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Why aren't there more antibiotics to fight resistant bacteria? Part of the reason is because developing and manufacturing them is not as profitable as with other medications. This month, Novartis drops out of antimicrobial development.
https://www.bloomberg.com/news/articles/2018-07-11/novartis-exits-antibiotics-research-cuts-140-jobs-in-bay-area
Antibiotic Apocalypse?
The first step of stewardship is education for healthcare professionals, patients, and the general public. Check out this important overview on the spread of antibiotic resistance with this video that everyone can enjoy!
Antibiotic found in our NOSES! WHAAAAAAAT!!!!
https://news.nationalgeographic.com/2016/07/antibiotics-nose-bacteria-mrsa-staphylococcus-health/
With resistance on the rise...
As time goes on, more powerful antibiotics are being prescribed for infections as doctors are faced with the rise of antimicrobial resistance. Stewardship programs improve treatment of these infections by using antibiotics only when necessary. Like and share if you think stewardship is making an important impact!
https://www.cdc.gov/antibiotic-use/stewardship-report/hospital.html
A Post-Antibiotic World?
This video on the effects of using antibiotics when they're not needed was released yesterday, highlighting the increasing importance of stewardship as we potentially enter a "Post-Antibiotic World."
https://www.npr.org/sections/goatsandsoda/2018/07/02/623962753/video-are-we-headed-toward-a-post-antibiotic-world
The meat industry has taken a small step towards stewardship in regards to chickens--but we still have a long way to go in terms of other livestock and overprescribing antibiotics for humans. Check out the link below.
https://www.motherjones.com/environment/2016/05/perdue-antibiotic-free-chicken-meat-resistance/
Skin and soft tissue infections (SSTIs) are a leading cause for hospitalizations in the United States. Few studies have addressed the appropriateness of antibiotic therapy in the management of SSTIs without complicating factors. We aimed to determine ...
How is your hospital doing? According to this study, only 20% of cases followed the appropriate treatment duration for skin and soft tissue infections for these two Pittsburgh hospitals. Click the link to read more.
Other nations report and track exactly how and where antibiotics are given to livestock, but in the US, that data is tied up in political football.
The info about agricultural antibiotic use in the US is limited and incomplete--political and commercial interests should not be a barrier to creating a unified dialogue that could protect public health.
Could antibiotic resistance and global climate change be linked?
Interesting study published last month found that warmer temperatures coincide with higher resistance in common pathogens like E. coli, K. pneumoniae and S. aureus. Scientists discuss how this may mean that current projections underestimate the burden of resistance in the future.
The Impact of Drug Shortages
The Impact of Drug Shortages on Antimicrobial Stewardship
By Margaret Heger, PharmD, BCPS, BCPPS
How do drug shortages happen? My answer is usually a discussion of two common issues. One – there is a manufacturing problem on a production line or an inspection of a facility, and that production line gets shut down. Two – a manufacturer (or two) chooses to stop manufacturing a drug entirely. In either scenario, the single remaining manufacturer is unable to ramp up supply to fulfill the needs of the market. The second scenario is how we end up with a cefotaxime shortage that has lasted more than year, without a true end in sight. Scenario three is a hurricane taking out an island with 50 drug manufacturing plants – didn’t see that coming!
There are times in antimicrobial stewardship where a drug shortage helps us out. During the shortage of meropenem, who didn’t love watching the use of that particular drug decline, with stringent guidelines for use and the threat of completely running out? In contrast, current drug shortages are hindering stewardship efforts and pushing us to use broader spectrum agents. Using ceftazidime in place of cefotaxime, as recommended by the AAP, exposes patients to an anti-pseudomonal agent and a third generation cephalosporin known to be a stronger inducer of ESBL than the other third generation cephalosporins. Losing the ability to use metronidazole has us looking to broader spectrum agents like piperacillin/tazobactam or meropenem for enteric anaerobic coverage. A small volume parenteral shortage makes it harder to incorporate extended infusion or continuous infusion dosing schemes that optimize therapy for patients.
