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:
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?
Will the successful community-based intervention projects need to be augmented to maintain the reduction in antibiotic use?
Diagnosing acute otitis media (AOM) remains difficult, particularly in young children. How can we improve our diagnostic accuracy?
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?
Can we identify “high-risk” children with AOM who clearly benefit from treatment with oral antibiotics?
Would young children with recurrent AOM benefit from early tympanostomy tube placement rather than recurrent courses of antibiotics?
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?
Are there new methods to treat infectious diseases, such as probiotics and oligosaccharides, which will further reduce use of oral antibiotics?
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
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?
Are there effective ways to encourage use of first-line antimicrobial agents for the treatment of AOM, streptococcal pharyngitis, and sinusitis?
Is there a way to ensure that parents continue to be educated about the appropriate role of oral antibiotics?
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?
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.
- Received July 26, 2002.
- Accepted September 4, 2002.
- Reprint requests to (H.B.) Boston Medical Center, Maternity Building, 91 East Concord St, Boston, MA 02118. E-mail:
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.
- ↵Paradise JL, Rockette HE, Colborn K, et al. Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics.1997;99 :318– 333
- Barnett ED, Teele DW, Klein JO, Cabral HJ, Kharasch SJ. Comparison of ceftriaxone and trimethoprim-sulfamethoxazole for acute otitis media. Pediatrics.1997;99 :23– 28
- Berman S, Byrnes P, Bondy J, Smith PJ, Lezotte D. Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric Medicaid population. Pediatrics.1997;100 :585– 592
- Arditi M, Mason EO, Bradley JS, et al. Three-year multicenter surveillance of pneumococcal meningitis in children: clinical characteristics, and outcome related to penicillin susceptibility and dexamethasone use. Pediatrics.1998;102 :1087– 1097
- Hardie W, Roberts NE, Reising SF, Christie CD. Complicated parapneumonic effusions in children caused by penicillin-nonsusceptible Streptococcus pneumoniae.Pediatrics.1998;101 :388– 392
- Andrade M, Hoberman A, Glustein J, Paradise JL, Wald ER. Acute otitis media in children with bronchiolitis. Pediatrics.1998;101 :617– 619
- Tan TQ, Mason EO, Barson WJ, et al. Clinical characteristics and outcome of children with pneumonia attributable to penicillin-susceptible and penicillin-nonsusceptible Streptococcus pneumoniae.Pediatrics.1998;102 :1369– 1375
- Arvola T, Laiho K, Torkkeli S. Prophylactic lactobacillus GG reduces antibiotic-associated diarrhea in children with respiratory infections: a randomized study. Pediatrics.1999;104(5) . Available at http//www.pediatrics.org/cgi/contents/full/104/5/e64
- Watson RL, Dowell SF, Jayaraman M, Keyserling H, Kolczak M, Schwartz B. Antimicrobial use for pediatric upper respiratory infections: reported practice, and parent beliefs. Pediatrics.1999;104 :1251– 1257
- Franz AR, Steinbach G, Kron M, Pohlandt F. Reduction of unnecessary antibiotic therapy in newborn infants using interleukin-8 and c-reactive protein as markers of bacterial infections. Pediatrics.1999;104 :447– 453
- ↵Mangione-Smith R, McGlynn EA, Elliott MN, Krogstad P, Brook RH. The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics.1999;103 :711– 718
- Toltzis P, Hoyen C, Spinner-Block S, Salvator AE, Rice LB. Factors that predict preexisting colonization with antibiotic-resistant Gram-negative bacilli in patients admitted to a pediatric intensive care unit. Pediatrics.1999;103 :719– 723
- Levine OS, Farley M, Harrison L, Lefkowitz L, McGeer A, Schwartz B. Risk factors for invasive pneumococcal disease in children: a population-based case-control study in North America. Pediatrics.1999;103(3) . Available at http://www.pediatrics.org/cig/contents/full/103/3/e28
- ↵Bauchner H, Pelton S, Klein JO. Parents, physicians, and antibiotic use. Pediatrics.1999;103 :395– 398
- Deeks SL, Palacio R, Ruvinsky R, et al. Risk factors and course of illness among children with invasive penicillin-resistant Streptococcus pneumoniae.Pediatrics.1999;103 :409– 413
- Feder HM, Gerber M, Randolph MF, Stelmach PS, Kaplan EL. Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics.1999;103 :47– 51
