You Asked for It! CE...Jul 20, 2018 · otitis media, acute bacterial sinusitis, pharyngitis, and community acquired pneumonia. By increasing vigilance for antibiotic misuse and promoting

AN ONGOING CE PROGRAMof the University of Connecticut

School of PharmacyEDUCATIONAL OBJECTIVESAfter participating in this activity pharmacists will beable to:●Apply knowledge to determine appropriate treatmentrecommendations based upon national guidelines forcommon outpatient pediatric infectious diseases●Discuss the impact of appropriate immunizations onthe recommendations for patients presenting with com-mon outpatient infectious diseases●Apply communication and workflow advice/tips tocommunity pharmacy settings in order to improve anti-microbial practices●Discriminate among reasons creating an urgency forantibiotic stewardship●Detail how to educate patients and parents about com-mon antibiotic adverse events and counsel on avoidance

After participating in this activity, pharmacy technicianswill be able to:●Identify common repercussions of irrational antibioticuse in pediatrics●Describe the prescription and OTC products and pro-cesses most likely to be used when children have infec-tions●Identify why and how to store and safely dispose of an-tibiotics●Discuss why patients and parents may need to be edu-cated about issues other than antibacterial resistance

The University of Connecticut School of Pharmacy is accreditedby the Accreditation Council for Pharmacy Education as a pro-vider of continuing pharmacy education.

Pharmacists and pharmacy technicians are eligible to participatein this application-based activity and will receive up to 0.2 CEU (2contact hours) for completing the activity, passing the quiz witha grade of 70% or better, and completing an online evaluation.Statements of credit are available via the CPE Monitor onlinesystem and your participation will be recorded with CPE Monitorwithin 72 hours of submission

ACPE UAN: 0009-9999-18-072-H01-P 0009-9999-18-072-H01-T

Grant funding: NoneActivity Fee: $7 for pharmacists, $4 for pharmacy techniciansINITIAL RELEASE DATE: July 20, 2018EXPIRATION DATE: July 20, 2021

To obtain CPE credit, visit the UConn Online CECenter https://pharmacyce.uconn.edu/login.php.Use your NABP E-profile ID and the session code18YC72-PFK44 for pharmacists or18YC72-ABC36 for pharmacy techniciansto access the online quiz and evaluation. First-time users must pre-register in the Online CE Cen-ter. Test results will be displayed immediately andyour participation will be recorded with CPE Moni-tor within 72 hours of completing the require-ments.

For questions concerning the online CPE activi-ties, email [email protected].

ABSTRACT: Traditionally considered an inpatient activity, antimicrobial steward-ship is making inroads in the community. Pharmacists and pharmacy techniciansneed a good understanding of antimicrobial stewardship activities and how theyapply to four common pediatric infections that may be viral or bacterial–acuteotitis media, acute bacterial sinusitis, pharyngitis, and community acquiredpneumonia. By increasing vigilance for antibiotic misuse and promoting appro-priate vaccinations, pharmacy staff become activists in the fight against microbi-al resistance.

FACULTY: Sonali Shah, BS, 2019 PharmD Candidate; Jen Girotto, PharmD, Associate Clinical Profes-sor; Sara E. Miller, BS, 2019 PharmdD Candidate; Jeannette Y. Wick, R,Ph., MBA, FASCP, AssistantDirector, Office of Pharmacy Professional development, University of Connecticut

FACULTY DISCLOSURE: Ms. Shah, Dr. Girotto, Ms. Miller, and Ms. Wick have no actual or potentialconflicts of interest associated with this article.

DISCLOSURE OF DISCUSSIONS of OFF-LABEL and INVESTIGATIONAL DRUG USE: This activity maycontain discussion of off label/unapproved use of drugs. The content and views presented in this ed-ucational program are those of the faculty and do not necessarily represent those of the Universityof Connecticut School of Pharmacy. Please refer to the official prescribing information for each prod-uct for discussion of approved indications, contraindications, and warnings.

INTRODUCTIONOur faculty presents this continuing education activity in two parts. Part 1 cov-ers common pediatric infections through the lens of antimicrobial stewardship.It discusses four common pediatric infections–acute otitis media, acute bacterialsinusitis, pharyngitis, and community acquired pneumonia–and educates phar-macy staff about current guideline recommendations that strive to reduce un-necessary antibiotic use.

Part 2 looks at antibiotic stewardship from a different angle. It recognizes thatmany patients need or want more than one reason to appreciate fully why pre-scribers may seem “stingy” with antibiotics. It also discusses antibiotic overuseand its potential repercussions to individual children and its proven affects onthe environment and society at large.

The post-tests cover both parts in one document.

You Asked for It! CE

The Pharmacist's Role inOutpatient Pediatric Antibiotic Stewardship

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TO REGISTER and PAY FOR THIS CE, go to: https://pharmacyce.uconn.edu/program_register.php

PART 1FUNDAMENTALS OF ANTIMICROBIAL

STEWARDSHIP FOR OUTPATIENTPEDIATRIC INFECTIOUS DISEASES

Sonali Shah and Jen GirottoIn 2013, the Centers for Disease Control and Prevention (CDC)reported “at least 2 million people become infected with bacte-ria that are resistant to antibiotics and at least 23,000 people dieeach year as a direct result of these infections.”1 Antibiotic resis-tance is a threat to patients in both inpatient and outpatient set-tings. In outpatient settings, such as doctor’s offices, clinics, andemergency rooms, patients (and often healthcare providers) arefrequently unaware of the potential for antibiotic resistant or-ganisms to cause infections. Since pharmacists are patients'most accessible healthcare providers, it is essential that pharma-cists understand, advocate for, and educate patients about ap-propriate antibiotic usage.

Traditionally, many clinicians used broad-spectrum antibioticswithout much concern for antimicrobial resistance. This methodwas effective and easy, but it contributed greatly to the rates ofantibiotic resistance we see with many antibiotics today. It hasalso prompted researchers to actively investigate new antibioticsthat can overcome bacterial resistance. Antimicrobial Steward-ship Programs (ASPs) in inpatient programs employ healthcareproviders with expertise in infectious diseases, usually physiciansand pharmacists, who ensure that patients receive the narrow-est effective antibiotic therapy to treat their infections. Health-care professionals who work in ASP programs design antibioticrestrictions, provide prospective prescribing review and feed-back, develop guidelines, and educate other healthcare provid-ers. In inpatient settings, these programs improve antibioticusage, limit antibiotic resistance, optimize clinical outcomes, de-crease unintentional hazards of antibiotic use, and decrease theoverall cost of care for patients with infections.1 In outpatientsettings, appropriate antibiotic prescribing is just as importantbut until recently, few outpatient settings have employed formalstewardship initiatives.

ASP principles are at least as important in outpatient settings, as30% of prescribed antibiotics are unnecessary and as many as50% are inappropriate in choice, dose, or duration.1 ASP princi-ples do not just apply to adult patients. Twenty percent of chil-dren’s visits to a healthcare provider result in antibioticprescriptions.1 These antibiotics are not without hazards. Antibi-otics are the cause of seven of the top 10 drug-related adversereactions associated with pediatric-related emergency roomvisits.1 In fact, 70% of all Clostridium difficile infections in chil-dren occur subsequent to outpatient antibiotic prescriptions.2

Stewardship programs in outpatient settings have different char-acteristics than those in inpatient areas. In 2016, the CDC pub-lished unique Core Elements for ASP in Outpatient Settings.3

These guidelines suggest inappropriate usage in these settings isoften related to knowledge gaps, patient expectations that they

UCONN You Asked for It Continuing Education July 2018 Page 2

“need” antibiotics, lack of sufficient time to see patients, and/orconcern regarding patient satisfaction scores if patients do notreceive antibiotic prescriptions.3 Community pharmacists whoare confident in their knowledge of current recommendationsfor the treatment of infectious diseases can assume an impor-tant role in outpatient stewardship.

