Q&A: ‘Shorter is better’ message slow to reach pediatrics
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Key takeaways:
- Studies have shown that shorter antibiotic courses are just as effective as longer ones for some infections.
- In pediatrics, strep pharyngitis, sinusitis and ear infections are targets for improvement.
Many studies have shown that shorter courses of antibiotic therapy are just as effective as longer ones for certain infections, including those that impact children. The idea is commonly referred to using the mantra “shorter is better.”
In an article published in the Journal of the Pediatric Infectious Diseases Society, physicians outlined the evidence supporting shorter antibiotic courses for three common pediatric upper respiratory tract infections and discussed the impact that academic imprinting has on prescribing practices in pediatrics.
We spoke with two of the authors — Rana E. El Feghaly, MD, MSCI, director of the outpatient antibiotic stewardship program at Children’s Mercy Kansas City, and Nicole M. Poole MD, MPH, associate medical director of the antimicrobial stewardship program at Children’s Hospital Colorado — to learn more.
Healio: Do you think the message that long antibiotic courses may not be necessary for many common illnesses has been received by most pediatricians?
Poole: The short answer is no, because antibiotics continue to be prescribed for long durations for many common illnesses. A challenge is that guidelines come out infrequently and new, more current research is available that is sometimes difficult for clinicians in a busy practice to keep up with. Overall, clinicians are open to prescribing shorter durations, which is why we thought it was so important to review the data in one article and be able to discuss how we can recalibrate what we consider default durations for these very common illnesses.
El Feghaly: I am not sure the message has been shared with most pediatricians yet! Studies have shown that prescribers and parents do not have reservations about shorter courses of antibiotics if they know they would be as effective as longer courses. This is where antimicrobial stewards can focus their efforts because it seems to me to be a low-hanging fruit for quality improvement efforts. In fact, investigators in Chicago found that merely changing the medical record’s preset durations allowed for substantial improvement in antibiotic duration use.
Healio: In the paper, you specifically mention group A strep pharyngitis, acute otitis media and acute bacterial rhinosinusitis. There are other illnesses — like community-acquired pneumonia (CAP) and UTI — that also may be treated with shorter than recommended courses. Why did you focus on those three?
El Feghaly: You are correct: The list we included is not exhaustive, and studies suggest that 5-day courses for UTI and CAP would be absolutely safe in children, but focusing on the three most common upper respiratory infections that result in antibiotic prescriptions made good sense as an initial effort.
Poole: Strep pharyngitis, sinusitis and ear infections are high-impact targets for improvement to decrease unnecessary antibiotic exposure in millions of children nationwide.
El Feghaly: Maybe we should be writing a “Give me 5” 2.0 article to address UTI and CAP! [Editor’s note: The title of the paper is, "‘Give Me Five’: The Case for 5 Days of Antibiotics as the Default Duration for Acute Respiratory Tract Infections.”]
Healio: Can you explain academic imprinting and the effect it has on prescribing?
Poole: Academic imprinting is a strong adherence to — and a bit of fear about straying away from — what’s already established in medical practice, often based on early studies. For antibiotic prescribing, the focus wasn't initially on how long you should take them or the risks of antibiotic overuse, and long durations were chosen. But since those studies, we have seen many changes in common infections — such as shifts in disease epidemiology after effective vaccine campaigns and understanding the many harms of antibiotic overuse.
We have also identified opportunities to increase the quality and safety of our clinical practices through large observational and smaller prospective studies. But because of academic imprinting, we often stick to outdated approaches because of our high academic standards. The burden of proof to change practice typically rests on rigorous multicentered prospective randomized studies that would require large and often unattainable participant numbers to statistically measure rare outcomes.
The thing is, these foundational studies that set the standard often had less rigorous methods than we tend to accept now, yet they still dictate practice because it is how we’ve always done it. To move medicine forward, we must challenge these ingrained practices.
Healio: What are some other reasons that guidelines haven’t necessarily changed for some of these conditions, or that prescribers may still opt for longer durations of antibiotics despite evidence showing that shorter courses work?
El Feghaly: The process of updating national guidelines is a collaborative effort that requires extensive review of the literature that can be undertaken only every few years, whereas new investigations continue to be published at a relatively fast pace. The guidelines we mention in our article are all over 10 years old. We have no doubt that when the new guidelines come out for these three diagnoses, they will include newer data, and we hope they will recommend shorter durations.
Poole: As for prescribers, I think they do often rely on national guidelines, and there can be a hesitation to prescribing differently, even with the understanding that guidelines might be archived or outdated. Going back to academic imprinting, there are also beliefs that have been long held but not completely accurate, such as the historical belief that there is a serious need to finish all your antibiotics — which was often 10 to 14 days — to prevent antibiotic resistance.
Prescribing short durations of antibiotics is a culture shift in our field in many ways, and I am grateful that many investigators have been studying how to push pediatrics forward for the benefit of our patients. We need to get the word out widely about current evidence so that prescribers feel empowered to provide the highest quality of care to their patient.
As mentioned in the article, parents are very open to shorter durations of therapy and trust clinician recommendations. When parents understand that fewer days of antibiotic are effective and safer, this could also help propel the “shorter is better” practice of antibiotic prescribing. We shouldn’t overlook the significance for parents of reducing the task of giving medication to a 2-year-old by 5 days.
El Feghaly: Although outpatient antimicrobial stewardship is getting a little more attention recently, it is still not where it needs to be in terms of resource allocation and support. Knowing that most antibiotics are prescribed in ambulatory settings, we need to do better! But if you are an antibiotic steward with no significant time or staff support for outpatient efforts, know that focusing those limited resources to duration may take you a long way! Also, resources other than guidelines are available on multiple platforms, such as clinical pathways from large institutions. Prescribers can use these resources to help them use the most updated evidence-based information.
References:
El Feghaly RE, et al. J Pediatric Infect Dis Soc. 2024;doi:10.1093/jpids/piae034.
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