthsfromthesamewoman.Toexaminetheimpactofdifferent
confoundersweconductedpartiallyadjustedmodelsaswellasfullyadjustedmodelsincludingallconfounders(yearofbirth,mode
ofdelivery,maternalandpaternaltype1diabetesstatusatchildbirth,maternalandpaternalageatchildbirth,maternaland
paternaleducationallevelatchildbirth,offspringsex,parity).Missingcovariateswerehandledbycompletecaseanalysis.
Additionalmodelsevaluatedthepotentialimpactofgestationalageandbirthweight.Weexploredthepotentialinteractionbetween
antibioticredemptionanddeliverymode,parentaltype1diabetesstatusatchildbirth,parityandmaternalredemptionofantibiotics
duringpregnancyandduringthefirst6monthsafterdeliverybyaddinganinteractiontermtothemodel.Toillustratetheeffectof
modeofdeliveryonthenumberofchildren,whoonaverageshouldbeexposedtobroadspectrumantibioticsduringthefirsttwo
yearsoflifetocausechildhoodtype1diabetesinonechild(diagnosedfromtwotofifteenyearsofage),wecalculatedthenumber
neededtoharmfordifferentsubgroupsofmodeofdelivery(alldeliveries,intrapartumcesareansectionandprelabourcesarean
section,respectively).[23]
Finally,potentialeffectsofspecificcategoriesofantibioticswereevaluatedinanalysesofchildrenexposedtothefollowing
antibioticsubcategoriesbasedonATCcodes:J01CA(Extendedspectrumpenicillin),J01CR(Combinedpenicillins,includingbeta
lactamaseinhibitors),J01CE(Betalactamasesensitivepenicillins),andJ01FA(Macrolides).

Results
Inthefinalpopulationof858,201singletonchildrenborninDenmarkduring1997to2010onaverage615,782children(71.8%)had
redeemedantibioticsduringthefirsttwoyearsoflife.Hereof,440,006children(51.3%)hadredeemednarrowspectrumantibiotics
and441.273(51.4%)broadspectrumantibiotics,as174,509(20.3%)hadredeemedonlynarrowspectrumantibiotics,175,776
(20,5%)onlybroadspectrumantibioticsand265.497(30.9%)bothnarrowandbroadspectrumantibiotics(Table1).

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161654

3/9

26/12/2016

BroadSpectrumAntibioticTreatmentandSubsequentChildhoodType1Diabetes:ANationwideDanishCohortStudy

Table1.Backgroundcharacteristicsforsingletonchildrenborn1997to2010andtheirparents .

http://dx.doi.org/10.1371/journal.pone.0161654.t001
Theoverallrateofchildrenwhoredeemedanytypeofantibioticswithinthefirsttwoyearsoflifewasstableinthebirthcohortsfrom
1997to2010.However,since2005broadspectrumantibioticsweremorefrequentlyredeemedthannarrowspectrumantibiotics
(Fig2).

Fig2.Redemptionofantibioticswithinthefirsttwoyearsoflife.

