Experts Corner: How to be an everyday antibiotic steward

Antibiotic resistance-Flett

Antibiotic resistance is not a theoretical problem anymore. We are encountering resistant bacteria that have few antibiotic options. To treat these bacteria, we have to reach for antibiotics that may not work as well and have more frequent toxicities.

Appropriate antibiotic use is often thought of as a balancing act between good patient care and avoiding antibiotic resistance. But, appropriate antibiotic use IS good patient care. Antibiotics have revolutionized medicine, but patients exposed to them are also more likely to develop resistant infections including C. difficile and adverse reactions. Avoiding antibiotics when they are not needed reduces the risk of these harmful events.

As providers, it’s important to consider what we can do to keep patients safe while curbing antibiotic resistance — and have the tools to communicate this to parents. Here are a few simple actions we can take:

Give antibiotics only when needed

Like all medications, antibiotics have adverse effects. Even a single dose of surgical antibiotic prophylaxis is associated with increased risk of an adverse reaction and a three-fold higher risk for C. difficile. Antibiotics are the leading cause of adverse drug events in pediatrics.  

Use the shortest effective duration of treatment

We provide the best patient care by prescribing antibiotics only when indicated and choosing the shortest effective duration. Longer antibiotic durations increase the risk of adverse effects and resistance but may not improve clinical outcomes. For example, most cases of pneumonia can be treated with seven days of therapy and most cases of cellulitis with five to seven days. While the difference between seven and 10 days is “just a couple of days,” choosing a shorter duration may prevent a difficile case, a resistant infection, or an allergic reaction. Parents may be happy to not wrangle the extra doses into their kids. All of this means that every dose matters.

Talk to parents about their expectations

Studies conducted in PCP offices show that pediatricians are more likely to prescribe an antibiotic if they believe a parent expects one. However, these same studies also found that we are not always good at judging their expectations about antibiotics. Parents are increasingly aware that antibiotics do not treat viruses. When a parent questions a viral diagnosis , it may lead us to assume they want an antibiotic, but this questioning is actually not correlated to their expectations.

Communication tips to use when antibiotics are not needed

  1. Explain why antibiotics aren’t needed:  “The strep test is negative, meaning your sore throat is caused by a virus and antibiotics won’t help.”
  2. Provide positive treatment recommendations: “Honey can actually soothe your child’s cough and help them feel better.”
  3. Provide a contingency plan: “If your child is not better in three-four days, call or come back and we can reassess the need for antibiotics then.”
For your patients:

The fight against antibiotic resistance is daunting and sometimes feels remote from the patient in front of us. However, using antibiotics appropriately does help that patient. We provide the best patient care by prescribing antibiotics only when indicated and choosing the shortest effective duration. We can communicate about antibiotics by asking parents about their expectations and providing positive, clear advice about how they can help their child feel better. We all can be, and need to be, antibiotic stewards.

 About our expert: 

Antibiotics-Kelly-Flett

Kelly Flett, MD, MMSc, is medical director of Boston Children’s Antimicrobial Stewardship Program and attending physician in Pediatric Infectious Diseases.