Antibiotic Awareness – PediaCast 418

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  • It is antibiotic awareness week! Join us as we reach into the PediaCast archive and share an interview with Dr Preeti Jaggi on antibiotic stewardship. We introduce the concept and share steps medical providers and families can take to reduce the misuse of antibiotics.

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  • Antibiotic Awareness and Stewardship

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Announcer 1: This is PediaCast.

[Music]

00:00:21

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio.

It's Episode 418 for November 15th, 2018. We're calling this one "Antibiotic Awareness."

I want to welcome everyone to the program.

So you've heard of antibiotics, right? I mean, probably, every person in this audience, at one point or another, has been on an antibiotic, or your kids have been on an antibiotic. If you've never been on one, you are fortunate.

So we want to raise awareness about antibiotics. Why would we want to do that?

Because antibiotics are great, except for when they're not. And other plenty of reasons why antibiotics would not be so great.

One of those reasons is because the antibiotic kills bad bacteria. And, you know, bacteria are not inherently good or bad. I mean, they have an effect on our bodies. And sometimes, that effect is a helpful beneficial symbiotic effect. You know, we actually, there's some numbers you've probably heard that we actually have more bacteria inside our gut than we have cells that make up our body.

So, if you want to think of that way, we're actually more bacteria than human. That's wonderful to think about.

But, all of those bacteria, you know, do some good things for us.

And so, when we take an antibiotic, we often kill those good bacteria. And that can have all sorts of effects on our body, on our immune system, as it turns out for many reasons that are quite complicated, that we're just really beginning to understand that the bacteria that live in our bodies, our immune system, you know, has to either recognize them as good or bad and respond in an appropriate way.

And we know that the way that our immune system responds affects other diseases and illnesses. You know, things like allergies, whether be food allergies, other types of allergic diseases, we've covered these things before.

So, you know, when we kill off our normal good bacteria, that's not necessarily a good thing.

On the other hand, we don't want to suffer and have more problems with illness and possibly even death as we talk about bacterial infections, and if they get into the bloodstream, and can cause sepsis, which is very bad.

So, we want to also use antibiotics when they're necessary.

We also don't want to create resistant bacteria by using antibiotics when it's not appropriate.

Because bacteria find a way, looks like Jurassic Park, life finds a way.

And so, you know, they mutate and they change their genetics. Sometimes, you know, you'd kind of select out those changed bacteria. Because if we use antibiotics, we kill the ones that the antibiotic would kill, but the ones that had mutated in a way that they can avoid being killed by the antibiotic. They reproduce and suddenly, you know, you're full of the resistant bacteria.

Again, because of this random mutation that occurred. Or, the mutations can actually be spread from one bacteria to another by a virus, of all things.

So, it gets kind of crazy, and just in terms of this science, it's important to know that antibiotics are great when they're useful, when they should be used.

But it can also be a problem. And we didn't even talk about, you know, the possibility of allergic reactions, and side effects, and other problems with antibiotics. You know, you can kill off normal bacteria in your gut, and then see if they can kind of take over with some antibiotics.

And so, there's a lot to consider. And we just want folks to be aware that yes they're a good thing, they can be a bad thing, we want to use them appropriately.

And just have to have some awareness about that.

So, as I thought about antibiotic awareness week, I did an interview with one of our Infectious Disease Doctors last year, Dr. Preeti Jaggi. And it was an interview that was done for our Continuing Medical Education Podcast, so PediaCast CME, over pediacastcme.org.

So, the target audience for this particular podcast into that being medical providers. So, doctors, nurse practitioners, nurses, anybody, you know, who are medical professionals.

So, we don't always use complete plain language necessarily. Although, as I listened back to it the interview, it was, I think very understandable for parents.

And one of the things that we covered in this particular interview was from a provider standpoint. You know, when or when we use antibiotics a little too much, whether maybe we're not using them enough, what could we do to improve our use of antibiotics.

00:05:34

And just one example of this, strep throat, you know, the strep bacteria for a lot of folks lives in the back of the throat but is not causing disease. So you can be a carrier of strep, it's just kind of a dormant back there, it's part of your collection of mouth microbes. But it's not actually causing a problem.

And so, if we take everyone who has a cold, and have a little bit of a sore throat with their cold virus, and then we swab them to see if strep is there, the swab comes back positive, and so, is it because you really have strep throat, and that's causing your problem, or do you have a cold virus, and you have the strep growing back there, but it's not really causing disease.

And so, if you use an antibiotic, you're not going to get any better, because it was the virus that was making you sick, to begin with. And we're using the antibiotics sort of inappropriately because you're just a carrier, the strep is only causing a problem.

And so, as we sort of consider even like who do you test for strep, in order to be good stewards of antibiotics, you know, that sort of the direction of these conversations went.

Even urinary tract infections, you know, about the times when girls have frequent urination or painful urination, and we suspect that maybe there's a UTI, but they don't have belly ache and fever and vomiting, or flank pain, or other signs of urinary tract infection. We check the urine and it's kind of that 'gray zone' You know, in the past we'd say, "Well, we'd rather treat and have been wrong than to not treat and have been wronged."

And so, we sort of 'overtreat'.

00:07:12

And that now, they've been initiatives to say, "Well, let's treat, but then let's follow the culture. And if nothing except growing and the symptoms got better, maybe we can stop the antibiotic.

So these are the kind of conversations that I think, as providers, we've started to have. But I think it's also a good idea for parents to understand sort of what we're discussing right now. So that you can be better informed as you go in this and see your health care provider.

So what I want to do this week is actually replay for you the interview that I had last year with Dr. Preeti Jaggi, and I think that it will really be sort of an 'aha moment' for many parents out there. Because, you realize that we really do have kids best interest in mind, as we think about medicine.

And so, the topics that we've talked about, I think I've interest the parents, as you just try to improve your own health literacy. And so, kind of debated, do we make a whole new interview about this? But I think it was done so well with Dr. Jaggi, I mean, she really, I think provided some insight and light, not only for that I think would be helpful for providers, but for parents as well.

So, this week, in recognition of Antibiotic Awareness Week, which it is, this week, in November, I just wanted to play that interview for you.

Before we get to that, I do want to mention, if you have not followed PediaCast on Facebook, or Twitter, please consider doing so. Very easy, just look for PediaCast, search for PediaCast, and follow us.

We do put some useful information out there on a daily basis, not just podcasts, which we do want to raise awareness and let you know, and so you can share with your own online audience, the things that you think would be helpful and useful for them.

But we try to share other things, lots of blog posts written by other pediatricians around the country, I love sharing those.

And so, I think you will find some great information that you can digest and share again on Facebook and Twitter.

We're also on Instagram, if you want to peak into the studio, we'd love for you to follow us. And if you follow us on Instagram, look for us to follow you back so that we can see also what's going on in your life, we can share in parenting with each other, I think that's a lot of fun.

So, again, just look for PediaCast on Instagram.

And also, you'll get a look into the studio, sometimes we post pictures. Just yesterday, in fact, I was involved in a moderating a behavioral health panel for parents, and one of our local school districts where we just raised awareness and answered parents' questions, and a discussion forum panel, sort of thing. And we took community questions about anxiety, depression, teen suicide, prevention efforts, you know, what do you do when your child has a mental health issue that you're concerned about? How can you get into the system as quickly as possible? or what kind of help could you give kids as you're waiting to get them into the system?

