|
High rates of antibiotic use by young children have contributed to the rise in antibiotic-resistant infections, according to Jonathan Finkelstein, MD, MPH, of Children’s Department of Medicine. Here, he discusses how pediatricians can eliminate nonessential prescriptions.
 |
|
By the early 1990s, antibiotic use by children had risen to levels that were extremely high. At its peak, young children were taking, on average, up to three antibiotics per year in some locales. Since the mid-1990s, we’ve seen a 25 to 40 percent drop in antibiotic use, likely because of state and national campaigns promoting judicious antibiotic prescribing, and pediatricians’ attention to the problem of antibiotic overuse. It’s one of the most dramatic changes in pediatric practice we’ve seen in the last couple of decades. The question we need to continue to ask is, Are we prescribing at the right rate now—one that balances clinical benefits with side effects for individual children and population-level effects on resistance?
Although otitis media still accounts for the greatest fraction of prescribing in young children, its diagnosis and accompanying antibiotic prescribing have dropped considerably. Although introduction of new vaccines (such as PCV7) may have had some impact, changes in clinical practice are likely much more important. Twenty years ago, a somewhat pink eardrum was often diagnosed as otitis media. Now, pediatricians are using a higher threshold, which is a bulging tympanic membrane or other clear signs of acute infection, before prescribing an antibiotic.
That’s consistent with the 2004 American Academy of Pediatrics’ guidelines, which also endorsed “watchful waiting”—an approach whereby mild infections can be observed for 48 to 72 hours in selected cases to see if the symptoms resolve without antibiotic treatment. Beyond ear infections, there’s been important progress in both the practice of physicians and the views of patients about antibiotic use for the common cold and other illnesses that are likely to be viral.
Antibiotic resistance is a moving target. The introduction of pneumococcal conjugate vaccine has caused rapid shifts in the population of this organism. Strains covered by the vaccine have been essentially eradicated from nasopharyngeal carriage in the community, but others have taken their place. While strains with high levels of penicillin resistance have become less common, there remains substantial penicillin non-susceptibility in the community. We still need to be careful about the frequency and spectrum of antibiotics used for initial treatment of common infections. The preferred first-line antibiotic for ear infections is still Amoxicillin, after all of these years. Of course, the emergence of methicillin-resistant staph aureus (MRSA) in the community reminds us that the next resistant pathogen may be right around the corner.
It’s challenging because most common infections don’t have associated objective laboratory tests to confirm a diagnosis. We still see prescribing for what physicians diagnose as bronchitis, which is essentially cough illness without signs of pneumonia. Most experts don’t believe that those represent bacterial infections, so decreasing antibiotic prescribing for bronchitis remains important.
Strep throat is the one infection for which we should be able to wipe out virtually all over-prescribing. I’d consider all prescriptions written for a sore throat without a documented positive rapid strep test or culture for group A streptococcal infection inappropriate. The National Committee on Quality Assurance has introduced a quality measure tracking how many prescriptions are given without testing.
One is parental pressure. But there has been a range of studies describing disconnections between what physicians think parents expect and what they actually desire. Physicians also cite the time it takes to explain to parents why an antibiotic isn’t needed, but studies have found it’s actually much shorter than doctors assume. As pediatricians, we have new groups of first-time parents every few years, and once we’ve trained parents to only expect antibiotics in appropriate situations, we can quickly wipe out most inappropriate demand within our practices.
We tested a three-year intervention in 16 Massachusetts communities promoting judicious antibiotic use. We encouraged physicians to have a short conversation about antibiotics with parents at the 6-month well-child visit. They gave them a handout and explained that their child would be given an antibiotic every time it was deemed helpful, but would not use them without clear indications. It was also useful to educate office staff so they wouldn’t set up inappropriate expectations when interacting with patients and families.
Of course, parents should give children antipyretics like Tylenol or ibuprofen for fever, encourage fluids and offer reassurance. For ear infections in particular, pain control is important, whether a child is taking antibiotics or not.
|
