60% of children with AOM recovered within 24 h, with or without antibiotics.
Current Problems in Pediatric and Adolescent Health Care
The Burden and Impact of Antibiotic Prescribing in Ambulatory Pediatrics
Introduction
Concern for infection is one of the top three reasons that children and adolescents are seen by a physician in clinic, accounting for 37 million, or about 20%, of all clinic visits.1 Young children have higher rates of antibiotic prescription than any other cohort of the population.2 The discovery of antibiotics was one of the most impactful medical advances for the health of children and dramatically reduced morbidity and mortality due to infectious diseases in the past century. However, rising trends in antibiotic use in both inpatient and outpatient clinical settings coupled with the emergence of antimicrobial resistance threaten the effectiveness of these life-saving drugs. Use of medically important antimicrobials in livestock and veterinary practices has also grown tremendously over the past several decades, adding significantly to the total global antimicrobial burden.3 The purpose of this review is to explore the current patterns of antibiotic use in pediatric ambulatory settings, review the recommended first-line antibiotics for common outpatient pediatric conditions and discuss the individual and societal consequences of increased, and at times inappropriate, antibiotic use.
Section snippets
Antibiotic prescribing patterns in the US pediatric population
About one-quarter of all pediatric ambulatory visits result in an antibiotic prescription; the approximately 70 million antibiotic prescriptions written annually represent one-quarter of all medications dispensed to children.4–6 Fig. 1 illustrates the distribution of ambulatory diagnoses leading to antibiotic prescription in children in 2010-2011, with otitis media, pharyngitis and sinusitis accounting for nearly half of all antibiotic associated diagnoses. In a recent retrospective study by
Geographic and specialty variability
Antibiotic prescribing varies by geographic region and clinician subspecialty. On a global scale, studies of retail pharmaceutical sales data comparing antibiotic prescription rates from different industrialized countries determined that the United States was in the top quartile of prescribing nations, prescribing nearly 25 doses of antibiotics per 1000 inhabitants per day. This is more than double the antibiotic prescribing rate in Germany or The Netherlands, as demonstrated in Fig. 2.8 Within
Appropriateness of antibiotic prescribing
Among the large volume of antibiotics prescribed to children every year, a substantial proportion of these antibiotics are considered inappropriate. Many childhood infections can be attributed to viruses, including bronchiolitis, bronchitis, upper respiratory infections (URIs) and many cases of pharyngitis and non-suppurative otitis media. In a 2014 meta-analysis, acute respiratory tract infections, which included otitis media, sinusitis, bronchitis, URIs and pharyngitis, were estimated to
Common acute ambulatory pediatric conditions and antibiotic use
Acute otitis media: Recently updated AAP guidelines address when antibiotics should be prescribed for AOM and which antibiotics should be used.13 Nevertheless, prescribing practices vary by geographic region and from physician to physician. Not all children with AOM require antibiotic treatment. A 2015 Cochrane review found that
Treatment of patients with penicillin allergy
Penicillin allergy is reported in 5–10% of children; however it is estimated that less than one percent of the population has a true IgE-mediated allergy, such as urticaria, angioedema or anaphylaxis.48, 49 This difference in reported penicillin allergy and true penicillin allergy is important because patients with reported penicillin allergy have worse clinical outcomes and increased health care costs compared to patients without reported penicillin allergy. A penicillin or
Adverse effects of antibiotic use
The consequences of inappropriate antibiotic use extend from direct and immediate effects on the individual using these medications to treat a current infection, to potential for developing chronic illness, to worldwide spread of multi-drug resistant bacteria.