So, those kinds of questions. But, my point is, that I did put some pictures of that panel on Instagram. So you just kind of see what we're up to here on PediaCast, and we can see what's up with your family as well.

Also, if there is a topic that you would like us to talk about, easy to get in touch. Just head over to pediacast.org, we have a contact link, just fill up that forms.

We also have a phone number, 347404-kids, 3474045437, if you would like to leave a message, that way, we can get your voice on the show! We love it when folks call in.

Also, I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.

So if you do have a concern about your child's health, be sure to call your doctor. And arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

So, let's take a quick break. I will be back with that interview with Dr. Preeti Jaggi, we'll talk about antibiotics. That's coming up right after this.

00:11:19

[Music]

00:11:48

Dr. Mike Patrick: Welcome back to the program, Dr. Preeti Jaggi is a Pediatric Infectious Disease Specialist at Nationwide Children's Hospital and an Associate Professor of Pediatrics at the Ohio State University – College of Medicine.

Welcome to the program, I really appreciate you joining us today.

Dr. Preeti Jaggi: Thanks for having me.

Dr. Mike Patrick: So, let's start with just the basics of antibiotics stewardship. Explain what that term means and why is it important?

Dr. Preeti Jaggi: Okay.

So, just kind of taking a little bit of a step back, when we think about how long we've been using antibiotics, it's been less than a hundred years. Antibiotics have certainly been miraculous drugs. We know, children used to die, so many children used to die of meningitis, and serious bacterial infections that we can now treat.

It is recognized that with this increased use, we've put pressure on microbes to then evolve resistance. And we know that about 23,000 people die every year of antibiotic-resistant organisms, and our children are growing up in that environment, and so there's been an increasing recognition in the Infectious Disease Community that we really need to be using this wisely.

So that term was actually coined in 1996, although I think there were efforts in antibiotic stewardship before that, but it's really trying to, try to give feedback to providers as to, you know, the appropriateness of antibiotic use.

And it really kind of started in the hospital setting, but we really have increasingly recognized that most of the antibiotics that we used are an outpatient setting. And so, there are now more efforts to try to forward antibiotic stewardship in the outpatient setting.

Dr. Mike Patrick: Absolutely.

And there's really, there's a fairly large scope of a problem in terms of what would be considered inappropriate antibiotic use. So there have been some adults studies. And the ones that I came across were done, you know, seven to ten years ago, but they looked at prescribing habits and sort of what the standard of care would be in terms of antibiotic use.

And then really followed prescribers with large patient populations and found that up to a third of the antibiotics that were prescribed were really not necessary or even considered standard of care.

00:13:58

Dr. Preeti Jaggi: Correct.

A lot of that has come out of the CDC with the enhanced database where they do surveys of providers in sentinel sites. And then they estimate the appropriateness of antibiotics.

Some of this is difficult to tease out. For instance, a diagnosis of sinusitis is really based on clinical and historical features.

Some of the ways that they estimated appropriately or inappropriate prescribing was comparing it to the lowest prescribing areas in the geographic region. Some of it was using the literature to say in how many children would be expected to have sinusitis for instance.

So there is more and more work that we need to do in this area, and I think a lot of that will also just be some systematic changes that we might be able to make in an office setting, to try to decrease parental pressure. Also, requesting at the best.

Dr. Mike Patrick: And it seems that with the increased awareness that I would imagine, things are getting a little better. Because you hear about this concept of antibiotic stewardship and how is it important to prescribe them appropriately. At least in my world, so in pediatric space. It seems like this is something that we've been talking about for a while. And with those studies being a few years ago, do you get the sense that things are improving?

00:15:16

Dr. Preeti Jaggi: I do get the sense that things are at least being recognized. And that prescriber, this was really was a 'talked about' before. I think we had sort of unchecked use of antibiotics on the inpatient setting and the outpatient setting for a very long time. And I think, just the fact that we're talking about it is a step forward.

Dr. Mike Patrick: Now, in addition to the resistance of microorganisms, there are some other reasons that antibiotic stewardship is important. One of those may have to do with the microbiome. Tell us about that relationship.

Dr. Preeti Jaggi: So some of the literature has come out, first really based on animal studies. There's a physician in New York, Martin Blaser, he's done some work and looking at lower-dose antibiotic prolonged exposure in animals and the effect on their microbiomes, so basically the diversity of their intestinal bacteria or you could really actually think about that in many different areas than microbiome, and many different areas that the guy has been looked at.

And then looking at effects on those organisms. So the question about adipose, that position has come up where might as well have more adipose deposition. Some animal studies have raised that question about asthmatic type symptoms, react-vary disease type symptoms, and so those are some of the animal studies that have looked at.

And humans, obviously, that's very, very difficult to elucidate, and there's so, it's so multifactorial. But some of the epidemiology data suggest that exposure to antibiotics may increase, and I would really want to say these are preliminary studies, the increased risk of inflammatory bowel disease, asthma, and those I think need to be, we need further studies, but there are at least some preliminary data suggested that.

00:17:01

Dr. Mike Patrick: And it certainly makes sense when you think about a mechanism for that, you know, in terms of the immune system, and the complex relationship between that and the microbiome and then with allergic-type and inflammatory diseases, kind of springing from that.

So there's a lot of still black boxes that were not quite sure of, but it certainly makes sense to start looking in that direction and to be thinking about our use of antibiotics and what other effects we're having when we use them.

And then, of course, there's the cause. You know, in terms of inappropriate antibiotic use if, you know, a third or more prescriptions aren't really necessary, you know, what is the pressure on the healthcare system in terms of the dollar amount, which we have to think about these days, too.

Dr. Preeti Jaggi: And one of the things that research were trying to look into all those, how many children they get an antibiotic comeback to a health care system? How many get a rash? How many get diarrhea that lands them in the emergency room? You know, a C. difficile is obviously an important consideration, too.

So, I think we need to start looking in that. And I think, the are other sorts of conversation change is that we sort of assumed, I think, as a healthcare provider, that antibiotics are fairly benign. And I think that conversation is starting to occur a lot.

You know, their not always benign. And we need to be certain think about that.

00:18:16

Dr. Mike Patrick: So, those who are thinking about establishing an antibiotic stewardship program, and I really, that sort of a program could be established. Whether it's a big institution or a small private practice. I mean, really, you can think of antibiotic stewardship.

But you really want to be sort of systematic with your approach. How do you go about establishing an antibiotic stewardship program?

Dr. Preeti Jaggi: Okay. So we can talk about that sort of an inpatient setting and the outpatient setting. And the inpatient setting, what we've really found to be effective, and this actually goes for the outpatient and inpatient setting as feedback.

So if we start tracking our antibiotic use, and providing feedback to providers, that really helps. We've done that here in the hospital with the use to some of the broad-spectrum agents. And we've seen that pretty, pretty dramatic decrease and how much we've been using some of those broad-spectrum agents.

Once we've started putting basically protocols in place, this is what we think it. Our reasonable uses, and giving feedback to providers. We never have been telling providers that they cannot use antibiotic, it's just that we're giving them feedback. And that has been really effective.

And the outpatient setting, the same has been all shown through a very nice study done by Jeff Kerber at top, where he looked at outpatient providers and he gave them feedback about prescribing and really it's a pretty dramatic decrease in their use of inappropriate prescribing.

And actually, when that feedback went away, that effect of decreased prescribing went away.

