By: Saul R. Hymes, MD

On September 16, 2013, the CDC issued a report on the extent of harm caused by antibiotic-resistant infections. While those of us in the infectious disease field have been aware of this growing problem, its extent was striking: 2,000,000 people sick every year with an antibiotic-resistant infection and 23,000 dead yearly from the same. The problem of antibiotic resistance, they said, "is one of our most serious health threats." Aside from the existing (and growing) number of infections and deaths, the CDC predicted "the loss of effective antibiotics will undermine our ability to fight infectious diseases and manage the infectious complications common in vulnerable patients." Complex infections would no longer be treatable due to complete antibiotic resistance, and thus procedures with known infectious complications like organ transplantation or cancer chemotherapy could become riskier or possibly abandoned altogether. Journalists envisioned this post-antibiotic era; the PBS series Frontline spent an hour of primetime TV on the subject; and in these reports and others, we doctors were labeled as part of the problem.

On March 4 of this year, the CDC released a report on the problem of antibiotic overuse in hospitalized patients. The report looks primarily at adult data, and found that 55.7% of patients discharged from 323 hospitals in 2010 received antibiotics while hospitalized; in more than a third of those patients, the antibiotic use was inappropriate and could have been improved upon. On the pediatrics side, we see similar findings: a recent study published in Infection Control and Hospital Epidemiology by Gerber et al (Gerber and 4 of his 6 coauthors are PIDS members) found that a majority of pediatric patients are similarly prescribed antibiotics while hospitalized. They found that just 4 conditions, representing only 1% of the diagnoses, contained 10% of the antibiotic use—and that use was highly inconsistent and often inappropriate. Our poor antibiotic prescribing practices in the past have now caught up to us—with a vengeance.

However, clichéd as it may be, we are not only part of the problem, but have been and can continue to be part of the solution. First and foremost, through the creation of inpatient antimicrobial stewardship programs (ASP’s), both adult and pediatric hospitals can gain control of their antibiotic use, standardize and minimize prescribing, and improve care as well as cut costs. PIDS and PIDS members have a number of ongoing efforts aimed at promoting ASP growth and research.

Every year for the past 4 years, PIDS has sponsored a conference on antimicrobial stewardship. Cosponsored by Children’s Mercy Hospital & Clinics, and led by Jason Newland, MD, MEd, the Director of Antimicrobial Stewardship there, the 5th annual conference will be occurring June 5–6, 2014, and offers the opportunity for PIDS members and nonmembers to learn more about starting an ASP, share their research and outcomes data, and learn from the work and research of others. Dr. Newland has also been instrumental in another broader effort around ASP research—the formation of the SHARPS group. A group made up of 7 children’s hospitals and their ASP’s, SHARPS was organized with the aim of conducting multi-center research on the benefits of pediatric ASP’s and where and how to implement strategies for improvement. To say the eventual results of their research are eagerly-awaited would be an understatement.

But most antibiotic prescribing goes on in the outpatient setting, far from the watchful eye of a traditional hospital-based ASP. Critical research by Theo Zaoutis, MD, MSCE, and others, has illustrated how we can perform outpatient stewardship to better ensure adherence to prescribing guidelines and use of narrower-spectrum antibiotics in the outpatient setting. This is an area many children’s hospitals, pediatric residencies, and infectious disease specialists have only begun to venture into and is one where we can make significant progress. Educational interventions through Grand Rounds and targeted lectures at practice sites, increased use of outpatient pediatric infectious disease care and phone consults to generalists, and, where feasible, active surveillance via prospective audit and feedback all have the potential to help improve antibiotic practices in this setting and are all areas where we as pediatric infectious disease practitioners can get involved.

The problem of antibiotic resistant infections is a daunting one, but it is one that PIDS members, pediatric infectious disease practitioners, and indeed all pediatricians and physicians can help combat. Think before you write a vancomycin order for one of your hospitalized patients. Do you really need to use that cephalosporin for ambulatory treatment of pneumonia, otitis or a UTI? On an individual level, every little bit helps, and on a larger scale, every institution and multi-institution group that can work on antimicrobial stewardship can make a real difference. Will we reach a post-antibiotic era? Some practitioners, for some patients and some infections, are already effectively working within it, though I certainly hope to never see its full arrival. Through improving our antimicrobial stewardship—in all settings—we have the best chance of delaying it as long as possible.

Infections caused by a concerning type of antibiotic-resistant bacteria are on the rise in U.S. children, according to a new study published in the Journal of the Pediatric Infectious Diseases Society and available online. Although still uncommon, the bacteria are increasingly found in children of all ages, especially those 1-5 years old, raising concerns about dwindling treatment options.

