Rational antibiotic therapy in paediatric practice

Antibiotics are among the most frequently used drugs in paediatric and adolescent medicine. Data from Germany, the United States and Switzerland show that the majority of antibiotic prescriptions in paediatrics and adolescent medicine are for respiratory tract infections. It is estimated that in one-third of these cases, the use of antibiotics is unnecessary. This is where rational therapy comes in: only children and adolescents who are likely to benefit from such a therapy should be treated with antibiotics.

As in many other countries, around 85% of all antibiotics in Switzerland are prescribed in the outpatient setting. Children and adolescents receive a disproportionately high number of antibiotics compared with adults. In children up to 11 years of age, they are mainly used for respiratory diseases, in adolescents mainly for the treatment of acne.

In paediatric and adolescent medicine, a frequent therapeutic goal is to prevent short- or long-term complications. The number of affected children who need to be treated to prevent cases of typical complications is usually very high. Initiatives promoting the rational use of antibiotics are therefore particularly desirable in paediatrics. Rational antibiotic therapy is designed to maximise direct benefits for children and adolescents and minimise risks. As a rule, this means using antibiotics less frequently and in a more targeted manner. This reduces the selection pressure on bacteria and has a positive effect on the overall antimicrobial resistance situation.

The “5 D” framework as a support in everyday practice, and the AWaRe classification

A framework that can be summarised in a simplified way as the “5 Ds” can serve as a guide to how antibiotics are to be used in the daily routine of doctors: Disease (indication), Drug (choice of antibiotic), Dose (dosage), Delivery (form of administration) and Duration (duration of administration). For optimum antibiotic therapy, all five dimensions must be considered in the decision process.

It is also important to consider what types of antibiotics are recommended. The WHO divides antibiotics into three groups (AWaRe classification):

Access: The Access group includes antibiotics that should be prescribed with priority when indicated, because the risk of resistance is lower here than with other drugs.
Watch (use with caution): The Watch group comprises antibiotics that should only be used as first choice in rare cases and are usually associated with a greater risk of resistance.
Reserve: These antibiotics should only be used when no others work. The Reserve group plays a negligible role in the outpatient setting.

Internationally, antibiotics in the Access group should be used with priority. The aim is to increase the share of Access group antibiotics among all prescribed antibiotics (see figure). In Switzerland, the share is 66%, and thus already above the WHO target of 60%. However, the experience of other countries such as Denmark (79%) shows that this share can be significantly increased

The WHO’s Antibiotic Book and other tools

The WHO handbook, published at the end of 2022, contains recommendations for 20 indications that are common in the outpatient sector worldwide and for 16 hospital-specific indications. For Switzerland, national guidelines have been developed by the Swiss Society of Infectious Diseases and published on ssi.guidelines.ch. The information presented there can also be accessed cross-linked with resistance data via the ANRESIS Guide tool (formerly infect.info).

An information sheet for paediatricians on the prescription of antibiotics in children developed within the framework of StAR provides further valuable information for practitioners. The Institute of Primary Health Care Berne (BIHAM) has also produced a decision aid to support family doctors and paediatricians in participatory decision-making with patients and parents. Easy-to-understand graphics show the advantages and disadvantages of therapy with and without antibiotics for one of the most common infectious diseases in paediatrics, otitis media. The aid is also ideal as food for thought and a training tool for quality circles.

Conclusion

Prescribing antibiotic therapy “just in case” is a thing of the past, because the assumption that even if it doesn’t work it won’t do any harm is false. With a structured approach, the exposure of children and adolescents to antibiotics can be reduced. At the same time, it can be ensured that minors with a clear indication receive optimal therapy.

Summary of an article on continuing education by PD Dr med. Julia Anna Bielicki and Dr med. Malte Kohns Vasconcelos, University Children’s Hospital of Basel, Basel; appeared in Vol.34/1-2023 of the journal PAEDRIATICA