So we think, probably, continuous feedback is necessary, but I do think that in the outpatient setting, a couple of things could be helpful to providers.

One is to get your staff involved in antibiotic stewardship efforts, nurses are with patients quite a bit, one of the things that we've done here in our outpatient urgent care network is to just give a little bit more guidance for our nurses for when to swab for potential strep pharyngitis.

And we've seen, actually, we are doing, about half the swabs that we were doing previously. And that was just giving them a little bit more guidance about when this is appropriate. So, they are often doing that before the physician when he walks in the room.

Another thing that can be really helpful in the outpatient setting is, this is actually comes from a study in outpatient adult primary care centers. Where they actually just put a poster on the wall. And that poster says, "We are committed to your child's health, We're recognizers. There are two types of germs, viruses, and bacteria. And we're committed to providing you antibiotics only when necessary because we don't want to harm, you know, your child in this case."

And actually, that poster, which is pretty cheap and fairly easy to do, and they actually had the picture of that physician and a signed commitment letter on the wall. And there's a decrease in about 30% of inappropriate prescribing in the outpatient adult practices.

So we've actually done that in our outpatient urgent care centers as well. And so, we have the script, and we'd be happy to share that, and that's a fairly cheap and easy way.

And you may actually just ask your staff to point the patients when they're in the room. This is in the examiner itself, to point the parents to that so that they can read it.

Dr. Mike Patrick: It seems like in a private practice or small practice, you'd probably want to have a champion who is really committed to antibiotic stewardship and then maybe provide education for the rest of the staff. They don't have to be an infectious disease specialist. Just sort of get caught up to speed on this and make it a priority for the office in terms of education, describing the scope of the problem, and then coming up with some sort of intervention that you're going to do. And with electronic medical record, it's easier to sort of keep track of these things, right?

Dr. Preeti Jaggi: Absolutely, yes. I think that having your staff just, you know, help you, point you to this direction. I think, one of the things that has been recognized is that parental perception if the clinician perceives that the parent wants antibiotics for their child, they are more likely to prescribe.

So and that on, it's a little bit more common we think and medicated patients, so perhaps patients of lower socio-economic class. So it's something important for us to recognize. And if your staff can help educate, that may help that situation.

00:22:30

Dr. Mike Patrick: Absolutely.

And in terms of the outpatient world, I wanted to focus on some specific disease processes where antibiotic stewardship is most likely to be helpful to listeners. Because we can really sort of divide some things in the inpatient versus outpatient.

So today, we're going to focus some of the outpatient conditions.

And probably, the first one that comes to mind, especially as we head into the fall and winter season, is just nasal congestion and cough-associated symptoms.

Because a lot of times, these things seem to linger, and once you get out, you know, it's been seven to ten days or more, and two weeks, for this cause been there for three weeks. You start to get tempted to use antibiotics.

So let's just talk about some of the disease, conditions, that result in congestion and cough and then talk about which ones of those antibiotics are appropriate for them, which ones maybe not so much.

00:23:24

Dr. Preeti Jaggi: Okay.

So, I think we all recognize that viral upper respiratory tract infections are very common, six to twelve potentially per year for children. Especially when they go to the daycare setting.

We know that your fever will last for several days, most, I kind of use the general rule of thumb of three to five days for most viruses. And I think, one of the probably important things to kind of review are the Infectious Diseases Society of America Guidelines for the Diagnosis of Sinusitis.

When is it a normal upper respiratory infection versus a sinusitis?

So really, they talk about three different scenarios in which you would consider sinusitis.

One, it would be kind of a double sickening where the child was getting had fever, cough, congestion, and they were getting better, and then all of a sudden they get much more severe symptoms. So kind of that double sickening.

The second would be prolonged symptoms, really there, the peak of viral symptoms might be three to five days. But it really can linger up to ten, even potentially twelve days.

So after you get into that point, and you may, I think this is a little difficult to tease out with children though, I have to say. Because they, you know, we have to ask the parent. Is it one symptom or versus you know, more than one symptoms.

00:24:44

Dr. Mike Patrick: And did they go a couple of days with no symptoms…

Dr. Preeti Jaggi: Yes.

Dr. Mike Patrick: If the symptoms started back again.

Dr. Preeti Jaggi: Yes, I definitely think that one would have to think about that as well. And really looking for facial pain or signs of severe symptoms.

In a younger child, we think that incidents of sinusitis is only about 8%. So that's actually pretty low.

So are we perhaps overdiagnosing sinusitis? That's potential. So, I would really be very cautious in making that diagnosis.

Dr. Mike Patrick: And if with the double sickening, then you also have to worry about could it be pneumonia, could it be an ear infection, there's other things that could also sort of mimic sinus infection in terms of those symptoms. Especially in younger kids.

And in older kids, you know, maybe it's a little easier because they can't tell you, you know, where it hurts in or the pressure is.

Is there a certain link of time before you would consider a sinus infection?

Dr. Preeti Jaggi: Generally, one of the scenarios to talk about is over at least ten days of symptoms, consistent symptoms. And again, I think that's a little bit difficult in children to tease out.

So, you know, watching and waiting for another two days, even at 10 days, I think seems reasonable.

Dr. Mike Patrick: And allergies, it can also cause the nasal congestion and then during, just in the back of the throat, and then irritations, and cough. So that could obviously last more than ten days, too. Is fever a good indicator? If you don't have a fever after that time…

Dr. Preeti Jaggi: If you have prolonged, you know, some people feel that this is one of the scenarios that may be a little bit overcall, it would be prolonged febrile symptoms for at least three days and severe patient pain.

So, there are some viruses we know that can cause prolonged symptoms of fever. Epstein-Barr Virus, Adenovirus, those are two really good examples of that.

So, again, I think that's a little bit more tricky to tease out in children because they can't tell us all of their symptoms but, you know, I would definitely, with the IDSA Guidelines says at least three days and you can even think about longer in children.

00:26:40

Dr. Mike Patrick: Maybe this is oversimplifying a little bit, but in terms of helping out, this is where I think sometimes comparing one provider in a practice to other providers can help. Because if you have one person who, you know, their way in which they're diagnosing a sinus infection is, you know, more like 20%. And everyone else is 6%. And, you know, pay attention to "Maybe I do need to change my habits."

So I think that can be helpful. Not to call someone help but really try to help learn and educate in the process.

Dr. Preeti Jaggi: I think one of the things that we have tried to do on, we have this, accountable care organization through children, called "Partners for Kids" and we've been looking at the claims data to see how often in a county in this case. So it's a whole county, not just a specific provider.

When you see any child with basically a respiratory complaint. So that could be anything, viral upper respiratory tract infection, laryngitis, otitis, pharyngitis, anything.

How often when you see that denominator of children? Do they get an antibiotic?

And we see tremendous heterogeneity. Actually, much less in Franklin County than some of the southern counties.

So that heterogeneity already will tell us that, you know, we need to probably build more streamline in how we diagnose this.

The other thing that is important is that there are some measures now by which providers may be getting judged which are the HEDIS measures to say, you know, we are not prescribing for a viral upper respiratory tract infection, which is great. Although some practitioners may then diagnose sinusitis.

So I think looking at the overall percentage by which of all the respiratory complaints that come into your office, how often do you give antibiotics, and to see your comparison to others may be actually a little bit more helpful. Even, you know, it's going to be difficult from an outside without actually listening into that visit. Is the sinusitis diagnosis appropriate? Is the otitis diagnosis appropriate? I think so. As I think that one general thing that can be helpful is just, how often are you prescribing for those children?

