Antimicrobial stewardship in pediatrics: focusing on the challenges clinicians face

Abstract

BackgroundAntimicrobial use is very common in hospitalized children. An assessment of clinician’s prevailing knowledge and clinical approach to prescribing antimicrobials is helpful in order to develop the best strategies for successful stewardship programs. The objectives of the study were to determine fundamental knowledge of principles, approach to antimicrobial use through the clinical vignettes and to identify perceived challenges in decreasing antimicrobial use.MethodsA questionnaire was developed by subject matter experts and pretested to ensure validity. Using a cross-sectional prospective design, the questionnaire was completed anonymously by staff and trainee physicians at a single tertiary care pediatric hospital between late November 2011 and February 2012.ResultsOf 159 eligible physicians, 86 (54.1%) responded, of which 77 (46 staff and 31 trainees) reported regularly prescribing antimicrobials. The majority of physicians had modest knowledge of factors that would increase risk of resistance however, less than 20% had correct knowledge of local resistance patterns for common bacteria. Almost half of physicians correctly answered the clinical vignettes. Over half of trainees and one third of staff relied most on online manuals for information regarding antimicrobials to assist prescription decision-making. Overall, physicians perceived that discontinuing empiric antimicrobials was the most difficult to achieve to decrease antibiotic use.ConclusionsOur results highlight several challenges that pediatric practioners face with respect to knowledge and approach to antimicrobial prescribing. Pediatric stewardship programs could in this setting focus on discontinuing antimicrobials appropriately and promoting local antibiograms in the proper clinical setting to decrease overall use of antimicrobials.

Knowledge, attitude and perception of medical and dental undergraduates about antimicrobial stewardship

“…Not even 50% of the respondents knew that prescribing broad spectrum AM when narrow spectrums are equally effective, is a fallacious practice contributing to AM resistance. [ 5 6 ] When the respondent's knowledge was assessed by prefabricated clinical scenario based questions it was found that 30% of the medical and 4% of the dental respondents had only average knowledge about the given clinical scenarios based questions. These findings differ from another study where 39% of the respondents scored above average[ 7 ] for the clinical scenario based questions.…”

Making a Case for Pediatric Antimicrobial Stewardship Programs

“…Further contributing to the challenges of prescribing antimicrobials to children is the unavailability of appropriate formulations or doses, leading to the preparation of extemporaneous formulations . Moreover, diagnostic uncertainty plays a more significant role in the pediatric population because infants and children more commonly present with nonspecific symptoms …”

“…Another issue is that children often have a different antimicrobial susceptibility profile compared with adults . Unfortunately, even though it is known that antimicrobial susceptibility varies by age and exposures, institutional antibiograms from largely adult‐based medical centers or hospitals often report all isolates together, making the antibiogram more representative of local adult data .…”

“…22 Moreover, diagnostic uncertainty plays a more significant role in the pediatric population because infants and children more commonly present with nonspecific symptoms. 22,23 Pediatric patients also pose a challenge in ensuring that they receive the optimal dose for their age, body size, disease, and condition. Pharmacokinetic processes-namely drug absorption, distribution, metabolism, and elimination-vary to some extent with the maturation of the pediatric patient.…”

“…29 Another issue is that children often have a different antimicrobial susceptibility profile compared with adults. 6,23,30 Unfortunately, even though it is known that antimicrobial susceptibility varies by age and exposures, institutional antibiograms from largely adultbased medical centers or hospitals often report all isolates together, making the antibiogram more representative of local adult data. 30 Furthermore, even antibiograms created at freestanding children's hospitals may report aggregate resistance rates among organisms, which does not address the expected variability in resistance rates among different units, patient populations, and sites of infection.…”