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PEDIATRICS Vol. 111 No. 3 March 2003, pp. 668-670

COMMENTARY

Promoting the Appropriate Use of Oral Antibiotics: There Is Some Very Good News

Abbreviations: AHRQ, Agency for Healthcare Research and Quality • AOM, acute otitis media

Over just the past 5 years Pediatrics has published 32 papers1–32 and an entire supplement33 related to the appropriate use of antibiotics and antibiotic resistance. Obviously, because of the increasing incidence of bacterial resistance, particularly of multidrug-resistant Streptococcus pneumoniae, this issue is critically important, impacting on the health and well-being of children. At a conference at the Agency for Healthcare Research and Quality (AHRQ) on April 10, 2002, clinicians, investigators, and representatives from the AHRQ, Centers for Disease Control and Prevention, National Institutes of Health, Food and Drug Administration, and Department of Defense explored the progress made in this area and delineated unanswered questions.

There is some very good news. First, oral antibiotic prescriptions for children are declining in the United States. The rate of decline appears to be variable, but it is estimated at between 20% and 40% since the early 1990s. This information is derived from two large national databases and hence reflects prescribing in general, and is not specific for pediatricians.34,35 The data about reduced prescribing are corroborated by a national survey of pediatricians in which 43% of the 483 respondents indicated that they dispensed antibiotics less often in 2000 than in 1997, with 48% indicating they prescribed the same amount and only 5% more in the recent period.36 Although it is not certain whether this decline in the number of antibiotic prescriptions will lead to a reduction in bacterial resistance, curbing oral antibiotic use is an important first step. Second, successful interventions have been developed at the community level that reduce antibiotic use.37 Projects in Massachusetts, Wisconsin, and Alaska have shown that by employing well-known approaches to changing physician behavior, inappropriate antibiotic prescribing can be curtailed.23,27,38 Third, we have learned that many factors contribute to inappropriate use, including parent-physician miscommunication,11,39 parental lack of knowledge about antibiotics,40,41 and physicians’ concerns about patient satisfaction and time needed to reeducate parents.14,40

At the AHRQ conference, participants articulated a series of questions that remain unanswered, and we have formulated additional areas of inquiry, some of which are the subject of current research projects. These questions include:

  1. Can hand-held devices, such as personal data assistants and other information technologies, such as electronic medical records, assist in promoting the appropriate use of oral antibiotics?
  2. Will the successful community-based intervention projects need to be augmented to maintain the reduction in antibiotic use?
  3. Diagnosing acute otitis media (AOM) remains difficult, particularly in young children. How can we improve our diagnostic accuracy?
  4. Given that only 1 in 8 older children with AOM benefit from antibiotic therapy, will parents and physicians be comfortable with a "watch-and-wait approach" in selected children?
  5. Can we identify "high-risk" children with AOM who clearly benefit from treatment with oral antibiotics?
  6. Would young children with recurrent AOM benefit from early tympanostomy tube placement rather than recurrent courses of antibiotics?
  7. Will the use of the conjugate pneumococcal vaccine impact on the treatment of AOM and infants who present with fever but no source? Two studies suggest that the vaccine reduces the rates of AOM.42,43
  8. Will serotypes of the pneumococcus that are not part of the conjugate vaccine begin to cause more clinical disease, and will antibiotic resistance increase in these strains?
  9. Are there new methods to treat infectious diseases, such as probiotics and oligosaccharides, which will further reduce use of oral antibiotics?
  10. How will the widespread use of the flu vaccine impact on AOM? One study showed that vaccinated children had 30% fewer episodes of febrile otitis media.44
  11. Can rapid testing for viral infections during the winter months in young infants with fever and respiratory symptoms be used as an effective strategy to avoid use of antibiotics?
  12. Are there effective ways to encourage use of first-line antimicrobial agents for the treatment of AOM, streptococcal pharyngitis, and sinusitis?
  13. Is there a way to ensure that parents continue to be educated about the appropriate role of oral antibiotics?
  14. How do childcare policies contribute to the inappropriate use of oral antibiotics? Daycare is a major risk factor for the development of AOM and antibiotic resistance. Is there any way to modify this risk?
  15. Most importantly, as oral antibiotic use declines, will we see a reduction or at least a stabilization in the pattern of antibiotic resistance?

Although it is not clear whether more appropriate antibiotic use will reduce antimicrobial resistance, there are other reasons why these practices are important. More appropriate prescribing should help to delay the emergence of resistance in new antimicrobial agents, minimize the adverse events that are associated with use of any pharmacologic agent, reduce health care expenditures, and sustain reductions in resistance that may be seen with more widespread use of the pneumococcal conjugate vaccine.45,46

Significant progress has been made in the campaign promoting the appropriate use of oral antibiotics. Clinicians, parents, governmental agencies, clinical investigators, and the news media have worked cooperatively to develop and implement effective strategies that promote the appropriate use of oral antibiotics.47 It is likely that the American Academy of Pediatrics and American Academy of Family Practice will remain active in this area, with guidelines and statements about common infectious diseases such as AOM and otitis media with effusion. However, this problem demands our continued attention because of its importance to the health of children.

Howard Bauchner, MD

Agency for Healthcare Research and Quality
Boston University School of Medicine/Boston Medical Center
Boston, MA 02118

Richard E. Besser, MD

Epidemiology Section
Respiratory Disease Branch
Centers for Disease Control and Prevention
National Center for Infectious Diseases
Atlanta, GA 30333

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FOOTNOTES

Received for publication Jul 26, 2002; Accepted Sep 4, 2002.

Reprint requests to (H.B.) Boston Medical Center, Maternity Building, 91 East Concord St, Boston, MA 02118. E-mail: howard.bauchner{at}bmc.org


   FOOTNOTES
 
These opinions are those of the authors and not those of the Agency for Healthcare Research and Quality or the Centers for Disease Control and Prevention.


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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics

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