This continuing education activity reviews recommended treat-ment for four common bacterial infections (acute otitis media,bacterial sinusitis, pharyngitis, and community-acquired pneu-monia) and vaccines’ role in prevention in children.

Acute Otitis MediaAcute otitis media (AOM) is one of the most common reasonschildren receive antibiotics.4 Prevalence is higher among chil-dren who are enrolled in daycare or have siblings because con-tact with others in close proximity increases the likelihoodpathogens will spread. Common causative bacterial pathogensinclude Stretococcus pneumoniae, non-typeable Haemophillusinfluenzae, and Moraxella catarrhalis. The American Academy ofPediatrics (AAP) published the current AOM treatment guide-lines in 2013; they provide recommendations for the treatmentof AOM in otherwise healthy patients six months of age andolder.4

The guidelines recommend that all children who have AOM re-ceive treatment for pain with a systemic analgesic such as acet-aminophen or ibuprofen. Ear drops containing benzocaine,procaine, or lidocaine should be used only has adjunctive thera-py because of limited evidence of effectiveness. Study resultsare unclear about whether these ear drops improve the illness,soothe symptoms related to liquid in the ear, or have a placeboeffect. 4

Pause and Ponder:Does your community address antibiotic overuseproactively with awareness campaigns?

© Can Stock Photo/philipim

age

Specific groups of children (see Table 1), including those withsevere presentation should also receive antibiotics. Severe pre-sentations of AOM include temperature of 102.2°F (39oC) orhigher, severe ear pain that restricts normal activity (e.g. sleep),or ear pain that persists for more than 2 days.4 Additionally,other patients diagnosed with AOM can either receive antibiot-ics or be observed to ensure that their symptoms improve asexpected. Further, even when antibiotic therapy is initiated, cli-nicians should reevaluate the patient within 48 to 72 hours toassess appropriate response to therapy.4

If a child is not responding to therapy, the prescriber should re-assess and and consider stepping up therapy to include antibi-otics that overcome the suspect reason for therapy failure.Antibiotics that should be considered includeamoxicillin/clavulanate acid (Augmentin), linezolid, levofloxa-cin, and clindamycin.4

The guidelines recommend amoxicillin as first-line therapy at adose of 80 to 90 mg/kg/day divided twice daily. In older chil-dren, the maximum dose is 1000 mg/dose.4 Inner ear concen-trations of amoxicillin have a much longer half-life than serumconcentrations, which allows twice daily dosing. Alternativerecommendations are summarized in Table 2.

Patients with conjunctivitis, recent use of amoxicillin, and thosewho have failed to respond to appropriately-dosed amoxicillintherapy are more likely to have infections caused by H. influen-zae. Because almost 50% of H. influenzae produce beta-lacta-mase, the guidelines recommend these patients receiveamoxicillin/clavulanic acid.4

In patients with penicillin allergy, clindamycin, cefuroxime, or athird generation cephalosporin (e.g. cefdinir, cefpodoxime) arealternative antibiotics. Importantly, clindamycin is an alterna-tive antibiotic that only provides coverage against S. pneumoni-ae. Other antibiotics that are sometimes considered in AOMtreatment because they are able to target penicillin-resistant S.pneumoniae are levofloxacin and linezolid. These are reservedto be only used when other antibiotics fail or when drug allergyprohibits the use of other antibiotics.4

When filling prescriptions for combination antibiotics, pharma-cy staff should exercise care; substitutions are not appropriatebecause each tablet strength has a different ratio of primaryantibiotic to β-lactamase inhibitor. For example, a prescriptionwritten for amoxicillin/clavulanic acid 500 mg cannot be substi-tuted as two amoxicillin/clavulanic acid 250 mg tablets becausethe amount of clavulanic acid in the 500 mg tablet (125 mg) isthe same as the amount of clavulanic acid (125 mg) in the 250mg tablet. Administering two 250 mg tablets would provide thecorrect amount of amoxiciilin, but double the prescribedamount of clavulanic acid. Therefore, it is important to dispensecombination antibiotic prescriptions as written.5


PAUSE AND PONDER:How many prescriptions for antibiotic suspensiondo you fill? Do you usually know the child’sdiagnoses? Do you ask?

Table 1. Conditions under Which Patients ShouldReceive Antibiotics for AOM3

● Severe presentation of AOM

● Recurrent AOM

● Bilateral AOM in patients six to 24 months

● AOM diagnosis in ill-appearing child

● Other bacterial illness is suspected

● Uncertain follow-upAOM = Acute otitis media

Antibiotics that are not currently recommended to treat AOM in-clude macrolides (e.g. erythromycin, azithromycin) andsulfamethoxazole/trimethoprim (cotrimoxazole or Bactrim).4

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Acute Bacterial SinusitisThe American Academy of Pediatrics published acute bacterialsinusitis clinical guidelines in 2013 (see Table 3).6 The guidelinesare based on identification of the pathogenic organism respon-sible for the infection using analysis of blood/sputum samplesfrom the patient. Common pathogens causing sinusitis in chil-dren are similar to AOM as both are upper respiratory tract in-fections. Level of resistance in the community plays animportant role in choosing an appropriate antimicrobial.6

Local laboraties tend to classify organisms as high resistance orlow resistance. High resistance results in decreased antibioticefficacy against bacterial pathogens because the bacteria pos-sess mechanisms that evade or destroy the antibiotic. Con-versely, antibiotics effectively eradiate low resistance bacteriawithout as much difficulty.6

In certain instances, such as S. pneumonia that is not suscept-able to penicillins, presence of moderate to severe illness, ageyounger than two years, daycare attendance, or recent antibiot-ic use, level of resistance is likely high.6 The preferred antibioticin these circumstances would be high-dose amoxicillin. Low like-lihood of resistance to antibiotics would be defined as infre-quent use of amoxicillin within the community or little to nopersonal use of amoxicillin. In this situation, low-dose amoxicil-lin (45 mg/kg/day in divided doses administered every 12 hours)is recommended.

