REDUCED ANTIBIOTIC USE IN A PAEDIATRIC PRACTICE: PRACTICAL OFFICE STRATEGIES BASED ON CURRENT EVIDENCE

Dr. M. Ipp June 2000

The rising incidence of bacterial resistance to common antibiotics, particularly, multi-drug resistant pneumococci, has prompted the need to use antibiotics judiciously in pediatric practice. Antibiotics are the second leading class of drugs prescribed, according to the National Ambulatory Medical Care Surveys, with the majority of such prescriptions being for respiratory infections. Children are the principal recipients of a disproportionate number of these prescriptions. Many of these antibiotics are unnecessarily prescribed for viral infections such as the common cold. In a pediatric practice in Memphis, Tennessee, 43% of children with uncomplicated upper respiratory tract infections or asthma were prescribed antibiotics. In a Kentucky study, 60% of patients were prescribed antibiotics for the common cold. In a Canadian study from Saskatchewan, 85% of antibiotics prescribed for respiratory tract infections in children less than 5 years of age were considered inappropriate.

Reducing antibiotic prescribing has been advocated as one way to protect patients against resistant infections. A national North American campaign has been developed to assist both the general public and prescribing physicians in understanding antibiotic resistance an in identifying specific situations in which unnecessary antibiotic use could be curtailed without compromising patient care.

ORIGINS AND COMMON JUSTIFICATIONS FOR PRESCRIBING ANTIBIOTICS IN CHILDREN WITH UPPER RESPIRATORY TRACT INFECTIONS

In order to improve antibiotic prescribing by physicians, a thorough review of current physician prescribing patterns must be understood (Table 1). Physicians surveyed on the misuse of antibiotics for the treatment of upper respiratory tract infections in children provide a number of reasons for their pattern of prescribing antibiotics. Their diagnostic uncertainty in differentiating bacterial from viral infections plays a major role - preferring to overtreat a viral infection than miss treating a bacterial one. They believe that antibiotics are safe, may be effective for viral infections, lessen the severity of viral illnesses, shorten the duration of viral illnesses and prevent secondary bacterial infection. Other physicians report a reluctance to reduce inappropriate prescribing because of the concern that patients will simply obtain antibiotics from colleagues whose routine practice may differ substantially from their own.

For some physicians, the constraints of daily practice make it easier to prescribe antibiotics rather than to take the time to discuss with the patient or parent the implications of antibiotic avoidance and symptom management. Many doctors maintain that parents continue to expect that an antibiotic will be prescribed where a pattern has been established over several years. "Friday medicine" is unique. Many physicians practice differently on Fridays than on any other day of the week because of their reduced coverage on weekends and because they may want to protect and prevent their patients from using other doctors or walk-in clinics. Antibiotics are often prescribed on Fridays "in case" it is needed in the event that the child's symptoms get worse over the weekend.

Socio-economic pressures also play a role in antibiotic overprescriptions with concern about lost income from work missed while attending to a sick child at home. Antibiotics will often be prescribed in the hope that they will be rapidly effective and allow children to return to daycare or school, thereby allowing their parents to get back to work sooner. Many parents and physicians believe that an antibiotic may prevent the need and cost for a return doctor's visit, including further time lost from work, if the child does not get better.

It is important to recognize that doctors who overprescribe antibiotics are not necessarily "bad doctors". They believe they are doing their best, consistent with their view of what is appropriate care for their patients. Re-education, using evidence to support the appropriate use of antibiotics, is necessary in order to effect a change in physician behavior and their antibiotic prescribing patterns.

DO ANTIBIOTICS SIGNIFICANTLY BENEFIT PATIENTS WITH URI?

Most upper respiratory tract infections are viral in origin and the use of antibiotics will NOT significantly benefit the patient. Based on studies dating back to the 1940ís, the potential efficacy of antibiotic therapy in the treatment of presumed respiratory viral infections has not been substantiated. A review on the question whether prevention of bacterial complications could be achieved with prophylactic antibiotics, concluded the following:

"The extensive use of antibiotics for prophylaxis is frequently not justified and is based more on wishful thinking than on factual information."

