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First-line antibiotic use varies for pediatric respiratory, ENT infections

SAN FRANCISCO — Research presented at IDWeek highlighted the inappropriate use of antimicrobial agents for pediatric respiratory and ear, nose and throat infections. The researchers said that in many cases, first-line antibiotics for these infections are often overlooked in favor of broad-spectrum agents.

“We found that in our practice network, the most common area of antibiotic overuse was in the choice of the appropriate agent, especially for sinusitis, where overuse of unnecessarily broad-spectrum antibiotics was common,” Adam L. Hersh, MD, PhD, an associate professor of pediatrics in the division of pediatric infectious diseases at the University of Utah, told Infectious Diseases in Children. “This problem was greater in urgent care settings compared with traditional office settings. This mirrors findings from other studies, and these settings are increasingly recognized as an important target for stewardship intervention.”

To support the creation and application of antimicrobial stewardship efforts within a pediatric clinic network, Hersh and colleagues conducted a retrospective cohort study between Jan. 1, 2016, and Dec. 31, 2017. Patients were included if they presented to any of the network’s 31 primary care or six urgent care clinics.

Of the 117,279 visits assessed, the researchers observed that 14% were for diagnoses that did not require antibiotics, such as bronchitis, bronchiolitis and upper respiratory infections. Fewer visits were related to acute otitis media (AOM; 5%), sinusitis (1%) and pharyngitis (4%).

Only a small number of patients with antibiotic-inappropriate diagnoses were given a prescription (3%). However, the use of first-line antibiotics for AOM, sinusitis and pharyngitis varied, with 27% of sinusitis and 91% of pharyngitis cases in urgent care settings receiving appropriate antibiotics.

A separate study presented at the meeting revealed that four in five cases of AOM are prescribed antibiotics, although the AAP recommends a “watchful waiting” approach to most cases of the infection, which was previously found to be appropriate for more than half of pediatric cases. Furthermore, many of the cases received excessively broad or suboptimal antibiotics for treatment.

“I think people are comfortable using some agents that were used in the past that are broader than is necessary and not currently recommended,” Shamim Islam, MD, DTM&H, a clinical assistant professor in the department of pediatrics at the University of Buffalo’s Jacobs School of Medicine and Biomedical Sciences, told Infectious Diseases in Children. “Also, azithromycin is a once-a-day convenient dosing that I think some providers turn to even though it is not one of the recommended agents.”

Islam added that azithromycin may not be as effective against otitis because it does not cover the main pathogen — Streptococcus pneumoniae — as effectively as amoxicillin and amoxicillin/clavulanate potassium, which are the recommended first-line agents.

Islam and colleagues conducted a large community-based sepsis point prevalence study that included all patients who were treated in several health care settings in Buffalo, New York, on Sept. 5, 2016, Dec. 5, 2016, March 6, 2017, and June 5, 2017. All patients were aged between 0 and 18 years.

The researchers identified 2,062 sick visits on the four dates, and 6% of these patients received a diagnosis of AOM. Antibiotics were prescribed for 82% of these cases (91% in the ED, 70% in urgent care, 83% in primary care).

Most of the time, physicians used first-line agents (69%), but in urgent care and primary pediatric offices, third-generation cephalosporins were the most commonly used agents. Azithromycin was the second most commonly used agent, with 20% of all urgent care and 8% of all pediatric primary clinics prescribing the medication. Most prescriptions lasted for at least 7 days (90%). The researchers did not observe differences between outpatient settings regarding prescribing practices.

“A lot of providers may be aware of the available guidelines, but what has been found for other conditions, such as pneumonia, is that direct education or refreshers to front-line providers can be helpful,” Islam said. “Additionally, work looking at upper respiratory infections and pneumonia has shown that regular follow-up and reviewing prescription rates with providers can be helpful in improving adherence to guidelines.” – by Katherine Bortz

References:

Hersh A, et al. Abstract 170. Presented at: IDWeek 2018; Oct. 3-7, 2018; San Francisco.

Islam I, et al. Abstract 282. Presented at: IDWeek 2018; Oct. 3-7, 2018; San Francisco.

Disclosures: Hersh and Islam report no relevant financial disclosures.