IncludedareallchildrenborninDenmark1997to2010,whobytheirtwoyearsbirthdaywerealiveandhadnotemigratedor
beendiagnosedwithtype1diabetes(n=858,201).Theproportionofchildrenredeemingbroadspectrumandnarrow
spectrumantibiotics,respectively,includealsochildrenwhohadredeemedbothbroadandnarrowspectrumantibiotics
withinthefirsttwoyearsoflife.
http://dx.doi.org/10.1371/journal.pone.0161654.g002
Redemptionofantibioticsduringthefirsttwoyearsoflifewasmostprominentinchildrendeliveredbycesareansection,males,
childrenwithabirthweightbelow2,500gorgestationalagebelow34weeks,childrenhavingyoungparentswithashorteducation,
aswellaschildrendeliveredbymotherswithtype1diabetesdiagnosedbeforechildbirth(Table1).
Type1diabeteswasdiagnosedin1,503children(Fig1).
Incrudeanalyses,childrenwhohadredeemedprescriptionsonanytypeofantibioticsduringthefirsttwoyearsoflifehada
comparablerateofchildhoodtype1diabetes,tochildrenwithoutredemptionsofantibiotics(HR1.0795%CI0.96to1.20).
Estimatesremainedessentiallyunchangedwhenadjustedforyearofbirth(HR1.0795%CI0.95to1.20)andmodeofdelivery
(HR1.0795%CI0.95to1.20),aswellasafterfurtheradjustmentforparentalage,educationandtype1diabetesstatusat
childbirth,parityandsex(HR1.0695%CI0.94to1.19,Table2).Thesamepatternwasfoundregardingnarrowspectrum
antibiotics.Incontrast,childrenwhohadredeemedprescriptionsonbroadspectrumantibioticshadahigherrateofchildhoodtype
1diabetesascomparedtochildrenwhodidnot,incrude(HR1.1495%CI1.03to1.26)aswellasinadjustedanalyses(HR1.13
95%CI1.02to1.25,Table2).Apartfrombroadspectrumantibioticsthefollowingpredictorsoftype1diabeteswasfound:
Primiparity(HR1.1295%CI1.00to1.26),paternaltype1diabetesdiagnosedbeforechildbirth(HR11.2195%CI8.85to14.20)
andmaternaltype1diabetesdiagnosedbeforechildbirth(HR6.1995%CI4.31to8.91).Theassociationwithmaternaleducation
(Shorteducation/skilledworker:HR1.1395%CI0.99to1.29)didnotreachstatisticalsignificance.Furtheradjustmentforbirth
weightorgestationalagedidnotchangeestimates(S3Table).Theassociationbetweenantibioticsduringthefirsttwoyearsoflife
andtype1diabeteswasstronglymodifiedbymodeofdelivery(Pvaluefortheinteractiontermbetweenbroadspectrumantibiotics
andmodeofdelivery:0.0023).Invaginallydeliveredchildrenredemptionofantibiotics,regardlessoftype,wasnotassociatedwith
anincreasedrateofchildhoodtype1diabetes.Incontrast,anassociationwithbroadspectrumantibioticswasfoundamong
childrendeliveredbyintrapartumcesareansection(HR1.7095%CI1.15to2.51)aswellasbyprelaborcesareansection(HR
1.6395%CI1.11to2.39).Inchildrendeliveredbyprelaborcesareansectionredemptionofantibioticsofanytypewasassociated
withatwofoldincreasedrateofchildhoodtype1diabetes(HR1.9195%CI1.14to3.20).Regardlessofmodeofdelivery,narrow
spectrumantibioticswerenotassociatedwithchildhoodtype1diabetes(Table3).

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161654

4/9

26/12/2016

BroadSpectrumAntibioticTreatmentandSubsequentChildhoodType1Diabetes:ANationwideDanishCohortStudy

Table2.Associationsbetweenredemptionofantibioticswithinthefirsttwoyearsoflifeandsubsequentonsetofchildhoodtype1diabetes(2
to14years,bothincluded).

http://dx.doi.org/10.1371/journal.pone.0161654.t002

Table3.Evaluationofpotentialeffectmodificationbymodeofdeliveryontheassociationbetweenredemptionofantibioticswithinthefirsttwo
yearsoflifeandsubsequentonsetofchildhoodtype1diabetes(2to14years,bothincluded).

http://dx.doi.org/10.1371/journal.pone.0161654.t003
Basedontheabsoluteriskdifferenceattributedtobroadspectrumantibioticsthenumberneededtoharmwere2,218inallchildren
regardlessofdeliverymode,433inchildrendeliveredbyintrapartumcesareansectionand562inchildrendeliveredbyprelabor
cesareansection.
Theassociationbetweenbroadspectrumantibioticsandchildhoodtype1diabeteswasnotmodifiedbygeneticpredisposition
(maternalorpaternaltype1diabetesdiagnosedbeforechildbirth)(Pvaluefortheinteractiontermbetweenbroadspectrum
antibioticsandgeneticpredisposition:0.66),parity(Pvaluefortheinteractionterm:0.70),maternalredemptionofantibioticsduring
pregnancy(Pvaluefortheinteractionterm:0.76)ormaternalredemptionofantibioticsduringthefirstsixmonthsafterdelivery(P
valuefortheinteractionterm0.78).
Wefoundnoindicationthattheriskoftype1diabeteswasincreasingwithincreasingnumbersofantibioticprescriptions(S4Table).
Whenenteringredemptionofbroadspectrumantibioticsduringpregnancytothefullyadjustedmodelitdidnotchangeestimates
fortheassociationbetweenbroadspectrumantibiotictreatmentofthechildandsubsequentdevelopmentofchildhoodtype1
diabetesandredemptionofbroadspectrumantibioticsduringpregnancywasnotapredictorofchildhoodtype1diabetes(S5
Table).
Inanalysesincludingexposurefromantibioticsubcategories,50.9%ofthechildrenhadbeentreatedwithextendedspectrum
penicillinbeforetheageof2yearsandthesechildrenhadanincreasedrateofchildhoodtype1diabetes(HR1.1295%CI1.01to
1.25).Useofmacrolides(usedby13.2%ofthechildren)wasalsoassociatedwithanincreasedrateofchildhoodtype1diabetes
(HR1.1695%CI1.01to1.34),whereastreatmentwithcombinedpenicillins,includingbetalactaminhibitors(usedby2.9%ofthe
children)andbetalactamasesensitivepenicillins(usedby44.6%ofthechildren)wasnot(HR0.8995%CI0.61to1.29andHR
0.9995%CI0.99to1.10,respectively).

