Appropriate Use of Antibiotic and Principles of Antimicrobial Stewardship in Children

Abstract

Antibiotics account for over 10% of the overall drug expense of the National Health System in Italy in 2021. Their use in children is of particular interest on one side, because acute infections are very common in children, while they build their immunologic library of competence; on the other side, although many acute infections are expected and turn out to be of viral origin, caregivers will often ask the family doctor or primary care attending to reassure them by prescribing antibiotic treatment, although it may often be unnecessary. The inappropriate prescription of antibiotics in children may likely be a source not only of undue economic burden for the public health system but also of increasing development of antimicrobial resistance (AMR). Based on those issues, the inappropriate use of antibiotics in children should be avoided to reduce the risks of unnecessary toxicity, increase in health costs, lifelong effects, and selection of resistant organisms causing undue deaths. Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure an optimal use of antimicrobials to improve patient outcomes while limiting the risk of adverse events including AMR. The aim of this paper is to spread some concept of good use of antibiotics for pediatricians or every other physician involved in the choice to prescribe, or not, antibiotics in children. Several actions could be of help in this process, including the following: (1) identify patients with high probability of bacterial infection; (2) collect samples for culture study before starting antibiotic treatment if invasive bacterial infection is suspected; (3) select the appropriate antibiotic molecule based on local resistance and narrow spectrum for the suspected pathogen(s); avoid multi-antibiotic association; prescribe correct dosage; (4) choose the best route of administration (oral vs. parenteral) and the best schedule of administration for every prescription (i.e., multiple administration for beta lactam); (5) schedule clinical and laboratory re-evaluation with the aim to consider therapeutic de-escalation; (6) stop antibiotic administration as soon as possible, avoiding the application of "antibiotic course".

Keywords: antibiotics; antimicrobial resistance; de-escalation; stewardship.

Figure 1

Percentage of oral formulations by AWaRe category (modified by [43]).

Figure 2

Pharmacokinetics of time-dependent drugs administered in continuous infusion.

Figure 3

Time-dependent antimicrobial pharmacokinetic in intermittent administration. Antimicrobial efficacy is determined by the time above MIC (T > MIC) of plasmatic unbound drug concentration. Arrows shows the time of administrations.

Figure 4

Kinetics of concentration-dependent drugs. The effectiveness of the drug is linked to how high the absolute peak (Cmax) and the area under the curve is above the MIC (AUC/MIC).