Other antibiotics that may be considered for acute bacterial sinus-itis are cephalosporins, linezolid, and clindamycin. Cephalosporinsare more commonly used as alternative antibiotics while linezolidand clindamycin are reserved as last-line options. Prescribers mayswitch from amoxicillin to a cephalosporin if the patient has adocumented penicillin allergy or to evade possible antimicrobialresistance to the penicillin drug class. Duration of therapy to treatacute bacterial sinusitis varies widely from a minimum of 10 daysto 28 days. Systematic studies have not determined an optimallength of therapy for treating acute bacterial sinusitis in the pedi-atric population.6

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Table 2. Guideline-Directed Care for Acute Otitis Media4

Indication Routine Alternatives

First line AOM treatment Amoxicillin 1. Amoxicillin in past 30 days or if conjunctivitis alsopresent: amoxicillin/clavulanate

2. Penicillin allergy, but able to tolerate cepha-losporins: cefpodoxime, cefdinir, or cefuroxime

3. Beta-lactam allergy (unable to tolerate penicillins andcephalosporins): clindamycin

Failure after at least 48 hours of treat-ment

Amoxicillin/clavulanate 1. If failed amoxicillin/clavulanate, ceftriaxone x 3 daysis preferred, alternatively can consider oral clin-damycin +/- cephalosporin

2. If failed cephalosporin or if failed more than oneabove measure: levofloxacin or linezolid maybe con-sidered

AOM = acute otitis media

Table 3: Antibiotic Recommendations for Acute Bacterial Sinusitis in Children6


Initial therapy Low dose amoxicillin(45 mg/kg/day)

1. Areas with high resistance rates:high-dose amoxicillin/clavulanate

2. Penicillin allergy: cefdinir, cefpodoxime, or cefuroxime

Lack of response to initial therapy Increase amoxicillin doseor consideramoxicillin/clavulanate orCephalosporin

1. Consider clindamycin or linezolid for resistant pneu-mococcus as most of the above cover H. influenzaeand M. catarrhalis well

AOM’s common causative bacterial pathogensinclude Stretococcus pneumoniae, non-typeableHaemophillus influenzae, and Moraxella catarrhalis.

Common pathogens causing sinusitis in childrenare similar to AOM as both are upper respiratorytract infections.

Community-Acquired PneumoniaCommunity-acquired pneumonia (CAP) is usually a viral respira-tory tract infection in children, especially children younger thanfour years of age.7 When CAP is bacterial in nature, the mostcommon cause in children is S. pneumoniae. The possibility ofbacterial CAP due to M. pneumoniae or C. pneumoniae is rare inyoung children and if present in older children, it is debatable iftreatment improves outcome. The Infectious Diseases Society ofAmerica released clinical guidelines for the treatment of CAP in2011. These guidelines apply to children older than threemonths of age.7,8

For viral CAP, unless influenza is suspected, parents should pro-vide supportive care measures and healthcare providers shouldeducate them concerning symptoms that require additional orimmediate medical attention. When influenza is suspected, thepreferred antiviral is oseltamivir dosed by age and weight giventwice a day for five days.7,8

With suspected bacterial CAP, high-dose amoxicillin (90mg/kg/day) is the preferred antibiotic due to its ability to coverS. pneumoniae.7,8 In areas where there is increased pneumococ-cal resistance it is recommended that the amoxicillin compo-nent be divided in three doses to maximize the bactericidalactivity. For unvaccinated pediatric patients,amoxicillin/clavulanic acid should replace amoxicillin to provideadditional coverage against beta-lactamase producing H. influ-enzae type b.7,8


Other antibiotics that can be used but should be reserved assecond or third-line antibiotics are cephalosporins, doxycy-cline, and levofloxacin. Traditionally, clinicians have avoidedtetracyclines in children younger than eight because of a risk oftooth enamel discoloration. Although recent data suggeststhat the risk of teeth staining in children from short courses islow, doxycycline should generally only be used in CAP in chil-dren 8 years and older because there are other safer alterna-tives available.7,8

PharyngitisPharyngitis (inflammation of the throat) is one of the mostcommon complaints among children.9 Viral pharyngitis is com-mon and only supportive therapy is necessary. Children agedfive through 15 years are at increased risk for Stretococcus py-rogenes or group A Streptococcus (GAS) pharyngitis or strepthroat. Especially in these patients, it is important to differenti-ate GAS pharyngitis with viral pharyngitis because up to 30% ofthe population is colonized with non-pathogenic GAS, a com-mon colonizer of normal gut flora.9,10

Some signs differentiate viral and bacterial pharyngitis. Viralpharyngitis is likely to cause a general viral upper respiratorysyndrome plus sore throat, whereas in GAS pharyngitis, respi-ratory symptoms besides sore throat are rare. Patients whohave GAS paryngitis should start treatment within a few daysas untreated pharyngitis can lead to acute rheumatic fever(ARF), acute glomerulonephritis, peritonsillar abscess, cervicallymphadenitis, and mastoiditis. These infections develop ifgroup A strep spreads from the pharynx to nearby physicalstructures.9,11

The Infectious Disease Society of America published clinicalguidelines for the treatment of pharyngitis in 2012.10 It isworth noting that appropriate antibiotic use decreases the in-cidence of all complications related to GAS pharyngitis otherthan the incidence of post-streptococcal glomerulonephritis(PSGN). The incidence of PSGN is not improved with the use ofantibiotics because it is caused by the immune system’s reac-tion to fighting group A streptococcus rather than a bacterialetiology.12

Pediatric patients who have symptoms of GAS pharyngitis

Table 4. Antibiotic Recommendations for Community Acquired Pneumonia6


Vaccinated infant /child Either no antibiotic or high-doseamoxicillin (divided 2 to 3 times aday based on local resistance)

1. If influenza is suspected: oseltamavir2. Penicillin allergy: cefdinir, cefpodoxime, doxycycline (age

> 8 years), or levofloxacin for 5 days based on patientspecific factors

3. Rarely coverage for Mycoplasma pneumoniae or other intracellular organisms is needed in older children /adolescents: azithromycinUnvaccinated infant /child High dose amoxicillin-clavulanate

divided in 3 daily doses

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Pediatric Vaccines to Reduce Respiratory Illnessin ChildrenVaccinations can prevent many childhood bacterial infectionsand limit their spread. Immunizations that are routinely recom-mended that can prevent the incidence or severity of the com-mon respiratory infections caused by influenza, pneumococcalspecies (e.g. targeting S. pneumoniae), and Haemophilus influ-enzae type b (Hib).14,11

Influenza vaccine is recommended annually beginning at theage of six months.11

Since its approval, pneumococcal conjugate vaccine (PCV13)has decreased pneumococcal-related AOM by 55% to 57% andCAP by 29% to 32% in children.15,16 PCV13 is recommended as afour-dose series at ages two months, four months, six months,and 12 to 15 months. Additionally, children two years old orolder who are immunocompromised or have other high-riskfactors for pneumococcal disease should receive the pneumo-coccal polysaccharide vaccine (PPSV23).11

The likelihood of Hib diseases including CAP have decreased inrecent years due to the availability of several brands of HiB vac-cine. Guidelines recommended starting the Hib series at twomonths of age followed by three or four dose series (dependingon brand administered) with booster completion at 12 to 15months of age.11

should have a rapid antigen detection test (RADT) performed. Ifthe RADT is positive, antibiotics are indicated. If the RADT isnegative, clinicians should obtain a culture. Testing is not usual-ly recommended for children younger than three years becauseGAS pharyngitis is rare in these children and when it does oc-cur, complications are unlikely.9,10

Similar to AOM, the guidelines recommend that patients withpharyngitis receive treatment for pain with a systemic analgesicsuch as acetaminophen or ibuprofen. Proper hydration shouldbe maintained in these patients; for those who are unable toeat or drink, ibuprofen is not recommended.9,10

