Research on Antibiotic Use in Children Gives Pediatricians Food for Thought

Elizabeth Adrianne Duque Hammershaimb, MD, MS, instructor of pediatrics in the Division of Infectious Diseases and Tropical Pediatrics at the University of Maryland School of Medicine and physician lead for the Pediatric Antimicrobial Stewardship Program at University of Maryland Children's Hospital, presents on the judicious use of antibiotics for common pediatric infections.

Dr. Hammershaimb reviewed current recommended practices for antibiotic use and encouraged clinicians to take their local area's susceptibility rates into account when prescribing antibiotics and to opt for shorter courses of antibiotics whenever possible, as emerging research is showing shorter courses to be as effective as longer courses for children, with fewer adverse effects.

Antimicrobial stewardship is important — for children and adults alike

Although they are undoubtedly useful when needed, antibiotics can also cause adverse side effects, which can affect children in significant ways. For instance, surprisingly high numbers of children visit the emergency room each year for antibiotic-related adverse effects.

The Centers for Disease Control and Prevention (CDC) collects data on antibiotic use from hospitals nationwide using specific measures and metrics. According to CDC data, more than half of antibiotic prescribing in U.S. hospitals during 2015 was not consistent with recommended practices.

The University of Maryland Children's Hospital's antimicrobial stewardship program's goal is to measure antibiotic prescribing and also to improve antibiotic prescribing by ensuring:

• Antibiotics are prescribed only when needed
• Necessary antibiotics are started promptly
• The right drug, dose, and duration are prescribed when antibiotics are needed

Specific considerations for the treatment of respiratory infections in children vs. adults

Most pneumonia is viral in etiology, which means most children with pneumonia don't need antibiotics at all. For the youngest children, bacterial pneumonia makes up a tiny percentage of pneumonia infections. As children age, the percentage increases.

Guidelines for treating:

• In the outpatient setting, amoxicillin is the first-line choice.
• There is good bioavailability, and high doses can overcome resistance.
• Ampicillin is the first-line therapy for inpatients.
• Don't use an antibiotic broader than amoxicillin by mouth or ampicillin by vein for community-acquired pneumonia in otherwise healthy, vaccinated children.
• Overuse of broad-spectrum antibiotics is a big problem.

In 2022, a groundbreaking trial (called the SCOUT-CAP trial) looked at short-duration doses (five days) versus standard-duration doses (10 days) for community-acquired pneumonia in children. The study concluded that five days was superior to 10 days. The effectiveness was the same, adverse reactions were the same and the researchers saw a lower rate of antibiotic resistance at the end of therapy in the short-course group.

Urinary tract infections (UTIs) in children

UTIs in children are common:

• Pyelonephritis is more common in children under 2.
• Cystitis is more common in children over 2.

Dr. Hammershaimb reviewed several recent trials and studies regarding the optimal treatment duration for UTIs in children. For example, she discussed a Johns Hopkins review of studies that attempted to determine the optimal treatment duration for children with pyelonephritis and found that shorter courses (less than 10 days) performed the same, or in some cases, better than longer courses. She discussed the SCOUT trial, which concluded that in some cases, it would be appropriate to offer families a five-day course with an option to extend it if needed. An Italian study of children 3 months to 5 years with febrile UTIs was stopped early because the results in favor of a shorter antibiotic course were so strong.

In summary, when it comes to treating UTIs in children:

• Longer is not necessarily better.
• In pyelonephritis, seven days of antibiotics is enough.
• Five days of oral antibiotics may be sufficient in kids older than 2 months with uncomplicated UTIs.
• Shared decision making is important.

Conclusion

Dr. Hammershaimb offered three concluding take-home points:

• Society guidelines are usually just a starting point. They are not always specific to pediatrics, and they can quickly become outdated.
• It's important to know your local susceptibility patterns for different antibiotics.
• Short antibiotic courses are usually better, with similar clinical outcomes, lower risk for adverse events and less selection for resistant bacteria.

The Division of Infectious Diseases and Tropical Pediatrics at the University of Maryland Children's Hospital offers comprehensive evaluation and treatment for children with proven or suspected infections. Our physicians and professional staff develop and interpret diagnostic evaluations and formulate management plans, including recommendations for antimicrobial therapy.