Individual effects
All medications, even the most benign, have consequences. Adverse drug reactions include immediate (IgE mediated) allergic reaction, delayed (non-IgE mediated) reactions, drug toxicity, intolerance and idiosyncratic reactions.58 The most common manifestations of adverse drugs reactions observed in children are gastrointestinal or dermatologic in nature.59 Antibiotic-associated diarrhea occurs in up to 25% of patients exposed to antibiotics, depending on the antibiotic.60 Diarrhea occurs in 25%
Societal effects of antibiotic overuse
Beyond the significant individual consequences of antibiotic overuse, there are mounting negative consequences to society, primarily in the form of antimicrobial resistance (AMR). Mechanisms of resistance to antimicrobial agents have been known since the discovery of the first antibiotic. The first clinically effective antibiotics, the sulfonamides, were introduced in 1937 and within a few years, sulfonamide resistant bacterial strains were discovered. Penicillinase producing bacteria were
Current trends in antimicrobial resistance
Recent estimates of the burden of antimicrobial resistance suggest that there are approximately 700,000 deaths worldwide every year due to infection with antimicrobial resistant bacteria, with nearly 50,000 of these deaths occurring in the United States and Europe.86 A report led by economist Jim O'Neil on antimicrobial resistance commissioned by the British government in 2014 projected that the number of annual deaths attributable to antimicrobial resistance would surpass 10 million by the
Antimicrobial resistance threats in the pediatric ambulatory setting
The most critical antimicrobial resistance threats worldwide according the World Health Organization are drug resistant malaria, multidrug resistant (MDR) and extensively drug resistant (XDR) tuberculosis and resistant HIV. These conditions, while increasing in prevalence and threatening significant morbidity and mortality in developing countries, are not commonly encountered in the United States in pediatric ambulatory primary care settings. The section below outlines the epidemiology and
Resistant Streptococcus pneumoniae and respiratory infections
Streptococcus pneumoniae, or pneumococcus, commonly colonizes the nasopharynx in children and is a frequent cause of infections such as acute otitis media, sinusitis, community-acquired pneumonia and meningitis. S. pneumoniae has traditionally been considered highly susceptible to penicillin, however over the past several decades resistance to one or several antibiotic classes has steadily been rising. Drug resistant Streptococcus pneumoniae is considered a serious threat, with an estimated
MRSA and skin and soft tissue infections
The CDC estimates that one in three people have nasal colonization with Staphylococcus aureus and that two out of every one hundred people carry MRSA.96 While initially considered a hospital acquired pathogen, community acquisition of MRSA now accounts for the majority of all invasive MRSA infections in children.96 In the ambulatory setting, community acquired MRSA commonly causes purulent skin and soft tissue infections (SSTIs). MRSA SSTIs are associated with higher rates of mortality, longer
Extended-spectrum beta-lactamase producing Enterobacteriaceae and UTIs
Many bacteria have the ability to produce beta-lactamase enzymes, which counteract beta-lactam antibiotics such as penicillin or cephalosporins. Some bacteria are inherently able to produce beta-lactamases but others gain the ability to produce these enzymes by plasmids transferred from bacteria to bacteria. There are several different types of beta lactamase enzymes, including some with a broad range of affected targets. Bacteria possessing these broad-range enzymes are known as
Multi drug-resistant gonorrhea
Multi-drug resistant Neisseria gonorrhoeae, the bacteria that causes the sexually transmitted infection gonorrhea, is considered one of the three “urgent threats” in antimicrobial resistance by the CDC.92 The WHO estimates that 78 million people are infected with gonorrhea worldwide every year with almost 500,000 cases reported in the United States annually. The rates of gonorrhea are rising fastest in the adolescent and young adult population.104, 105 One quarter of these new cases are
Conclusion
Antibiotic use in children has doubled over the past several decades and approximately one quarter of these antibiotics are unnecessary. Unintended consequences of antibiotic use include short term and long term effects on individual patients, as well as harmful societal effects by selecting for antibiotic-resistant bacterial strains. Antimicrobial resistance continues to rise, threatening the effectiveness of available antibiotics. While the projected global impact on morbidity, mortality, and
References (108)
- et al.
Outpatient antibiotic prescribing in the United States: 2000 to 2010
BMC Med.
(2014) - et al.
Adolescent sexuality
Pediatr Clin N Am
(2017) - et al.
Health care use and serious infection prevalence associated with penicillin ‘allergy’ in hospitalized patients: a cohort study
J Allergy Clin Immunol
(2014) - et al.
Patient-reported penicillin allergy symptoms in the pediatric emergency department
Acad Pediatr
(2017) - et al.
Increased risk of childhood asthma from antibiotic use in early life
Chest
(2007) Increasing incidence of penicillin and cefotaxime resistant streptococcus pneumoniae causing meningitis in India: time for revision of treatment guidelines?
