A dose of communication may be more effective than antibiotics

BOSTON — There are a myriad of reasons why antibiotics are prescribed too often, not the least of which is pressure from a patient’s parents about expectations of an antibiotic prescription.

But the “pressure” exerted concerning antibiotic prescriptions may not always be what the pediatrician believes it is. Many times, a simple contingency plan of what to do if a patient’s symptoms do not improve can be just as effective as writing a prescription for an antibiotic.

Parental pressure

“Parental pressure is usually reason number one why antibiotics are overprescribed,” said Laurence B. Givner, MD, of Wake Forest University School of Medicine. Givner and Sheldon L. Kaplan, MD, of Baylor College of Medicine, discussed the issue of antibiotics and the office pediatrician, here at the AAP’s National Conference and Exhibition.

Givner said the pressure to prescribe could sometimes be alleviated by a discussion with a parent and child about the child’s illness. Givner cited a study in the journal Pediatrics that found that a physician’s perception of parental expectation was the only predictor of antibiotic use. In that study, 62% of physicians prescribed antibiotics when they thought a parent wanted a prescription for an antibiotic, compared with only 7% who prescribed when they did not think a parent expected antibiotics.

Hence, Givner said, a key to reducing skyrocketing antibiotic resistance rates is to improve family communication. The idea, he said, is to convey to parents that a child’s unnecessary use of antibiotics could actually be harmful to their health. Another area of discussion could include a “contingency plan” if the child’s symptoms do not resolve within a day or two.

Disturbing resistance trends

Even with increased communication between patients and physicians about judicious use of antibiotics, it is clear the medications are being over prescribed and overused.

“We know that increased antibiotic use is associated with antibiotic resistance,” Givner said.

He cited a study last year in the New England Journal of Medicine that looked at group A Streptococcus (GAS) rates in Pittsburgh, which found that almost 40% of GAS isolates in a particular community were resistant to erythromycin.

Givner said the study clearly illustrates a point, “for group A strep, penicillin is recommended, otherwise macrolides shouldn’t be used routinely for treating GAS. They especially shouldn’t be used if you don’t know the susceptibility levels to macrolides in your community.”

Another illness that has seen growing resistant rates is invasive Streptococcus pneumoniae. A growing number of S. pneumoniae isolates are becoming resistant to macrolides.

“It’s a widespread problem, especially in pathogens that are common in kids,” Givner said.

But S. pneumoniae is just a part of the whole that makes up the overwhelming antibiotic prescription rates.

Givner cited one study that looked at prescription rates for antibiotics, revealing that acute otitis media (AOM) accounts for a third of all antibiotic prescriptions given to children. Upper respiratory infections – which clearly don’t warrant antibiotics – made up 12% of all antibiotic prescriptions. Pharyngitis made up 10%, sinusitis made up 4%, and when a pediatrician made a diagnosis of bronchitis – which Givner said he is uncertain even occurs in children – an antibiotic prescription was given 75% of the time in the study.

On acute sinusitis, Givner said “at least 60% of sinusitis cases resolve spontaneously,” making the use of antibiotics “questionable.”

Concerning antibiotics for otitis media, Kaplan said that studies are generally concluding that a five-day course of amoxicillin is effective as a first line treatment in older patients who don’t have chronic disease. If patients have risk factors or have AOM for more than three days, current guidelines call for treatment with high-dose amoxicillin or amoxicillin/clavulanate (Augmentin, GlaxoSmithKline). Patients with complicated AOM also can be treated with three injections of ceftriaxone sodium (Rocephin, Roche), but this is based on limited clinical experience and should only be used in severe infections.

Prophylaxis for recurrent AOM is a controversial area, but Kaplan said it’s generally felt that the pneumococcal vaccine (PCV7, Prevnar, Wyeth) may reduce AOM.

Another area where resistance rates have been a problem is in the treatment of methicillin-resistant Staphylococcus aureus (MRSA). MRSA is of particular concern because the resistance has crossed over many different types of drugs, including vancomycin.

Also of concern are MRSA isolates that are coming from the community, Kaplan said.

Kaplan cited several studies, in particular one out of Texas, that found up to 85% of the MRSA seen was from the community, with many of those infections being skin and soft tissue infections. He said reports have also shown MRSA coming from day care centers.

Kaplan said the take-home message for physicians living in communities where 10% or more of the isolates are MRSA is, “start out with another agent like vancomycin (for septic shock) clindamycin (Cleocin, Pharmacia) (for osteoarthritis), or vancomycin or clindamycin for severe or complicated pneumonia.”

Other reasons for rising resistance rates

Beyond rising prescription rates, what are some of the other causes for increased antibiotic resistance?

“There are many reasons for it, even appropriate use of antibiotics plays a role. We have more chronically, immunosuppressed children that are prone to infections, where the same antibiotics are used over and over,” Givner said. Additionally, “we have more kids in day care, and they are more prone to infections, more so than kids who aren’t in day care, so they spread bacteria that are resistant to antibiotics. Clearly that’s part of the problem.”

Another problem area is antimicrobial use among animals. He said 25 million pounds of antibiotics are given annually in the United States to animals for non-therapeutic reasons and that is causing concern about a possible leap to increased antimicrobial resistance in humans.

For more information:

• Givner LB, Kaplan SL. Update on antibiotic resistance for the office pediatrician. Session S359. Presented at the AAP National Conference and Exhibition. Oct. 19-23, 2002. Boston.

• Dr. Givner receives research support funds from Roche.
• Dr. Kaplan has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.