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American Academy of Pediatrics
Commentary

Vaccines and Outpatient Antibiotic Stewardship

Adam L. Hersh and Katherine E. Fleming-Dutra
Pediatrics September 2017, 140 (3) e20171695; DOI: https://doi.org/10.1542/peds.2017-1695
Adam L. Hersh
Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah; and
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Katherine E. Fleming-Dutra
Centers for Disease Control and Prevention, ‎Atlanta, Georgia
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  • Abbreviations:
    Hib —
    Haemophilus influenzae b
    PCV —
    pneumococcal conjugate vaccine
  • Antibiotics pose a great public health irony. Their existence and use have made possible the treatment of previously untreatable infections. But simultaneously, rampant antibiotic overuse has promoted the development of antibiotic resistance and new untreatable, highly resistant infections. To address this growing threat, The National Action Plan for Combating Antibiotic-Resistant Bacteria established a goal to reduce inappropriate outpatient antibiotic use by 50% by 2020.1 Antibiotic stewardship, or the effort to measure and improve antibiotic use, is a central component in achieving this goal and aims to promote and facilitate judicious antibiotic use.

    In addition to the problems of resistance, antibiotic overuse also poses other significant health threats, including adverse drug events and Clostridium difficile infections, consequences that can also be mitigated by antibiotic stewardship. Additionally, young children and especially infants, who receive more antibiotics per capita than any other age group, are particularly vulnerable to other problems associated with antibiotic use because of the disruption of the normal microbiome, which may include increased risks for chronic diseases such as inflammatory bowel disease, allergies, and asthma.2 As a result, minimizing unnecessary early-life antibiotic exposure is crucial to protecting the health of children.

    In the study by Kinlaw et al,3 the authors used Danish national antibiotic dispensing data matched with a birth registry to conduct surveillance for changes in antibiotic exposure during infancy among annual birth cohorts from 2004 to 2012. During this time, 2 pneumococcal conjugate vaccines (PCVs) (PCV7 in 2007 and PCV13 in 2010) were introduced along with national antibiotic prescribing guidelines in 2007. Overall, the authors found that antibiotic prescribing to infants decreased from 40.7% of infants born in 2004 receiving at least 1 antibiotic prescription in their first year of life to 34.6% of infants born in 2012 receiving at least 1 antibiotic. During the same time frame, Denmark had low levels of penicillin resistance among Streptococcus pneumoniae (pneumococcal) isolates from invasive diseases.4

    This story is similar to what has happened in the United States. In 2000, PCV7 was introduced, which was replaced by PCV13 in 2010,5 and several national treatment guidelines aimed at common pediatric infections were released during this time.6 Although there is still need for improvement,7 rates of antibiotic prescribing to children in the United States have declined since the 1990s.8,9 PCV has directly led to decreases in the incidence of pneumococcal disease, both invasive and noninvasive, including acute otitis media (the major driver of antibiotic use in children) and in penicillin resistance among pneumococcus.5,10 PCV has also had significant indirect effects in preventing pneumococcal disease among unvaccinated persons.5 Decreasing inappropriate antibiotic use for young children may also be another indirect effect of PCV and other vaccines like the Haemophilus influenzae b (Hib) vaccine, which was introduced decades earlier. The fear of serious infectious complications, like meningitis, leads clinicians to prescribe antibiotics inappropriately.11 Widespread PCV and Hib vaccinations have led to the near elimination of 2 of the most feared invasive bacterial infections in children, with substantial implications for the care of febrile infants and toddlers.12 In the PCV and Hib vaccine era, observation (rather than antibiotic treatment) may be more likely to be perceived as the appropriate and safer management strategy for many febrile infants and toddlers because most of these children have viral etiologies of fever.

    Vaccines, guidelines, and other factors likely synergized to lead to the reductions observed in antibiotic prescribing for children. Education of the public and clinicians and interventions targeted at clinicians to promote more judicious antibiotic prescribing are recommended stewardship interventions.13 There is growing evidence of greater awareness of the harms caused by antibiotic overuse, and parental demand for antibiotics for nonspecific respiratory illnesses may be diminishing.14

    The Danish and American experiences demonstrate that vaccines combat antibiotic resistance through the direct effect of preventing diseases from antibiotic-resistant pathogens and likely also through the indirect effect of changing the way pediatric clinicians practice medicine. Vaccines have long been hailed as one of the greatest public health achievements of the 20th century. Combined with other measures to reduce unnecessary antibiotic use, vaccines remain at the forefront of our tools for antibiotic stewardship and combating antibiotic resistance in the 21st century.