Discussion
Redemptionofbroadspectrumantibioticsduringthefirsttwoyearsoflifewasassociatedwithanincreasedriskofchildhoodtype1
diabetesinchildrendeliveredbycesareansection.Inanalysesofspecificcategoriesofantibiotics,increasedriskofchildhoodtype
1diabeteswasfoundinoffspringtreatedwithextendedspectrumpenicillinsandmacrolides.
Otherstudies

Associationsbetweenuseofantibioticsandsubsequentdevelopmentofchildhoodtype1diabeteshavebeenevaluatedinthree
otherhumanobservationalstudies.AcasecontrolstudyfromFinlandincluding437childrendiagnosedwithtype1diabetesand
1,748matchedcontrols,foundthatoverall,therewasnoassociationbetweenantibioticusebeforepregnancy,duringpregnancyor
duringchildhoodandtheriskofchildhoodtype1diabetes.However,whenevaluatingeffectsofsubgroupsofantibioticsaswellas
severalpotentialsubcomparisonscombiningantibioticexposurebefore,duringandafterpregnancy,theyfoundanincreasedrisk
ofchildhoodtype1diabetesinchildrenfrommotherchildpairs,wheremacrolideswereusedbothbythemotherbeforepregnancy
andbythechildcomparedtopairswhereneitherusedmacrolides(OR1.76,95%CI1.052.94).Furthermore,childrenbornto

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161654

5/9

26/12/2016

BroadSpectrumAntibioticTreatmentandSubsequentChildhoodType1Diabetes:ANationwideDanishCohortStudy

motherstreatedwithphenoxymethylpenicilins(OR1.70,95%CI1.08to2.68)orquinoloneantimicrobials(OR2.43,95%CI1.16
to5.10)oneyearpriortopregnancyhadincreasedriskoftype1diabetes.Theuseofmorethansevenpurchasesofantibiotics
duringchildhoodwasassociatedwithincreasedriskoftype1diabetesinthechild(OR1.66,95%CI1.24to2.24),butnodose
responseeffectwasobservedintheantimicrobialsubgroups.Thestudydidnotaccountorcorrectforthenumberofincluded
comparisons.[11]ADutchcasecontrolstudyincluding925individualswithtype1diabetesand3,591controlsfoundthatpatients
inthetype1diabetesgroupreceivedmoreantibacterialsthancontrols(49.8vs.40.0%,P<0.001),andthatthenumberofanti
infectiveprescriptionswerehigherinthetype1diabetesgroupfromeightyearsbeforeuntilfouryearsafterthediagnosis.[10]A
previousDanishcohortstudyincludingallchildrenborninDenmark19952003,hereof454childrendiagnosedwithtype1
diabetes,foundnostatisticallysignificantassociationbetweenoveralluseofantibioticsduringchildhoodandriskoftype1diabetes
(rateratio1.16,95%CI0,91to1,50).Nospecificclassofantibiotics(extendedspectrumpenicillin,betalactamasesensitive
penicillins,macrolidesorothersystemicantibiotics)wasassociatedwithtype1diabetes,nospecificageofusewasassociated
withtype1diabetesandnospecificageofonsetwasassociatedwithantibioticuse.Hospitalizationwithseriousbacterialinfections
wasnotassociatedwithincreasedriskoftype1diabetes.Thestudydidnotexplorepotentialeffectsofmodeofdelivery.[9]
Strengthsandlimitations

