Choosing Wisely: inappropriate antibiotic prescribing in kids

the Am Acad of Pediatrics just published their 5 concerns about antibiotic prescribing (see http://www.choosingwisely.org/societies/american-academy-of-pediatrics-committee-on-infectious-diseases-and-the-pediatric-infectious-diseases-society/ . Published on the Choosing Wisely website http://www.choosingwisely.org/ , developed to “advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures”.

1. Don’t initiate empiric antibiotic therapy in the patient with suspected invasive bacterial infection without first confirming that blood, urine or other appropriate cultures have been obtained, excluding exceptional cases. The issue here, i assume (not explicitly stated) is that we may be treating non-bacterial infections (eg we may be not treating a viral infection appropriately, or may be giving antibiotics for a non-infectious process); and even for a bacterial infection, it may be hard to figure out what the best oral antibiotic to choose after a response to the initial broad-spectrum IV ones chosen without a known organism and sensitivities
2. Don’t use a broad spectrum antimicrobial agent for perioperative prophylaxis or continue prophylaxis after the incision is closed for uncomplicated clean and clean-contaminated procedures. Narrow-spectrum antibiotics (eg cefazolin) help prevent post-op infections when given prior to surgery and stopped after the incision is closed for "uncomplicated clean and clean-contaminated procedures (ie respiratory, gastrointestinal, or genitourinary sites are breached but without infection or inflammation". broad-spectrum antibiotics or those given after the incision is closed have been shown not to help
3. Don’t treat uncomplicated community-acquired pneumonia in otherwise healthy, immunized, hospitalized patients with antibiotic therapy broader than ampicillin. Most infections in healthy and immunized kids are from S. pneumonia, respond to penicillins, and broad-spectrum antibiotics don't add any benefit. though they do contribute to antibiotic resistance and C. difficile infections
4. Don’t use vancomycin or carbapenems empirically for neonatal intensive care patients unless an infant is known to have a specific risk for pathogens resistant to narrower-spectrum agents. Studies suggest no survival benefit by using vancomycin, which is so commonly used as a first-line agent (should be limited to kids known to be colonized with MRSA)
5. Don’t place peripherally inserted central catheters and/or use prolonged IV antibiotics in otherwise healthy children with infections that can be transitioned to an appropriate oral agent. They emphasize that extended IV therapy is not needed for kids with complicated pneumonia, ruptured appendicitis, and osteomyelitis, and that they can be put on orals prior to hospital discharge. No sepcific data given, but it seems that many patients do continue with IV antibiotics when oral ones can be given, and 40% of kids discharged from the hospital with PICC lines end up returning to the ED with a complication (though this is also not broken down by specific infections, and the complications from PICC lines could conceivably be different in different infections with different bugs). 

Commentary:

--though these 5 points are directed at in-hospital pediatric medicine, their basic thrust is quite relevant to those of us practicing clinic-based medicine: we should avoid using antibiotics unless clearly indicated and we should use the narrowest-spectrum antibiotics that would be effective in cases where indicated.

    --studies show that most antibiotics are given for nonbacterial infections, and are unnecessary:

            --see http://gmodestmedblogs.blogspot.com/2016/01/antibiotic-overprescribing-and-acute.html  for several articles on the huge amount of antibiotic overprescribing for very common nonbacterial conditions

--See http://gmodestmedblogs.blogspot.com/2018/07/antibiotic-overprescribing-in-urgent.html  which finds much less antibiotic overprescribing in primary care offices vs urgent care

    --one major concern is antibiotic resistance

            --see http://gmodestmedblogs.blogspot.com/2014/05/who-report-on-antimicrobial-resistance.html  for a 2014 WHO report detailing the dramatic development of antimicrobial resistance world-wide, and identifying the specific challenges of the future

            --see http://gmodestmedblogs.blogspot.com/2017/07/take-full-course-of-antibiotics.html   for an interesting article suggesting that taking the usual full course of antibiotics is not often necessary and may lead to more antibiotic resistance

    --and, the other big issue is unhealthy changes in the microbiomes (gut, lung, skin, vagina....), much more of an issue with broad-spectrum antibiotics, including:

        --bad other infections (eg C diff in the gut; selecting for MRSA in the skin; yeast vaginal infections....)

            --see http://gmodestmedblogs.blogspot.com/2018/04/c-difficile-guidelines-for-adults-and.html for overall review of C diff, including causes, different virulent strains, and treatment

        --potentially long-term microbiome changes from antibiotics

            --see http://gmodestmedblogs.blogspot.com/2018/01/antibiotic-use-in-kids-narrow-spectrum.html reviewing an article finding that narrow-spectrum antibiotics were just as good as broad-spectrum for the most common causes of pediatric infections, along with links to many articles on antibiotic resistance, microbiome changes (including long-term changes with short-term antibiotics, development of colonic adenomas)

geoff

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