Narrow-spectrum antibiotics preferred over broad spectrum for ARTIs in kids
Not only are broad-spectrum antibiotics no better than narrow-spectrum antibiotics in reducing treatment failures and improving other patient-centred outcomes, their use may come with more side effects than narrow-spectrum antibiotics in children with acute respiratory tract infections (ARTIs), suggests a recent study.
“Many children unnecessarily receive broad-spectrum antibiotics for common infections, which can lead to antibiotic resistance and unnecessary side effects,” said lead author Dr Jeffrey Gerber from the Center for Pediatric Clinical Effectiveness at Children's Hospital of Philadelphia in Philadelphia, Pennsylvania, US.
The study involved two cohorts of children (aged between 6 months to 12 years) with an ARTI and who received an oral antibiotic: a retrospective cohort of 30,159 children assessed for clinical outcomes, and a prospective cohort of 2,472 children assessed for patient-centred outcomes. The ARTIs analysed included acute otitis media, group A streptococcal pharyngitis, and acute sinusitis. [JAMA 2017;318:2325-2336]
Broad-spectrum antibiotics include, but are not limited to, amoxicillin-clavulanate, cephalosporins, and macrolides; while narrow-spectrum antibiotics include penicillin and amoxicillin. Although not recommended for acute sinusitis and acute otitis media, the researchers said macrolides were also included as broad-spectrum antibiotics “because of the frequency of reported use for these conditions in this health care network as well as nationally.”
In the retrospective cohort, the primary outcome of treatment failure rate at 14 days was not lower in children receiving broad-spectrum vs narrow-spectrum antibiotics (3.4 percent vs 3.1 percent) in both the stratified (p=0.88) and full-matched analyses (risk difference, 0.3 percent; p=0.39).
Among children in the prospective cohort, those prescribed broad-spectrum antibiotics had a slightly worse child quality of life than narrow-spectrum antibiotic users (PedsQL* score, 90.2 vs 91.5; p=0.008).
Other patient-centred outcomes such as missed school days, lingering symptoms on day 3, and sleep disturbance affected more children receiving broad-spectrum vs narrow-spectrum antibiotics, although the differences between groups were not statistically significant.
In contrast, broad-spectrum antibiotics were associated with a greater risk of adverse events, regardless of whether the events were reported by clinicians in the retrospective cohort (3.7 percent vs 2.7 percent; p<0.001) or by patients in the prospective cohort (35.6 percent vs 25.1 percent; p<0.001).
“This study showed that inappropriate prescribing of antibiotics also affects families at a much more practical level, such as missed days from school and work, side effects of the drugs, and costs for extra childcare. These can be a real burden for families,” said Gerber. “These data support the use of narrow-spectrum antibiotics for most children with ARTIs.”
In addition, the findings remained consistent across clinical and patient-centred outcomes regardless of stratification by individual ARTI (except group A streptococcal pharyngitis in the retrospective cohort). However, as children who received antibiotics within the past 30 days were excluded from the study, the results should not be generalized to other populations.
The study reflects an “antimicrobial stewardship” approach which aims to reduce the risk of antibiotic resistance. “Research tells us that antibiotic stewardship programs not only reduce the overall burden of antibiotic resistance, but also improve patient outcomes,” said Gerber.
Nonetheless, the researchers questioned the clinical relevance of the 1.4-point difference in PedsQL score between groups, as a previous study has suggested that a difference >4 points was clinically meaningful. [Ambul Pediatr 2003;3:329-341] “The 1.4-point higher score observed in children who received narrow-spectrum antibiotics, though statistically significant, does not necessarily support a clinically superior outcome for narrow-spectrum antibiotics,” the researchers said.
“Instead, this finding rejects the notion that broad-spectrum antibiotics provide a clinically meaningful advantage,” they added.