Antibiotics administered prophylactically in a double-blind study in a private pediatric practice involving 781 children with assumed viral URI, did not reduce the incidence of bacterial complications. In another study of children with upper respiratory tract infections where bacterial and viral pathogens were cultured by nasopharyngeal swabs, there was no difference in the response of children who were treated with antibiotics compared to those who were not. In both groups, there was no difference in the mean duration of fever, the failure to improve the development of complications or the persistence of bacterial pathogens in the nasopharynx.

MANAGING CHILDREN WITH UPPER RESPIRATORY TRACT INFECTIONS

In the first instance, parents need to be educated using a handout like the one provided (see Parent Hand out). This brief and succinct outline will provide a basis for further discussion with the physician regarding the appropriate use of antibiotics. Many parents are already aware of the fact that antibiotics have been overprescribed by physicians and are very accepting of the new strategy that physicians are using.

There are four major indications for the use of antibiotics in children with upper respiratory tract infections. The following specific recommendations can be made:

  1. Otitis media. Acute otitis media (ear pain) associated with fluid (pus in the middle ear) must be distinguished from otitis media with effusion (middle ear fluid without symptoms). Middle ear effusion does not require antibiotics. Acute otitis media should be treated with antibiotics in all children under two years of age. In selected children over 2 years of age, who are at low risk for serious sequelae (Table 2), treatment with analgesia and observation for 24 to 48 hours may be sufficient and antibiotics need only be prescribed if symptoms persist or get worse. There is good evidence that 80% of ear infections will resolve spontaneously and only approximately 20% of children with continued pain will ultimately require antibiotic treatment.
  2. Sore throats. The majority of sore throats are caused by viruses and do not require antibiotics. Generally, antibiotic treatment should not be prescribed without laboratory confirmation on a Group A streptococcus infection. A positive rapid streptococcus antibody test done in the office is highly specific and may be used as confirmation of the streptococcus infection for which antibiotics should be prescribed. In the absence of a rapid strep test or a negative strep test, a throat culture should be used. Not all children require throat swabs, in particular, those children with a viral-like illness, who have a sore throat accompanied by a cough, cold, runny nose or congestion, do not require a throat swab.
  3. Sinus infections. Parents need to know that sinusitis is rare in childhood and that the presence of a green-yellow nasal discharge does not necessary imply secondary bacterial infection. The natural course for an upper respiratory tract infection with rhinitis is that a clear running nose will become yellow-green for a few days during the middle of a cold then revert back to a clear runny nose as the cold subsides. Generally, waiting seven to ten days of a persistent purulent rhinitis or productive cough without improvement is recommended before treating children for sinusitis with antibiotics. Treatment should be initiated sooner if the child has a high fever, looks unwell, has facial pain or severe headache.
  4. Coughs and Colds. These are caused by viruses and last for up to two weeks. They do not require antibiotics. With the development of pneumonia, there is often fever that develops late in the illness. The children often become irritable and cranky or lethargic and sleepy, may refuse to eat or drink and on examination, may have features suggestive of pneumonia but may just have tachypnoea and even grunting in the younger child. These children should obviously be treated with antibiotics.

SELECTED READING

1. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz B. Otitis media- principles of judicious use of antimicrobial agents. Pediatrics 1998; 101:165-171

2. Ipp M. Otitis Media in Evidence-Based Pediatrics, Feldman W., Editor, B.C.Decker Inc., Publisher, Hamilton, 2000.

3. Schwartz B, Marcy SM, Phillips WR, Gerber MA, Dowell SF. Pharyngitis - Principles of judicious use of antimicrobial agents. Pediatrics 1998; 101:171-174

4. O'Brien KL, Dowell SF, Marcy SM, Schwartz B Phillips WR, Gerber MA,. Sinusitis- principles of judicious use of antimicrobial agents. Pediatrics 1998; 101:174-177.