TheDanishregistersprovideuniquedataastheyarenationwide,almostcompleteandwithhighvalidity.[1620]Theprospectively
collecteddatalimitstheriskofselectionandinformationbias.Itisastrengthofthestudythatantibioticsareonlysoldon
prescriptionandredemptionsareautomaticallytransferredtotheRegisterofMedicinalProductStatistics.[19]
Nootherstudieshaveexploredthepotentiallymodifyingeffectofdeliverymode,parityandgeneticpredispositionorfocusedonthe
increasinguseofbroadspectrumantibioticsandthepresentstudyisthelargestwiththelongestfollowuptime.Despitetherising
incidencechildhoodtype1diabetesisstillararedisease,butitisassociatedwithanincreasedmorbidity.[24]Studieshaveshown
thatupto50%ofallantibioticprescriptionscouldhavebeenomitted,[25]andthatthecesareansectionratesaremuchhigherthan
medicallyindicatedinmanycountries.[26]Thereforeanumberneededtoharmofaround500inchildrendeliveredbycesarean
sectionisofclinicalimportance.
Antibioticscanbecategorizedaseithernarroworbroadspectrumantibioticsaccordingtothespectrumofactivity,butthereisno
universalalgorithmforthiscategorization,[27]andthecategorizationiscomplicatedasthespectrumofactivitychangesdueto
changesintheresistancepatternsovertime.Traditionally,bacteriaarecategorizedusingtheGramstain.Antibioticsonlyactive
eitheragainstGrampositiveorGramnegativebacteriahaveanarrowspectrumwhilstantibioticsactiveagainstbothgroupshavea
broadspectrum.[2128]WechosetheDanishantibioticscategorizationwhichiswelldefinedandfoundedonconsiderationsofthe
nationalresistancepatterns,[21]butothercategorizationshavebeensuggested.[2931]Wefoundanincreasedriskofchildhood
type1diabetesinchildrenexposedtoextendedspectrumpenicillinsandmacrolides,ofwhichthefirstisconsideredbroad
spectrumfollowingtheDANMAPcategorizationbutnarrowspectrumfollowingothercategorizationsandthelattertheoppositeway
around.Thisfindingunderlinesthepotentialassociationbetweenantibiotictreatmentduringchildhoodandlaterchildhoodtype1
diabetes,butitalsostressesthechallengesassociatedwiththecategorizationintobroadandnarrowspectrumantibiotics.
[212931]Wefocusedtheanalysesonthepotentialassociationbetweentreatmentwithantibioticswithinthefirsttwoyearsoflife,
afterwhichthemicrobiotahasbeenfoundtobeindistinguishablefromtheadultmicrobiota.[2]Wefurthermorefocusedonbroad
spectrumantibiotics,wellknowingthat31%ofthechildrenhadredeemedbothnarrowandbroadspectrumantibiotics.Nodose
responseeffectswerefound.
Unfortunately,wedidnothaveaccesstoinformationontheunderlyinginfectionorantibiotictreatmentduringhospitalization.
However,missinginformationregardingpatientcomplianceandantibiotictreatmentduringhospitalizationdilutetheeffectand
underestimatethetrueeffectofantibiotics,andapreviousDanishstudyincludinginformationregardinghospitalizationwithserious
bacterialinfectiondidnotfindaneffectofthisexposureontype1diabetesrisk.[9]Itisafurtherlimitation,thatwedidnothave
accesstoinformationregardingethnicorigin,infantdietorbreastfeeding.
Thepredictivevalidityoftype1diabetesdiagnosesbasedondischargecodesfromtheNationalPatientRegistryoronredeemed
insulinprescriptionswasin1996estimatedtobe96%inthegeneralpopulationandin2007tobe94%to97%inchildren.[3233]
Thereareseveralpotentialpathogenicexplanationstothefindingsofanassociationbetweenredemptionofbroadspectrum
antibioticswithinthefirsttwoyearsoflifeandincreasedriskofchildhoodtype1diabetesonlyinchildrendeliveredbycesarean
section.
Firstly,itmaybeacausalassociationwithbroadspectrumantibiotics.Thepathogenesisoftype1diabetesissupposedtobe
multifactorial,withastronggeneticpredispositioninfluencedbyseveralintrauterine,perinatalandpostnataltriggers.Children
deliverybycesareansectionhasalessdiverseandmorepathogenicmicrobiota,[34]whichcombinedwithaprolongedrecovery
phasefollowingtreatmentwithbroadspectrumantibioticsmayresultineradicationofharmlessandbeneficialtypesofbacteriaand
overgrowthofmorepathogenicbacteria,introducinganimbalanceinthemicrobiotaanddisturbanceoftheimmunological
maturation.Thishygienetheoryhasbeenproposedtobeapotentialetiologyforincreasedautoimmuneactivity.[12]
Secondly,ithasbeenproposedthatdeliverybycesareansectionmayinitselfweakenthebabysimmunesystemthrougha
reducedstressresponse.Combinedwithamorepathogenicgutmicrobiotacausedbybroadspectrumantibioticsthismayinduce
autoimmuneactivityoraccelerateautoimmuneprocesses.[235]
Thirdly,itmaynotbeacausalassociationwithbroadspectrumantibioticsbutratheranassociationwiththeunderlyinginfection
whichmaytriggerautoimmunity.Studiesshowinconsistentresults.[13637]Thefindingsoftheassociationonlyamongchildren
deliveredbycesareansectionindicateatwohitpathogenesis,thatthesechildrenarevulnerabletoharmfuleffectsofeither
infectionsorsideeffectsfrombroadspectrumantibiotics.
Finally,theassociationmayreflectthatpatientswithdiabeteshavemorebacterialinfectionsandthereforeredemptionofbroad
spectrumantibioticsbeforeonsetofdiabetescouldactasaproxyforsubclinicaldiabetes.[38]However,thenitwouldbeexpected
thatsimilarassociationswerefoundirrespectiveofmodeofdelivery.
Wefoundacomparableassociationwithbroadspectrumantibioticsinchildrendeliveredbyprelaborandintrapartumsection.This
couldindicatethatthecodingofcesareansectionisinvalid,thatthemicrobiotaisequallyaffectedfromintrapartumandprelabor
cesareansectionorthattheinteractionwithcesareansectionisrelatedtosharedfactorslikeanesthesia,operativeprocedure,a
reducedfetalstressresponseorantibioticsgiveninrelationtotheoperation.Additionally,intrapartumantibioticswouldhavebeen
giventoaproportionofwomenhavingintrapartumcesareansection,whichcouldintheorydisturbthegutmicrobiotaofthese
childrenmorethanthedisturbanceattributedtocesareansectionperse.Unfortunately,wedidnothaveaccesstoinformation
regardingintrapartumantibiotictreatment.

