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The Role of Antibiotic Stewardship in Children

Video: Dr Sanjay Patel provides an introduction to the importance of antibiotic stewardship in children and management of suspected infections.
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My name is Sanjay Patel, and I am a consultant in paediatric infectious diseases at Southampton Children’s Hospital. I continue to find it distressing when children are admitted to our paediatric intensive care unit with overwhelming sepsis or other serious bacterial infections. It’s an extremely difficult time for the family, and all of the healthcare professionals involved. However, I keep reminding myself of one thing– that the absolute risk to any individual child of having an invasive bacterial infection is lower at this moment in time than it’s ever been before, simply because of the introduction of novel vaccines to the routine immunisation schedule– the Hib vaccine in ‘92, MenC in ‘99, the PREVNAR vaccine in 2006, and most recently, the MenB vaccine in 2015.
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However, I think it is really challenging for both us as health professionals and for parents to acknowledge that the actual chance of an unwell child having a serious bacterial infection is extremely low– especially as we’re constantly being reminded to think sepsis. And we regularly see stories on the front pages of tabloids about doctors failing to pick up a diagnosis of sepsis or meningitis. Obviously, GPs, primary care nurses, and parents all feel the need to ensure children are safe from potentially life threatening infections. But we mustn’t let this concern about these rare cases bias our decision-making in terms of antibiotic prescribing– leading us to prescribe antibiotics just in case.
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What we need is robust systems to identify the unwell child, and to distinguish the child with a bacterial infection from one with a viral infection. But just as importantly, we need to better understand the factors that drive parents to bring their children to see us in increasing numbers each year– with them often simply seeking reassurance from someone they trust. During this webinar we’re hoping to get the following messages across. In general, parents don’t actually expect antibiotics when they bring their child to see a doctor. Most just want someone to listen to them, to examine their child, and tell them that they’re OK. Parents often mirror our behaviour.
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If we practice defensive medicine and prescribe antibiotics just in case, we’re educating the parent to expect antibiotics the next time their child has similar symptoms.
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We know that one source of uncertainty for front line primary care clinicians treating children with respiratory tract infections and cough is knowing which children might go on to need hospital care for their infection. And this uncertainty can drive use of antibiotics. Using a shared decision-making approach where health professionals and parents go to resources together can have a huge impact on antibiotic prescribing in future re-consultations. The impact of GPs using the when should I worry resources developed in Cardiff and published in the BMJ a few years ago showed a 50% reduction of antibiotic prescribing in children, and a 70% reduction in future re-consultations.
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Clearly, investing time upfront may save you a huge amount of time in the long run, and avoid lots of unnecessary anxiety for parents– especially as children under five years of age present acutely to GPs on average four times a year. Providing parents with clear safety netting materials and information about home care, such as on the Caring for Children with Cough website and the Healthier Together website, which I’ve developed in Hampshire, is an excellent way of empowering them not only during the child’s current illness, but also during future illnesses. Giving parents clear, nice, guideline-based based, safety netting information can help keep children safe.
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Deep down we know that it’s not easy to distinguish whether a child has a viral or bacterial infection. However, exposing children to unnecessary antibiotics will simply result in side effects, and will drive antibiotic resistance. I suggest looking for resources on common infections available to you, and signposting parents them during the consultation– identifying some clear safety netting advice resources. And if you’re really not sure if an infection is viral or bacterial, consider putting in place a follow up to reassess the child, or using a delayed prescribing strategy.
Sanjay suggests that robust systems are required to diagnose the infection in children but it is also vital to look at the drivers for why the parents are seeking help as in many cases the parents are not expecting an antibiotic prescription and are seeking reassurance.
A shared decision making approach with parents is also very important along with providing appropriate safety netting information.
Sanjay highlighted some important resources that are available here for you to use in your own practice.
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