Dr. Mike Patrick: And again, if you are more an outlier, start to really think about your practices and how you go about making that diagnosis.

With the sort of lingering coughs, and I know I come across this in my own patients and in myself, sometimes you get a virus and the cough just lasts for about three weeks, and, you know, that 'Mucociliary Elevator' in the tract, you once that gets disrupted by a virus, it takes a little while to make those cells again, and you just get this persistent cough to protect the airway but not necessarily with the fever, you may not even feel that bad.

But then oftentimes, that gets called bronchitis.

To talk a little bit about that diagnosis bronchitis in kids and when that's appropriate and when it's not.

00:29:29

Dr. Preeti Jaggi: I mean, that diagnosis is really nebulous to me. "Do you have a lower respiratory tract infection?" Would be really the question. And is it viral versus a bacterial? If it's bacterial, then you're going to be thinking about a bacterial pneumonia with Streptococcus Pneumonia, and really looking for focal signs on the long exam.

And if it's viral or an atypical pathogen, you may have a little bit more diffuse sounds.

So, I think it's really important to do, the cough itself is not going to point you in, I think it's a physical exam, that's going to really help you.

Dr. Mike Patrick: And the clinical scenario, that if you have a bacterial infection, you're probably also going to feel sick. Not just have a lingering cough.

Dr. Preeti Jaggi: Probably not. And I think another thing that can be helpful is, you know, as it kind of a getting a little bit better as days progress.

I think the bronchitis diagnosis should go out of our real break really, is it, are we thinking if a lower respiratory tract infection, is it bacterial pneumonia versus viral pneumonia? I think that should be probably what we're really labeling it.

Bronchitis is a very nebulous description.

Dr. Mike Patrick: And I think it's used a lot more in the adult world but then parents hear that "Hey, I have bronchitis, or Dad does, and this, you know, my kids got the same symptoms." And so then, you may be tempted to call a bronchitis on a child as well. When really, everybody now has the same viral infection.

In terms of choosing an antibiotic, I'm going to have a bunch of links in the show notes for this Episode 31 over pediacastcme.org.

But some of them that I used, and if there are others that you find helpful in terms of once you make a diagnosis of a bacterial infection in the upper respiratory tract or elsewhere, lower respiratory tract, the other things that we're going to talk about.

The Red Book is a good place to get information, UpToDate, Sanford Guide, if you really want to know what to know the evidence behind recommendations are, the Cochrane Collaborative, DynaMed, there's a lot of evidence-based resources that folks can use.

And we'll put links to all of those in the show notes, rather than talk about all of them so that we can concentrate on the various disease processes rather than which antibiotic should you choose. As that a pretty good collection, there's something that would have…

Dr. Preeti Jaggi: I think that's probably the other resources, there's an article from the AAP about judicious use of antimicrobials, that's also a really good resource. But I think all of those are great.

Dr. Mike Patrick: Good. And we'll get it. We'll try to get a link to that one in the show notes as well for folks.

Dr. Preeti Jaggi: And I think, one more probably would be the Infectious Disease Society of America Guidelines for Bacterial Rhinosinusitis. That's another really good one, we can put on there.

00:32:07

Dr. Mike Patrick: Excellent.

So let's move on to ear infections.

Ear infections are commonly diagnosed in kids. And a few years back, there was this idea that maybe we could watch and wait with ear infections rather than treat them right away.

What are so the thinking on that these days?

Dr. Preeti Jaggi: So, really, I think under six months diagnosis of Otitis Media should be treated. But we can start thinking about less severe symptoms in the older child, especially a child over two years of age that has Unilateral Otitis Media with mild symptoms. No high fever, no severe symptoms.

We really can think about watching and waiting for those children, the other thing that is helpful with them is that they're going to be able to tell us about their symptoms a little bit more than a younger child. And you can treat their pain. Of course, we know that some otitis media is due to viruses, but we do not obtain in-ear fluid, and so we cannot make that to termination.

So I think really focusing on those over two-year-old children with milder symptoms is very very reasonable. And hopefully, parents, we just need to inform them that if the symptoms are persisting or worsening, then we would provide treatment.

Dr. Mike Patrick: So this is, you want a family, you know, that you trust, you have a relationship with, and then you want to make access to the antibiotic relatively easy for them if things are getting worse on the next couple of days. Right?

I mean, that they come, and you know, you have to wait for an hour or half to see you, and then they got to come back the next day, and wait maybe even longer, you're going to have an upset parent.

Dr. Preeti Jaggi: Yes. And I think, some, one strategy that some practitioners have used is to give the prescription but date it for there, so from when the visit is. And so the parents have that prescription in their hand if they need to start the antibiotic.

Dr. Mike Patrick: What about in urgent care and emergency department where you don't necessarily have a relationship with the family? Is this an area that then ear infections probably get more antibiotics than they need to because you're not getting necessarily to see these folks again.

Dr. Preeti Jaggi: That is a good question. I don't know that they, that is really clear and in literature studies for, I think that that is a very valid concern that you don't know, that if the parents are going to be coming back.

So I think, you know, if again you could give the prescription with the delayed start date, that is a reasonable thing. And of course, it's just going to be a conversation with the family, see if that's something that they would go along with.

Dr. Mike Patrick: And maybe there'll be, it's a little difficult with electronic medical records and sending prescriptions electronically, that sure hide changes the date on those if it's not handwritten.

But maybe you'd still have that conversation that "Okay, I'm sending the antibiotic" But, you know, maybe explain why antibiotic stewardship is important, and giving it a day or two before you go pick it up, and then, of course, they're not going to fill it at the pharmacy, they're not going to reconstitute it until you're there…

Dr. Preeti Jaggi: Until you're there.

Dr. Mike Patrick: So it's not like, you know, then that medicine gets thrown away.

Dr. Preeti Jaggi: And I think, probably one of the challenges that I hear from primary care practitioners is that it takes time to explain that. So I, you know, I think also just doing some more general education before you're in a difficult situation where your child is crying and they're sick. Explaining to them why we try to reserve antibiotics only when necessary, when maybe, perhaps that a well-child be saved in.

Maybe more helpful than talking at that scenario when there are more than what they already said in.

Dr. Mike Patrick: So just having that commitment, that culture, maybe those posters you were talking about to jumpstart conversations that other times excellent point.

Okay, so let's talk about throat infections. So, strep throat, what is the problem?

So traditionally, what we have done, if a kid says that they have a sore throat, you do the throat swab, if it's positive, you treat them for strep throat. If it's negative, we know that there's a quite few false negatives. And so, we do a secondary test. And if that's positive, we treat them.

But now, there's some issue with that in terms of maybe overtreating. Tell us the situation there.

00:36:12

Dr. Preeti Jaggi: So it's just important to recognize that most pharyngitis is due to viral ideology. And again, we don't typically get viral testing to determine it.

So, Epstein-Barr Virus, cytomegalovirus, adenovirus, all these viruses that can cause a pharyngitis.

And we know that the really the justification for treating for streptococcal pharyngitis is to prevent rheumatic fever, and those are very old studies. We know that there were met instances or rheumatic fever in our area here is pretty low. So we have to balance that as really the primary justification for treating streptococcal pharyngitis. With perhaps treating a streptococcal carrier.

