Jayshree Kumta, MD
Director, Inpatient Pediatrics,
Newark Beth Israel Medical Center
Amrita Sunkad, MD
Pediatric Resident,
Newark Beth Israel Medical Center
Antibiotic treatment forms an important cornerstone of treatment for infections. The serendipitous discovery of Penicillin in 1928 changed the landscape of treatment and introduced the world to the new and powerful tool of antibiotics.
Are We Doing it Right?
CDC estimates that up to 28% of the antibiotics prescribed are not needed with the majority of them prescribed in the outpatient setting. In 2022, healthcare providers prescribed 236.4 million antibiotic prescriptions dispensed from U.S. community pharmacies, roughly 7 prescriptions for every 10 people in the outpatient setting with Amoxicillin—Clavulanate and Azithromycin among the most prescribed medications. This rampant use of antibiotics gives rise to antimicrobial resistance which makes the very use of these medications ineffective for treatment. Antibiotic resistance now is an urgent global public health threat, killing at least 1.27 million people worldwide and associated with nearly 5 million deaths in 2019!
The pandemic resulted in more resistant infections and increased antibiotic use. In July 2024, CDC published Antimicrobial Resistance Threats in the United States, 2021- 2022, highlighting that new data show that six bacterial antimicrobial-resistant hospital-onset infections (Carbapenemresistant Enterobacter ales (CRE), Carbapenem-resistant Acinetobacter, Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococcus (VRE), Extendedspectrum beta-lactamase (ESBL)-producing Enterobacter ales and Multidrug-resistant (MDR) Pseudomonas aeruginosa) increased by a combined 20% during the COVID-19 pandemic compared to the pre-pandemic period, peaking in 2021, and remaining above pre-pandemic levels in 2022.
According to a collaborative CDC study, the estimated national cost to treat infections caused by six antimicrobial-resistant germs frequently found in health care can be substantial—more than $4.6 billion annually. Environmental and social factors like climate change, migration, food and water shortage leads to increased incidence of infections and the potential for birth of unusual pathogens. AAP aptly points out that the increase in multidrug-resistant infections has outpaced the development of novel antibiotics capable of treating them.
CDC works to collaborate with healthcare systems and professionals to monitor the prescription of antibiotics and characterize the trends. These are opportunities to reflect on current antibiotic use, its adverse effects and to discuss steps for improvement.
What Can Pediatricians Do?
1. Encourage Hand Hygiene: Hand hygiene is the best known tool to decrease the spread of Hospital acquired infections and other infections in the community setting.
2. Encourage Breastfeeding: It helps to nurture a strong and healthy microbiome in the baby and builds a robust immunity for the child throughout life
3. Follow the rule of D’s in the use of Antibiotics:
- Diagnosis: Make an accurate diagnosis and practice diagnostic stewardship
- Drugs: Choose the right drug
- Dose: Prescribe the correct dose for the child
- Duration: follow prescribed guidelines to determine length of therapy
- De-escalation: Follow your local children’s hospital Antibiogram to titrate antibiotic therapy as soon as possible
- Discontinuation: Discontinue the antibiotic as soon as possible.
4. Practicing Antibiotic Stewardship for common infections such as Otitis media, Strep Throat and Community Acquired Pneumonia in the following manner:
- Watchful waiting and delayed prescription of oral antibiotics to prevent antibiotic treatment of viral otitis media.
- Diagnosis of Streptococcal pharyngitis using appropriate clinical criteria such as the CENTOR criteria helps avoid treatment of streptococcal colonization on the basis of positive rapid streptococcal test.
- Reserving the use of powerful antibiotics such as Ceftriaxone for pertinent Infections, minimizing its use in treatment of Community Acquired Pneumonia in a fully vaccinated child who could be treated with Ampicillin instead.
The ASP, representing pediatric providers, including pediatric infectious disease specialists and pharmacists, exchange ideas, discuss case management strategies and develop and implement guidelines to be shared system wide, as well as serve as a resource for community physicians.
For more educational information, research and best practices from the Children’s Health Network at RWJBarnabas Health, visit rwjbh.org/childrenshealthresearch.
Resources
https://www.cdc.gov/antibiotic-use/site.html#hcp https://www.cdc.gov/antibiotic-use/hcp/data-research/antibiotic-prescribing.html#cdc_report_pub_study_section_2-key-u-s-statistics
CDC “Be antibiotics aware”- watchful waiting for ear infections AAP publication: Antibiotic stewardship in Pediatrics - https://doi.org/10.1542/peds.2020-040295
New Jersey department of health- Principles of Antimicrobial Stewardship: https://www.nj.gov/health/cd/edu_training/ASP/Documents/ASRP_Webinar_ACUTE.pdf
Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet DOI: 10.1016/S0140-6736(21)02724-0
CDC. COVID-19: U.S. Impact on Antimicrobial Resistance, Special Report 2022. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2022.
National Estimates of Healthcare Costs Associated With Multidrug-Resistant Bacterial Infections Among Hospitalized Patients in the United States | Clinical Infectious Diseases | Oxford Academic (oup.com)
CDC Antimicrobial Resistance Threats in the United States, 2021-2022. https://www.cdc.gov/antimicrobial-resistance/data-research/threats/update-2022.html