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161654

6/9

26/12/2016

BroadSpectrumAntibioticTreatmentandSubsequentChildhoodType1Diabetes:ANationwideDanishCohortStudy

Thefindingthatpaternalandmaternaltype1diabetesarestrongpredictorsoftype1diabetesisknownfromotherstudies.We
found,thatchildrenofmotherswithashorteducationhadahigherriskoftype1diabetes.Otherstudieshavefounddiverging
associationsbetweenmaternaleducationallevelandtheriskoftype1diabetesinthechildren.Thefindingofahigherriskoftype1
diabetesinfirstbornchildrenmaybesupportiveofthehygienehypothesisastheywouldnothavebeenexposedtomicrobesfrom
siblings.

Conclusions
Redemptionofbroadspectrumantibioticsduringthefirsttwoyearsoflifeisassociatedwithanincreasedriskofchildhoodtype1
diabetes,however,stronglymodifiedbymodeofdelivery,astheassociationwasonlyobservedinchildrendeliveredbycesarean
section.Thefindingmayreflectacausalassociationwitheitherbroadspectrumantibioticsortheunderlyingconditionleadingto
thetreatmentandthattheassociationismodifiedbyconditionsassociatedwithdeliverybycesareansection.Treatmentwith
extendedspectrumpenicillinsandmacrolidesmayconferspecificrisk.

SupportingInformation
S1Table.Specificationofregistersandcodesusedfordefinedvariables.

doi:10.1371/journal.pone.0161654.s001
(DOCX)
S2Table.ClassificationoftypesofantibioticsintonarroworbroadspectruminaccordancewiththeDANMAPdefinition.

doi:10.1371/journal.pone.0161654.s002
(DOCX)
S3Table.Associationsbetweenredemptionofbroadspectrumantibioticswithinthefirsttwoyearsoflifeandsubsequentonsetofchildhoodtype1
diabetes(2to14years,bothincluded).

Effectsofbirthweightandgestationalage.
doi:10.1371/journal.pone.0161654.s003
(DOCX)
S4Table.Associationsbetweenredemptionofbroadspectrumantibioticswithinthefirsttwoyearsoflifeandsubsequentonsetofchildhoodtype1
diabetes(2to14years,bothincluded).

