The Judicious Use of Antibiotics in Paediatrics
What is “judicious use” is often considered a difficult dilemma facing many physicians. On one hand, rampant, over-prescribed, indiscriminate and often inappropriate, antibiotic prescriptions leads to widespread resistance. Yet, on the other are sick children with anxious parents who may not be able to return for a follow up due to economic reasons (travel, doctors fees, loss of daily wages), difficulty in access/availability of medical care due to distance, and a host of other reasons. At times like these, many of us physicians weigh the pros and cons and often write liberally for an antibiotic, even if it is most likely a viral illness. Unfortunately, the patients most likely to receive antibiotics in this manner are infants and young children. The common diagnoses for which antibiotics are prescribed are respiratory (upper and lower) infections, which are most often of viral aetiology. For example, only certain upper respiratory infections such as otitis media, streptococcal pharyngitis, sinusitis, tonsillitis, should be treated with antibiotics. Hence, it is imperative that a paediatrician be aware of clinical criteria/guidelines to make a correct clinical diagnosis to avoid unnecessary antibiotics.
So, what does “judicious” mean? Judicious does not imply just reduced use. It implies appropriate use when treating the right aetiology, in this case bacterial infections, with the appropriate antibiotic to which it will be sensitive. One of the potential barriers to the judicious use of antibiotics possibly is that either doctors do not give importance to following strict diagnostic criteria or that they seriously underestimate the magnitude of antibiotic resistance. Another potential barrier lies within the scope of medical practice concerning types of patients; those that are either uneducated and cannot understand the treatment rationale of ‘wait and watch’ or may not be reliable to detect worsening of the medical condition or those who are economically disadvantaged and may not be able to return to the physician for another visit. Other barriers could be personal, such as when doctors either succumb to parental pressure demanding antibiotics due to their (parents) misconceptions or a physician’s lack of knowledge of diagnosis and accurate treatment.
Overcoming these barriers is possible with widespread education among doctors on the importance of scrutinising signs and symptoms, being aware of diagnostic criteria to provide a correct diagnosis, treating according to clinical guidelines by prescribing antibiotics only if appropriate. It is no longer acceptable to tell patients that “it is a viral” and then prescribe an antibiotic.
The medical community needs to understand the potential implications of antibiotic resistance; it becomes a threat to treating severe illness as stronger, more toxic antibiotics need to be used and there are fewer novel antibiotics in the pipeline that will be available soon. Bringing out the “big guns” when first and second-line antibiotics are no longer effective, leads to greater side effects for the patient compromising patient safety. These are also usually more expensive, and often less effective than the first or second-line would have been. Research has shown that patients with resistant infections require a longer course of treatment, have far more adverse effects associated with therapy, with longer hospital stays and recovery periods, and often have a higher risk of mortality associated with them.
Health campaigns and public health strategies should educate both patients and doctors. Changes such as adherence to establishing an accurate diagnosis, access to antibiotics only through prescriptions, better accountability by physicians by establishing proper clinical/medical records which clearly justify antibiotic use based on clinical criteria or laboratory diagnosis need to be implemented. Preventive strategies also should be implemented such as immunization against common bacterial diseases, education about antibiotic resistance, prevention of spread of disease through better infection control measures, patient education, timely diagnosis and treatment, screening of contacts, and isolation of infectious patients.
In conclusion, rapidly emerging antibiotic resistance is becoming a dangerous threat for all and to decrease it, there needs to be a coordinated involvement not only within the medical field but across other disciplines, such as the clinical medicine decision makers, public health officials, infectious disease experts, educators of the community at large with better infection control strategies to prevent spread of resistant bacteria. As physicians, we need to individually take on a stance of participation and commitment. It may necessitate changing one’s office practice to incorporate a few changes such as frequent follow-up telephone calls/visits to the patient after sending them home without antibiotics, spending more time during the patient’s visit explaining the reason that viral illnesses such as the common cold/nonspecific upper respiratory infections do not need antibiotics, and keeping abreast with current trends, clinical guidelines, and antibiotic resistance patterns existing in the community.
It’s the first step…. Baby steps moving forward!
Divya Menezes, M.D. (Paediatrics)