GAS is very susceptible to penicillins and cephalosporins, sosusceptibility testing is not recommended. Penicillin 250 mgtwo to three times daily for 10 days or amoxicillin 50mg/kg/day (maximum 1000 mg/day) for 10 days are recom-mended as first-line antibiotics. Since children often dislike thetaste of penicillin suspension, most pediatric healthcare provid-ers would recommend amoxicillin. When patients are allergic topenicillins but can tolerate cephalosporins, cephalexin 40mg/kg/day divided twice a day (maximum 1000 mg/day) for 10days is recommended. Alternatives to penicillins and cepha-losporins include clindamycin 21 mg/kg/day in three divideddoses (maximum of 300 mg/dose) for 10 days or azithromycin12 mg/kg/day for five days (maximum of 500 mg/dose everyday). Unlike in AOM, azithromycin is recommended for a selectgroup of patients, specifically in those with beta-lactamallergies.7 However, resistance to macrolides occurs more oftenthan resistance to beta-lactams; therefore high doses ofazithromycin are needed.10

Most people who are GAS carriers are colonized with non–pathogenic GAS, but certain colonized individuals should re-ceive treatment towards eradication (Table 5). Clindamycin andrifampin may be more likely to eradicate GAS because theywork using protein synthesis inhibition. Prophylaxis is reservedfor patients who have experienced ARF and is otherwise notrecommended.9,13

Table 5. Circumstances in which Antibiotics areRecommended for GAS Eradication.10

● Community outbreak of ARF, poststreptococcal glomer-ulonephritis, or invasive GAS infections

● Outbreaks of GAS in closed community

● Presence of family or personal history of ARF

● Family with high anxiety about GAS

● Tonsillectomy is being considered because of GAS car-riage

Abbreviations: ARF = acute rheumatic fever; GAS = Group AStreptococcus

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Stewardship: Incorporating Principlesinto PracticePharmacists already perform many of essential roles in outpa-tient stewardship on a daily basis. Pharmacists

● provide education to parents regarding over-the-coun-ter management of cough and colds

● review antibiotic therapies to optimize drug therapy aspart of medication therapy management

● review prescriptions for interactions and allergies● educate parents regarding appropriate usage and ex-

pected side effects.

Pain management is an important factor in appropriate treat-ment of AOM and pharyngitis. Pharmacists can provide parentswith appropriate education about pain medications for theirchildren and how to dose them effectively. Pharmacists' com-munity accessibility gives parents opportunities to ask ques-tions and tailor therapy for their children.4,10

Many people are unaware that antibiotics are used for bacterialinfections rather than viral infections; in 2003, 57% of the pub-lic believed “antibiotics are not an effective treatment for viralinfections.”17 A 2011 study revealed improvement, with 67% ofthe public agreeing that antibiotics are inappropriate for viralinfections. However, more improvement is needed.18 For exam-ple, pediatric CAP is commonly caused by viruses. If patientswere to take antibiotics for viral infections, it would not helpbut could instead only cause adverse effects.

Viral infections can be as severe as bacterial infections. Coughs,colds, viral pharyngitis, and many cases of pediatric CAP arecaused by viruses for which targeted treatments are unavail-able. If young children contract influenza, pharmacy staffshould recommend parents consult a pediatrician promptly todetermine if oseltamivir is indicated.7 In cases when pediatri-cians do not prescribe antibiotics, the pharmacist can dispel themyth that the decision to use an antibiotic is based on the in-fection’s severity (i.e. the more severe the infection, the moregreater the likelihood antibiotics will help). This is a not true.Additionally, pharmacists can also help parents find options forsymptomatic management. Finally, pharmacists should alwaysremind parents to seek additional medical help if a child pres-ents with fever > 380C (100.40F) along with a cough or cold.2

Last, it is also important for community pharmacists to learnabout local antibiotic susceptibility rates in their geographiclocations.2 A local hospital laboratory that cares for childrenwould be a place to start; ask for an antibiogram. This informa-tion can assist pharmacists in assessing and optimizing dosingfor children with AOM, sinusitis, and CAP.

Patient CounselingFinally, the pharmacist and pharmacy staff have unique respon-sibilities to counsel families on proper antibiotic use, storage,dosing, and side effects when dispensing medications. Properstorage of antibiotics is important for a variety of reasons suchas maintaining stability and taste. Table 6 lists the proper stor-age requirements, duration, and food considerations neededfor antibiotic suspensions.

Along with timing doses to be given with or without food, otherconsiderations include timing of concurrent medications or sup-plements. Cefdinir and levofloxacin suspensions should be sep-arated from antacids and iron supplements by at least twohours to avoid chelation of the antibiotics by cations. Parents ofpediatric patients should also be aware that cefdinir suspen-sions discolor stool to look reddish, but this should not be con-fused for blood in stool.4,21 Rifampin also discolors bodily fluids(skin, urine, sweat, saliva, tears, and feces) to an orangish colorand may permanently stain soft contact lenses.13

Nausea and gastrointestinal adverse effects are most common-ly reported for beta-lactam antibiotics.4,21 Allergic reactions arealso possible and often initially present as a rash. Fluoroquino-lones are saved as “last resort” antibiotics in children becausetheir labeling includes a boxed warning for tendonitis, tendonrupture, and worsening of myasthenia gravis. Boxed warningsalso note the potential for peripheral neuropathy that may beirreversible in both children and adults.22,24 Fluoroquinolonesare also associated with serious cardiac, dermatologic, and hy-persensitivity reactions.22,24 Linezolid is reserved as a last-lineantibiotic because it has drug-food and drug-drug interactionsand associations with hematologic suppression.3

Table 6. Antibiotic Suspensions Storage, Duration of Stability, and Food Considerations4,5, 19-23

Antibiotic Suspension Method of Storage Duration of Stability Food ConsiderationsAmoxicillin Refrigerator for taste 14 days Take without foodAmoxicillin/clavulanate Refrigerator for stability 10 days Take with foodAzithromycin Room temperature 10 days Take without foodCefdinir Room temperature 10 days Take with or without foodCefpodoxime Refrigerator 14 days Take with foodCefuroxime Refrigerator 10 days Take with foodClindamycin Do NOT refrigerate 14 days Take without foodLinezolid Room temperature 21 days Take without food

Ibuprofen should be avoided in children who are not eating ordrinking fluids sufficiently as it is associated with gastrointesti-nal ulcers and acute kidney injury. Aspirin should be avoided inchildren until the age of 12 due to the risk of causing Reye’ssyndrome (a condition that causes confusion, liver damage,and swelling in the brain when triggered by aspirin use during aviral illness or infection).4 Products containing codeine are nowcontraindicated in children younger than 12 years of age andshould be avoided in adolescents between 12 and 18 yearswho are obese or have conditions such as obstructive sleep ap-nea or severe lung disease due to increased risk of seriousbreathing problems.25

For children who present with pharyngitis, it is important tocounsel parents/guardians to hydrate their child properly withsix to eight glasses of water per day. Topical analgesics/garglesor, hard candies/lozenges (in children six years and older) cansoothe the throat. Children under the age of six should not begiven lozenges or hard candies, as they are possible chokinghazards.10

Communicating with Healthcare ProvidersMedication therapy management for common respiratory in-fections is important. Initially, pharmacists may have to reachout frequently to clinicians who lack understanding of or har-bor misconceptions about pharmacist responsibilities. Face toface communication is best. In outpatient pharmacy, barriersto communication between the pharmacist and other health-care providers often exist.2,14 In community pharmacy, themain mode of communication is the telephone; rarely does thepharmacist have the opportunity to communicate in personwith community pediatricians. Before filling prescriptions forantibiotics, the pharmacist should gather all necessary informa-tion to determine if antibiotics are appropriate. With each anti-biotic prescription, the following information should beobtained:

● patient weight● allergies● current working diagnosis● recent or current medications.

