Wise Use of Antibiotics

Prescribing Antibiotics? Tidbits to Teach Families

Author: Annie Wirtz, PharmD, BCPPS | Co-Director, Antimicrobial Stewardship Program | Clinical Pharmacy Specialist, Pediatric Infectious Diseases

Column Editor: Rana El Feghaly, MD, MSCI | Director, Clinical Services | Director, Outpatient Antibiotic Stewardship Program | Associate Professor of Pediatrics, UMKC School of Medicine

In the outpatient setting, one-third of antibiotic prescriptions are unnecessary.¹ Given so, stewardship efforts have greatly focused on reducing unnecessary prescribing. Recent data suggest most caregivers are not actively seeking antibiotic prescriptions, but instead are looking for reassurance that their child is not seriously ill.² Therefore, a multitude of communication strategies have been developed to guide discussion when antibiotics are not prescribed.

While education is provided when antibiotics are not prescribed, what is being discussed with families who are given antibiotics? Misuse of antibiotics goes far beyond unnecessary prescribing. The harms (i.e., bacterial resistance) of not taking an antibiotic as prescribed may not resonate with all families. Recently, a survey of pediatric caregivers reported that 16% had leftover antibiotics in the home. Approximately, 12% reported they intended to or had administered someone else’s antibiotic prescription to their child, with many agreeing this was appropriate for a similar type of illness.³

Patient counseling on administration and side effects is thought to be the role of a pharmacist at prescription pick-up. Competing demands, such as COVID-19 vaccinations or high fill volumes, limit time for pharmacists to counsel families.⁴ Offering counseling is required by law but may be limited to closed-ended questions such as “do you have any questions for the pharmacist?” and caregivers may refuse.

Therefore, there are opportunities for health care providers to ensure families have the necessary information to utilize antibiotics appropriately. Described below are the top five pearls to discuss when patients are prescribed an antibiotic.

1. How should you give your child this antibiotic?

It is important to review how often the antibiotic should be administered as families can be confused about appropriate intervals between doses. For antibiotics given multiple times per day, consider identifying specific administration times (e.g., after school) at appropriate intervals which work with the family’s schedule to improve adherence.

Additionally, specify situations where antibiotics should be spaced away from food or interacting medications (e.g., iron or calcium-containing products), such as with fluoroquinolones or tetracyclines. Advise families which antibiotics can be taken with food to avoid gastrointestinal symptoms, including amoxicillin/clavulanate or clindamycin.

2. Why is your child receiving this antibiotic instead of another?

Discussing antibiotic resistance with families can be challenging. Most have a general awareness of what antibiotic resistance is, but do not feel it directly relates to antibiotic use in their own child.² Additionally, few families understand the correlation between use of broad-spectrum agents and development of resistance. The terms broad-spectrum or narrow-spectrum antibiotics are confusing and often inconsistent among prescribers.⁵

Consider discussing with families the reasoning behind specific antibiotic choices and how it relates to their child’s infection. For example, treating a sinus infection with a Z-Pak® may seem appealing to families due to once-daily dosing for only a few days compared with amoxicillin; however, it is important to educate that this antibiotic may not be as effective at getting rid of the bacteria (e.g., Streptococcus pneumoniae) which we are of most concern for with this type of infection. In this case, using a more broad-spectrum antibiotic (e.g., azithromycin), may not adequately treat the infection and may promote the development of resistance.  

3. How long should your child take this antibiotic?

Duration of antibiotics can seem contradictory for families as prescribers encourage short courses yet dissuade families from stopping antibiotics early despite feeling better. Collaborate with families to select short, yet effective durations. Educate on the importance of course completion to avoid bacterial resistance or treatment failure.

Occasionally, pharmacies will dispense excess antibiotic liquid to ensure all doses can be withdrawn.⁶ Discourage families from keeping excess medication for future use as possible harms include accidental ingestion; use of expired, less effective, or toxic medication; or administration of incorrect doses of antibiotics. Medications should be disposed of appropriately to reduce environmental exposure. Children’s Mercy provides resources for safe disposal of medications here.

4. If your child refuses the antibiotic, what should you do?

Administering antibiotics to children can be challenging, especially with poor palatability. For example, clindamycin liquid tastes bitter and based on concentration and dosing, results in a large volume per dose. This is stressful for families. Patient refusal has been cited as a top reason for antibiotic nonadherence in pediatrics.⁷

Encourage families to call if their child is struggling to take an antibiotic. There are interventions to try to improve this or an alternative antibiotic could be prescribed. Children’s Mercy Child Life has created a handout with useful tips for giving medication to children which can be accessed here. Before recommending, clarify the practice is OK with a pharmacist based on the antibiotic being prescribed.

5. What side effects should you look out for?

Families should be counseled on possible harms associated with antibiotics, both mild and severe. Data demonstrate that most families have a general wariness surrounding antibiotic use including concerns about adverse effects.² Prescribers should engage in a risk-benefit discussion with families. Highlight opportunities to mitigate side effects, such as avoiding excess sunlight while on doxycycline due to photosensitivity. Provide specific guidance on when a health care provider should be contacted due to severity of an adverse effect (i.e., hives or severe, profuse diarrhea). In doing so, prescribers can explain differences between a side effect and a true antibiotic allergy, which is commonly confused among families.

In summary, prescribers can engage in antimicrobial stewardship strategies by providing informative counseling for families who are prescribed an antibiotic to ensure appropriate use and reduce harm.

References:

1. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among U.S. ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873.
2. Szymczak JE, Klieger SB, Miller M, Fiks AG, Gerber JS. What parents think about the risks and benefits of antibiotics for their child’s acute respiratory tract infection. J Pediatric Infect Dis Soc. 2018;7(4):303-309.
3. Bharath A, Sathian U, Zmitrovich A, et al. Pediatric caregiver behaviors related to oral antibiotic use. J Pediatric Infect Dis Soc. 2021;piah020. [Online ahead of print].
4. Gabler E. How chaos at chain pharmacies is putting patients at risk. New York Times. Jan. 21, 2020. Accessed August 24, 2021. https://www.nytimes.com/2020/01/31/health/pharmacists-medication-errors.html.
5. Sanchez GV, Roberts RM, Albert AP, Johnson, DD, Hicks LA. Effects of knowledge, attitudes, and practices of primary care providers on antibiotic selection, United States. Emerg Infect Dis. 2014;20(12):2041-2047.
6. Dusdieker LB, Murph JR, Milavetz G. How much antibiotic suspension is enough? Pediatrics. 2000;106(1):E10.
7. Baguley D, Lim E, Bevan A, Pallet A, Faust SN. Prescribing for children – taste and palatability affect adherence to antibiotics: a review. Arch Dis Child. 2012;97:293–297.