The impact of this kind of shortage may take years to assess. Will we see more resistance in the coming years as a result? Will there be patients in the near future that we won’t be able to treat due to lack of resources? Does there need to be a call for more regulation to ensure drug supply? Which entity needs to take that on? All of these are questions without good answers. At the front lines, we do what we can with what we have, and contemplate the future impacts of these dilemmas.
ASP Culture Change
At this year’s ID Week there was an interesting pro versus con session about whether ASP programs should invest in trying to change culture or invest in deploying technology to help improve antimicrobial use in your institution. The answer is obviously both, but I voted for the changing culture side because I feel this is where our multidisciplinary ASP teams can have the most long-term payback. It is true that our EHR programs can scour every order and send out text alerts 24/7 for bug/drug mismatches, monitor for renal toxicity as labs come in in real time, provide decision support at the time of ordering, and automatically restrict agents to well defined indications. However, humans are clever and for as long as modern medicine has existed, technology that doesn’t conform to our “way of doing things” has faced the infamous workaround. So instead of an ever escalating war of trying to prevent this, I feel we should invest in changing “the way things are done” which of course is our culture.
We all know that changing culture is really, really hard, but that’s the very reason to do it. Once you establish a cultural change in your institution it becomes the norm and it then perpetuates itself with minimal effort. I also believe the physically rounding ASP team is the best mechanism for effectuating cultural modification. I am not a sociologist but here are my musings on how we can usher in durable changes in institutional culture when it comes to antimicrobial agents.
· Be physically present on the floors and units you cover. Although the bulk of ASP work can be done by doing chart review and calling providers, this makes your program seem like an anonymous force that has no skin in the game. I believe this is one of the reasons EHR alerts are less effective and one of the barriers to doing effective outpatient ASP. If you can visit the teams while they are on morning rounds you can get details about the patient that are not in the chart, have an active dialog about your recommendations and even modify them after discussion with the primary team, and also do some general teaching using an actual patient so your lessons will be retained. We all know that in high-risk environments such as the units and the Hematology-Oncology floor, antibiotics are often being used as anxiolytics for the providers. Sometimes making that physician explain this to your face in the presence of residents, medical students and other members of the rounding team can be the leverage you need to get them to accept your recommendation.
· Use your outpatient-worried-Mom-communication skills. The physician that wants to prescribe antibiotics as an anxiolytic, in my mind, is similar to the parent that wants antibiotics for a viral illness. Therefore, you can use some of the same strategies you use for the anxious parent with your reluctant physicians. Again, being physically present is paramount so you can show your concern about their patient’s health with nonverbal signals to help you in your cause. Acknowledge their fears and concerns, but point out the data that argues against the need for antibiotics. After that you can make your recommendation for no antibiotics, but you need to follow this up with assurances that if antibiotics are needed the ASP team will be supportive and will assist in making the best choice.
· Rejection does not equal defeat. While most of the time our ASP recommendations are accepted, there is always the one physician or service line that is more resistant. In much the same way a toddler won’t try a new food until presented with it 20 times, I feel the ASP team just has to be persistent and accept rejections. However, I don’t think the effort is totally wasted because with each episode it is an opportunity to engage in a dialog and you may be making incremental progress in changing the behavior which may be unapparent until the behavior finally changes. Just as dripping water can cut through stone, a persistent ASP team can change a provider’s behavior. I also think it is really important to note when they utilize antibiotics in a way that coincides with the culture you are trying to establish and go out of your way to positively reinforce that action. As they say, honey catches more flies than vinegar.
Yes, changing culture is hard work but I feel the groundwork you lay out over time will provide lasting benefits. Also as individuals go off to different institutions, they may also help to seed some of your culture elsewhere and vice versa. What tips do you have from your ASP practice that can help nudge the culture of your institution forward?