 

 

Table 1. REASONS PHYSICIANS USE TO JUSTIFY ANTIBIOTIC PRESCRIBING IN CHILDREN WITH UPPER RESPIRATORY TRACT INFECTIONS

Impractical to differentiate viral from bacterial infections

Prefer to overtreat viral infection than miss a bacterial infection

Antibiotics prevent secondary bacterial infection

Antibiotics lessen the severity of viral illnesses and are safe

Antibiotics are effective for viral infection and speed the recovery phase

Concern that patients will obtain antibiotics from a colleague

Constraints of daily practice make discussion (vs prescription) time consuming

Patient expectation that an antibiotic will be prescribed

"Friday medicine" - prescribing antibiotics "in case".

Socio-economic factors - getting parents back to work sooner

Prescribing antibiotics may prevent the need and cost of a return visit

 

Table 2. Children with Acute Otitis Media considered at low risk for serious sequelae and who may be initially treated with observation and analgesia

Older than 2 years of age

Mild and/or unilateral AOM

No toxicity or severe pain

Normal host (no chronic disease etc.)

No otorrhea

No history of chronic or recurrent AOM

Availability of good follow up

 

PARENT HANDOUT

APPROACH TO THE APPROPRIATE USE OF ANTIBIOTICS IN CHILDREN

The significant worldwide increase in antibiotic resistant bacteria has made it imperative that we only use antibiotics when properly indicated. Antibiotics are among the most important drugs available in our society. We as physicians together with you as parents must become more responsible in using antibiotics wisely.

HOW DO BACTERIA BECOME RESISTANT TO ANTIBIOTICS?

Each time a child takes an antibiotic, sensitive bacteria are killed, and resistant ones are left behind to grow and multiply. Repeated use of antibiotics is one of the main causes for the increase in resistant bacteria. These resistant bacteria can be spread to others in the family and the community.

FACTS YOU SHOULD BE AWARE OF

HOW DOES ONE DETERMINE WHEN TO USE ANTIBIOTICS OR NOT?

EAR INFECTIONS

There are a number of different types of ear infections, some of which need treatment and some which do not. The age of the child and other factors may be important in deciding whether to use antibiotics or not and for how long. "Fluid" in the middle ear (without pain) does not require antibiotic treatment whereas "pus" (with pain) generally does. Children who have significant symptoms, such as ear pain, fever and irritability and are under two years of age should be treated with antibiotics. Older children (over 2 years of age) with mild pain, who do not have a history of recurrent ear infections or tubes or a runny ear, may be closely watched for 24-48 hours using pain relief only. Antibiotics should be administered if there is severe pain or failure to respond to pain relief alone. The strategy of observation without antibiotics for older children should only be used provided good physician follow up is available.

SORE THROATS

The majority of sore throats are caused by viruses and do not require antibiotics. The main bacterial cause of a sore throat is "strep" (streptococcal tonsillitis) which is usually not accompanied by a cough, cold, or congestion. The diagnosis of strep should be confirmed by a laboratory test (throat swab) and treated with an antibiotic for a full 10 days.

SINUS INFECTIONS

Sinusitis is rare in childhood. It is not uncommon for a clear runny nose to become yellow or green for a few days during a regular cold. Snotty, green or yellow runny noses need only be treated with antibiotics if associated with a sick child who has a high fever and productive daytime cough, or if accompanied by facial pain or severe headache or if it has persisted for more than 7-10 days.

COUGHS AND COLDS

These are caused by viruses and may last for up to 2 weeks. They do not require antibiotics. Virus infections may rarely become secondarily infected with bacteria. When this happens the child will often become irritable and cranky, or lethargic and sleepy, develop a fever, and refuse to eat or drink. An antibiotic may be efficacious in these situations