- Dusdieker LB, Murphy J, Milavetz G. How much antibiotic suspension is enough? Pediatrics.2000;106(1) . Available at http://www.pediatrics.org/cgi/contents/full/106/1/e10
- American Academy of Pediatrics, Committee on Infectious Diseases. Policy statement: recommendations for the prevention of pneumococcal infections, including the use of pneumococcal conjugate vaccine (Prevnar), pneumococcal polysaccharide vaccine, and antibiotic prophylaxis. Pediatrics.2000;106 :362– 366
- American Academy of Pediatrics, Committee on Infectious Diseases. Technical report: prevention of pneumococcal infections, including the use of pneumococcal conjugate and polysaccharide vaccines and antibiotic prophylaxis. Pediatrics.2000;106 :367– 376
- Pichichero ME, Green JL, Francis AB, Marsocci SM, Murphy ML. Outcomes after judicious antibiotic use for respiratory tract infections seen in a private pediatric practice. Pediatrics.2000;105 :753– 759
- Lan AJ, Colford, JM Jr. The impact of dosing frequency on the efficacy of 10-day penicillin or amoxicillin therapy for streptococcal tonsillopharyngitis: a meta-analysis. Pediatrics.2000;105(2) . Available at: http://www.pediatrics.org/cgi/contents/full/105/2/e19
- ↵Belongia EA, Sullivan BJ, Chyou P, Madagame E, Reed KD, Schwartz B. A community intervention trial to promote judicious antibiotic use and reduce penicillin-resistant Streptococcus pneumoniae carriage in children. Pediatrics.2001;108 :575– 583
- Wheeler JG, Fair M, Simpson P, Rowlands LA, Aitken ME, Jacobs RF. Impact of a waiting room videotape message on parent attitudes towards pediatric antibiotic use. Pediatrics.2001;108 :591– 596
- Clinical practice guideline: management of sinusitis. Pediatrics.2001;108 :798– 808
- Toltzis P, Dul MJ, Hoyen C, et al. Molecular epidemiology of antibiotic-resistant Gram-negative bacilli in a neonatal intensive care unit during a nonoutbreak period. Pediatrics.2001;108 :1143– 1148
- ↵Finkelstein JA, Davis RL, Dowell SF, et al. Reducing antibiotic use in children: a randomized trial in 12 practices. Pediatrics.2001;108 :1– 7
- Trepka MJ, Belongia EA, Chyou P, Davis JP, Schwartz B. The effect of a community intervention trial on parental knowledge and awareness of antibiotic resistance and appropriate antibiotic use in children. Pediatrics.2001;107(1) . Available at: http://www.pediatrics.org/cgi/content/full/107/1/e6
- Christakis DA, Zimmerman FJ, Wright JA, Garrison MM, Rivara FP, Davis RL. A randomized controlled trial of point-of-care evidence to improve the antibiotic prescribing practices for otitis media in children. Pediatrics.2001;107(2) . Available at: http://www.pediatrics.org/cgi/content/full/107/2/e15
- Garbutt JM, Goldstein M, Gellman E, Shannon W, Littenberg B. A randomized, placebo-controlled trial of antimicrobial treatment for children with clinically diagnosed acute sinusitis. Pediatrics.2001;107 :619– 625
- Bauchner H, Osganian S, Smith K, Triant R. Improving parent knowledge about antibiotics: a video intervention. Pediatrics.2001;108 :845– 850
- ↵Samore M, Magill MK, Alder SC, et al. High rate of multiple antibiotic resistance in Streptococcus pneumoniae from healthy children living in isolated rural communities: association with cephalosporin use and intrafamilial transmission. Pediatrics.2001;108 :856– 865
- ↵Dowell SF, ed. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics.2002;101 :163– 184
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- ↵Kolagotla L, Bauchner H, Klein JO. Use of conjugate pneumococcal vaccine will alter management of fever and acute otitis media [abstract]. Pediatri Res.2002;51 :219A
- ↵Besser R. How to alter prescription patterns: promoting appropriate antibiotic use. In: Soulsby L, Wilbur R, eds. Antimicrobial Resistance: Proceedings of a Meeting Held in Washington, 4–5th May, 2000. London, U.K.: RSM Press; 2001:151–158
- ↵Hennessy TW, Petersen KM, Brudgen D, et al. Changes in antibiotic-prescribing practices and carriage of penicillin-resistant Streptococcus pneumoniae: a controlled intervention trial in rural Alaska. Clin Infect Dis.2002;34 :1543– 1550
- ↵Barden LS, Dowell SF, Schwartz B, Lackey C. Current attitudes regarding use of antimicrobial agents: Results from physicians’ and parents’ focus group discussions. Clin Pediatr.1998;37 :665– 672
- ↵Gonzales R, Malone DC, Maselli JH, Sande MA. Excessive antibiotic use for acute respiratory infections in the United States. Clin Infect Dis.2001;33 :757– 762
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- Copyright © 2003 by the American Academy of Pediatrics