Smart Antibiotic Use: What Parents Need to Know – PediaCast 593
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Show Notes
Description
Dr Jason Newland visits the studio as we consider antimicrobial medications and the stewardship programs aimed at saving them. Antibiotics emerged as miracle drugs in the early 20th Century. However, these life-saving treatments can lose their effectiveness if not used correctly. Tune in to learn more, including the role each of us can play in keeping them working!
Topics
Antibiotic Resistance
Antimicrobial Stewardship Programs
Guest
Dr Jason Newland
Chief of Pediatric Infectious Diseases
Nationwide Children’s Hospital
Links
Pediatric Infectious Diseases at Nationwide Children’s Hospital
Core Elements of Antibiotic Stewardship
2019 Antibiotic Resistance Threats Report
Antibiotic Durations for Skin and Soft Tissue Infections in Outpatient Pediatrics
Episode Transcript
[Dr Mike Patrick]
This episode of PediaCast is brought to you by Pediatric Infectious Diseases at Nationwide Children's Hospital.
[Music]
[Dr Mike Patrick]
Hello everyone, and welcome to another episode of PediaCast. We are a pediatric podcast for moms and dads.
This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 593.
We're calling this one Smart Antibiotic Use, What Parents Need to Know. I want to welcome all of you to the program. We are so happy to have you with us this week.
As you likely know, antibiotics were a miracle drug when they were first introduced in the early to mid-20th century, and they have in fact saved millions and millions of lives. However, when they are overused or misused, they can lose their power. Bacteria can evolve to evade the damage caused by these medications, which leads to antimicrobial resistance.
And this is a growing problem that impacts children and adults around the world because it means antibiotics can lose their effectiveness, which leads to difficult to treat and sometimes life-threatening infections and the need to develop new drugs, which can be quite expensive. And these are dollars that could have been spent developing treatments for non-infectious diseases if the antibiotics that we have continued to work. So, this week we are exploring antimicrobial resistance and the importance of stewardship programs aimed at preventing this resistance from occurring.
By the way, right out of the gate, let's get some definitions squared away. Antibiotics target bacteria. Antimicrobials, you'll also hear us use this word today.
It's a bigger classification that includes antibiotics, but it also includes drugs aimed at stopping other kinds of microbes such as viruses, fungus and or yeast and parasites. So, a stick around as we discover how each of us can play a role in keeping antibiotics and those other antimicrobials working so they can protect us when we need them now and for generations to come. We'll also consider how vaccines play a role in all of this and the risks of using antimicrobials when they are not needed.
And just a hint, resistance is not the only concern. We will also explore some exciting new therapies on the horizon for the future treatment of infectious diseases. Of course, in our usual PediaCast fashion, we have a terrific guest joining us in the studio to discuss the topic.
Dr. Jason Newland is the chief of pediatric infectious diseases here at Nationwide Children's Hospital. He'll be here soon. Before he gets here, I do want to remind you the information presented in every episode of our podcast is for general educational purposes only.
We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you are concerned about your child's health, be sure to call your healthcare provider. Also, your use of this audio program is subject to the PediaCast terms of use agreement, which you can find at pediacast.org.
So, let's take a quick break. We'll get Dr. Jason Newland settled into the studio, and then we will be back to talk about smart antibiotic use. It's coming up right after this.
[Music]
[Dr Mike Patrick]
Dr. Jason Newland is chief of pediatric infectious diseases at Nationwide Children's Hospital and a professor of pediatrics at the Ohio State University College of Medicine. His research interests are focused on establishing antimicrobial stewardship programs at children's hospitals, including here at Nationwide Children's. But what exactly is an antimicrobial stewardship program?
Why are they important? What impact do they have? And how can parents help these programs succeed? Well, you are about to find out. But first, let's offer a warm PediaCast welcome to our guest, Dr. Jason Newland. Thank you so much for joining us today.
[Dr Jason Newland]
Well, Dr. Mike, thank you. You know, this is a huge honor to get to go on PediaCast. I mean, like this, I've been wanting to be on as soon as I arrived in July of 2024.
So, thank you. Thank you for this opportunity.
[Dr Mike Patrick]
Well, you are, you are welcome and you are more than welcome on PediaCast anytime. So, if you have ideas, just shoot them my way and we'll get you back on the program. I think a great place to start here is just sort of a definition of antimicrobial resistance, because the reason that we even have stewardship programs is because of this thing called resistance.
And I'm sure a lot of moms and dads have heard that word before. What do we mean when we say resistance to antibiotics or that microbes have developed resistance?
[Dr Jason Newland]
Yeah, no, this is tremendous, right? This is, this is fundamental of what, where we are. So, we're like, we have all these microorganisms in our environment.
I mean, way more of them than us. And these can be bacteria. They can be viruses.
They can be parasites. We most are familiar with bacteria, right? The things that cause ear infections, like a bacteria called streptococcus pneumoniae, maybe the bacteria that causes a urinary tract infection, like E.
coli. These are, these are what people hear. Well, you know, back in 1928, Alexander Fleming noticed this petri dish with a clearing of basically with Staph aureus.