This information can be obtained from the pediatrician orchild’s parent. The pharmacist can then review an antibioticguide such as the Connecticut Children’s Medical Centers’ Em-piric Outpatient Antimicrobial Guide(http://www.cidrap.umn.edu/asp/clinicaltools/empiric-outpatient-antimicrobial-guide) to evaluate antibiotic choiceand dose for that patient.26

Establishing open communication relationships with healthcareproviders promotes information sharing. Ideally, doctor-phar-macist collaboration should go hand-in-hand; understandingeach other’s professional roles can be beneficial not only to im-proving workflow, but also to improve patient outcomes.2


Maintaining a consistent flow of information from the provider’soffice to the pharmacist would allow for better patient care,which leads into the next communication barrier.

When communicating with healthcare professionals, it is best toavoid using abbreviations.2 Although we all work in healthcare,many abbreviations have more than one meaning and may beused in a different context in settings other than pharmacies.Avoiding abbreviations can prevent miscommunication or misun-derstand and allow for more effective communication.

Methods to Improve WorkflowAccording to the CDC’s Core Elements of Outpatient AntibioticStewardship, “action is necessary to transform policy and practiceinto measurable outcomes.”2 Applying antimicrobial stewardshipknowledge to routine workflow prevents emerging antibiotic re-sistance. Incorporating techniques summarized below can im-prove workflow and overall patient treatment experience.3

1 Work with prescribers to communicate routinely and helpthem understand the pharmacists' role in antibiotic treat-ment. If prescribers agree to provide the indication along

with patient weight and allergies on all prescriptions, this can im-prove care.

2 Pharmacists can also counsel parents on children’s medica-tions prior to reconstituting the suspension to make surethey understand the medication's importance and storage

requirements.

3 Counsel families on appropriate adjunctive over-the-coun-ter medications such as pain medications to take with anti-biotics and help children feel more comfortable during

treatment of their infection. When other symptomatic medica-tions are appropriate, it is important that parents receive neces-sary information on those as well.

4 Use storage and food auxiliary labels appropriately andconsistently for antibiotic medications to ensure that anti-biotics remain stable and effective throughout the entire

prescribed course of treatment. Parents should also understandthat antibiotics should be disposed of following discontinuation ofthe antibiotic and resolution of the infection.

Part 2DECREASING “RESISTANCE” TOANTIBIOTIC STEWARDSHIP: THREE MOREREASONSSara E. Miller and Jeannette WickEvery year, children receive an estimated 11.4 million unneces-sary antibiotic prescriptions.1 Inappropriate antibiotic use con-tributes to antimicrobial resistance, which causes costly,resource-consuming, hard-to-cure illnesses with increased risk ofcomplications. Infections with bacteria resistant to antibiotics killat least 23,000 people annually.2

To reduce the dangers of antibiotic resistance, the Centers forDisease Control and Prevention (CDC) defines “Core Elements ofOutpatient Antibiotic Stewardship,” fundamentals that pharma-cists can use to develop innovative stewardship programs. Anti-microbial stewardship programs promote evidence-basedprescribing and proper patient use of antibiotics to decrease mi-crobial resistance and the spread of resistant infections. They al-so improve patient outcomes.3

The companion continuing education activity discusses the im-portance of antibiotic stewardship in children with an emphasison preventing antibacterial resistance. This activity offers threeadditional reasons to promote antibacterial stewardship.

Often, people need to understand situations on a personal levelbefore they understand the problem’s urgency and embrace so-lutions. In the case of pediatric antibiotic prescribing, parents of-ten need to know what could happen to their own children, andthe implications of unnecessary antibiotics for society at large.These explanations need to be provided in ways that are reason-able and measured, and don’t frighten people unnecessarily.Pharmacists can educate and empower patients, families, andproviders to reduce or eliminate inappropriate antibiotic use by

● raising awareness of antibiotic adverse effects● emphasizing consequences of misuse, and● explaining irreversible environmental effects.

Antibiotic Adverse EffectsMore than 30% of children taking antibiotics for at least 14 daysexperience an adverse event (AE) that warrants therapychange.4 Pediatrics are inherently at high risk for AEs. Multiplemedications, comorbidities, and longer duration of therapiesfurther increase risk.5

Antibiotics cause more pediatric emergency department (ED)visits than any other medication. They account for 56% of visitsin children younger than 5 years old, and 32% in those aged sixto 19 years old. Reasons for ED visits include AEs and accidentalingestions. Amoxicillin-containing, sulfonamide-containing, andcephalosporin antibiotics are implicated most often.6 Few stud-ies of severe antibiotic reactions have been conducted in pedi-atrics, but antimicrobials, particularly minocycline andamoxicillin/clavulanate, are known to cause 45% of drughepatotoxicity.7 Experts hope to heighten awareness ofthis potential AE, and recommend monitoring blood counts andliver function tests during long-term therapy.7

Most antibiotic effects are mild and self-limiting, but diarrheaand rash can be hallmarks for more severe AEs.4 Providersshould counsel on conditions under which parents or caregiversmust seek immediate medical care for diarrhea and rash (SeeTable 1). Table 2 lists possible side effects of common antibiot-ics prescribed to pediatrics.


Table 1. When to Seek Medical Care for Antibiotic-Associated Diarrhea or Rash4,8

Children need additional medical attention if they develop thesesymptoms of DIARRHEA:

Caregivers should stop administering the drug and seek emer-gency care if a RASH:

�� Bloody stool, very liquid stool, or stool that burns theperi-anal area

�� Explosive diarrhea�� Signs of systemic dehydration�� Painful evacuation�� Loss of appetite�� Inability to drink or urinate�� Any diarrhea that continues for two weeks or more

�� Appears painful, purple, or dark colored�� Develops on the face or mucous membranes�� Is accompanied by tongue swelling, a fever (>104°F),

shortness of breath, joint pain, or low blood pressure

© Can Stock Photo/canimage

Parents have been inundated with advertising coaching them totreat minor cuts and scrapes with an antibiotic ointment orcream. Note that bacitracin was the ninth most common aller-gen reported between 1998 and 2002.9,10 Subsequently, in 2003,the American Contact Dermatitis Association named bacitracinits Allergen of the Year.9,10 Over the counter topical antibioticslike bacitracin are not appropriate for routine care due to risk ofallergy and anaphylaxis. Pharmacists can discourageparents/patients from using these products, and educate themthat the best way to treat a minor cut or scrape is to clean itwith mild soap and water and apply plain petrolatum if theyneed an emollient. Patients need to see a healthcare provider ifa cut or scrape will not stop bleeding; is painful to the touch formore than 24 to 72 hours; or inflammation suggestive of infec-tion develops.9

Consequences of Antibiotic MisuseInappropriate medication dosing is the most common pediatricmedical error because of complex weight-based dosing and age-dependent formulations.5 Overall, pediatric antibiotic prescrib-ing has decreased in recent years, but prescribing for inappropri-ate indications persists.11 About 58% of pediatric antibioticprescriptions are used inappropriately for common respiratoryinfections including otitis media, bronchitis, and sinusitis.11 TheU.S. spends more than $10.7 billion on antibiotics; inappropriateprescribing consumes money, time and resourcesunnecessarily.2

