There are some signs of progress in drug-resistant infections in pediatrics, suggesting that antibiotic stewardship efforts may be having an effect and fewer broad-spectrum agents are being used on this important patient group, the Centers for Disease Control and Prevention (CDC) reports.1
CDC investigators looked at common pathogens and antimicrobial resistance patterns for healthcare-associated infections (HAIs) among pediatric patients that occurred in 2015-2017. These were data reported to the CDC’s National Healthcare Safety Network (NHSN).
Antimicrobial resistance data were analyzed for pathogens implicated in central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonias (VAPs), and surgical site infections (SSIs). This analysis was restricted to device-associated HAIs reported from pediatric patient care locations and SSIs among patients younger than 18 years old.
Overall, 2,545 facilities performed surveillance of pediatric healthcare-associated infections (HAIs) in the NHSN during this period. Staphylococcus aureus (15%), Escherichia coli (12%), and coagulase-negative staphylococci (12%) were the three most commonly reported pathogens associated with pediatric HAIs. Among CLABSIs, the percentage of resistance was generally lowest in neonatal intensive care units and highest in pediatric oncology units. Staphylococcus spp. were common particularly among orthopedic, neurosurgical, and cardiac SSIs; however, E. coli was more common in abdominal SSIs. Overall, antimicrobial resistance was less prevalent in pediatric HAIs than in adult HAIs.
Q & A
Hospital Infection Control & Prevention sought additional details on the study and the CDC responded via email. The following answers were attributed to CDC personnel Sarah Kabbani, MD, medical officer, Office of Antibiotic Stewardship, and Cliff McDonald, MD, associate director for Science in the Division of Healthcare Quality.
HIC: What are your thoughts on why there is less antibiotic resistance in pediatrics? This seems counterintuitive to the large number of antibiotics prescribed in outpatient pediatric care.
CDC: We attribute the differences in resistance between adult and pediatric infections to differences in the overall characteristics of these patient populations. The pediatric patient population, as a whole, tends to have accumulated fewer exposures to antibiotics and healthcare facilities compared to adult patients, who are more likely to have had numerous interactions with healthcare facilities and antibiotics over many years.
In the outpatient setting, antibiotic prescribing rates in children have been decreasing from 2011 to 2016, whereas prescribing rates in adults have increased. The antibiotic prescribing rate in older adults over age 65 is higher than any other age group.2 Another factor is that adults are more likely to receive broad-spectrum antibiotics than children, for example, for respiratory tract infections.3
Some pediatric patients, such as those in pediatric oncology units, may have complex medical needs, frequent antibiotic exposures, and recurrent use of indwelling medical devices. Infections in these patients may be more likely to be associated with an antibiotic-resistant pathogen compared to other pediatric patients. However, the cumulative proportions of resistant pathogens, overall, tend to be lower in the pediatric population compared to adults.
HIC: Are pediatric settings doing some specific things with antibiotic stewardship that are proving effective in keeping drug-resistant pathogens in check?
CDC: There are multiple factors that could lead to lower drug-resistant pathogens in pediatrics. As mentioned earlier, there are differences in the overall characteristics of adult and pediatric populations. However, the American Academy of Pediatrics and the Pediatric Infectious Diseases Society have consistently incorporated antibiotic stewardship principles into their guidelines, by recommending treatment strategies, such as “watchful waiting,” before deciding whether antibiotics are needed for certain infections and recommending narrow-spectrum antibiotics as first-line therapies when antibiotics are needed. The CDC has led educational efforts to improve antibiotic use among children since 1995 and the initial efforts were aimed at parents and pediatricians. Vaccines in children also have reduced antibiotic resistance and the need for antibiotics. For example, pneumococcal conjugate vaccine has led to decreases in pneumococcal infections, including serious infections like pneumococcal pneumonia and bacteremia, and common infections such as acute otitis media, which drive antibiotic use. Both overall and antibiotic-resistant pneumococcal infections decreased simultaneously. The CDC tracks the implementation of the Core Elements of Antibiotic Stewardship in U.S. hospitals, and a larger proportion of children’s hospitals met all seven core elements compared to other hospitals.
HIC: In the CDC’s recent antibiotic resistant threats report,4 was there one or two that are of particular concern in pediatrics?
CDC: We did not do any stratified analyses of the HAI antibiotic-resistant threats data by age. Thus, we cannot base a response on that basis. In terms of just the HAI antibiotic-resistance, the overall increasing threat of extended-spectrum beta-lactamase (ESBL) appears to extend to pediatrics, at least from the NHSN reports. Assuming this holds true in the community (i.e., similar increasing rates) it would be safe to say this threat is of particular concern in pediatrics (as it is adults).
HIC: Can you characterize how much Clostridioides difficile you are seeing in pediatric patients and any particular antibiotics that may be predisposing them to that infection?
CDC: While there were increases in C. diff infections (CDIs) among children, as there were among adults, in the mid/late 2000s, it is safe to say that these have at least plateaued, if not decreased.
In addition, overall [CDI] rates are much lower in children and adolescents than adults.
Outpatient antibiotic prescribing has declined (i.e., more effective outpatient antibiotic stewardship) more in children/adolescents than adults. Whether the latter is leading to more declines in CDI among children/adolescents than adults, we do not know quite yet. However, there is good reason to think these changes in outpatient antibiotic prescribing could have an effect in overall pediatric CDI, as an even greater proportion of CDI in children/adolescents is community-associated (i.e., no recent inpatient care) than in adults. In terms of antibiotics that are associated most with CDI in pediatrics, a recent paper suggests that in the outpatient setting, the cephalosporins stand out.5
- Weiner-Lastinger LM, Abner S, Benin AL, et al. Antimicrobial-resistant pathogens associated with pediatric healthcare-associated infections: Summary of data reported to the National Healthcare Safety Network, 2015-2017. Infect Control Hosp Epidemiol 2019; Nov 25. doi:10.1017/ice.2019.297. [Online ahead of print].
- King LM, Bartoces M, Fleming-Dutra KE, et al. Changes in US outpatient antibiotic prescriptions from 2011-2016. Clin Infect Dis 2019; Mar 16. doi:10.1093/cid/ciz225. [Online ahead of print].
- Hersh AL, Fleming-Dutra KE, Shapiro DJ, et al. Frequency of first-line antibiotic selection among US ambulatory care visits for otitis media, sinusitis, and pharyngitis. JAMA Intern Med 2016;176:1870-1872.
- Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States 2019. Available at: https://bit.ly/2roWiaO. Accessed Jan. 8, 2020.
- Weng MK, Adkins SH, Bamberg W, et al. Risk factors for community-associated Clostridioides difficile infection in young children. Epidemiol Infect 2019;147:e172.