But then we had our first, one would say penicillin be one of the big first antibiotics. Sulfa drugs were right before that, that were then finally put in practice around the 1940s. And right.
There are bacteria. And so, we're focused on bacteria like this streptococcus pneumoniae or Staph aureus that causes skin effects. These things replicate fast.
They evolve; they change. We started trying to get rid of them because they're causing infection. Whether it's an ear infection, pneumonia, bad pneumonia.
Maybe a bad skin infection. And what we see with resistance is essentially I'm giving an antibiotic to kill that bacteria. You name it.
I don't care what name it is. And it changes because you know what it wants to survive. And so, by it then has mechanisms to say, hey, you're going to do that.
I'm going to do this. Not only bacteria do it, fungus do it more complicated. We have fungus now.
Thankfully our immune systems handle, and it's not as big a deal, but if you're immunocompromised, that might be an issue. So, we have fungus, maybe parasites, a famous parasite, malaria worldwide. So, we use, we have drugs to treat malaria.
It can have resistance. So, it's just this it's evolution at its finest because they can do it fast. It changes.
[Dr Mike Patrick]
Now, when you say it says, I want to survive, it really, the, the microbe is just having random. Changes. Is that right?
I mean, there's random changes or is there something that invokes resistance?
[Dr Jason Newland]
Well, we know that if you look at areas where there's a lot of antibiotic use. Right. So, if I give a lot of penicillin in an area, we'll find a lot of bacteria that have that resistant.
This notion that I don't, we say it's random, Dr. Mike, I, I would, I would argue this probably coordinated a way that it's saying, hey, I got to change. It's not like, hey, I'm thinking I'm going to change. I'm going to change you.
But you see that structure happen. I think a bacteria we see in the hospital. So, all those listening that work in, you know, in the hospital setting Pseudomonas aeruginosa.
Right. And you're in medicine, right? We hear about Pseudomonas.
We're trained about Pseudomonas from soon into medical school or it's nurses. I mean, everyone knows that's a really complicated back, what we call a gram negative, so it looks pink under the microscope bacteria, and it has all kinds of mechanisms it's developed. It produces like an enzyme that goes in attacks and antibiotic it changes.
It kicks antibiotics out of its cell. Like it can. And I think this is what makes it so hard.
Bacteria have developed so many strategies, and we keep identifying new ones have resistance. So, what I would tell you and our audience is that we are not going to overcome resistance from pathogens. There's a lot more of them.
They're changing. We have to do our best to number one, develop new drugs to help, but also limit the pressure when we don't have to give pressure, meaning I'm giving more of it when I don't have to. So, it doesn't develop the resistance.
It's tricky. Here's a story. Can I tell a story?
[Dr Mike Patrick]
Yeah. Yeah, absolutely.
[Dr Jason Newland]
Here's a history. June 30th, 1924, Calvin Coolidge Jr. Is playing tennis on the white house lawn. I tell this story all the time.
This is the president's son. That's right. It's the president's son playing tennis, gets a blister.
He's doing a barefoot, gets a blister on his big toe. On July 7th, 1924, he dies. His blister was an infection, right?
It's probably a staph aureus infection, right? This germ that lives on your skin or group A, maybe it's group A. We don't know.
But what you do know is that he developed sepsis and he was in what is now, I think what would have been Walter Reed and he died on July 7th, 1924. That was only 101 years ago, guys. That's not that long ago.
And to think of a child, a 16-year-old dying of having a skin infection of their big toe, we can't even comprehend that because that doesn't happen. But yet we could go back to that.
[Dr Mike Patrick]
If, if bacteria develop resistance to everything we have or it becomes too expensive to make, you know, the, the research and development that's needed. We see dollars, especially in medical research being taken away and we, you know, we just assume that these things are going to work and we're going to find new ones and we'll, we'll overcome any resistance, but those are not good assumptions, especially in today's research climate.
[Dr Jason Newland]
That's exactly right. And I think what I, I always, I always say like, you know, so I'm, I'm, I'm older. Right.
I'm in the, I like to say I'm mid, so I think I'm still mid-career based on my age, but I'm like on the later end of the mid-career, right?
[Dr Mike Patrick]
Yeah, that's, that's where I am too.
[Dr Jason Newland]
Right. Like, so you know, you're 20 years into this game and I, and I basically talked, hey, we need to use antibiotics where we can use the antibiotics for it. But now what I've failed to really talk more about is the prevention side, which hearkens to vaccines.
And so, if you think about vaccines, they prevent infections, right? So, they perfect, you know, have a strep pneumonia vaccine for that bacteria. We have seen a tremendous reduction in invasive pneumococcus, same strep pneumo invasive, meaning pneumonia, meningitis, right?
I mean, we're talking bad infections because of that. Think about influenza vaccine, right? That's what you're like, Jason, that's a virus.
I said, yeah, it is. But guess what? If you roll into somebody's office, clinical clinic office, people know this and you have a high fever and you're running nose and cough and I look in your ear and I'm like, Oh, that's red.
And maybe a little bulging. It might be the virus, but so you don't know. So, if you don't show up and I don't have to think about, I'm not going to give an antiviral.
