More Data Supports Delayed Antibiotic Prescribing for Kids with respiratory infections

One of the hardest things to do in medicine is nothing. In pediatric medicine, where our younger patients typically come down with 6-8 viral illnesses a year on average*, this is especially true. For myriad reasons, which I’ll get into, we have a lot of trouble recommending masterful inactivity when caring for children with symptoms consistent with an upper respiratory infection. Despite the efforts of the American Academy of Pediatrics, the Choosing Wisely campaign, and my 2013 post on the subject, overuse of antibiotics is still rampant.

As I wrote in 2013, and still believe today, medicine is hard:

So what is the deal with us pediatricians? Why can’t we keep our Hannah Montana brand non-latex examination mitts off of the prescriptions pad every time little Timmy has a runny nose or a cough? Why don’t we listen to the well-meaning experts from the AAP and our own inner voices? To put it bluntly, it’s because medicine is hard. It’s messy, it’s complicated, and it is practiced by humans beleaguered by the same propensity for bias and intellectual laziness as everyone else.

Y’all don’t need me to tell you why overusing antibiotics is problematic. And every single healthcare professional who does it knows why as well. The issue isn’t that we aren’t aware of the individual and societal harm we are causing. So why do we do it? In my 2013 post on antibiotic overuse, I mention the following reasons:

1. Caregiver pressure – Some parents are not comfortable with seeing how things go. They may have unrealistic expectations and a poor understanding of the natural course of viral illnesses in children. They may be scared that their child is going to suffer or even die if antibiotics aren’t prescribed. This is a legitimate reason but it is a poor excuse in my opinion.
2. Defensive medicine – Some providers may prescribe antibiotics that they don’t believe are truly necessary out of fear of being sued for malpractice. My personal belief is that excuse tends to be more of a post-hoc rationalization than a true impetus to overprescribe.
3. Economic pressure – Some providers may worry that if they are seen as being unhelpful it will impact their ability to maintain a stable pool of patients and to make enough money to pay the bills and maintain the lifestyle that they desire. This is a concern that thankfully I’ve never had to face as a salaried hospitalist, but I know that this can be a real problem in some areas.
4. Intellectual laziness – Some providers just don’t care and do whatever moves things along the most efficiently. They may want to avoid tough conversations because they are annoying. They may have developed a number of powerful rationalizations designed to reduce cognitive dissonance and truly believe that each and every antibiotic prescription is the right thing to do.
5. Discomfort with uncertainty – But what if it is a bacterial infection? What if the patient doesn’t get better? What if they get worse? What if that cold turns into pneumonia? What if…..ahhhhhhhh! Some of us just don’t do well with the uncertainty of medicine. It may not be every patient, but they may have a lower than average threshold for prescribing antibiotics out of genuine concern for their patient’s well-being.
6. Medicine is hard – I’ve come full circle. There will always be an overuse of antibiotics unless some kind of groundbreaking diagnostic tool comes on line. It is sometimes legitimately challenging to differentiate bacterial from viral infections and, especially in certain high-risk populations, we must err on the side of caution. Ultimately, most of us just want children to get better and we try our best to practice good medicine.

In the March edition of Pediatrics, the flagship journal from the AAP, there was a randomized clinical trial out of Spain that looked at the use of delayed antibiotic prescriptions for pediatric respiratory infections. Specifically, they took a few hundred kids with likely viral respiratory infections (ear infection, sore throat, sinusitis, bronchitis) and randomized them into three groups: immediate antibiotic prescription (IAP), delayed antibiotic prescription (DAP), or no antibiotic prescription (NAP). They found that there were no differences when it came to how long it took for the illness to resolve.

I mentioned the concept of delayed, or Safety Net Antibiotic Prescribing (SNAP), in my 2013 post as well. I’ve never understood why it hasn’t become more commonplace. It involves prescribing an antibiotic in cases where it isn’t entirely clear that treatment is necessary, but parents are counseled to only fill the prescription if the child doesn’t improve or shows signs of worsening. The prescription is written such that it cannot be filled after a certain point, usually a few days after the visit. Previous studies have shown that these prescriptions are never filled in the majority of cases.

In the Spanish study, very few children in the DAP and NAP groups ended up getting an antibiotic. And again, the outcomes were similar to the group of kids who were prescribed an antibiotic with the intention to fill it immediately. In that group, 96% were at least started on the treatment. As a secondary outcome, and one that shouldn’t surprise anyone, the study found that children who were started on an antibiotic had more gastrointestinal side effects. So this large study supports an approach that involves caregiver education on symptomatic care (fluids, fever medications, TLC) and methods to delay antibiotic prescribing, which can be done using a SNAP protocol or advising that the child be brought back should they not improve or worsen.

There is an accompanying commentary co-written by Bonnie Offit, a pediatrician in Philadelphia who I believe is Paul Offit’s wife. Neat. She writes that children in the United States average more than 1 antibiotic prescription each year, the vast majority of which are written for acute respiratory tract infections that are largely viral in origin.

According to the CDC, up to a half of all antibiotic prescriptions are not necessary. It’s higher in kids. Again, this is bad. Offit points out the elephant in the room in her commentary. We already know that we should reduce antibiotic prescribing. There is already ample evidence to support watchful waiting for most pediatric respiratory infections, especially ear infections, which are by far the most common illness for which children are prescribed an antibiotic. I can’t argue with this.

*Not in 2020, however. If the reason for the shockingly low incidence of common viral respiratory illnesses in kids last year wasn’t a deadly worldwide pandemic, pediatricians would be dancing in the streets. Sure, it’s a good thing that for the first time in my nearly 20 years of pediatric medicine I did not take care of a single severely ill child with bronchiolitis, but it’s not worth the cost. Plus there is a high likelihood that these ailments will make a huge comeback once life returns to all its germ-spreading normalcy because there will not be a reservoir of older infants and toddlers with full or partial immunity from the previous Winter’s seasonal spike.