Antibiotic Stewardship

Shah Lekha (2)

By Lekha Shah

Jenna Wade, a feisty 17-month-old toddler, presents the ER because her mom found a swollen, red, tender area on her right buttock today after she spiked a fever. On clinical exam, she has a soft tissue abscess. She will require Incision & Drainage (I&D) under procedural sedation. Her distraught mother asks, “How did this happen?” and “What can I do to prevent this next time?”

We are largely to blame for the current epidemic increase in MRSA. Abscesses and cellulitis from CA-MRSA (community acquired MRSA) are routine, rather than rare. Many pediatric providers have memorized the dose and concentration of Bactrim and Clindamycin suspensions. CA-MRSA is so widely prevalent in the US that the CDC’s Choosing Wisely campaign now recommends against the routine use of wound culture; instead soft tissue infection should be presumed be due to MRSA or S. pyogenes. Many CHOA PEM physicians sedate for I&D approximately once (or more) per shift per provider and treat MRSA-associated cellulitis on a daily basis.

What is the scope of the antibiotic overuse problem? The antibiotic prescribing rate for children under age 2 years exceeds that of elderly adults over 65 years! Acute viral respiratory infections (e.g., sinusitis, acute bronchitis, viral pharyngitis, and otitis media) account for 75% of antibiotic prescriptions written for children, mostly under 2 years of age. According to a large UK database analysis of 3.4 million respiratory infections (excluding pneumonia) treated with antibiotics, the number need to treat (NNT) to prevent 1 complication was > 4000 (Peterson).

Regarding more serious adverse events, a recent CDC analysis found 944 pediatric Clostridium difficile infections in the US in 2010-11. Of the community acquired C. difficile isolates, 71% occurred in infants. Horton, et als’ study in the May issue of Pediatrics, found a dose-dependent association between antibiotic exposure and onset of Juvenile Idiopathic Arthritis compared to age-matched controls.

From the ER perspective, adverse events attributable to antibiotics account for >142,000 ER visits/per year in the US. Allergic reactions account for four-fifths of these ER visits; the most common culprit drugs are penicillins and cephalosporins. These are bread-and-butter drugs in any pediatric practice.

Many of our patients, and perhaps some of us, believe that antibiotics are benign, but consider this statement in an opinion piece by Linder regarding antibiotics in acute URI treatment: “For your infection, there is ~1 in 4000 chance that an antibiotic will prevent a serious complications, a 5-25% chance that it will cause diarrhea, and an ~1 in 1000 chance that you will require a visit to the emergency department because of a bad reaction to the antibiotic.”

For further information, please visit the CDC Get Smart: Know When Antibiotics Work website at

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