Vaccines are tremendous. We've also learned that in developing worlds where maybe antibiotics are used, maybe not, they have some of the most highly resistant bacteria. We see infrastructure matters.
Sanitation matters, climate change, more bad climate disasters, where then you have, you know, bad water, people getting hurt, all this stuff. That's just adding to, so now I'm like, well, we got to focus on antibiotic use and antimicrobial use. Use it better.
Use it right. Right drug, right dose, right duration.
[Dr Mike Patrick]
Yep. And that's where antimicrobial stewardship then comes in. What exactly is that?
How does it accomplish the goal of reducing resistance to microbes?
[Dr Jason Newland]
Well, I think that's it, right? Like, so I think we do the antibiotic stewardship for two big reasons. One is the one that we're talking about, the resistance issue.
This notion that we have, you know, if I use a lot, I'm going to see more resistance. I'm going to say we're not going to zero antibiotic use. Resistance is going to be one of these situations that's going to happen.
But can we stop the rate by having programs in place that help all of us use antibiotics or antimicrobials better? So, in our hospital, right, Nationwide Children's Hospital, we have an inpatient stewardship program led by Drs. Josh Watson and Dr. Jeanette Tavares as the physicians. And it's co-led by our wonderful pharmacist, Dr. Jessica Tansmore. And they, many people in the hospital, especially the clinicians know they come walking around a few days a week to do what we call handshake stewardship to make sure to talk to teams about using certain antibiotics correctly. That's one of these things. But additionally, many of you know, you can go onto our websites and see our guidelines, and they have things like, hey, if you have acute otitis media and you're two or older, use it for five days, right?
That's a duration of antibiotics. Don't use it for the classic. We used to say 10.
We have many guidelines, skin and soft tissue infections, urinary tract infections that says, hey, not only use it for five days, but you know what? For your urinary tract infection. If you think use Keflex, we have learned that our E.
coli is 95 plus percent are susceptible to Keflex. So therefore, we're not putting pressure on some other antibiotics that we need to use later. So that's what antibiotic stewardship is, formed programs trying to help guide the use of antibiotics.
I literally just walked out of presenting with our surgical colleagues. And one of the areas we work there is that postoperative prophylaxis and make sure we're using that correct. I'd say that to everybody because as an infectious disease doctor, we, we can't do this alone.
And we, I think the, and I believe this in all of medicine, collaboration is key. And I, that statement of you want to go fast, go alone. If you want to go far, go together, that go together, go together, go together is what antimicrobial stewardship has to be so that you have lasting change.
[Dr Mike Patrick]
And, you know, parents from their point of view, you know, a lot of times things change in medicine. And so, the perception of the parent is a lot of times, oh, they don't know what they're doing. They change this, they change that.
It used to be that if you don't do the whole 10 days that you could contribute to developing resistant bacteria. And so now we're saying, no, it's better to go shorter in order to not have resistant bacteria develop. That's right.
And so, this, but this is science in action. This is, we have a problem. We're going to have a hypothesis.
We're going to test it. And you know what? Five days of antibiotic generally work in kids who are a little older, not the little babies, but the, you know, the over two, we want to use antibiotics for a shorter period of time.
And let's just, you know, let's see what, what happens. And first, what happens? Cause you don't want to, you know, you don't want the parents to think, oh, we're experimenting on your kid.
It's so a lot of times what we'll do is first look back. Well, if there were kids who did get only five or seven days instead of 10, what were the outcomes? And we can see, oh, there weren't any bad outcomes.
So, let's just try to start doing that, you know, with informed consent and all that. And then we discover that it is okay to do a shorter round.
[Dr Jason Newland]
Yeah, I, um, I think that's so well said, Dr. Mike, I think when, you know, we're. That's the beauty of this work too, right? It's like the learning and the investigation and that science scientific method to use, and, you know, it's both of, hey, can I look back over tens of thousands of patients and really identify some, and then it's doing the randomized controlled trial, right?
So, for outpatient community acquired pneumonia, there is a randomized controlled trial where kids were enrolled to 10, they got randomized to five days versus 10 days. And it's interesting. We found that five days was better than 10 days because you had less adverse events, meaning, you know, less vomiting diarrhea.
So, let's like, well, they all get better. I might as well use five days cause they're all better. And now they have less, they have a better outcome because they have fewer side effects.
I mean, there we go. I mean, now those are hard trials to do. They cost gobs of money.
And so, you have to, like, I just, but thank you for bringing that up. I think that is so key. And we're always trying to iterate and learn, identify maybe, you know, antibiotics revolutionized healthcare.
I've, I adopt my daughter. I have three wonderful children. My oldest is Will 23.
My two daughters are Ilsa with an eye. She's 22 and Anna. That's right.
All you frozen fans out there. They were born before frozen, right? It's great.
I'm a pediatrician. I get to use this. It's like heaven.
They actually went at Ilsa and Anna for Halloween this year, but they flipped. Anna went as Ilsa, Ilsa went as Anna. I love that.
I love that. Right. But Anna, Anna had an orbital cellulitis when she was six years old.
And this was in the time of resistant pneumococcus before we got pneumococcal conjugate vaccine 13, which was tremendous. They got rid of some of our highly resistant strep pneumos vaccines. You know, I wasn't scared at all.