George C. Fogg, MD/PhD
Pediatric Infectious Diseases
Helen DeVos Children’s Hospital
Grand Rapids, Michigan
Nurses as Partners in Stewardship Efforts
Nurses as Partners in Stewardship Efforts
By: Jen Goldman, MD and Elizabeth Monsees, MSN, MBA, RN, CIC, FAPIC
Did you know that nurses support antibiotic stewardship processes through their daily activities?
Nurses have a key role in making sure antibiotics are used appropriately. Here’s a brief list of activities that demonstrate how nurses inform decision making and prevent patient harm from antibiotic use.
· Placing patients in isolation
· Assuring that cultures are obtained before initiating antibiotics
· Evaluating the need for continued antibiotic use
· Assessing for a history of medication adverse drug events and allergies
· Assessing for signs and symptoms of sepsis and responding to deteriorating patients
· Obtaining therapeutic peak and trough levels
· Evaluating appropriate surgical prophylaxis timing
· Notifying providers of wrong antibiotic doses
· Minimizing or batching central line entries with laboratory samples or medications
· Evaluating opportunities for transitioning patients from IV to PO
· Ensuring patient prevent infections through immunizations
· Educating patients on bacterial resistance and appropriate antibiotic use
Recognizing the pivotal role nurses have in safeguarding patients and that they represent the largest clinical discipline in healthcare, The Centers for Disease Control and Prevention (CDC), The Joint Commission, and various nursing organizations, such as the American Nurses Associations (ANA), American Academy of Nursing, and National Institute of Nursing Research, have endorsed efforts to include nurses in formalized stewardship programs (Manning, Pfeiffer, & Larson, 2016). Recently the CDC and ANA partnered to develop a White Paper on Nurses’ Role in Antibiotic Stewardship, which you can access here: http://nursingworld.org/HomepageCategory/NursingInsider/Archive-1/2017-NI/July17-NI/ANA-and-CDC-Release-White-Paper.html
The Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) collaborative is committed to recognizing the value of nurses in stewardship efforts. Our goal is to continue to raise the visibility of nursing contributions and acknowledge through our shared efforts to optimize antibiotics. Nurses are essential partners in this important patient safety effort.
References:
Manning, M. L., Pfeiffer, J., & Larson, E. L. (2016). Combating antibiotic resistance: The role of nursing in antibiotic stewardship. American Journal of Infection Control. doi:10.1016/j.ajic.2016.06.023
Pediatric Residents and Preventing Antibiotic Resistance.
Antibiotic resistant bacterial infections continue to increase in pediatric patients around the world. Excess and inappropriate antibiotic use drives this resistance. In some hospitals, pediatric residents are in charge of initially prescribing antibiotics to hospitalized children, making them potential “frontline defenders against antibiotic resistance”. In order to assess if residents are appropriately prescribing antibiotics, a cross-sectional electronic survey was given to pediatric residents at Children’s National Medical Center and Nicklaus Children’s Hospital.
The survey was designed to evaluate the resident’s knowledge about appropriate antibiotic treatment for acute ear infections, strep throat, sinus infections, pneumonia, and urinary tract infections. It also assessed residents’ awareness of antibiograms (tools to help select the most effective antibiotics), frequency of prescribing antibiotics for viral infections, and significant factors that influence prescription of antibiotics.
Approximately 50% of the residents completed the survey. The results indicated that most of the pediatric residents followed the standard antibiotic prescribing guidelines for ear infections, strep throat, and urinary tract infections. However, the residents’ answers significantly differed when asked about treatment protocols for sinusitis and pneumonia. Many residents chose non-guideline recommended antibiotics to treat sinusitis and pneumonia. Interestingly, only 3% of the participating residents frequently used antibiograms and 17% had no knowledge of what an antibiogram was. Out of the residents that were aware of antibiograms, only half knew where to access them.