So I think this is a really important area especially as we are focusing more on stewardship, kind of simultaneously in the microbiology world, they're really working towards tests that are going to probably make our method of testing a little bit different. Right now, we do a rapid streptococcal test and then we perform back up testing with either culture or perhaps the molecular test.

Really, they're kind of working towards getting a very sensitive molecular test.

So that means, as clinicians, we need to be very, very focused on who we actually swab. That's an area, that's called diagnostic stewardship.

When is it appropriate to swab?

And I think that is really, really important to follow the Infectious Disease Society of America Guidelines which really say, it's really primarily for children over the age of three, because children under the age of three generally did not get rheumatic fever historically, and those without viral symptoms.

So, this may be again an area that you can focus on with your nursing staff perhaps. Because they may be swabbing before you actually walk into the room. And I've heard that from practitioners.

So really, we actually just made a chart basically with the Infectious Disease Society of America Guidelines for Outpatient Urgent Care Nurses, and it really does says, if a child has prominent upper respiratory symptoms with cough rhinorrhea, then you don't swab automatically. Wait for your clinician to go see the child.

If they've got diarrhea, more than three stools in a 24-hour period, mouth sores, that's also a little bit more indicated of a viral ideology. Don't automatically swab.

And if they're under three and they have no contacts with streptococcal pharyngitis, really, that would not be an indicate to swab immediately.

And then, you can make that decision up to the clinician that's going in to see the child. Because a couple of times, the primary care providers have told me that they wouldn't have actually swab, but the test is positive and they feel a little bit stuck.

So that may be a situation where you're treating a streptococcal carrier.

So I think that it's really important to have your nurse and staff really aware about those scenarios when it's appropriate to swab.

00:39:00

Dr. Mike Patrick: And being a carrier for strep, it is not associated with an increased risk of rheumatic fever, correct?

Dr. Preeti Jaggi: Correct. We think that that is just harboring the organism and the post-reference, but no long-term consequences.

Dr. Mike Patrick: And so, there are a lot of kids then with positive rapid strep test who are really a carrier and they don't have streptococcal disease. And so, they're not in an increased risk of rheumatic fever, and should not be treated with an antibiotic.

Dr. Preeti Jaggi: Correct. And I think that really probably the best way to focus on this is to just really be very judicious of who gets the swab in the first place.

Dr. Mike Patrick: And there's going to be, you know, if we say if they have predominant upper respiratory symptoms, then they shouldn't get a swab.

But this is then where the judgment call. The providers going to be important because if you look in their mouth, then they have palpable petechiae and their tonsils are enlarged, and they have exudate on them, and they have a tender lymph node, you know, then you're more likely to say "No, this is a kid we should swab."

Even though they have a cough and runny nose.

Dr. Preeti Jaggi: And I think what we'd focused on is really, I don't think we can rely on the nurses having to make that judgment call, that seems a little bit over beyond the scope of what they're going to do and that sort of a 'Triage Process'.

Dr. Mike Patrick: Because they're just trying to get people through it quickly…

Dr. Preeti Jaggi: They're just trying to get people through.

So we really just trying, we're trying to focus on that. Even that has made a really significant difference in the amount of swabs that have been performed.

So, you know, we're not saying "You never would swab, it's just that you're just leaving it up to the clinician to decide once they see the child and get a little bit, perhaps more history.

And I think, sometimes, some of the symptoms are very mild, they may have coughed a couple of times, or do they really, how prominent are those symptoms, they're just some subjectivity to that, too.

So, we're just trying to get at, you know, the ones that really we think are very, very over swabbed. And then the clinician always make that to termination.

Dr. Mike Patrick: And this is when it would be easy to come up with an intervention in office, in terms of setting up an antibiotic stewardship program where you could come up with a set of the case. "So here's the criteria of when the nurses are going to swab before I go in."

And then you could also just take look at who's getting antibiotics, and what was the result, what was the swab done, or they're just giving an antibiotic without the swab, and then looking at the result of the swabs, and whether an antibiotic was prescribed or not.

So you could get some feedback and see how each individual provider's doing. And then look overall, are we treating less strep? Or we diagnosing less strep pharyngitis?

Dr. Preeti Jaggi: Absolutely.

Dr. Mike Patrick: Because really, you should treat all of them if we truly think that's what it is, right?

Dr. Preeti Jaggi: And I think…

Dr. Mike Patrick: And if we do diagnose…

Dr. Preeti Jaggi: We do have the chart of those it's fairly easy to follow that we can put on the website and people can use that in their offices as well.

Dr. Mike Patrick: Just the outline of the flowchart.

Dr. Preeti Jaggi: Just the flowchart, it's pretty simple actually, but sometimes it's a little bit nicer to have it in a chart form versus just sort of a written document because I think it's a little bit easier for the nurses to follow.

Dr. Mike Patrick: One point, this is sort of going beyond the antibiotic stewardship. But you've got to hear it, the questions in my mind. So if we're seeing less rheumatic fever, is that because we're doing a better job diagnosing and treating strep? Or is it because they were strains of strep that were more associated with rheumatic fever and maybe those aren't circulating as much?

00:42:09

Dr. Preeti Jaggi: There is probably a combination of factors which are not completely elucidated but hygiene, actually, and closed-living conditions have also improved in the last thirty to forty years. So that may be one factor would decrease transmission.

The types of strains circulating, that's been conjectured to be one of the reasons as well. We think it's one of the postulates is that there's M Protein on the Group A strep bacteria, and there's cross-reactivity to that M Protein and the types of M Protein that were circulating thirty-four years ago in the United States seem to be different than the ones that are circulating now.

So that may be one reason as well, and that we're treating streptococcal pharyngitis.

So there are lots of different reasons there which we don't know, you know, kind of the absolute contribution of each of those factors.

Dr. Mike Patrick: And then you'd mentioned in terms of young kids, so less than three years of age. Should those, are there instances where you should test them for strep? Or just not at all?

Dr. Preeti Jaggi: So, it's important to clarify that children under the age of three can get, the can get Invasive Group A Streptococcal Infection, they can get a Streptococcus, which tended to be a really purulent nasal pharyngitis in those children.

And, you know, we might think about it if there's a, especially if you're kind of getting closer to that three-year-old age if you any have a contact with streptococcal pharyngitis, maybe a sibling.

That might be reasonable. But in general, I don't think it should be our rule of thumb, that we are treating those children.

Dr. Mike Patrick: Okay.

Dr. Preeti Jaggi: They've also can get a local purulent complication of streptococcal pharyngitis, like a deep-neck infection, a pair of tonsillar infection, or perhaps a retropharyngeal infection.

So, it's not that they can never get it. It's just that they're generally not going to get rheumatic fever. It's very very rare in the history.

Dr. Mike Patrick: But again, other strep infections which we've not really talked about, that would go beyond just a simple tonsillitis, pharyngitis, so peritonsillar abscess, retropharyngeal abscess, those kinds of things. You are going to need the diagnose of other ways, either clinically or with imaging. And those, obviously, you do want to treat.

Dr. Preeti Jaggi: And those, obviously, you do.

Dr. Mike Patrick: And even you don't treat those based on whether the strep is positive or negative, those just get treated.

Dr. Preeti Jaggi: Those would be. Because there can be anaerobes and the pharynx are also causing that. One of the big ones is Fusobacterium, which is one of the anaerobes.

So I would be looking out for torticollis in the child, a lot of drooling in the child. Generally, we're not going to see torticollis with a simple pharyngitis.