Knowledge gaps, patient expectations, lack of time, and concernabout patient satisfaction lead to inappropriate prescribing.3

Providers often develop decreased mindfulness, a phenomenonUCONN You Asked for It Continuing Education July 2018 Page 10

Table 2. Antibiotic Side Effects in PediatricsAntibiotic Class Antibiotic Names Common Side Effects Rare Side Effects*Penicillins Penicillin, amoxicillin,

amoxicillin/clavulanate, ampicil-lin

N/V/D, rash, abdominal pain,black hairy tongue, candidiasis,C. difficile

Hepatic and renal dysfunction,anemia, neutropenia, extrinsictooth discoloration (from liquidformulations)

Cephalosporins Cephalexin, cefuroxime, ceftriax-one, cefdinir, cefpodoxime

N/V/D, rash, dyspepsia, abdomi-nal pain, genital pruritus, C. dif-ficile

Seizure, hepatic and renal dys-function, anemia, hemorrhage(primarily from cefamycins)

Macrolides Azithromycin, clarithromycin,erythromycin

N/V/D, rash vomiting, abdominalpain, C. difficile

Hepatic and renal dysfunction,anemia, ototoxicity, torsades depoint

Sulfonamide derivatives Trimethoprim/sulfamethoxazole Photosensitivity, nausea, vomit-ing, abdominal pain, rash, C. dif-ficile

Hepatic and renal dysfunction,anemia, hyperkalemia

Fluoroquinolones Ciprofloxacin, levofloxacin Photosensitivity, rash, mus-coskeletal effects

Tendon, joint and muscle pain, a“pins and needles” tingling orpricking sensation, confusion,and hallucinations

Tetracycline derivatives Doxycycline N/V/D, phototoxicity, rash Effects on tooth development,growth, and color before age 8

*All antibiotics have the potential to cause hypersensitivity reactionsABBREVIATIONS: N/V/D = nausea vomiting diarrhea

called alert fatigue, when electronic Clinic Decision Supportprograms routinely generate alerts about potential interactionsand clinically acceptable dosing parameters. Clinicians mayshrug off the alert, or have knowledge gaps, so they don’t com-pletely understand the alert’s potential repercussions. Clinical-ly, high false positive rates cause alert fatigue and cliniciansoverride approximately 77% of alerts. Once a healthcare pro-vider overrides an alert, it’s unlikely that any other safety mea-sure will catch an error. Experts are urging pharmacists toincorporate—and pay attention to—antibiotic overdose alertsbecause 38% of pediatric antibiotic alerts are true overdoses.For optimal patient safety, providers must recognize knowl-edge gaps and wake up to alert fatigue.5

Although antibiotic overdoses don’t usually cause pediatricdeaths, even one death is too many.12 All parents and provid-ers should know how to approach overdose situations. Speedycontact with an emergency response team or the National Cap-ital Poison Center by phone (1-800-222-1222) or on the website (https://www.poison.org) can save a life.

Misuse of systemic antibiotics in patients younger than five isone of the top reasons for calls to Poison Control.12 Antibioticsuspensions have appealing colors and flavors that may in-crease the risk that a child will be attracted to the bottle andpossibly drink part or all of its contents; this increases risk ofoverdose. The most common causes of unintentional exposureinclude administering a dose twice by accident or giving dosestoo close together; giving the wrong medication or someoneelse’s medication; and confusing dosage units. 12


Clinical effects of excessive oral antibiotics include stomach up-set and diarrhea, for which pediatricians often recommend sup-portive care (hydration and rest). If the exposure is ophthalmicor dermal, advise parents to flush the area with water beforecontacting poison control.12

Pediatric antibiotic dosing is complex, so provider knowledge ofpediatric-specific tolerability and pharmacokinetic parametersis critical.7 Pharmacists and other healthcare providers shouldask questions about the patient’s medical history, co-inges-tions, symptoms, time of ingestion, and suspected amount ofingestion (pill count, spill volume, and sometimes, mouthcolor/odor).12

Pharmacists can remind parents by providing key information:● Consider it an emergency if the child gasps for air, col-

lapses, seizes, or isn’t waking up.● Handle any emergency overdose (described in the bul-

let above) by calling 911 for immediate care beforepoison control.

● In all overuse circumstances, pay attention to thechild’s airway, breathing and circulation. 12

Antibiotics have “Environmental Side Effects”This may surprise readers: Antimicrobials are now ubiquitous inthe environment.13 The largest use of antimicrobial agents out-side human medicine is in food animals. Children are at highrisk of developing infections with resistant organisms linked di-rectly to the agricultural use of antimicrobials.13

Historically, the U.S. Food and Drug Administration (FDA) hasallowed use of antibiotics in farm animals to stimulate growthand to treat, control, and prevent infections.14 Resistant bacte-ria that spread from food and animals cause about one in fiveresistant infections in humans.15,16 To combat antimicrobial re-sistance, the FDA released voluntary guidance on judicious useof medically important antibiotics in food-producing animals(poultry, swine, or cattle) in 2017.14

The media has been replete with stories about antibiotic resis-tant bacteria in food on our grocery store shelves, and in fastfood.17,18 Meat producers and popular fast food restaurantshave capitalized on the recommendation—and on growing con-cern among health-minded Americans—to voluntarily phaseout antimicrobials for growth stimulation by using and advertis-ing “antibiotic free” meat.19

To limit further resistance, the FDA suggests veterinary over-sight when using antimicrobial therapy in food-producing ani-mals. Note the FDA now prohibits use of fluoroquinolones andcertain cephalosporins in poultry because of high risk of resis-tance development.20 Figure 1 shows mechanisms resistantbacteria spread through the environment.15

After any mammal consumes an antibiotic, it has to eliminate itvia urine or stool. Human sewage treatment plants often do notremove residue, and when animal eliminate onto or into thesoil, residue contaminates ground water. Fluoroquinolones,macrolides, and tetracyclines persist in water supplies, diffusinginto the entire body of water and accumulating in increasinglyhigher concentrations.21 Mechanisms including high efficiencymembranes, chlorination, and high UV radiation successfullydecrease bacteria’s ability to survive in wastewater but they arecostly and used in only newer sewage treatment plants. Re-searchers must prioritize developing wastewater treatmentplants that remove all antibiotic disintegrates effectively andefficiency.22

Increasing antibiotic use causes immediate direct and indirectlong term effects in the environment. Many factors influencethe antibiotics’ environmental impact including the concentra-tion, exposure time, receiving ecosystem (e.g. soil or water),and co-occurrence with other antibiotics or contaminants. Anti-biotics’ direct bactericidal and bacteriostatic effects on mi-crobes kill entire microbial populations that have valid andimportant ecological functions, such as maintenance of soil andwater quality.21

Also, sewage treatment plants contain diverse bacterial com-munities with several hundred species, increasing risk of resis-tant gene transfer.23 Once a microbial population acquiresresistance genes, it’s impossible to reestablish complete drugsensitivity, even if humans are able to reduce antibiotics in theenvironment.21

Indirect effects of antibiotics in the environment include conse-quent development of multi-resistant bacteria, death of aquaticenvironments, and adverse effects on birds and bees. Research-ers indicate they haven’t yet identified all of antibiotics’ indirectlong-term effects in the ecosystem.21

Antibiotics flushed down the toilet directly harm the environ-ment. Pharmacists should find safe medication disposal sitesaround the community to recommend to patients.● Walgreens has an online resource to find the nearest safe

medication disposal kiosk.● The U.S. Drug Enforcement Administration (DEA) sponsors

National Prescription Drug Take Back Day. Promoting safemedication disposal is an easy way to help preserve our envi-ronment.