Prescribing antibiotics for a viral infection was reported by almost 75% of the residents. When residents were asked why they made these decisions, 63% answered that they were following orders from an attending or senior resident. Furthermore over half of the residents said that their general pediatric inpatient attending physician majorly influenced their knowledge about prescribing antibiotics.
These survey results provide key areas for antimicrobial stewardship programs and pediatric training programs to address. First, more education is needed regarding the use and accessibility of the antibiogram. Second, barriers to following guideline based antibiotic recommendations need to be further understood. Finally, education and collaboration with attending level clinicians is essential in improving the use of antimicrobials as they have significant influence on the future prescribing of pediatricians.
Prateek J. Shukla, Maria Behnam-Terneus, Beatriz Cunill-De Sautu, Geovanny F. Perez. Antibiotic Use by Pediatric Residents: Identifying Opportunities and Strategies for Antimicrobial Stewardship. Hospital Pediatrics, 2017; 7 (9): 553 DOI: 10.1542/hpeds.2017-0059
The Importance of Rapid Diagnostics in Antimicrobial Stewardship
Aimee Dassner, PharmD
Clinical Pharmacy Specialist, Pediatric Infectious Diseases
Carolinas HealthCare System
The inappropriate use of antibiotics leading to poor patient outcomes and increased antimicrobial resistance is a focus of both national and global attention. Antimicrobial stewardship programs (ASPs) work to improve patient outcomes by optimizing antimicrobial selection, dosing and duration of therapy. The definitive selection of an appropriate antibiotic regimen, however, requires organism identification and antimicrobial susceptibility results. For blood specimens, pathogen identification and sensitivities via traditional culture methods require organism growth on solid media after positive Gram-stain. These results are rarely available prior to 48 hours from culture-positivity. Fortunately, with the advent of rapid diagnostic testing (RDT) methods, such as rapid molecular assays and mass spectrometry, the identification of infectious pathogens and select resistance markers is becoming more timely.
The methodology, time to identification, and extent of organism and resistance marker detection differs between rapid diagnostic platforms. Some platforms require organism growth on solid media, while others can be done direct from patient specimens. Matrix-assisted Laser Desorption Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS), for example, can detect an array of bacterial and fungal organisms from multiple specimen sample sites (including blood, wound, urine and sputum) within an hour of colony growth on solid media, but it is not FDA-approved to detect antimicrobial resistance genes. In comparison, Verigene® Gram-positive and Gram-negative blood culture panels can additionally detect several key resistance markers (vanA, vanB, mecA, KPC, NDM CTX-M, VIM, IMP and OXA genes) via nucleic acid assay direct from specimen within 2.5 hours of blood culture positivity. Another platform, Biofire FilmArray® blood culture identification (BCID), detects 24 Gram-positive, Gram-negative and Candida species, and four key resistance markers (mecA, vanA, vanB, and KPC) via multiplex polymerase chain reaction (PCR) within 1 hour of blood culture positivity.
Regardless of the platform used, the prompt microbiologic results offered by RDT can enhance stewardship efforts by significantly reducing time to optimal, targeted antimicrobial therapy. Guidance from the Infectious Diseases Society of America (IDSA) highlights the importance of maximizing the benefit of RDT implementation by providing active ASP support in the interpretation of and response to RDT results for blood specimens. A recent meta-analysis of 5,920 adult and pediatric patients evaluating the impact of various molecular RDT on improved clinical outcomes for bloodstream infections reported that the use of molecular RDT significantly lowered the risk of mortality, as compared to conventional microbiology methods (OR 0.66, 95% CI 0.54-0.80).1 Importantly, mortality was significantly lower in the molecular RDT studies where an active ASP was present, as compared to those that did not have an active ASP (OR 0.64, 95% CI 0.51-0.79 versus OR 0.72, 95% CI 0.46-1.12). These data suggest the mortality benefit of implementing molecular RDT for bloodstream infection is associated with using RDT in concert with ASP support and intervention.