Doseresponseeffects.
doi:10.1371/journal.pone.0161654.s004
(DOCX)
S5Table.Associationsbetweenredemptionofbroadspectrumantibioticswithinthefirsttwoyearsoflifeandsubsequentonsetofchildhoodtype1
diabetes(2to14years,bothincluded).

Effectsofbroadspectrumantibioticsduringpregnancy.
doi:10.1371/journal.pone.0161654.s005
(DOCX)

AuthorContributions
Conceivedanddesignedtheexperiments:TDCTBOBMAFESRNKECL.
Analyzedthedata:OBFE.
Contributedreagents/materials/analysistools:TDCTBOBMAFESRNKECL.
Wrotethepaper:TDCTBOBMAFESRNKECL.

References
1. WenL,LeyRE,VolchkovPY,StrangesPB,AvanesyanL,StonebrakerAC,etal.InnateimmunityandintestinalmicrobiotainthedevelopmentofType
1diabetes.Nature2008Oct23455(7216):110913.doi:10.1038/nature07336.pmid:18806780
ViewArticle
PubMed/NCBI
GoogleScholar
2. VangayP,WardT,GerberJS,KnightsD.Antibiotics,pediatricdysbiosis,anddisease.CellHostMicrobe2015May1317(5):55364.doi:
10.1016/j.chom.2015.04.006.pmid:25974298
ViewArticle
PubMed/NCBI
GoogleScholar
3. BaileyLC,ForrestCB,ZhangP,RichardsTM,LivshitsA,DeRussoPA.Associationofantibioticsininfancywithearlychildhoodobesity.JAMAPediatr
2014Nov168(11):10639.doi:10.1001/jamapediatrics.2014.1539.pmid:25265089
ViewArticle
PubMed/NCBI
GoogleScholar
4. ClausenTD,BergholtT,ErikssonF,RasmussenS,KeidingN,LokkegaardEC.PrelaborCesareanSectionandRiskofChildhoodType1DiabetesA
NationwideRegisterBasedCohortStudy.Epidemiology2016July27(4):547555.doi:10.1097/EDE.0000000000000488.pmid:27031040
ViewArticle
PubMed/NCBI
GoogleScholar
5. VaaralaO.Gutmicrobiotaandtype1diabetes.RevDiabetStud20129(4):2519.doi:10.1900/RDS.2012.9.251.pmid:23804264
ViewArticle
PubMed/NCBI
GoogleScholar

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161654

7/9

26/12/2016

BroadSpectrumAntibioticTreatmentandSubsequentChildhoodType1Diabetes:ANationwideDanishCohortStudy

