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Developing antibiotic stewardship programs in pediatrics
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Infectious Diseases in Children asked Ingrid Camelo, MD, pediatric infectious disease fellow, division of pediatrics infectious diseases at Boston Medical Center, Leslie Grammatico-Guillon, MD, PhD, guest researcher, pediatric infectious diseases, Boston University, and Vishakha Sabharwal, MD, assistant professor of pediatrics and attending physician, pediatrics infectious disease, Boston University School of Medicine, to discuss whether physicians should have to justify their use of antibiotics. Would this be an effective strategy to reduce unnecessary prescribing if included in electronic medical records, and is the potential frustration with the process worth the effort to curb antimicrobial resistance?
Each year in the United States, at least 2 million people become infected with antibiotic-resistant bacteria and 23,000 people die as a direct result of these infections, according to the CDC. Antibiotics are among the most commonly prescribed drugs, and it was estimated that by 2013, about 10 million antibiotic prescriptions were flooding the homes of American children. However, up to 50% of all the antibiotics prescribed were not needed or optimally effective as prescribed. There is no doubt that overprescribing and misprescribing are contributing to the growing challenges posed by antibiotic-resistant bacteria.
Even though the amount of prescriptions in the pediatric outpatient setting has been declining, children still have the highest level of antibiotic exposure, according to multiple published studies. Many pediatricians report the need to prescribe antibiotics under parental pressure and concerns about the inability to truly differentiate bacterial from viral infections. Pediatric antibiotic prescribing during ambulatory visits still accounts for more than 20% of the visits, according to Hersh and colleagues in a 2011 study in Pediatrics. As evidence of the impact of antimicrobial stewardship on antimicrobial resistance are trending, all efforts must be made to develop multidisciplinary pediatric antibiotic stewardship programs (ASPs).
ASPs in pediatrics have been on the rise since the 2007 IDSA guidelines came out but have been slow to catch up and harder to implement by institutions, according to research published in Hospital Control & Hospital Epidemiology. Interventions to reduce injudicious antibiotic use include formal ASPs (ID and pharmacy team for screening, audit/feedback to physicians) and certain nonstewardship actions (such as clinical practice guidelines for antibiotic prescribing or standardized antibiotic protocols for outpatient use and educational strategies for the practitioners). Both of these strategies have shown success.
Regarding acute respiratory tract infections (ARTIs), stewardship programs worldwide have shown a decline in antibiotic consumption and improvement in adherence to guidelines by physicians taking care of children with ARTIs. One such program that included clinician education along with audit and feedback involving 25 pediatric primary care practices in the U.S. demonstrated improved adherence to prescribing guidelines for common bacterial ARTIs but did not affect antibiotic prescribing for viral infections, Gerber and colleagues reported in JAMA. Despite several challenges faced by pediatric practitioners with respect to knowledge and approach to antimicrobial prescribing, the adherence to these ASPs is often over 80% to 90%. Thus, interventions must take into account the difficulties and preferences of the physicians to enhance the impact of ASPs. The physicians’ perception of direct patient harm impacts the antibiotic decision-making process, which has implications for antibiotic stewardship. Evaluation of both the types and distribution of ASP recommendations provides essential feedback to better understand the stewardship programs and allows adherence of the physicians involved.
Hence, supporting the clinical teams, screening and reporting the prescriptions with audit and feedback using electronic medical record can lead to judicious antibiotic use and thus lead to improved adherence and acceptance of these guidelines by the physicians.
- References:
- Anderson H, et al. J. Paediatr Child Health. 2017;doi:wiley.com/10.1111/jpc.13616.
- https://www.cdc.gov/drugresistance/index.html
- Fishman N. Infect Control Hosp Epidemiol. 2012;doi:10.1086/6665010.
- Gerber JS, et al. JAMA. 2013;doi:10.1001/jama.2013.6287.
- Goldman JL, et al. Infect Control Hosp Epidemiol. 2015;doi:10.1017/ice.2015.45..
- Green SK, et al. Pediatrics. 2012;doi: 10.1542/peds.2011-3137.
- Hersh AL, et al. Pediatrics. 2011;doi:10.1542/peds.2011-1337.
- Hersh AL, et al. J Pediatric Infect Dis Soc. 2015;doi:10.1093/jpids/piu044.
- Saha D, et al. Pediatrics. 2017;doi:10.1542/peds.2016-2103.
Disclosures: The authors report no relevant financial disclosures.