Effective ASP strategies to provide real-time RDT support require careful consideration and will not be a “one-size-fits-all” approach. ASPs may face limitations in providing around-the-clock, real-time RDT decision support. Thus, as the availability of RDT increases, an important opportunity for ASP and microbiology laboratory collaboration emerges to optimize the impact of these novel diagnostics. The continued development and implementation of rapid diagnostic testing is an exciting time in antimicrobial stewardship. As RDT for other non-blood specimen sources, such as viral RDT for respiratory specimens, continue to become available and incorporated into clinical care, they provide meaningful opportunities to improve antimicrobial use and optimize care for our pediatric patients!
1. Timbrook TT, Morton JB, McConeghy KW et al. The effect of molecular rapid diagnostic testing on clinical outcomes in bloodstream infections: a systemic review & meta-analysis. Clin Infect Dis. 2016 Sep 26. pii: ciw649. [Epub ahead of print]
Patient Story
By: Jason Newland, MD, MEd
Washington University School of Medicine, St. Louis, MO
In the United States, 23,000 Americans die from an antibiotic resistant infection each year. Unfortunately, as a Pediatric Infectious Diseases physician, I have cared for children who have died from such infections. While these instances are rare, they are moments you never forget.
One of these children was a previously health child who was admitted to the Pediatric Intensive Care Unit. The child was quite active playing numerous sports and having a zest for life. In interviewing the family and examining the child I could see my own three children. I could feel the hopes and dreams these parents had for their child and their intense fear and sadness of having their child in the intensive care unit.
When I first evaluated this child, I never thought death would be the ultimate outcome. Even though it was evident this child had a serious bacterial infection, I did not doubt that the antibiotics we would use would be unable treat this infection. Unfortunately, I was wrong. This beautiful child had methicillin resistant Staphylococcus aureus (MRSA) in the bloodstream and in the lungs. Despite utilizing both old and new antibiotics that were tested and were shown to be effective against MRSA we were unable to get rid of this bacteria from these places. As one of the physicians, I did not know what to do next as we had added and changed antibiotics to try and provide the best antibiotic regimen possible. All the healthcare providers were doing everything they could in providing the medical care and support to this child and their family. Unfortunately, this antibiotic resistant bacteria had caused such a severe infection and was so difficult to treat that we could not get ahead and we lost. We lost a thriving child to an antibiotic resistant infection. While the loss we felt cannot compare to that of the family, the disbelief and despair was realized by all of us caring for this child.
I asked my father, a family practice doctor for 30 plus years, if he ever thought we would have bacterial infections we couldn’t treat with antibiotics. He confirmed what I thought, not in his lifetime. Unfortunately, antibiotic resistant infections are all to common and now many of us clinicians have cared for and watched people die of what previously were treatable infections. I ask all of you to remember this case and to think what you can do to assure we use antibiotics appropriately so we can maintain these life-saving therapeutic agents.
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Tread Lightly: the Importance of Antimicrobial Stewardship in Hematopoietic Stem Cell Transplant Recipients
By: Rachel Wattier University of California San Francisco
Every year in the United States over 10,000 people receive transplanted blood-forming stem cells with the intention of curing disease (1). Known as hematopoietic stem cell transplantation, this procedure usually involves intensive chemotherapy, sometimes radiation, and frequently uses additional measures to suppress the immune response so that the new stem cells can take hold in the person’s bone marrow. The upside of this treatment is the high likelihood of cure for an increasing spectrum of diseases, including leukemia and inherited disorders of the immune system. One downside is that the time from depletion of the host immune system to replacement by the donor immune system can be prolonged and fraught with risk of infection. This is particularly true for people who receive allogeneic transplants, those coming from another person as the donor. Given the high risk of infection in someone undergoing a transplant, the balance of risk and benefit might seem to favor aggressive antibiotic use. While antibiotics play an important role in supportive care during transplantation, emerging data shows that too much antibiotic exposure can have a profoundly negative impact on transplant-related outcomes.
