Friday, May 29, 2015

Why is over prescribing antibiotics a problem?

The American Academy of Pediatrics is encouraging doctors to judiciously use antibiotics for pediatric upper respiratory infections since many viruses to not require them. The over usage has lead to drug resistant bacteria, which are difficult to treat.

Why is over prescribing antibiotics a problem?


Today, one in five visits to a pediatric healthcare provider results in a prescription for an antibiotic – this accounts for nearly 50 million antibiotic prescriptions each year in the United States.

However, most upper respiratory tract infections – those in the nose, sinuses and throat -- are caused by viruses and require no antibiotics.  As many as 10 million antibiotic prescriptions annually are directed toward respiratory conditions for which they are unlikely to provide benefit. Over prescribing these medications can cause avoidable drug-related side effects, contribute to antibiotic resistance, and add unnecessary medical costs.

To reduce the indiscriminate use of antibiotics for these common infections, the American Academy of Pediatrics released today three principles for the judicious use of antibiotics for pediatric upper respiratory infections. 

How did we get to this point? From time immemorial until the late 1950s, bacterial infections were the leading cause of death among children. These included diphtheria, pneumonia, mastoiditis, and meningitis.  Paul Ehrlich, a 19th century German physician and scientist, identified arsphenamine, an arsenic-based compound that was effective for the treatment of syphilis and the first effective antibiotic.  Unfortunately, the side effects of arsenic therapy were sometimes worse than the disease itself.  Ehrlich predicted that someday, a “magic bullet”, an antibiotic that killed bacteria, but not patients would be discovered. 

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In the 1940s, sulfa drugs became available.  Over the ensuing years, a host of new drugs became available.  Of these, penicillin and its derivatives were the safest and most effective.  As a result, penicillin, ampicillin, and other related compounds achieved wide use and remain a mainstay of therapy today.  The use of these agents dramatically reduced the morbidity and mortality of many common serious pediatric infections.

But the pervasive use and misuse of these agents has produced many strains of drug resistant bacteria that threaten to set medicine back to the19th century.  CRE (carbapenem resistant Enterobactericeae), VRE (vancomycin resistant enterococci),  and MRSA (methicillin resistant Staphylococcus aureus) are just a few of the drug resistant organisms that have emerged in the past 10 years with more coming all of the time.

The vast majority of antibiotic prescriptions are for infections of the throat, ears and other associated structures.  Here’s what the AAP advises that your health care provider consider before giving your child antibiotics:

  1. Determine the likelihood of a bacterial infection.  The vast majority of upper respiratory infections in children are viral in origin. Acute otitis media (ear infections), sinus infections and strep throats are the 3 infections caused by bacteria. This policy details the criteria that should be used by the pediatrician to make these diagnoses accurately.
  2. Weigh benefits versus harms of antibiotics.  Studies have shown that treating the upper respiratory infections of bacterial origin shorten the duration of symptoms. For strep throat, antibiotic therapy reduces the incidence of late complications and reduces spread of the disease. On the other hand, adverse events associated with antibiotic usage results produce more than 150,000 additional healthcare visits per year. Diarrhea, severe skin reactions, and rare allergic reactions occur in up to 5 percent of children who receive antibiotics. 
  3. Implement judicious prescribing strategies.  Deciding when to use antibiotics is only half of the battle.  Selecting an antibiotic active against those bacteria that are most likely causing the infection, but not so broad as to cause resistance, dosing the drug correctly, and administering the antibiotic for an appropriate period of time are essential. Knowledge of local patterns of antibiotic resistance is critical. In some communities, amoxicillin alone is adequate for the treatment of ear and sinus infections; local drug resistance patterns may require the use of Augmentin (amoxicillin-clavulanic acid) for these infections.  Similarly, azithromycin may be fine for the treatment of strep throat in some locales, but not others.

In summary, widespread, indiscriminate use of antibiotics has produced bacterial drug resistance as well as excessive costs for unnecessary therapy and for healthcare visits resulting from side effects.  The judicious use of antibiotics by pediatric healthcare providers should address these issues.

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Chair of the Department of Pediatrics at Temple University Hospital
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The Healthy Kids blog is your window into the latest news, research and advice around children's health. Learn more about our growing list of contributors here.

If you have questions about your child's health, ask them here.

Anna Nguyen Healthy Kids blog Editor
Sarah Levin Allen, Ph.D., CBIS Assistant Professor of Psychology at Philadelphia College of Osteopathic Medicine
Stephen Aronoff, M.D., M.B.A. Chair of the Department of Pediatrics at Temple University Hospital
Peter Bidey, D.O. Medical Director of Family Medicine at Philadelphia College of Osteopathic Medicine
Christopher C. Chang, MD, PhD, MBA, FAAAAI, FACAAI Associate Professor of Medicine in division of Rheumatology, Allergy and Clinical Immunology at UC Davis
Katherine K. Dahlsgaard, Ph.D. Lead Psychologist of The Anxiety Behaviors Clinic at Children's Hospital of Philadelphia
Gary A. Emmett, M.D., F.A.A.P Director of Hospital Pediatrics at TJU Hospital & Pediatrics Professor at Thomas Jefferson Univ.
Magee DeFelice, M.D. Division Chief of Allergy and Immunology at Nemours/Alfred I. duPont Hospital for Children
Hazel Guinto-Ocampo, M.D. Chief of Pediatric Emergency Services at Nemours duPont Pediatrics/Bryn Mawr Hospital
Rima Himelstein, M.D. Adolescent Medicine Specialist at Crozer-Keystone Health System
Jessica Kendorski, PhD, NCSP, BCBA-D Associate Professor in School Psychology/Applied Behavior Analysis at Philadelphia College of Osteopathic Medicine
Anita Kulick President & CEO, Educating Communities for Parenting
Janet Rosenzweig, MS, PhD, MPA VP for Programs & Research for Prevent Child Abuse America
Beth Wallace Smith, R.D. Registered Dietitian at Children's Hospital of Philadelphia
Emiliano Tatar, M.D. Pediatrician at Einstein Healthcare Network Roxborough Plaza
Jeanette Trella, Pharm.D Managing Director at The Poison Control Center at CHOP
W. Douglas Tynan, Ph.D., ABPP Director of Integrated Health Care for American Psychological Association
Flaura Koplin Winston, M.D., Ph.D. Scientific Director of the Children’s Hospital of Philadelphia’s Center for Injury Research and Prevention
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