Researchers led by Latania K. Logan, MD, of Rush University Medical Center in Chicago, analyzed resistance patterns in approximately 370,000 clinical isolates from pediatric patients, collected nationwide between 1999 and 2011. Specifically, they determined the prevalence of a resistant type of Gram-negative bacteria, Enterobacteriaceae, that produces a key enzyme, extended-spectrum beta-lactamase (ESBL). The enzyme thwarts many strong antibiotics. Another indicator of ESBL prevalence, susceptibility to third-generation cephalosporins—an important class of antibiotics used to treat many infections—was also measured.

The prevalence of ESBL-producing bacteria increased from 0.28 percent to 0.92 percent from 1999 to 2011; resistance to third-generation cephalosporins increased from 1.4 percent to 3.0 percent. ESBLs were found in children across the country of all ages, but slightly more than half of the isolates with this resistance were from those 1-5 years old. Nearly three-quarters (74.4 percent) of these bacteria were resistant to multiple classes of antibiotics.

"These antibiotic-resistant bacteria have traditionally been found in health care settings but are increasingly being found in the community, in people who have not had a significant history of health care exposure," Dr. Logan said. "In our study, though previous medical histories of the subjects were unknown, 51.3 percent of the children presented in the outpatient or ambulatory setting."

While the overall rate of these infections in children is still low, ESBL-producing bacteria can spread rapidly and have been linked to longer hospital stays, higher health care costs, and increased mortality, the study authors noted. In a 2013 report, the Centers for Disease Control and Prevention called ESBLs a "serious concern" and a significant threat to public health.

Physicians should obtain cultures for suspected bacterial infections to help determine which antibiotics are best, Dr. Logan said. "Some infections in children that have typically been treated with oral antibiotics in the past may now require hospitalization, treatment with intravenous drugs, or both, as there may not be an oral option available."

More research is needed to define risk factors for these infections in children, their prevalence in different settings, and their molecular epidemiology, Dr. Logan said. A companion study by several of the same researchers, also now available online in the Journal of the Pediatric Infectious Diseases Society, suggests that children with neurologic conditions are at higher risk for infections caused by ESBL-producing bacteria.

Additional drug development, keeping younger patients in mind, is also needed. "The overwhelming majority of current research for new pharmaceuticals against antibiotic-resistant organisms are in adults," Dr. Logan said. "New drug options will need to be available for young children."


Published quarterly, the Journal of the Pediatric Infectious Diseases Society represents the spectrum of peer-reviewed, scientific and clinical information on perinatal, childhood, and adolescent infectious diseases. The journal is a publication of the Pediatric Infectious Diseases Society (PIDS), the world's largest professional organization of experts in the care and prevention of infectious diseases in children.

PIDS membership encompasses leaders across the global scientific and public health spectrum, including clinical care, advocacy, academics, government, and the pharmaceutical industry. From fellowship training to continuing medical education, research, regulatory issues and guideline development, PIDS members are the core professionals advocating for the improved health of children with infectious diseases both nationally and around the world, participating in critical public health and medical professional advisory committees that determine the treatment and prevention of infectious diseases, immunization practices in children, and the education of pediatricians.

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Please click here to view the letter from the CDC.

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ARLINGTON, VA, August 9, 2012 – The Journal of the Pediatric Infectious Diseases Society (JPIDS) today released the largest and most rigorous evaluation to date of the impact on reducing the days of antibiotic therapy in a children's hospital using a prospective-audit-with-feedback antibiotic stewardship program (ASP). The study utilized a control group of the 25-member children's hospitals of the Child Health Corporation of America. A companion article describes how the ASP was created within this 317-bed tertiary care children's hospital and clinicians' attitudes toward it—the first published account of such a pediatric program.

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Register today for the Antimicrobial Stewardship in Practice Educational Series! PIDS has partnered with SHEA to bring you the pediatric antimicrobial stewardship module derived from the June 3rd conference at Children's Mercy Hospital in Kansas CIty.

On October 25, 2011, the journal The Lancet Infectious Diseases published an article entitled "Efficacy and Effectiveness of Influenza Vaccines: A Systematic Review and Meta-Analysis." 

The Pediatric Infectious Diseases Society is pleased to announce the launch of its new quarterly journal, Journal of the Pediatric Infectious Diseases Society (JPIDS), dedicated to perinatal, childhood and adolescent infectious diseases.  For more information, please click here.

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