I had no worry about her getting better. And I always say like, what if it was 19?
[Dr Mike Patrick]
Yeah. Oh yeah.
[Dr Jason Newland]
Right. What happens? They take her eye out.
By the way, she plays college soccer. She's division three college soccer player. They're in the NCAA tournament on Saturday against a bit of rival.
Like, am I experiencing that with both my daughters on the same team? Probably not.
[Dr Mike Patrick]
Yeah. Yeah. Yeah, no, absolutely.
There, there were like before my day, I trained like in the nineties and the pneumococcal vaccine was just coming out. The chicken pox vaccine was just coming out. I remember hearing stories of haemophilus influenza type B or Hib.
And I tell parents, you know, we see kids in the ER, and it'll say on the chart that they haven't, they don't have their vaccines. And that's when I just bring up, I'm like, look, I feel like I need to tell that before my day, there were kids dying left and right of things like meningitis of epiglottitis things that we don't see today, but that my predecessors saw all the time and saw just tragedies that are prevented by these vaccines. And so then, you know, when you hear all the misinformation that's out there and, and things that are associated in time, but not cause and effect, it really.
I don't know. It's just disheartening sometimes because we see on the front lines of what these things are capable of, of, of preventing.
[Dr Jason Newland]
Yeah. You know, Dr. Mark, I know, and I mean, like, and you see that, that child that suffers from one of these bacterial infections, especially when you're like, man, that are a bad influenza, I got, I remember all the places I've been when a child's died of influenza and I, I just, it hurts me. It hurts.
And that's it. And that's selfish, right? I, you think about the families and the, and what it's done.
I mean, no one should bury their child and it's just awful. It's not selfish. It's empathy.
Yeah. Thank you. I mean, you know, I mean, like, but it's hard, right?
Like, I mean, my father tells a story about, he remembers standing in line to get his polio vaccine. He remembers his, he's the oldest of five in 1950 that his mom wouldn't let him go to the pool in the summer because that's when he had polio outbreaks. Yeah.
And, and while that's like, that's not necessarily antibiotic resistant, but like, that's a part of our infectious diseases approach to making sure our children are healthy, they grow and then go solve the big problems of the world.
[Dr Mike Patrick]
Right. Yeah.
[Dr Jason Newland]
Our futures, our kids and vaccines allow us to have those, that future and mops influenza type B. Right. I mean, my, I mean, in the world of infectious diseases, you talk to my amazing colleague, colleague, Dr. Bill Barson, who's right on the other side of this wall. Who's been at Nationwide Children's for 50 years and is like the best of the best.
[Dr Mike Patrick]
Oh yeah, he was, he was one of my attendings when I was a resident.
[Dr Jason Newland]
He's like the best, but he'd be like, look, man, we had him energize all the time. Yeah. Yeah.
I mean, this was not uncommon. I mean, I, one of my favorite stories is one of the guys that got me interested in ID, they tell the story how he's walking through the ED and he looks over to the right in the ED, and he knows the kid has buccal cellulitis, right? This cheap infection.
And he's like, tap that kid. He has mops influenza B and that's exactly what he had. And the kid was saved because you did that.
[Dr Mike Patrick]
Yeah.
[Dr Jason Newland]
Our residents don't even know that buccal cellulitis means mops influenza type B. Thankfully.
[Dr Mike Patrick]
Yeah. No, now we think, oh, they must have a dental abscess. That's right.
Right. So, uh, the pneumococcal vaccine, so this one protects against strep pneumonia, but it, it's not just pneumonia. It also can cause ear infections.
As you said, it can cause meningitis. We have seen a resistance rate to pneumococcus really drop. And here in central Ohio in the outpatients, it's like less than 5%.
So, my question is in communities where the resistance rate is low, do we still need to use the high dose antibiotics? B because like we did it to overcome resistance and I feel like we just have never stopped doing it once resistance rates came down.
[Dr Jason Newland]
Oh, Dr. Mike, you are the best. I mean, what a perfect, I get into, I get into arguments with ER pharmacists about this, I think this is the best question, you know, so, all right. So, I love it.
I mean, this is one of these fundamental things that we learned in like literally kind of the early nineties that if, so the resistance, I'm going to ID nerd on you guys. Right. So, when you, the resistance mechanism of streptococcus pneumonia is they basically have this protein called the penicillin binding protein.
It's an enzyme that helps with the cell wall and it changes. So, it changes so that then you're that penicillin, what we call this beta lactam antibiotic can't attach and impact that enzyme. Well, what we learned was that we just jack up the dose.
We actually can overcome this resistance mechanism. And so, it became right. We all learned this, right?
Dr. Mike, myself, even I think today this is, Hey, what dose of penicillin high dose? What's that? Oh, 80 to a hundred per kilo.
I mean, it just, it just rolls off people's tongue, and it was off the resistance. And then we have, it's so rude. No one's like, no one even wants to change it.