6. JernbergC,LofmarkS,EdlundC,JanssonJK.Longtermimpactsofantibioticexposureonthehumanintestinalmicrobiota.Microbiology2010
Nov156(Pt11):321623.doi:10.1099/mic.0.0406180.pmid:20705661
ViewArticle
PubMed/NCBI
GoogleScholar
7. BrugmanS,KlatterFA,VisserJT,WildeboerVelooAC,HarmsenHJ,RozingJ,etal.Antibiotictreatmentpartiallyprotectsagainsttype1diabetesinthe
BioBreedingdiabetespronerat.Isthegutflorainvolvedinthedevelopmentoftype1diabetes?Diabetologia2006Sep49(9):21058.pmid:16816951
ViewArticle
PubMed/NCBI
GoogleScholar
8. HansenCH,KrychL,NielsenDS,VogensenFK,HansenLH,SorensenSJ,etal.EarlylifetreatmentwithvancomycinpropagatesAkkermansia
muciniphilaandreducesdiabetesincidenceintheNODmouse.Diabetologia2012Aug55(8):228594.doi:10.1007/s0012501225647.pmid:22572803
ViewArticle
PubMed/NCBI
GoogleScholar
9. HviidA,SvanstromH.Antibioticuseandtype1diabetesinchildhood.AmJEpidemiol2009May1169(9):107984.doi:10.1093/aje/kwp038.
pmid:19318617
ViewArticle
PubMed/NCBI
GoogleScholar
10. FazeliFS,SouvereinPC,vanderVorstMM,KnibbeCA,deBA,MantelTeeuwisseAK.Populationbasedcohortstudyofantiinfectivemedicationuse
beforeandaftertheonsetoftype1diabetesinchildrenandadolescents.AntimicrobAgentsChemother2014Aug58(8):466674.doi:
10.1128/AAC.0308014.pmid:24890584
ViewArticle
PubMed/NCBI
GoogleScholar
11. KilkkinenA,VirtanenSM,KlaukkaT,KenwardMG,SalkinojaSalonenM,GisslerM,etal.Useofantimicrobialsandriskoftype1diabetesina
populationbasedmotherchildcohort.Diabetologia2006Jan49(1):6670.pmid:16344923
ViewArticle
PubMed/NCBI
GoogleScholar
12. CardwellCR,SteneLC,JonerG,CinekO,SvenssonJ,GoldacreMJ,etal.Caesareansectionisassociatedwithanincreasedriskofchildhoodonset
type1diabetesmellitus:ametaanalysisofobservationalstudies.Diabetologia2008May51(5):72635.doi:10.1007/s001250080941z.
pmid:18292986
ViewArticle
PubMed/NCBI
GoogleScholar
13. SevelstedA,StokholmJ,BonnelykkeK,BisgaardH.Cesareansectionandchronicimmunedisorders.Pediatrics2015Jan135(1):e92e98.doi:
10.1542/peds.20140596.pmid:25452656
ViewArticle
PubMed/NCBI
GoogleScholar
14. KhashanAS,KennyLC,LundholmC,KearneyPM,GongT,AlmqvistC.Modeofobstetricaldeliveryandtype1diabetes:asiblingdesignstudy.
Pediatrics2014Sep134(3):e806e813.doi:10.1542/peds.20140819.pmid:25092933
ViewArticle
PubMed/NCBI
GoogleScholar
15. SteneLC,MagnusP,LieRT,SovikO,JonerG.Noassociationbetweenpreeclampsiaorcesareansectionandincidenceoftype1diabetesamong
children:alarge,populationbasedcohortstudy.PediatrRes2003Oct54(4):48790.pmid:12815116
ViewArticle
PubMed/NCBI
GoogleScholar
16. KnudsenLB,OlsenJ.TheDanishMedicalBirthRegistry.DanMedBull1998Jun45(3):3203.pmid:9675544
ViewArticle
PubMed/NCBI
GoogleScholar
17. KnudsenLB.TheDanishFertilityDatabase.DanMedBull1998Apr45(2):2215.pmid:9587707
ViewArticle
PubMed/NCBI
GoogleScholar
18. AndersenTF,MadsenM,JorgensenJ,MellemkjoerL,OlsenJH.TheDanishNationalHospitalRegister.Avaluablesourceofdataformodernhealth
sciences.DanMedBull1999Jun46(3):2638.pmid:10421985
ViewArticle
PubMed/NCBI
GoogleScholar
19. KildemoesHW,SorensenHT,HallasJ.TheDanishNationalPrescriptionRegistry.ScandJPublicHealth2011Jul39(7Suppl):3841.doi:
10.1177/1403494810394717.pmid:21775349
ViewArticle
PubMed/NCBI
GoogleScholar
20. PedersenCB,GotzscheH,MollerJO,MortensenPB.TheDanishCivilRegistrationSystem.Acohortofeightmillionpersons.DanMedBull2006
Nov53(4):4419.pmid:17150149
ViewArticle
PubMed/NCBI
GoogleScholar
21. TheDanishIntegratedAntimicrobialResistanceMonitoringandResearchProgramme(DANMAP)2013.www.danmap.org.
22. ToddJA.Etiologyoftype1diabetes.Immunity2010Apr2332(4):45767.doi:10.1016/j.immuni.2010.04.001.pmid:20412756
ViewArticle
PubMed/NCBI
GoogleScholar
23. LaubenderRP,BenderR.Estimatingadjustedriskdifference(RD)andnumberneededtotreat(NNT)measuresintheCoxregressionmodel.StatMed
2010Mar3029(78):8519.doi:10.1002/sim.3793.pmid:20213710
ViewArticle
PubMed/NCBI
GoogleScholar
24. LindM,SvenssonAM,KosiborodM,GudbjornsdottirS,PivodicA,WedelH,etal.Glycemiccontrolandexcessmortalityintype1diabetes.NEnglJ
Med2014Nov20371(21):197282.doi:10.1056/NEJMoa1408214.pmid:25409370
ViewArticle
PubMed/NCBI
GoogleScholar

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161654

8/9

26/12/2016

BroadSpectrumAntibioticTreatmentandSubsequentChildhoodType1Diabetes:ANationwideDanishCohortStudy