Pause and Ponder:What do you know about antibiotics in our foodsupply and in the environment?Do you know enough?


Centers for Disease Control and Prevention. Available at https://www.cdc.gov/drugresistance/about.html

Figure 1

Take Action TogetherAntibiotic resistance is a growing global threat; prescribersand patients must acknowledge national goals for improv-ing outpatient antibiotic prescribing. It’s a particularly trou-bling (and frustrating) situation because researchers haveproduced no new antibiotic class in almost 30 years. Thismeans our antibiotic selection is limited. The White HouseNational Action Plan for Combating Antibiotic-ResistantBacteria aims to reduce inappropriate antibiotic outpatientuse by 50% and a Healthy People 2020 objective discourag-es antibiotic use for inappropriate indications, includingpediatric ear infections and common colds.20

Effective parent-provider communication has potential toreduce inappropriate antibiotic prescribing using rapport-building, exchange of critical information, and shared-deci-sion making. 21 Researchers must study effective strategiesfurther to prevent inappropriate antibiotic prescribing andits effects on healthcare costs, patient visits, and antibioticresistance.21 Pharmacists who counsel children and theircaregivers can and should discuss antimicrobial resistancewhen they dispense antibiotics. As with all things, some-times people need to be nudged a little harder to appreci-ate a problem’s urgency. Discussing adverse effectavoidance, the potential for accidental poisonings, and en-vironmental effects can underscore the urgency. Figure 2suggest ways pharmacies can step up their involvement.

Best❶Be COMMUNITY CHAMPIONS and talk about individualand societal risks of antibiotic overuse❷Collaborate with local pediatricians to enhance informa-tion transfer and improve patient safety❸Examine your workflow to ensure you are takingadvantage of every opportunity to implement theprinciples of Antimicrobial Stewardship.

Better❶Always ask for age, weight, and allergies on kids’ prescrip-tions for antibiotics❷Post signage about antimicrobial resistance in prominentplaces in the pharmacy❸ Know the guidelines for common pediatric infections

Good❶Be familiar with antimicrobial resistenceand potential antibiotic adverse effects andtoxicities❷Educate patients about the differences be-tween bacterial and viral infections

© Can Stock Photo / ymgerman

Figure 1. Advancing Pharmacists and Pharmacy Technicians Role in Antibiotic Stewardship

© Can Stock Photo / lunamarina


REFERENCES

PART 1FUNDAMENTALS OF ANTIMICROBIALSTEWARDSHIP FOR OUTPATIENTPEDIATRIC INFECTIOUS DISEASES1. Centers for Disease Control and Prevention. Antibiotic resistancethreats in the United States. April 23, 2013.https://www.cdc.gov/drugresistance/threat-report-2013/index.html.Accessed January 20, 2018.2. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elementsof outpatient antibiotic stewardship. MMWR Recomm Rep2016;65(No. RR-6):1–12.3. Centers for Disease Control and Prevention. Core elements of out-patient antibiotic stewardship. Available athttps://www.cdc.gov/antibiotic-use/community/improving-prescribing/core-elements/core-outpatient-stewardship.html. Ac-cessed Jaly 9, 2018.4. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis andmanagement of acute otitis media. Pediatrics. 2013;131(3):e964-99.5. Amoxicillin/Clavulanate Potassium: Pediatric Dosing. (2018). In Mi-cromedex (Columbia Basin College Library ed.) [Electronic version].Greenwood Village, CO: Truven Health Analytics. Available athttp://www.micromedexsolutions.com/. Access July 2, 2018.6. Wald ER, Applegate KE, Bordley C, et al; American Academy of Pedi-atrics. Clinical practice guideline for the diagnosis and management ofacute bacterial sinusitis in children aged 1 to 18 years. Pediatrics.2013;132(1):e262-e280.7. American Academy of Pediatrics Statement of Endorsement. Man-agement of community-acquired pneumonia (CAP) in infants and chil-dren older than 3 months of age. Pediatrics. 2011; 128 (6);e1677.8. Bradley JS, Byington CL, Shah SS, et al; Pediatric Infectious DiseasesSociety and the Infectious Diseases Society of America. The manage-ment of community-acquired pneumonia in infants and children olderthan 3 months of age: clinical practice guidelines by the Pediatric In-fectious Diseases Society and the Infectious Diseases Society of Ameri-ca. Clin Infect Dis. 2011 Oct;53(7):e25-76.9. Centers for Disease Control and Prevention. Group A streptococcal(GAS) disease, United Sates, 2016. Available athttps://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html. Ac-cessed June 30, 2018.10. Infectious Diseases Society of America. Clinical practice guidelinefor the diagnosis and management of group A streptococcal pharyngi-tis: 2012 update by the Infectious Diseases Society of America. Avail-able athttp://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_By_Organ_System-81567/Lower/Upper_Respiratory/Streptococcal_Pharyngitis/. Ac-cessed July 9, 2018.11. Centers for Disease Control and Prevention. Recommended immu-nization schedule for children and adolescents aged 18 years or young-er, United States, 2018. Available athttps://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Accessed June 5, 2018.12. Centers for Disease Control and Prevention. Post-streptococcalglomerulonephritis. September 16, 2016. Available atwww.cdc.gov/groupastrep/diseases-public/post-streptococcal.html.Accessed July 7, 2018.13. Rifadin (rifampin) complete prescribing information. Bridgewater,NJ; sanofi-aventis U.S. LLC: 2018.14. Nijjer S, Gill J, Nijjer S. Effective collaboration between doctors andpharmacists. Hosp Pharmacist. 2008; 15:179-182.