    Footnotes

      • Accepted June 13, 2017.
    • Address correspondence to Adam L. Hersh, MD, PhD, Division of Infectious Diseases, Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108. E-mail: adam.hersh{at}hsc.utah.edu
    • Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

    • The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or of the Agency for Healthcare Research and Quality.

    • FINANCIAL DISCLOSURE: Dr Hersh received support from grant K08HS023320 from the Agency for Healthcare Research and Quality. Dr Fleming-Dutra has no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    • COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-0441.

    References

    1. ↵
      1. The White House
      . The National Action Plan for Combating Antibiotic-Resistant Bacteria. 2015. Available at: https://obamawhitehouse.archives.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf. Accessed April 1, 2017
    2. ↵
      1. Vangay P,
      2. Ward T,
      3. Gerber JS,
      4. Knights D
      . Antibiotics, pediatric dysbiosis, and disease. Cell Host Microbe. 2015;17(5):553–564pmid:25974298
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    3. ↵
      1. Kinlaw A,
      2. Sturmer T,
      3. Lund J, et al
      . Trends in antibiotic use by birth season and birth year. Pediatrics. 2017; 140(3):e20170441
      OpenUrlAbstract/FREE Full Text
    4. ↵
      1. European Centre for Disease Prevention and Control
      . Surveillance atlas of infectious disease. Version 2.0. 2016. Available at: http://atlas.ecdc.europa.eu/public/index.aspx?Instance=GeneralAtlas. Accessed April 1, 2017
    5. ↵
      1. Nuorti JP,
      2. Whitney C; Centers for Disease Control and Prevention (CDC)
      . Prevention of pneumococcal disease among infants and children—use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR11):1–18
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      1. Hersh AL,
      2. Jackson MA,
      3. Hicks LA; American Academy of Pediatrics Committee on Infectious Diseases
      . Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics. 2013;132(6):1146–1154pmid:24249823
      OpenUrlAbstract/FREE Full Text
    7. ↵
      1. Fleming-Dutra KE,
      2. Hersh AL,
      3. Shapiro DJ, et al
      . Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864–1873pmid:27139059
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    8. ↵
      1. McCaig LF,
      2. Besser RE,
      3. Hughes JM
      . Trends in antimicrobial prescribing rates for children and adolescents. JAMA. 2002;287(23):3096–3102pmid:12069672
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    9. ↵
      1. Centers for Disease Control and Prevention (CDC)
      . Get smart: know when antibiotics work in doctor’s offices: measuring outpatient antibiotic prescribing. Available at: www.cdc.gov/getsmart/community/programs-measurement/measuring-antibiotic-prescribing.html. Accessed April 24, 2017
    10. ↵
      1. Tomczyk S,
      2. Lynfield R,
      3. Schaffner W, et al
      . Prevention of antibiotic-nonsusceptible invasive pneumococcal disease with the 13-valent pneumococcal conjugate vaccine. Clin Infect Dis. 2016;62(9):1119–1125pmid:26908787
      OpenUrlCrossRefPubMed
    11. ↵
      1. Sanchez GV,
      2. Roberts RM,
      3. Albert AP,
      4. Johnson DD,
      5. Hicks LA
      . Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States. Emerg Infect Dis. 2014;20(12):2041–2047pmid:25418868
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    12. ↵
      1. Greenhow TL,
      2. Hung YY,
      3. Herz A
      . Bacteremia in children 3 to 36 months old after introduction of conjugated pneumococcal vaccines. Pediatrics. 2017;139(4):e20162098pmid:28283611
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    13. ↵
      1. Sanchez GV,
      2. Fleming Dutra KE,
      3. Roberts RM,
      4. Hicks LA; Centers for Disease Control and Prevention (CDC)
      . Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep. 2016;65(6):1–12
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    14. ↵
      1. Finkelstein JA,
      2. Dutta-Linn M,
      3. Meyer R,
      4. Goldman R
      . Childhood infections, antibiotics, and resistance: what are parents saying now? Clin Pediatr (Phila). 2014;53(2):145–150pmid:24137024
      OpenUrlCrossRefPubMed
    • Copyright © 2017 by the American Academy of Pediatrics
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    Adam L. Hersh, Katherine E. Fleming-Dutra
    Pediatrics Sep 2017, 140 (3) e20171695; DOI: 10.1542/peds.2017-1695

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    Vaccines and Outpatient Antibiotic Stewardship
    Adam L. Hersh, Katherine E. Fleming-Dutra
    Pediatrics Sep 2017, 140 (3) e20171695; DOI: 10.1542/peds.2017-1695
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