00:44:48

Dr. Mike Patrick: And if there's a shift of the uvula…

Dr. Preeti Jaggi: The shift of the uvula, absolutely.

Dr. Mike Patrick: Over one tonsil's a little bigger than the others. But should there's some fullness surrounded, then you may be concerned more about the invasive process.

Dr. Preeti Jaggi: Absolutely. And probably more ill-appearing child, as well.

Dr. Mike Patrick: Yes, yes.

Dr. Preeti Jaggi: People has to talk about a bulging poster referring, I think you really got a one-second look. But, asymmetry of the tonsils is very important.

Dr. Mike Patrick: Drooling…

Dr. Preeti Jaggi: And drooling…

Dr. Mike Patrick: Kind of what we call 'hot potato voice'.

Dr. Preeti Jaggi: And they can actually get a bit of a neck mass as well. So it's sort of, doesn't feel very superficial like the lymphadenitis. But they can get a sort of a mass in the neck, too. So that would be another clue that may be going on.

Dr. Mike Patrick: And then Epstein-Barr Virus, so mononucleosis can cause a bad pharyngitis as well. And in fact, if you treat that with an antibiotic, you may end up, especially with the penicillin antibiotic, you may end up with a rash.

Dr. Preeti Jaggi: Right.

Dr. Mike Patrick: And if you think you're allergic to penicillin…

Dr. Preeti Jaggi: Exactly.

[Laughter]

Dr. Mike Patrick: Things will get complicated.

Let's move on to urinary tract infections. This is another area where we have an opportunity to practice antibiotic stewardship.

00:45:49

Dr. Preeti Jaggi: So I think a couple of the things that are really important here is to recognize that we need to do catheterized specimens in children that are not able to give us a clean catch basically.

So we know that the utility of doing the bag urine specimen is going to give you normal perineal flora.

So I think that's one of the really big things, again, this is sort of the concept of diagnostic stewardship. We're not going to be sending cultures on a bag specimen.

You know, sometimes, it's very uncomfortable to do the catheterization, parents don't like it. You can do a urinalysis, and then say if the urinalysis is normal than I do catheterization, that could be an option. But really doing cultures on bag specimens should be really discouraged.

I think that's a very important thing.

And it's important to…

Dr. Mike Patrick: Also the, sometimes you'll see a clean cup, like "Okay, it's a brand new one, and plastic, and we'll put the insert into a little potty chair."

That is just as bad as a bag.

Dr. Preeti Jaggi: As the bag. You really want to only be doing it clean-catch in a person who can give you a mid-stream urine.

And it's important to recognize that the AAP Guidelines for Urinary Tract Infection between two and twenty-four months, really rely on both Peoria and positive urine culture.

We have seen scenarios where people are treated for presumed urinary tract infection and they never have a culture, and that young age strip, you really do need a culture.

So that's another important part of, again, diagnostic stewardship.

And actually, one of my colleagues, Dr. Watson, and Dr. Saha, in the urgent cares, we've done a project where they really just asked the nurses to follow up on young cultures and tell the parents to stop the antibiotic if they were treated for a presumed urinary tract infection. And in fact, the culture was negative.

And really, they saved over several periods about three thousand days of antibiotic therapy.

Dr. Mike Patrick: Wow, that's impressive.

Dr. Preeti Jaggi: That's a pretty easy thing to, and it also helps the parents recognize that you might be getting treated empirically, but you may not have a urinary tract infection. And it's very difficult in young children where they're not going to be able to tell us really about their symptoms.

00:47:52

Dr. Mike Patrick: And if you have that culture in the office where someone's following up on the urine culture, and that letting the parent know, "Okay, we're going to stop the antibiotic because we don't think there's really urinary tract infection," but that kind of plans that see that "Hey, this antibiotic stewardship is an important thing." So then when you have the next conversation about an ear infection, or about the strep throat, makes that conversation easier. Just because the whole office is kind of on board with this.

Dr. Preeti Jaggi: Exactly.

Dr. Mike Patrick: So, how do you diagnose urinary tract infection? What is it look like on the urine strip that would make me say "This is the kid I'm going to treat."

Dr. Preeti Jaggi: So you're going to be looking for evidence of an inflammatory process, so pyuria, you can use leukocyte esterase as a surrogate. If you're doing actually microscopic urinalysis, you really do want to do then several hours.

So in an office setting, you may not be able to do that. So the AAP says that you can use the leukocyte esterase as a surrogate marker of pyuria.

We know that nitrites would be very helpful test, although it's a very low-sensitivity but higher specificity for pathogen in the urine.

So that could help you, as well.

And really looking for that would be the big things that I've been looking for.

Dr. Mike Patrick: So, it's easy when that comes back with large leukocyte esterase, nitrites are present, the kid's got a fever, and says that it hurts when they pee. But then there are these cases where you get a trace of leukocyte esterase and nothing else.

What about those situations?

Dr. Preeti Jaggi: I think that's, it's not very specific. So, you're going to have to follow your urine culture. Now, the question then comes, who do we empirically treat and who do we not empirically treat? And we're kind of trying to look into that. I think that there are, we're going to have to correlate with clinical symptoms. Obviously, if you have flank pain and fever, we are going to say, "You likely should be treated."

A person that has maybe mild symptoms, or very non-descript symptoms, I think, we're trying to sort out what are the factors associated with that positive urine culture.

So I think, we're not completely clear on that.

But if they seem to have mild symptoms, maybe perhaps a febrile, maybe it would be able to wait a day and see if the urine culture's positive.

Dr. Mike Patrick: Because those two usually grow pretty quickly…

Dr. Preeti Jaggi: They usually do grow pretty quickly. Absolutely. You'll at least see some preliminary growth, you may not have full identification but you'll at least see some preliminary growth.

So having a good relationship with your micro lab is important. Sometimes, they're not going to, they're going to be checking it different frequencies for those urine cultures. Sometimes they track later in the morning, you might have to check it first thing in the morning.

So having a relationship that you could call with the micro lab, it can be very helpful, as well.

00:50:28

Dr. Mike Patrick: And then, when would you consider a culture positive?

Dr. Preeti Jaggi: I would, in general, over a hundred thousand colony forming units of a single uropathogen, so that's very important. Any uropathogen.

So what we generally would be thinking about is E. coli, obviously is our most common cause. We know that Staphylococcus saprophyticus can cause symptoms in a sexually-active female or an older female.

So this would be the two things.

And then, of course, you're going to be looking at prior history of urinary tract infections. If somebody has had a prior infection or they have an abnormal urinary tract with a Pseudomonas or Klebsiella, those can certainly cause. But those would be a little bit less complicated.

Dr. Mike Patrick: And those in complex kids…

Dr. Preeti Jaggi: Those who are generally complex…

Dr. Mike Patrick: You're not surprised they have urinary tract infection and you can kind of look and see what grew last time.

Dr. Preeti Jaggi: Yes.

And then, I think it's important to, generally, if you're going to give impaired treatment, probably give impaired treatment for what they've had in the past. That seems to make sense.

Dr. Mike Patrick: And speaking of impaired treatment, actually let's go back to the culture real quick.

So over a hundred thousand, and then but if it's a cath specimen, then you have a little lower limit on that.

Dr. Preeti Jaggi: A little bit lower. Okay, so, you know, over fifty thousand colonies, could've been AAP, would be, and evidence of pyuria, of a single uropathogen, could be pretty good evidence of the trigger of urinary tract infection.