But to your point, Dr. Mike, it's probably fine because we don't have that resistance level. It's so much that Dr. Shelly Kaplan, the other thing you guys should know, like we are sitting like this institution has been monitoring streptococcus pneumonia isolates. Dr. Bill Barson with Dr. Shelly Kaplan in Houston since 19, like 93. And they've been monitoring kind of these serotype, the main serotypes resistance and these things. And Dr. Shelly Kaplan, who's led this study from Texas children's and came and spoke at the Dwight Powell lectures last, last spring for our inaugural Bill Barson lecture. He's actually, to your point, suggested that when you have someone meningitis, a presumed bacterial meningitis, you don't need vancomycin because we have such low strep pneumo resistant.
[Dr Mike Patrick]
Yeah. Yeah.
[Dr Jason Newland]
So, well, I mean, like if someone said, hey, I'm gonna do it. I'm like, okay.
[Dr Mike Patrick]
Well, it, well, the thing is that it's that when you have the higher doses or when you use vancomycin, there's also a risk benefit there. And so, the higher doses are going to kill off, you know, maybe almost resistant or borderline resistant bacteria that's in your gut. And then the, the resistant bacteria in your gut are going to multiply because now there's room for them to grow.
And now your gut's going to be filled with more resistant things because you've killed off some of the good stuff that's easy to kill, right?
[Dr Jason Newland]
Any antibiotics going to do that. And that's that interesting thing from Clostridioides difficile or C diff, right? Like any antibiotic though, we always implicate clindamycin and Cipro and the adult Ciprofloxacin in adult world more.
And I'm not, no. And the other thing you're talking about is I'm not sure we know the dose relationship with the amount you kill off. Now I will say, have we, I'm not sure we have a good study that suggests if I give you a higher dose, do I have more vomiting, more diarrhea, more likely to get a rash three or four days later, which then could lead to someone getting labeled a penicillin allergy and that body of literature.
[Dr Mike Patrick]
Like if we could do a whole episode, well, we have actually, Dave Stukas has been on, we've talked about this before.
[Dr Jason Newland]
You don't want to be labeled with penicillin allergy label. Now, some people truly do have it, but you don't want that label. Just trust me.
You don't want that label because it impacts you later on in your life. And most adults get the label before 10 and that'll impact you negatively. So, to your point, right?
Like, right. Let's use the right, again, right dose because of some downstream effects. I think here's it, but here's the true thing, right?
To this notion of we're always learning. I think we're also just hesitant to go back. This whole de-implementation of a common practice scares the bejesus out of everybody.
Not everybody, clearly not you, but I think that's a hard thing. But again, that's where this whole science that I've got to be involved with implementation science is super awesome because it is dealing with behavioral factors that frankly are huge in medicine.
[Dr Mike Patrick]
Yeah, yeah. What are some of the risks of taking antibiotics? So, and that's to your point of the right, you know, the right medicine for the right disease at the right time for the right duration, all of those things.
What is the risk of not doing the right ones or for the, you know, the wrong length of time or the wrong dose or just in general, what are some risks of antibiotics that parents should be, again, antibiotics are fantastic. They save lives, but they also, when not used judiciously, come along with some of their own risks and what are some of those?
[Dr Jason Newland]
Yeah, I mean, I mean, so, okay, number one, right. If we're using the wrong antibiotics. So, if I'm not using penicillin, but I've decided to use clindamycin for group, you know, so strep throat and like, hey, you have a penicillin allergy.
I'm going to give you clindamycin. Well, clindamycin definitely has a higher rate of toxicity, meaning more diarrhea, more vomiting. More stopping.
Cause they won't take it. Cause it might taste bad though. Anna Newland thought clindamycin was fine to take when she had her.
That was shocking. So, I'm like, well, I don't know. It tastes bad for some, but not others.
But so, there's that, right? I can't take it because of factors. There are others like, well, if I use that antibiotic clindamycin, then I have exposed to all these bacteria we talked about before to your point.
Staph aureus now is seeing clindamycin. And we like to use clindamycin for staph aureus infections that cause skin infections and others. Now it's resistant to clindamycin.
Cause I'm using more clindamycin. We actually saw in this study we did with ENT doctors that kids that had a bunch of drainage from their ears. Cause they had those tubes to help.
They were getting a lot of eardrops. And then we looked, well, if they had staph aureus, was it resistant to clindamycin or not? Guess what?
50% resistant to clindamycin. They never even received clindamycin. They just received drops versus if I had just a bad infection of their skin here, like a lymph node here, never seen an antibiotic pretty much.
They were always susceptible to clindamycin.
[Dr Mike Patrick]
Yeah. Yeah. But then what can happen?
So, a lot of times it's our own mouth bacteria that cause these things. And if there is resistance in a community, we share whether you like it or not. We share, communities share these mouth bacteria because, you know, you cough into your hand, you touch a shopping cart, you know, someone else comes along.
And so, the behavior of others in a community as relates to antibiotics does impact each of us as individuals because it does dictate to some degree which microbes are growing in our mouth because you can't get rid of all of them. And if you do, you'll have fungus growing there. So, it is important to take antibiotic stewardship seriously, not only for our own kids and our family, but really to think about it on a community scale as well, because of the fact that we share all of these bacteria and other microbes.