25. KronmanMP,ZhouC,MangioneSmithR.Bacterialprevalenceandantimicrobialprescribingtrendsforacuterespiratorytractinfections.Pediatrics2014
Oct134(4):e956e965.doi:10.1542/peds.20140605.pmid:25225144
ViewArticle
PubMed/NCBI
GoogleScholar
26. YeJ,ZhangJ,MikolajczykR,TorloniMR,GulmezogluAM,BetranAP.Associationbetweenratesofcaesareansectionandmaternalandneonatal
mortalityinthe21stcentury:aworldwidepopulationbasedecologicalstudywithlongitudinaldata.BJOG2016Apr123(5):74553.doi:10.1111/1471
0528.13592.Epub2015Aug24.pmid:26331389
ViewArticle
PubMed/NCBI
GoogleScholar
27. SanchezGV,RobertsRM,AlbertAP,JohnsonDD,HicksLA.Effectsofknowledge,attitudes,andpracticesofprimarycareprovidersonantibiotic
selection,UnitedStates.EmergInfectDis2014Dec20(12):20417.doi:10.3201/eid2012.140331.pmid:25418868
ViewArticle
PubMed/NCBI
GoogleScholar
28. WeinsteinL,BrownRB.Colonization,suprainfectionandsuperinfection:majormicrobiologicandclinicalproblems.MtSinaiJMed1977Jan44(1):100
12.pmid:321944
ViewArticle
PubMed/NCBI
GoogleScholar
29. ESACNet.http://ecdceuropaeu/en/activities/surveillance/ESAC_Net2015
30. AcarJ.Broadandnarrowspectrumantibiotics:anunhelpfulcategorization.ClinMicrobiolInfect1997Aug3(4):3956.pmid:11864148
ViewArticle
PubMed/NCBI
GoogleScholar
31. vanSR,FaircloughS,PetrosA.Broadandnarrowspectrumantibiotics:adifferentapproach.ClinMicrobiolInfect1998Jan4(1):567.pmid:11864237
ViewArticle
PubMed/NCBI
GoogleScholar
32. NielsenGL,SorensenHT,PedersenAB,SabroeS.Analysesofdataqualityinregistriesconcerningdiabetesmellitusacomparisonbetweena
populationbasedhospitaldischargeandaninsulinprescriptionregistry.JMedSyst1996Feb20(1):110.pmid:8708487
ViewArticle
PubMed/NCBI
GoogleScholar
33. SvenssonJ,MarinelliK,EisingS.[ComparisonofregistrationofdatafromtheDanishChildhoodDiabetesRegisterandTheNationalDischarge
Register].UgeskrLaeger2007Jan8169(2):1225.pmid:17227658
ViewArticle
PubMed/NCBI
GoogleScholar
34. SalminenS,GibsonGR,McCartneyAL,IsolauriE.Influenceofmodeofdeliveryongutmicrobiotacompositioninsevenyearoldchildren.Gut2004
Sep53(9):13889.
ViewArticle
PubMed/NCBI
GoogleScholar
35. ThysenAH,LarsenJM,RasmussenMA,StokholmJ,BonnelykkeK,BisgaardH,etal.Prelaborcesareansectionbypassesnaturalimmunecell
maturation.JAllergyClinImmunol2015Jun17.
ViewArticle
PubMed/NCBI
GoogleScholar
36. CardwellCR,CarsonDJ,PattersonCC.NoassociationbetweenroutinelyrecordedinfectionsinearlylifeandsubsequentriskofchildhoodonsetType1
diabetes:amatchedcasecontrolstudyusingtheUKGeneralPracticeResearchDatabase.DiabetMed2008Mar25(3):2617.doi:10.1111/j.1464
5491.2007.02351.x.pmid:18201209
ViewArticle
PubMed/NCBI
GoogleScholar
37. SteneLC,RewersM.Immunologyintheclinicreviewseriesfocusontype1diabetesandviruses:theenteroviruslinktotype1diabetes:criticalreview
ofhumanstudies.ClinExpImmunol2012Apr168(1):1223.doi:10.1111/j.13652249.2011.04555.x.pmid:22385232
ViewArticle
PubMed/NCBI
GoogleScholar
38. MullerLM,GorterKJ,HakE,GoudzwaardWL,SchellevisFG,HoepelmanAI,etal.Increasedriskofcommoninfectionsinpatientswithtype1andtype
2diabetesmellitus.ClinInfectDis2005Aug141(3):2818.pmid:16007521
ViewArticle
PubMed/NCBI
GoogleScholar

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0161654

9/9