If you have between ten to fifty thousand colony-forming units, I think that is important to recognize that there are a couple of scenarios where it could be a true urinary tract infection. So again, if you have flank pain, and a lower colony count, it may be a true urinary tract infection.

So, we have had, sometimes, patients that have had even unusual pathogens like an MRSA, Methicillin-Resistant Staphylococcus Aureus. And they have a phrenic abscess for instance. They could have lower colony-forming units in the urine.

So we can never devoid that from the clinical scenario. So, but in general, that may be a lower threshold for a kind of a typical urinary tract infection.

00:52:30

Dr. Mike Patrick: So you really have to look at the whole picture. You know, what is the, what's the clinical state of the child. But then, also, how was the urine collected. And then, how much is growing.

And if you ever have any question, you can always call your friendly Infectious Disease Specialist, right? At your local children's hospital.

Dr. Preeti Jaggi: Yes, and we also have a guideline for urinary tract infections, that we can also put on the resources.

Dr. Mike Patrick: Okay. Excellent. That'll be fantastic.

In terms of impaired treatment, so a lot of this really kind of depends on your local area, right? In terms of what the common organisms that would cause urinary tract infection, like  garden-variety E. coli, what the sensitivities are. And you can get that kind of information from your local lab, correct?

Dr. Preeti Jaggi: Correct, yes.

So it's really important. They usually will publish an antibiogram, where they going to show you the number of isolates that they looked at, are E. coli isolates are from the urine specifically? And non-urine isolates, so you can look at that.

Many of our E. coli isolates actually are sensitive to the first generation cephalosporin. So we can sometimes just use cephalexin to treat empirically for urinary tract infections.

This is going to be really important to look at your antibiogram in your area.

Dr. Mike Patrick: Maybe listening to this five years from now, and who knows what the sensitivities are going to.

Dr. Preeti Jaggi: It may change. It's going to something that you're going to want to see if you can for your local lab to see what their published antibiogram is.

It is a little bit tricky in children. Because if you're going to a lab that has mixed with adult population cultures, they're not going to necessarily tease out the pediatric isolates. And we have actually an antibiogram, we've changed it between outpatient and inpatient.

So with an outpatient antibiogram, and an inpatient antibiogram. Because those scenarios are actually pretty different.

Dr. Mike Patrick: With the drug resistance patterns for sure.

And so, this is another opportunity with urinary tract infections where you could set up an intervention within a primary care office. Pretty easily, just in terms of making sure that every, first setting that how having a commitment, setting the policy, when we're going to check for urinary tract infection, and that we're going to get a culture every time that we are suspicious that there is a urinary tract infection.

Dr. Preeti Jaggi: And then following up on those cultures.

Dr. Mike Patrick: Yes.

And then you can go back and see "Hey, did we get a culture every time we diagnose a urinary tract infection?" and "Did we actually follow up on every one of those and then stop the antibiotic if it didn't look like there really was an infection there."

So that's one that you could then track and get some feedback…

Dr. Preeti Jaggi: Absolutely.

Dr. Mike Patrick: And would be a great program for a primary care office.

Dr. Preeti Jaggi: Absolutely.

00:55:03

Dr. Mike Patrick: Let's move on to some skin infections.

So, you know, MRSA abscesses, it seems like we see lots of those and drain them.

Should we, beginning a culture every time or if the kid has a history of MRSA that looks like MRSA that's probably what it is.

Dr. Preeti Jaggi: That's a good question. We generally advocate for getting a culture. I think I'm a little bit biased because I'm in the inpatient setting. I think that the, I think if somebody's have repeated culture, repeated skin infections, that is a really nice time to get cultures especially.

The reason is, because not all MRSA are sensitive to the things that were tending to empirically treat, for instance, with clindamycin. We can have both constitutive and inducible resistance to clindamycin.

So because a lot of people are empirically using that, I think that would be important, if you've started to get repeated infections, I think it would be important to do that.

The question is also: "Do you need to treat for a simple skin infection?" That is less than five centimeters in an afebrile child, well-appearing child.

So actually, there was a pretty big study that was involved adults and children that was published to share in The New Journal of Medicine. And what they, they randomized the children to either get, the patients aren't that all children, to get either placebo clindamycin or trimethoprim-sulfamethoxazole.

And they saw their clinical cure rate at about seven days. And then, also the recurrence rate within a month.

Dr. Mike Patrick: And this is without drainage.

Dr. Preeti Jaggi: This is with drainage.

Dr. Mike Patrick: The which drain?

Dr. Preeti Jaggi: This is for abscess. This is for, with drainage.

Dr. Mike Patrick: Okay.

Dr. Preeti Jaggi: And actually, about 60% of the children that have placebo had a clinical cure rate at around seven days. And it was a little bit higher though, for those with clindamycin, that had received clindamycin or trimethoprim-sulfamethoxazole it was like 80%.

So there is a little bit higher clinical cure rate with that, if you're an optimist, you could look at that and say 60% got better with nothing. The only other kind of caveat is that there was a little bit higher recurrence rate at a different site within a month.

So I do think it's probably reasonable to treat. If you have a really good relationship with the family, I mean, I think that's one thing that primary care providers have an advantage. You could call them and ask them if they're doing well and then start in a day or two, that's potentially an option for you.

00:57:23

Dr. Mike Patrick: So it's kind of like with the ear infections, the watch and wait. But you want to have that relationship with the parent, and then follow up, and make sure that if it is getting worse or not getting better, that you have the opportunity to get the antibiotic started.

Dr. Preeti Jaggi: Yes. So I think that's, generally in a hospital setting, or urgent care, I think we generally are starting treatment because there is a bit of a higher cure rate with treatment.

And then the other question is: "How long do you treat for skin and soft tissue infections?"

So the IDSA Guidelines really say, they say kind of seven to ten days. When we've looked at our healthcare claims data, most people are treating for ten days. And that's actually for either cellulitis or abscess.

So one of the prospective studies, another prospective study, that enroutes in children for abscess actually is seven days of treatment with trimethoprim-sulfamethoxazole and had good success rate with that.

So that, I think is an option, probably staying in the lower duration is probably better than doing ten days.

And for cellulitis, the Infectious Disease Society of America Guidelines actually just say five days and reassess.

And I think that using claim study, we can really elucidate if it's abscess or cellulitis. You can only do that clinically. But I think that's very reasonable to start with a five-day course.

Dr. Mike Patrick: And if you're in a situation like an urgent care, an emergency department, where you're not necessarily going to be the one following up, just making sure that they have that follow up with their regular doctor. If you're going to do a shorter course.

Dr. Preeti Jaggi: Absolutely.

Dr. Mike Patrick: To see if they still need it. And would that apply in clindamycin as well?

Dr. Preeti Jaggi: Yes, so clindamycin, in the prospective study that I just mentioned where the use the three treatments, the placebo, trimethoprim-sulfamethoxazole, clindamycin, actually chose ten days of treatment. Which is, that's just what they chose, which I was a little bit disappointed with.

[Laughter]

I wish they would have chosen at least seven days of treatment.

But, at least for, in another perspective study they used seven days of trimethoprim-sulfamethoxazole on a good success rate, so I think seven days is probably pretty reasonable.

Dr. Mike Patrick: Okay.