16. Pavia M, Bianco A, Nobile CG, Marinelli P, Angelillo IF. Efficacy ofpneumococcal vaccination in children younger than 24 months: a meta-analysis. Pediatrics. 2009;123(6):e1103-e1110. Oseltamivir Phosphate:Pediatric Dosing. (2018). In Micromedex (Columbia Basin College Libraryed.) [Electronic version]. Greenwood Village, CO: Truven Health Analyt-ics. Available at http://www.micromedexsolutions.com/. Access July 2,2018.17. McNulty C, Joshi P, Butler CC, et al. Have the public’s expectationsfor antibiotics for acute uncomplicated respiratory tract infectionschanged since the H1N1 influenza pandemic? A qualitative interviewand quantitative questionnaire study. BMJ Open. 2012;2(2): e000674.18. McNulty CAM, Boyle P, Nichols T, Clappison P, Davey P. The public’sattitudes to and compliance with antibiotics. J Antimicrob Chemother.2007;60(Suppl 1):i63–i68.19. Amoxicillin: Pediatric Dosing. (2018). In Micromedex (Columbia BasinCollege Library ed.) [Electronic version]. Greenwood Village, CO: TruvenHealth Analytics. Available at http://www.micromedexsolutions.com/.Accessed July 2, 2018.20. Cefdinir: Pediatric Dosing. (2018). In Micromedex (Columbia BasinCollege Library ed.) [Electronic version]. Greenwood Village, CO: TruvenHealth Analytics. Available athttp://www.micromedexsolutions.com/. Accessed July 2, 2018.21. Doxycycline Calcium: Pediatric Dosing. (2018). In Micromedex(Columbia Basin College Library ed.) [Electronic version]. Green-wood Village, CO: Truven Health Analytics. Available athttp://www.micromedexsolutions.com/. Accessed July 2, 2018.22. Levofloxacin: Pediatric Dosing. (2018). In Micromedex (Co-lumbia Basin College Library ed.) [Electronic version]. GreenwoodVillage, CO: Truven Health Analytics. Available athttp://www.micromedexsolutions.com/. Accessed July 2, 2018.23. Clindamycin Hydrochloride: Pediatric Dosing. (2018). In Mi-cromedex (Columbia Basin College Library ed.) [Electronic ver-sion]. Greenwood Village, CO: Truven Health Analytics. Availableat http://www.micromedexsolutions.com/. Accessed July 2,2018.24. US Food and Drug Administration Center for Drug Evaluationand Research. “Drug Safety and Availability - FDA Drug SafetyCommunication: FDA updates warnings for oral and injectablefluoroquinolone antibiotics due to disabling side effects.” 2016.Available at www.fda.gov/Drugs/DrugSafety/ucm511530.htm.Accessed July 7, 2018.25. US Food and Drug Administration, Center for Biologics Evalu-ation and Research. Drug safety and availability - FDA Drug SafetyCommunication: FDA restricts use of prescription codeine painand cough medicines and tramadol pain medicines in children; rec-ommends against use in breastfeeding women. 2018. Available atwww.fda.gov/Drugs/DrugSafety/ucm549679.htm. Accessed July 7,2018.26. Girotto J, Bennett N. Empiric outpatient antimicrobial guide. Con-necticut Children's Medical Centers Antimicrobial Stewardship Program,2017. Available atwww.connecticutchildrens.org/wpcontent/uploads/2017/06/EmpiricOutpatientAntibiotic2016. Accessed July 7, 2018.


REFERENCES

PART 2DECREASING “RESISTANCE” TO ANTIBIOT-IC STEWARDSHIP: THREE MORE REASONS1. Kronman MP, Zhou C, Mangione-Smith R. Bacterial prevalence andantimicrobial prescribing trends for acute respiratory tract infections.Pediatrics. 2014;134(4):956-965.2. Centers for Disease Control and Prevention. Measuring outpatientantibiotic prescribing. Available at https://www.cdc.gov/antibiotic-use/community/programs-measurement/measuring-antibiotic-prescribing.html. Accessed June 28, 2018.3. Centers for Disease Control and Prevention. Core elements of out-patient antibiotic stewardship. 2016. Available athttps://www.cdc.gov/mmwr/volumes/65/rr/rr6506a1.htm?s_cid=rr6506a1_e#F1_down. Accessed June 28, 2018.4. Olsen SC, Smith S, Weissman SJ, Kronman MP. Adverse events in pe-diatric patients receiving long-term outpatient antimicrobials. J Pediat-ric Infect Dis Soc. 2015;4(2):119-125.5. Kirkendall ES, Kouril M, Dexheimer JW, et al. Automated identifica-tion of antibiotic overdoses and adverse drug events via analysis ofprescribing alerts and medication administration records. J Am MedInform Assoc. 2017;24(2):295-302.6. Shehab N, Lovegrove MC, Geller A, et al. US emergency departmentvisits for outpatient adverse drug events, 2013-2014. JAMA.2016;316(20):2115-2125.7. Serranti D, Montagnani C, Indolfi G, et al. Antibiotic induced liver in-jury: what about children? J Chemotherapy. 2013;25(5):255-272.8. Valeyrie-Allanore L, Sassolas B, Roujeau JC. Drug-induced skin, nailand hair disorders. Drug Safety. 2007;30(11):1011-1030.9. Wick JY, Zanni GR. Skin tears: Prevention and treatment. ConsultPharm. 2008;23(7):508-518.10. Mowad CM. Contact allergens of the year. Adv Dermatol.2004;20:237-55.11. Centers for Disease Control and Prevention. Office-related antibi-otic prescribing for persons aged ≤14 years United States, 1993-1994to 2007-2008. 2011. Available athttps://www.cdc.gov/mmwr/preview/mmwrhtml/mm6034a1.htm.Accessed June 28, 2018.12. National Capital Poison Center. Antibiotics: Overdose vs Misuse.Available at https://www.poison.org/articles/2012-oct/antibiotics-overdose-vs-misuse. Accessed June 28, 2018.13. Shea, KM. Antibiotic Resistance: What is the Impact of AgriculturalUses of Antibiotics on Children’s Health? Pediatrics. 2003;112(1):253-257.14. Food and Drug Administration. Guidance for Industry #213. 2013.Availableathttps://www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdf AccessedJune 28, 2018.15. Centers for Disease Control and Prevention. Antibiotic resistancefrom the farm to the table.; 2017. Available athttps://www.cdc.gov/foodsafety/pdfs/ar-infographic-508c.pdf. Ac-cessed June 30, 2018.16. Centers for Disease Control and Prevention. Antibiotic ResistanceThreats in The United States. 2013. Available athttps://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf. Ac-cessed June 30, 2018.17. Consumer Reports. More Fast-Food Restaurants Are Serving ‘NoAntibiotic’ Meat. 2016. Available athttps://www.consumerreports.org/food-safety/more-fast-food-restaurants-serving-no-antibiotic-meat/. Accessed June 30, 2018.

18. Nedelman M. Restaurant report card: What's in your fast foodmeat? CNN. September 28, 2017. Available athttps://www.cnn.com/2017/09/27/health/fast-food-antibiotics-grades/index.html. Accessed Ju;y 3, 2018.19. Cook H. Most grocery store meat contains antibiotic-resistant bacte-ria: 4 things to know. Available athttps://www.beckershospitalreview.com/quality/most-grocery-store-meat-contains-antibiotic-resistant-bacteria-4-things-to-know.html. Ac-cessed July 3, 2018.20. Food and Drug Administration. Extralabel Use and Antimicrobials.2018. Available athttps://www.fda.gov/AnimalVeterinary/SafetyHealth/AntimicrobialResistance/ucm421527.html. Accessed June 30, 2018.21. Grenni P, Ancona V, Caracciolo AB. Ecological effects of antibioticson natural ecosystems. Microchemical J. 2018;136(1): 25-39.22. Lood R, Erturk G, Mattiasson B. Revisiting antibiotic resistancespreading in wastewater treatment plants. Front Microbiol.2017;8(2298):1-7.23. Fleming-Dutra KE, Prevalence of inappropriate antibiotic prescrip-tions among US ambulatory care visits, 2010-2011. JAMA.2016;315(17): 1864-1873.24. Goggin K, Bradley-Ewing A, Myers AL, et al. Protocol for ran-domized trial of higher versus lower intensity patient-providercommunication interventions to reduce antibiotic misuse in twopaediatric ambulatory clinics in the USA. BMJ Open. 2018;8(5):e020981.

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You Asked for It! CE...Jul 20, 2018 · otitis media, acute bacterial sinusitis, pharyngitis, and community acquired pneumonia. By increasing vigilance for antibiotic misuse and promoting