[Dr Jason Newland]
Yeah. And I think, I don't know, like an example that I really like in this notion, is we think about group B streptococcus. So, group B streptococcus for people out there, like lives in the vaginal tract of women and people that have had babies know that they get tested for group B streptococcus during their pregnancy.
And then if they are found to have group B streptococcus, they're going to get an antibiotic prior to delivery, because we know that that can be transmitted to the baby probably sometime during the birthing process and cause a bad infection. That to me is this notion, right? We're all together in this and that.
And, and also, we've learned how to use antibiotics to even in a good situation to keep people healthy. And so, we don't have to use, even use more antibiotics. By the way, pets, one of my good friends in St. Louis did this great study showing Staph aureus on pets. So, your animals matter and there's this whole, and we're really lucky here at OSU, they do this in the vet school, this one health approach, like we're all together, animals, plants, humans, all intersect, all this notion that that our environment impact us, not only the people around us, but in any piece. And so, this notion of this appropriate use of antibiotics beyond just human medicine is also really important and vaccines beyond human medicine, right? Vaccines for pets matters.
So, I think that's kind of, I find it really good. And I think, you know, choosing back to that initial question, right. Choosing the right antibiotic and right duration limits some of the toxicities for the person, but also limits the impact on a, on a larger scale, on that societal scale that encompasses more than just us as people.
[Dr Mike Patrick]
Yeah. Yeah. Yeah, absolutely.
And, and allergic reactions, even though they're much rare than what we think based on labels, when you think of all the people, you know, I think Dr. Stukas had said that 10% of all people think they're allergic to penicillin or get labeled as allergic to penicillin, but only 10% of them actually are. And so, if you are, or your kids are labeled as penicillin allergic, go see your, your friendly local pediatric allergist and take some penicillin in their office and find out for sure. I mean, I think that's something that you would want to know if you really are, as you said, that can impact the rest of your life.
So, you, you really want to know.
[Dr Jason Newland]
Yeah, it's true. And you know, it's, I'm so impressed, right? Like I think our primary care now, our primary care docs, or they, one of our wonderful colleagues put together that practice where in our NCH primary care, they'll do that kind of Amoxicillin challenge in those that really from the leadership of those.
And I think that's a tremendous work. Yeah. Yeah.
[Dr Mike Patrick]
And it's usually within, within an hour that you're going to have anaphylactic reaction. So, and if you get an itchy rash three or four days later, that's much more likely to be a kind of a combination of the bacteria, the antibiotic, your immune system, all playing together and creating that rash. But that doesn't mean that'll happen the next time you take the antibiotic, because it's the unique combination of maybe a particular virus with like with mono, for example.
[Dr Jason Newland]
And we know that other, that's a whole nother ball of wax that I'm like, so into right now, but I, we, I will, I, that will, we'll have to have you back.
[Dr Mike Patrick]
We'll, we'll talk about that because, because you know, parents, when you talk about it in the ER, they, their ears, their eyes widen and you know, like, oh, mono, who have you been kissing? And then I have to explain. It's not just.
[Dr Jason Newland]
And there's always interesting things that I think are on that. We, that we still need to learn about it and how to treat it, honestly. But yeah.
[Dr Mike Patrick]
Now I want to talk a little bit about the development of new antibiotics because of course we want to prevent antibiotic resistance of microbes to antibiotics and other antimicrobials. And so antibiotic stewardship programs are aimed to do that. We still, in some kids, you need to use it in order to save their life, in order to decrease, you know, make the illness go away, stop community spread, all of those things.
So, the development of new antibiotics is still an important thing. And we had talked before about that being often an expensive thing, which then dictates how the price of the medicine after it's been developed, you know, if it costs a lot of money to develop, then the pharmacies are going to, pharmaceutical companies are going to charge more for it. So, a lot of these newer antibiotics are extremely expensive.
So, what does the world look like in terms of new development of antibiotics, hopefully in a way that is affordable?
[Dr Jason Newland]
Yeah, Dr. Mike, this has been a really ongoing struggle. There's been different agencies within the U.S. government to try to address this because here to really, here's the story I like to tell people about this situation. So here we're on, you're, you're listening to me as an antibiotic steward who really goes around.
And for the most part, right, we're labeled as someone telling you not to use antibiotics, not always, but right. We want you to use it the right time. They revolutionized health care.
However, I don't want you on an antibiotic the rest of your life. I don't want you on like, but if you're a diabetic or you have high blood pressure, right, you have to be on medicines for the rest of your life. We are in a, you know, capitalistic society.
So, you know, if you're a company you like when someone's on your drug for a long time, cause you're going to continue to have them. That's not an antibiotic. Antibiotics are a finite thing.
And so, you know, someone told me, says, hey, Jason, you know how much, let's say like Dr. Mike has this great idea for an antibiotic. We're like, man, Dr. Mike's brilliant. I'm, I'm going to invest.
Sure. I'm going to invest with you. But the question should be is, well, what's my return on investment?
It's like a negative $10 million. Negative. I didn't say positive negative.
So, who's going to do that? And so, as we've seen startup companies come in and develop, then they get bought, but the big companies, they aren't doing the R and D cause there's no money in it for them. Yeah.