And then, kind of stepping backward, because we didn't talk about the length of treatment for these other conditions. But I think that's an important consideration.

So, urinary tract infections? Ten days?

Dr. Preeti Jaggi: There is actually an ongoing study right now for febrile urinary tract infections. It's randomized, I believe five to ten days if I'm not mistaken.

So we will probably have a little bit answer to that question when that prospective study comes out.

And, you know, I think this is really an important subject because we really didn't have a lot of studies, we're looking at duration of treatment.

Dr. Mike Patrick: It's just ten days, that's in pediatrics.

Dr. Preeti Jaggi: I think, for a younger child, where you suspect that it was a pyelonephritis. Meaning that they have a fever, flank pain, or vomiting. I generally have been doing seven days, but I'm hoping that that study will give us a little bit more information.

Dr. Mike Patrick: Strep pharyngitis, we can use at least as of today, in 2017, we can do more low dose, some amoxicillin, so I think it's 50mg…

Dr. Preeti Jaggi: Can do once a day, absolutely.

Dr. Mike Patrick: Once a day. But for ten days?

01:00:23

Dr. Preeti Jaggi: The studies have really been, the studies that have been done in the past used ten days. That's why we use ten days.

Again, we have to had probably more prospective studies to help us with that.

Dr. Mike Patrick: And ear infections, same, the days?

Dr. Preeti Jaggi: Ear infections, there is a nice study that was done by Alejandro Hoberman in Pittsburgh and they, this is only for children under the age of two. And they randomized them at five or ten days and, ten days was a little bit better.

Dr. Mike Patrick: Okay.

Dr. Preeti Jaggi: So for under two with a bonafide otitis media diagnosis, probably ten days is appropriate.

Dr. Mike Patrick: And some of that…

Dr. Preeti Jaggi: Or maybe shorter courses for older children.

Dr. Mike Patrick: Sure. And some of that depends on how well the antibiotic gets to the infection. So, if noticed, if you don't get as good of a concentration of the antibiotic, maybe you need to do it longer so you could see well, it's going to get in the urine. The antibiotic, if, you know, as long as it's excreted by the kidneys, it's going to really get in the urine pretty well.

Or is the middle ear space may be a little more difficult to concentrate the antibiotic. Am I off mark there?

Dr. Preeti Jaggi: No, I don't think you're off mark, and I think that that clinical study really showed us that at least under two, we should be treating for ten days.

And that was a well-designed prospective study.

Dr. Mike Patrick: Sure.

Well, we really appreciate you stopping by and talking about antibiotic stewardship with us, and we're going to have tons of resources in the show notes this week over pediacastcme.org. Look for the show notes for Episode 31 and we'll have, all the things that we've been talking about, we'll have links for folks so they can find it easily.

Dr. Preeti Jaggi: And one more resource that may be helpful for clinicians is actually comes from the sociologists that worked on antibiotic stewardship, and they have a couple of guidelines for how to talk to parents when you do not think that they need an antibiotic for a viral upper respiratory infection, so they really talked about first saying. You know, on one hand, we don't need antibiotics for this infection because we don't think it's too adjourned that we'll respond to that.

And then on the other hand, trying to then mention some things that they can do to help their child to feel better.

So they talked about really pairing sort of a negative or we're not going to do anything recommendation first, saying that and then giving some positive recommendations.

And have a look at that with patient satisfaction, and that's pretty helpful. So we can put that on the site as well.

I think that actually, our sociology colleagues may be helpful to us in medicine because, really, there are a lot of factors that are involved when you make the decision to prescribe an antibiotic. And I think they have a lot of expertise in that area that were not necessarily trained then.

01:02:43

Dr. Mike Patrick: And I think that one issue that comes up is that if you aren't used to seeing a lot of kids, sometimes you feel safer like "Well, just put him on the antibiotic just in case." Because, you know, we care about kids, parents care about their kids. And so you want to kind of go that extra step.

But if we started thinking about the fact that "No, we actually may be harming those kids when we're using antibiotics inappropriately" then it's important to really educate ourselves especially maybe those who don't see as many kids as others do.

Dr. Preeti Jaggi: Absolutely.

Dr. Mike Patrick: Well, Dr. Preeti Jaggi, Infectious Disease Specialist here at Nationwide Children's Hospital, thanks so much for stopping by today.

Dr. Preeti Jaggi: Thanks for having me.

01:03:21

[Music]

01:03:50

Dr. Mike Patrick: We are back with just enough time to say thanks to all of you for taking time of your day in making PediaCast a part of it, we really do appreciate that.

Also, thanks to our guest this week, Dr. Preeti Jaggi, really appreciate her sharing her expertise with us on antibiotics.

Don't forget, you can find PediaCast in all sorts of places. There may be a way to listen, that is easier than however you came across us today.

We are in the Apple Podcast app, so please do subscribe to us there, if that's where you get your podcast. iTunes, Google Play, iHeartRADIO, Spotify, most mobile podcast apps for iOS and Android.

If you do come across a podcast app and you can't find PediaCast in there, be sure to let me know. Just head over to the landing site, which is pediacast.org.

We have a contact page there. And let me know if you can't find us in wherever that you like to listen to podcasts.

Also, with that contact page, you know, write in, let us know what you like to hear. What kind of topics you would like us to talk about, we have all of 2019 ahead of us, and we're slowly filling our editorial calendar. But if there are topics that you want to hear about, I do want to make sure we include those.

We also take questions from listeners, so if you have a pediatric or parenting question for me, fire it away. Just use that contact page. And we'll try to get your question answered on the program.

We also have our entire archive of past programs, so 418 episodes there. Along with the show notes for each episode, our transcripts, written transcripts of many other programs. And of course, our Terms of Use Agreement which is very important.

And once again, please do consider connecting with us on social media, we're on Facebook, Twitter, and on Instagram.

And of course, we really appreciate it when you tell others about the program, whether that's leaving a review, wherever you listen to podcasts, reviews are so important and helpful. And we always use reviews as we make decisions throughout the day anymore. And listening to that listening to podcast is part of that. And, you know, reading a review to see "Hey! Is this podcast worth my time?" is helpful.

And so, if you do find PediaCast to be helpful, even if you don't, please do consider leaving a review for us.

And of course, we really do appreciate it when you tell your family, your friends, your neighbors, your co-workers, babysitters, daycare workers, anyone who has kids or takes care of kids, who you think would benefit from hearing PediaCast.

And that includes, by the way, your child's pediatric healthcare provider. Please do let them know about the shows, so they can share it with their other parents and families.

And while you have their ear, let them know we have a program for them, as well.

PediaCast CME, that stands for "Continuing Medical Education" It's similar to this program, we turn up the science of a couple of notches, we offer free Category 1, Continuing Medical Education credit, for those who listen. In fact, today's interview was originally a part of that program. But I just thought it was so important and useful that a parent would get something over that one, out of today's too. Hopefully, you did.

And the shows and details for PediaCast CME are available at the landing site for that program pediacastcme.org. Those shows are also available on Apple Podcast, iTunes, Google Play, iHeartRADIO, Spotify, and most mobile podcast apps, hopefully, all of them.

Simply search for "pediacastcme"

Thanks again for stopping by, I do hope everyone has a very happy thanksgiving. And we'll catch up the week after that.

Until then. This is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids.

So long everyone!

01:07:16

[Music]

01:07:32

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast. 's. Thanks for listening. We'll see you next time on PediaCast. 

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