How the Times Have Changed: Antibiotic Use In Children
This Editorial is a personal reflection on an article from the Consultant archives.
Carlos A. Arango, MD
University of Florida, Jacksonville, Florida
Jennifer Andrews, MD
University of Florida, Jacksonville, Florida
Arango CA, Andrews J. How the times have changed: antibiotic use in children [published online September 13, 2018]. Infectious Diseases Consultant.
Hammond K. When to use antibiotics for respiratory infections in children. 1961; 1:36-38. https://www.consultant360.com/exclusive/infectious-diseases/pediatrics/when-use-antibiotics-respiratory-infections-children.
In 1961, Dr Keith Hammond wrote an article1 regarding when to use antibiotics for respiratory infections in children. His takeaways are as insightful today as they were 5 decades ago:
- Viral infections do not respond to antibiotics.
- Most respiratory infections are actually viral, not bacterial.
- Antibiotics are not recommended as a prophylactic measure for respiratory infections.
- Few bacteria can cause clinically recognized conditions in the body.
- Identify an organism, obtain sensitivities, and treat as indicated.
Dr Hammond’s “5 helpful points” serves as a framework for all practicing clinicians, but especially for pediatricians. The points allow us how to start the conversation with parents/guardians who want an antibiotic for their child when it is not warranted.
If we are able to share these 5 simple but true points with the parents/guardians of our patients, they may realize that prescribing an antibiotic for a respiratory infection is often unnecessary. In addition, we must explain to them that prescribing antibiotics unnecessarily can cause antibiotic resistance, which can cause their child undue harm in the long term.
The first clinical case of penicillin-resistant Streptococcus pneumoniae (PRSP) was reported in Boston, Massachusetts, in 1965.2 Initially that case report was thought to be an isolated issue. Then new reports surfaced in Australia in 1967, as well as in South Africa in 1977. Moreover, in the 20 years since, PRSP has increased more than 10% in certain areas of the United States and globally.2 In the 1990s, antimicrobial resistance to penicillin and macrolides spread in the United States up to 45% in some areas.3 Fortunately, between 2000 and 2004, the population of multi-resistant organism stabilized to around 30%.3
Erythromycin-resistant strains are predictably resistant to clarithromycin, azithromycin, and roxithromycin, and are usually resistant to penicillin and other antibiotics.4
Before 1967, penicillin was the drug of choice for pneumococcus; this pathogen was uniformly susceptible to penicillin. Penicillin G is still the drug of choice for today’s penicillin-susceptible S pneumoniae (minimum inhibitory concentration [MIC], <1 ug/mL), and PRSP (MIC >4 ug/mL) can be treated with ß-lactam antibiotics. Macrolides can be used to treat pneumococcal infections, but the local resistance pattern needs to be taken into consideration.
Since the development and implementation of the pneumococcal vaccine containing 7 serotypes in Europe5 (6A, 6B, 9V, 14, 19A, 19F, and 23F) and in the United States6 (4, 6B, 9V, 14, 18C, 19F, and 23F), the so-called “pediatric serotypes,” we have seen a decrease in invasive pneumococcal infection. Concern for an increase in non-PCV7 was noted, then 6 new serotypes (1, 3, 5, 6A, 7F, and 19A) were added for today’s new PCV13. Surveillance for new trends for nonvaccine serotypes is ongoing.7
In a world where reimbursement is driven by patient satisfaction and parents/guardians often want to leave the clinic with medication for their sick child, there is a lot of pressure to prescribe antibiotics, even when it contradicts your clinical impression.
Though medicine is a rapidly changing field with frequent new discoveries and changes in clinical practice, some basic tenants have not changed. It will continue to serve us well to return to these basic roots for insight again.
Carlos A. Arango, MD, is an associate professor in the Department of Pediatrics at the University of Florida in Jacksonville, Florida.
Jennifer Andrews, MD, is a fellow in the Department of Pediatrics at the University of Florida in Jacksonville, Florida.
- Hammond K. When to use antibiotics for respiratory infections in children. 1961; 1:36-38. https://www.consultant360.com/exclusive/infectious-diseases/pediatrics/when-use- antibiotics-respiratory-infections-children.
- Appelbaum PC. Antimicrobial resistance in Streptococcus pneumoniae: an overview. Clin Infect Dis. 1992; 15(1):77-83.
- Jenkins SG, Brown SD, Farrell DJ. Trends in antibacterial resistance among Streptococcus pneumoniae isolated in the USA: update from PROTEKT US Years 1-4. Ann Clin Microbiol Antimicrob. 2008; 7:1.
- Garau J. Treatment of drug-resistant pneumococcal pneumonia. Lancet Infect Dis. 2002;2(7):404-415.
- Liñares J, Ardanuy C, Pallares R, Fenoll A. Changes in antimicrobial resistance, serotypes and genotypes in Streptococcus pneumoniae over a 30-year period. Clin Microbiol Infect. 2010; 16(5):402-410.
- Pichichero M, Kaur R, Scott DA, et al. Effectiveness of 13-valent pneumococcal conjugate vaccination for protection against acute otitis media caused by Streptococcus pneumoniae in healthy young children: a prospective observational study. Lancet Child Adolesc Health. 2018; 2(8):561-568.
- Balsells E, Dagan R, Yildirim I, et al. The relative invasive disease potential of Streptococcus pneumoniae among children after PCV introduction: A systematic review and meta- analysis [published online July 2, 2018]. J Infect.