So, there has been legislation pushed forward to try to decouple the selling of the drugs to your point, Dr. Mike is, yeah, we got to develop it, but we also have to make it affordable, right? So, decouple, so you can keep companies in business to do the research and develop the studies, which aren't cheap so that we make sure they're safe and they're effective. FDA regulates it, make sure that you do trials in children so that we know the right dose in a child.
That's the last thing to happen. You know, doing all these things that make sure that we're getting this right is really key to do that. And, and so I think thankfully there's still companies that are doing this.
Thankfully in like Europe, they've kind of gone to this decouple selling from that. And so, we have some new antibiotics that have kind of in the pipeline. We need an oral carbapenem.
So, one of these really what we call broad spectrum drugs, mainly for urinary tract infections. I've had two normal, healthy kids need an IV central line, right? Goes up because they're bacteria was resistant to every oral antibiotic we have, like that stinks for a kid that basically have to have a procedure to put something in and then get that daily at home and then to have it taken out.
Can't swim in the summer. If you have a PICC line, by the way. Um, yeah, we need it and we have to come with stress, but this is going to be an ongoing issue.
There are things called bacteriophages that have been looked at to be used, essentially take a virus that can attack a bacteria. Super cool.
[Dr Mike Patrick]
You can imagine what's what people are going to say about that. Yeah.
[Dr Jason Newland]
Well, right.
[Dr Mike Patrick]
I mean, no, no, you know, the whole, we were changing the DNA and now what are these phages going to do to our own cells?
[Dr Jason Newland]
And I'm just like, yeah, I mean, but again, I've taken care of kids that have a bacteria that's resistant to everything we got, and we're trying to come up with all these strategies, trying to save their life was trying to save their life. So, I would say, Dr. Mike, five, we had this conversation five years ago. I've been, uh, I was more concerned, especially around our gram-negative antibacterial agents.
We're a little better off right now, but it, but it's, none of us are surprised when we have a really multidrug resistant and it's usually people that have more complexity, but like I said, I had a urinary tract infection and a normal healthy person that was resistant to everything, but every oral option. So, it's not like you can't hit others.
[Dr Mike Patrick]
Yeah. Yeah, absolutely. Let's, let's put a focus on families here for a minute.
What, you know, a mom or dad who's listening to this podcast, I'm like, what are thinking? What can we do? Like, how can we protect our kids?
How can we hopefully prevent the need for an antibiotic? If there is an antibiotic, what questions should we be asking our provider to, you know, that would help let them know, hey, we're thinking about this thing. But what can families do?
[Dr Jason Newland]
Well, I mean, I think the first thing we start with collaboration is essential. And not only is it collaboration across us and medicine, but it's also with our families, all family members. And I, and I use family as all those people that care for our kids, right?
You don't, you don't have to be blood to be family. So, I think all of us have these families that matter. And I, and I think we talked about vaccines and me, you know, that's a real hot topic right now.
And I think we, especially me need to listen more to those who are like, man, I'm not sure about this right now and all this stuff. So, you know, how do we collaborate on vaccines? And that's going to be an ongoing, because we know how important vaccines are to prevent things like pertussis and influenza and even COVID.
And I, I'll say it right. All of these things matter, but we need to really have great conversation. So that'd be one, right?
Let's, let's have conversation. Let's listen. Let's be a part of it.
Let's do this together. Number two is like you're in the office, right? Your clinician has spent a lot of time learning and figuring this out.
And there's interesting data that says that if the clinician perceives you are expecting an antibiotic, the clinician, Dr. Mike, Dr. Jason, or whomever is way more likely to give you an antibiotic because we care. We want you to be better. We want you to be happy.
We want you to have a great visit. So, this notion of expectation really influences us. And so how do you have that collaboration where, you know, look, hey, I, I trust you and we know this is important.
That's tremendous. And that's super helpful for all clinicians to know that. But it's okay to say some of these things about what you've been learning.
It's okay to say, hey, is this the right dose? Are we sure this is the right amount of time? Cause I'd rather not take it for 10 days.
If I don't have to, I will say there's interesting data that suggests if a family member questions. You and your antibiotic usually is probably on why don't we need it? We're more likely to give as well, but I think in the end, Dr. Mike, the key is the conversation and the trust. And so that we collaborate together on a problem that doesn't talk, isn't talked about enough, hence why I'm so excited to talk about this.
[Dr Mike Patrick]
Yeah. Yeah. And it's one of those things too, where as a, as a, gosh, you have pressures on both sides because you want to explain to parents why you're making the choices that you're making, like, why are we choosing this antibiotic?
Why are we doing it twice a day instead of three times a day, but with larger doses and why, you know, this is why we think it's okay to do it for five days instead of 10 days, but there's the pressure of also there's a whole waiting room of people who want to see you. And so, there is that balance of when you talk more. And I think from the parent standpoint, like if you just go in and just not say anything, it's going to be a much quicker visit, you're going to learn a lot less.
But I think most physicians, if a parent starts asking them questions, they're likely to answer those questions, even if it takes time. And so one way that you can advocate for your kids is by asking the questions that are coming to your mind and, you know, not necessarily in an adversarial way or, you know, arguing, but just to get more information, but you almost as a parent have to initiate that a lot of times, just because from the doctor's standpoint, there's a whole waiting room of kids that also need to come through.