To understand how antibiotic exposure affects transplant recipients, remember that most microorganisms inhabiting the human body are not harmful, and often serve a protective function. One of the key roles of normal or commensal bacteria is to provide colonization resistance, preventing pathogenic organisms from taking hold and causing disease. People undergoing stem cell transplantation experience a loss of intestinal bacterial diversity, partly because of damage sustained to the gut lining during transplant preparation, and partly from broad-spectrum antibiotics that are given to treat or prevent infection (2). In some cases, this loss of diversity can lead to emergence of dominant populations of pathogenic bacteria, a phenomenon known as intestinal domination. When dominant bacteria emerge in the gut, they are more likely to invade into the bloodstream, causing life-threatening illness (3).
In addition to providing colonization resistance against pathogenic bacteria, normal intestinal bacteria interact with the human immune system, helping to ensure that the immune response is well regulated. This turns out to be especially important for someone receiving a new immune system via transplantation, and the reasons are only beginning to emerge. Among stem cell transplant recipients, greater disturbance of normal intestinal flora has been associated with higher post-transplant mortality (4), and in particular mortality due to graft-versus-host-disease (GvHD) (5). GvHD is a serious complication in which the transplanted immune system attacks the host tissues.
The mechanism of risk is not entirely clear, but studies have found increased risk of GvHD-related mortality in stem cell transplant recipients who receive antibiotics with activity against anaerobic bacteria (5,6). Anaerobic bacteria metabolize nutrients in the absence of oxygen, and they make up over 99% of bacteria in the human intestine. Thus, antibiotics that kill anaerobic bacteria could be expected to have a substantial impact on human intestinal bacteria. What is the connection between intestinal bacteria and GvHD? The authors of one study showed in a mouse model that receipt of an antibiotic with anaerobic activity was associated with GvHD, increased inflammatory mediators, and loss of the protective mucous lining the intestine (6). Certain intestinal microbes have been shown to be protective against GvHD, and others to be more associated with GvHD and gut mucosal disruption (5,6). The current working hypothesis is that antibiotics with anaerobic activity disrupt microbial communities in the gut, shifting the balance away from protective bacteria and toward bacteria that may damage the lining of the gut and cause excessive inflammation.
Although there is much more to be understood about the role of intestinal bacteria, broad-spectrum antibiotics, and GvHD, the initial data has many transplant physicians reconsidering antibiotic choices for their patients. At the hospital where I work, if a transplant patient develops fever or signs of infection, the transplant physicians are more likely to choose antibiotics with less anaerobic activity. Beyond choice of antibiotic, it is also important to consider carefully when antibiotics are necessary, and when they can be safely discontinued. The ability to perform a highly specialized transplant procedure depends on having effective antibiotics to treat and prevent infections. The emergence of antimicrobial resistance threatens all patients, but it is particularly dangerous for those who have the least means to fight off infection on their own. With new data focusing attention on intestinal bacterial diversity following transplantation, now is an opportune time for antimicrobial stewardship programs to collaborate with transplant specialists to optimize antibiotic use in this vulnerable group of patients.
______________________________________________________________
1. Pasquini MC, Zhu X. Current uses and outcomes of hematopoietic stem cell transplantation: CIBMTR Summary Slides, 2015. Available at: http://www.cibmtr.org
2. Holler E, et al. Metagenomic analysis of the stool microbiome in patients receiving allogeneic stem cell transplantation: loss of diversity is associated with use of systemic antibiotics and more pronounced in gastrointestinal graft-versus-host-disease. Biol Blood Marrow Transplant 2014;20:640-5.
3. Taur Y, et al. Intestinal domination and the risk of bacteremia in patients undergoing allogeneic hematopoietic stem cell transplantation. Clin Infect Dis 2012;55:905-14.