Indian J Med Microbiol
(2017)- Combined NAMCS/NHAMCS Data.Table 2: Top 5 diagnoses at visits to office-based physicians and hospital outpatient...
- et al.
US outpatient antibiotic prescribing variation according to geography, patient population and provider specialty in 2011
Clin Infect Dis
(2015) - et al.
Global trends in antimicrobial use in food animals
Proc Natl Acad Sci USA
(2015) - et al.
Antibiotic prescribing in ambulatory pediatrics in the United States
Pediatrics
(2011)
Variations in antibiotic and azithromycin prescribing for children by geography and specialty – United States, 2013
Pediatr Infect Dis J
Trends of outpatient prescription drug utilization in US children, 2002–2010
Pediatrics
Comparison of outpatient systemic antibacterial use in 2004 in the United States and 27 European Countries
Clin Infect Dis
Variation in antibiotic prescribing across a pediatric primary care network
J Pediatr Infect Dis Soc
Bacterial prevalence and antimicrobial prescribing trends for acute respiratory tract infections
Pediatrics
Clincal practice guideline for the diagnosis and management of group a streptococcal pharyngitis: 2012 update by the Infectious Disease Society of America
Clin Infect Dis
IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults
Clin Infect Dis
The diagnosis and management of acute otitis media
Pediatrics
Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years
Pediatrics
Committee on infectious diseases. principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics
Pediatrics
Pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Disease Society and the Infectious Diseases Society of America
Clin Infect Dis
Antibiotics for acute otitis media in children
Cochrane Database Syst Rev
Prevalence of fusobacterium necrophorum in children presenting with pharyngitis
J Clin Microbiol
Group A streptococcal pharyngitis and pharyngeal carriage: a meta-analysis
PLoS Negl Trop Dis
Healthcare claims data: an underutilized tool for pediatric antimicrobial stewardship
Clin Infect Dis
Viral features and testing for streptococcal pharyngitis
Pediatrics
Improving guideline-based streptococcal pharyngitis testing: a quality improvement initiative
Pediatrics
Recent patterns in antibiotic use for children with group a streptococal infections in Japan
J Glob Antimicrob Resist
Age specific prescribing and adherence to guidelines in pediatric patients in primary care
Pediatr Infect Dis J
Guideline concordant antibiotic prescribing for pediatric outpatients with otitis media, community acquired pneumonia and skin and soft tissue infections in a large multispecialty healthcare system
Clin Res Infect Dis
Variability in antibiotic prescribing for community-acquired pneumonia
Pediatrics
Identifying targets for antimicrobial stewardship in children's hospitals
Infect Control Hosp Epidemiol
Outpatient antimicrobial stewardship targets for treatment of skin and soft-tissue infections
Infect Control Hosp Epidemiol
Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Disease Society of America
Clin Infect Dis
A placebo-controlled trial of antibiotics for smaller skin abscesses
N Engl J Med
Decreasing duration of antibiotic prescribing of uncomplicated skin and soft tissue infections
Pediatrics
Status report from the scientific panel on antibiotic use in dermatology of the American Acne and Rosacea Society: part 1
J Clin Aesthetic Dermatol
Trends in prescribing behavior of systemic agents used in treatment of acne among dermatologists and non-dermatologists: a retrospective analysis, 2004–2013
J Am Acad Dermatol
Guidelines of care for management of acne vulgaris
J Am Acad Dermatol
Prevalence of urinary tract infection in childhood: a meta-analysis
Pediatr Infect Dis J
Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months
Pediatrics
Antibiotic prescription practice for pediatric urinary tract infection in a tertiary center
Open Forum Infect Dis
Acute health care utilization and outcomes for outpatient-treated urinary tract infections in children
J Pediatr Urol
The growing epidemic of sexually transmitted infections in adolescents: a neglected population
Curr Opin Pediatr
Screening for nonviral sexually transmitted infections in adolescents and young adults
Pediatrics
Azithromycin versus doxycycline for the treatment of genital chlamydia infection: a meta-analysis of randomized controlled trials
Clin Infect Dis
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Foreword: Outpatient antimicrobial stewardship
2018, Current Problems in Pediatric and Adolescent Health CareRational use of antimicrobials in the treatment of upper airway infections
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2023, Anti-Infective Agents
The authors have no financial disclosures.