[Dr Jason Newland]
Yeah. This is why I'm so impressed by you and all, all our wonderful primary care individuals. My dad was a family doc in small town, Oklahoma for all these years.
And I just, you guys are inspiring to me because you do that hard work on a daily basis and interacting in it. It's, I find it a privilege to be able to help when I can. The joke, right?
For, you know, I'm sitting up in this beautiful ivory tower office, but really want to make sure that I'm providing what I can to help you and families and others who really, you know, well, we are on the same boat, right? We want the best for our future, which is our children.
[Dr Mike Patrick]
Yeah. A hundred percent. Absolutely.
So, at the end of the day, then what is your main message for families when it comes to antimicrobial stewardship?
[Dr Jason Newland]
Yeah. So, the appropriate use of antibiotics is essential. Antibiotics are revolutionized healthcare.
We, we can have, our children can live and thrive, and we don't worry about routine things, routine infections. However, they're, they're a finite resource. So, we have to do everything we can to protect them.
That includes vaccination. That includes preventing infections in all ways, whether that's washing your hands, or if you're, you have a child that has an underlying condition that needs a central, you know, one of those IV lines, intravenous lines that go up to your heart, doing all the things that are required to protect that from getting infected, these sorts of things are going to be key for us to maintain these amazing resources known as antibiotics or antimicrobials. And it is really a global societal total group collaborative effort that's needed to really maintain that. And I think that is what I've learned over and over.
So, I guess, I think it's an, it's going to be an ongoing conversation and I think that's why I'm so excited and I look forward to talking to more family members and people and on all these topics, because I think, you know, making sure kids are healthy and safe and happy is nothing better.
[Dr Mike Patrick]
Yeah. Yeah, absolutely. Well, this has been a wonderful conversation.
We definitely need to have you back on the podcast and talk, talk more about various infections. Parents are always interested in those, those conversations. We are going to have some links in the show notes.
So, if you're interested in learning more about antibiotic stewardship, or I should say antimicrobial stewardship, please do check out the show notes, episode 593 over at pediacast.org. We do have, of course, a link to the Pediatric Infectious Diseases folks at Nationwide Children's Hospital. We also have a couple of resources from the CDC, the Centers for Disease Control and Prevention.
We have one article called Core Elements of Antibiotic Stewardship, another one on the Antibiotic Resistance Threat Report that you may find interesting. And then from the Journal of the Pediatric Infectious Disease Society, Antibiotic Durations for Skin and Soft Tissue Infections in Outpatient Pediatrics. We do have a lot of providers who also listen to this.
So, if you're a pediatrician, family practice doc, nurse practitioner, you may want to check out the Journal of the Pediatric Infectious Diseases Society. They have some recommendations in terms of length of treatment for skin and soft tissue infections. So, we'll have a link to that in the show notes as well.
So once again, Dr. Jason Newland, Chief of Pediatric Infectious Diseases at Nationwide Children's Hospital, thank you so much for stopping by today.
[Dr Jason Newland]
Yeah, thanks, Dr. Mike, and congrats to all the great work you do. I appreciate it.
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[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. We really do appreciate your support. Also, thanks again to our guest this week, Dr. Jason Newland, Chief of Pediatric Infectious Diseases at Nationwide Children's Hospital. Don't forget, you can find us wherever podcasts are found. We're in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android. Our landing site is pediacast.org.
You'll find our entire archive of past programs there, along with show notes for each of the episodes, our terms of use agreement, and that handy contact page if you would like to suggest a future topic for the program. Reviews are also helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show, and we love connecting with you on social media.
You'll find us on Facebook, Instagram, Threads, LinkedIn, and X, also BlueSky, simply search for PediaCast. Don't forget about our sibling podcast, PediaCast CME.
It is similar to this program. We do turn the science up a couple of notches and offer free continuing medical education credit for those who listen. And it is category one credit, not only for physicians, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.
And since Nationwide Children's is jointly accredited by many professional organizations, it's likely we offer the credits you need to fulfill your state's continuing medical education requirements. Shows and details are available at the landing site for that program, PediaCastCME.org. You can also listen wherever podcasts are found, simply search for PediaCast CME.
And then one other podcast that I host, if you are medical faculty or actually any of the health sciences, so if you teach medical learners in medicine, nursing, dentistry, vet med, really any of the health sciences, if you are a teacher in academic medicine, then this is a podcast for you. It's called FAMEcast. You can find it at FameCast.org and wherever podcasts are found. Again, just search for FAMEcast. And again, that is a faculty development podcast. So, we talk about things like work-life balance, promotion and tenure, teaching skills, listening, getting along with others, you know, playing nice in the sandbox, all of, all of those sorts of things.
So again, if you are a faculty in the health sciences, please do check out FAMEcast again over at FameCast.org or wherever you get your podcast. Thanks again for stopping by and until next time, this is Dr. Mike saying, stay safe, stay healthy, and stay involved with your kids. So long, everybody.
[Music]