4. Taur Y, et al. The effects of intestinal tract bacterial diversity on mortality following allogeneic hematopoietic stem cell transplantation. Blood 2014;124:1174-82.
5. Jenq RR, et al. Intestinal Blautia is associated with reduced death from graft-versus-host-disease. Biol Blood Marrow Transplant 2015;21:1373-83.
6. Shono Y, et al. Increased GVHD-related mortality with broad-spectrum antibiotic use after allogeneic hematopoietic stem cell transplantation in human patients and mice. Sci Transl Med 2016;8:339ra71
Is It Worth It? YES. Antimicrobial Stewardship in the Ambulatory World
Written by Rosemary Olivero, MD for Get Smart Week 2016
Section Chief, Pediatric Infectious Diseases
Director of Antimicrobial Stewardship
Helen DeVos Children’s Hospital of Spectrum Health, Grand Rapids, Michigan
Antimicrobial stewardship has quickly evolved over the past decade. Many of us may think that antimicrobial stewardship should be limited to Infectious Diseases physicians and pharmacists. But in reality, *ALL* medical providers can be stewards for antibiotic use.
While most formal antimicrobial stewardship programs are developed in adult and pediatric inpatient facilities, this addresses only the tip of the antibiotic-use iceberg. The vast majority of antibiotic prescriptions take place in ambulatory practices, with antibiotics being prescribed at a quarter to a third of outpatient acute visits. The outpatient world is a tremendously important target for stewardship efforts that can have a huge impact on antimicrobial resistance.
Here are some guiding principles of outpatient antimicrobial stewardship:
1) The vast majority of acute respiratory tract infections (ARTIs) in children and adults are VIRAL in origin, and antibiotics will not alter course of these infections, and will only cause unneeded side effects while promoting antimicrobial resistance.
2) When a patient has an ARTI, antibiotics are only indicated when a bacterial superinfection is present. Some examples:
a. Acute otitis media in children with severe symptoms or otorrhea requires treatment. In other scenarios, observation may be appropriate. High-dose amoxicillin is first-line therapy in children without allergies to amoxicillin/penicillin who haven’t received amoxicillin within 30 days.
b. Otitis-conjunctivitis (due to Haemophilus influenzae) should be treated with amoxicillin-clavulanate.
c. Sinusitis requires antibiotic treatment only when:
i. Persistent signs/symptoms for ≥10 days with no improvement
ii. Severe signs/symptoms (fever ≥102F, purulent nasal discharge, facial pain) for at least 3-4 consecutive days at beginning of illness
iii. Worsening signs/symptoms (fever, headache, increase in nasal discharge) following typical ARTI that lasted 5-6 days, after initial improvement (“double-sickening”)
3) When a bacterial superinfection is present, use the narrowest agent possible to treat the bacterial infection.
4) Acute pharyngitis only requires antibiotic treatment if testing for Streptococcus pyogenes is positive in the correct setting. Testing and back-up with culture is only indicated for acute pharyngitis *without* cough, coryza, runny nose, diarrhea and ulcerative stomatitis. Remember, Streptococcus pyogenes has no resistance to amoxicillin or penicillin, so these are first-line treatments!
5) Community-acquired pneumonia in infants is often viral and does not routinely require antibiotic therapy. For children with mild to moderate illness and low risk for resistant Streptococcal pneumoniae infection, amoxicillin is first-line treatment.
6) Use evidenced-based guidelines whenever they are available! The IDSA and AAP provide guidelines for many ARTIs encountered in the outpatient setting. See below.
The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: https://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2011%20CAP%20in%20Children.pdf
Clinical Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America: https://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2012%20Strep%20Guideline.pdf
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children in Adults: https://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/IDSA%20Clinical%20Practice%20Guideline%20for%20Acute%20Bacterial%20Rhinosinusitis%20in%20Children%20and%20Adults.pdf
The Diagnosis and Management of Acute Otitis Media: http://pediatrics.aappublications.org/content/131/3/e964