Overview
Definition:
Antibiotic stewardship is a coordinated program that promotes the appropriate selection, dosing, route, and duration of antimicrobial therapy
In pediatrics, it is crucial due to the unique pharmacokinetic and pharmacodynamic properties of children, their developing immune systems, and the increasing threat of antimicrobial resistance
The choice between narrow-spectrum and broad-spectrum antibiotics is a cornerstone of effective and safe pediatric antimicrobial prescribing.
Epidemiology:
Pediatric antibiotic use is high, with significant variations by country and healthcare setting
Upper respiratory tract infections are the most common indication for antibiotic prescriptions in children, many of which are viral and do not require antibiotics
Antimicrobial resistance is a growing global concern, impacting treatment outcomes and increasing healthcare costs
Stewardship programs aim to mitigate this through optimal antibiotic use.
Clinical Significance:
Appropriate antibiotic stewardship in pediatrics is vital for several reasons: it optimizes clinical outcomes by targeting the causative pathogen, minimizes adverse drug reactions and toxicity in vulnerable children, reduces the development and spread of antimicrobial resistance, and lowers healthcare expenditures
Understanding the difference between narrow and broad-spectrum agents allows for more precise and effective treatment while preserving the utility of broader agents for resistant infections.
Narrow Vs Broad Spectrum
Narrow Spectrum Definition:
Narrow-spectrum antibiotics are designed to target a limited range of specific microorganisms, primarily either Gram-positive or Gram-negative bacteria, or even a single species
Examples include penicillin, vancomycin (against Gram-positive cocci), and aminoglycosides (against Gram-negative bacilli).
Broad Spectrum Definition:
Broad-spectrum antibiotics are effective against a wide range of microorganisms, including both Gram-positive and Gram-negative bacteria, and sometimes atypical pathogens
Examples include amoxicillin-clavulanate, piperacillin-tazobactam, carbapenems, and fluoroquinolones (though their use in pediatrics is often restricted).
Advantages Narrow:
Reduced disruption of normal flora, leading to fewer side effects like C
difficile infection
Lower risk of promoting resistance to a wide range of antibiotics
More targeted therapy when the pathogen is identified, potentially leading to faster resolution and less toxicity.
Advantages Broad:
Useful in empiric therapy when the causative pathogen is unknown or when polymicrobial infection is suspected
Provides coverage for a wider range of potential pathogens in critically ill or severely immunocompromised children
Essential for treating serious infections with unknown etiology while awaiting culture results.
Disadvantages Narrow:
May be ineffective if the causative pathogen is not susceptible
Requires definitive identification of the pathogen and its susceptibility pattern, which can delay treatment.
Disadvantages Broad:
Higher risk of disrupting the microbiome, leading to opportunistic infections (e.g., Candida, C
difficile)
Increased selective pressure for resistance development, potentially rendering broad-spectrum agents ineffective over time
Higher incidence of collateral damage to beneficial bacteria.
Diagnostic Approach And Selection
Initial Assessment:
Thorough history including fever, site of infection, duration of symptoms, recent antibiotic use, allergies, and vaccination status
Physical examination focusing on vital signs, general appearance, and localized signs of infection.
Pathogen Identification:
Cultures are paramount
Blood, urine, cerebrospinal fluid, wound, or respiratory secretions should be cultured and Gram-stained to guide therapy
Susceptibility testing (antibiogram) is crucial for guiding antibiotic choice and de-escalation.
Microbiology Guidelines:
Local antibiograms are essential for understanding prevalent resistant strains in the hospital or community
Consulting infectious disease specialists or pharmacists can aid in appropriate selection based on suspected or confirmed pathogens and local resistance patterns.
Empiric Therapy Considerations:
When initiating empiric therapy, consider the likely pathogens based on the site of infection, patient's age, immune status, local resistance patterns, and the severity of illness
Broad-spectrum agents may be initially indicated in severe or life-threatening infections, with a plan for de-escalation once culture results are available.
Management Strategies
Empiric Antibiotic Choice:
For common pediatric infections like otitis media, pharyngitis, or uncomplicated pneumonia, narrow-spectrum agents (e.g., amoxicillin) are often preferred first-line
For more severe infections (e.g., meningitis, sepsis, febrile neutropenia), broad-spectrum coverage (e.g., a third-generation cephalosporin with or without an aminoglycoside, or a carbapenem for suspected ESBL-producing organisms) is typically required.
De Escalation:
Once culture and susceptibility results are available (usually 48-72 hours), antibiotics should be narrowed to the most effective agent with the narrowest spectrum that covers the identified pathogen
This reduces collateral damage and resistance pressure.
Duration Of Therapy:
Adhere to evidence-based guidelines for the duration of antibiotic therapy
Shorter durations are often as effective as longer ones for many common infections, reducing exposure and the risk of resistance.
Drug Selection And Dosing:
Select antibiotics based on confirmed or suspected pathogen, site of infection, patient factors (age, renal/hepatic function, allergies), and local susceptibility patterns
Pediatric dosing is critical and differs significantly from adult dosing
always refer to updated pediatric dosing guidelines.
Key Issues In Pediatric Antibiotic Stewardship
Antimicrobial Resistance:
The overuse and misuse of antibiotics, both in human medicine and agriculture, have driven the emergence and spread of multidrug-resistant organisms (MDROs)
Pediatric patients, due to frequent infections and antibiotic exposure, are particularly vulnerable to acquiring and disseminating resistant strains.
Adverse Drug Events:
Children are more susceptible to antibiotic-related adverse events, including allergic reactions, gastrointestinal disturbances, and disruption of the gut microbiome
Stewardship programs aim to minimize these risks by selecting the safest and most appropriate agents.
Common Pediatric Infections:
Focus on appropriate use for common conditions like otitis media, sinusitis, pharyngitis, and pneumonia
Emphasize viral diagnosis and avoid unnecessary antibiotic prescriptions for conditions like the common cold or viral gastroenteritis.
Special Populations:
Particular attention should be paid to neonates, immunocompromised children, and those with chronic underlying conditions, as their management may require specialized protocols and closer monitoring.
Key Points
Exam Focus:
Understand the rationale behind choosing narrow vs
broad-spectrum antibiotics in various pediatric clinical scenarios
Be prepared to discuss empiric therapy, de-escalation, and antibiotic duration based on evidence-based guidelines.
Clinical Pearls:
Always obtain cultures before starting antibiotics if feasible, especially in severe illness
Actively pursue de-escalation of therapy once culture results are available
Educate parents about the viral nature of many childhood illnesses and the ineffectiveness of antibiotics in such cases.
Common Mistakes:
Prescribing broad-spectrum antibiotics empirically for viral infections
Failing to de-escalate therapy after obtaining culture results
Using inappropriate doses or durations of antibiotics
Relying solely on adult dosing guidelines for pediatric patients.