Antimicrobial update: optimizing prescribing for common infections

With more than 2.8 million antibiotic-resistant infections in the United States every year, “even 1 antibiotic course can influence resistance patterns of future infections in the patient and population,” Rana E. El Feghaly, MD, MSCI, associate professor, University of Missouri-Kansas City, Children's Mercy Kansas City, Missouri, noted at the 2022 AAP National Conference & Exhbition. Additionally, antibiotics can cause adverse events, microbiome alteration, C. difficile infections, and be costly for families, making choosing the right antibiotic for the right amount of time even more crucial.

“When taking into account what antibiotic to prescribe,” said El Feghaly, “note the patient’s immune system; look at disease severity; antibiotic allergies; local antibiograms; absorption; the activity at the site of the infection as well as unique environments (such as acidity or anaerobic conditions).”

El Feghaly also looked at antibiotic use in the context of diversity, equity, and inclusion. For example, compared to non-Black children, Black children are less likely to receive an antibiotic resistance bacteria prescription from the same clinician per visit; less likely to receive diagnoses that warranted antibiotics; more likely to receive guideline-recommended antimicrobials; and less likely to receive broad-spectrum antimicrobials. Overall, “non-Hispanic Black and Hispanic children are less likely to receive antibiotics compared to non-Hispanic White children,” said El Feghaly.

Uncertain diagnoses, decision fatigue, time constraints, and other circumstances can make optimal prescribing a challenge to clinicians. Additionally, a look at recent FDA-approved antibiotics (since 2015), such as lefamulin, cefiderocol, omadacycline, sarecycline and others all were approved only for adult populations.

So then, how best to treat the pediatric population with antibiotics? El Feghaly went through several case studies with recommended courses of action from screening to diagnosis to treatment, such as:
--never send a bagged urine for culture
--in adolescents, consider STIs in the setting of pyuria
--know resistance patterns (such as enterococci, intrinsically resistant to cephalosporins; here, ampicillin, vancomycin are generally the drugs of choice)
--know the etiologies of community-acquired pneumonia
and others.

Ultimately, “For changes in your practice,” said El Feghaly, “Use the narrowest antibiotics for the suspected infection; use your local antibiogram to determine antibiotic choices; and reduce antibiotic duration when you can.”

Reference
El Feghaly RE. Antimicrobial update: optimizing prescribing for common infections. 2022 AAP National Conference & Exhibition. October 7, 2022. Anaheim, California.