Posted by Clay Jones on December 4, 2015
While it is both easy and fun to point out the inadequacies of unscientific modalities such as chiropractic and homeopathy, our goal at Science-Based Medicine is the application of a single standard to all medical practice, even if it stings a bit. We are far from perfect. While I firmly believe that most conventional healthcare professionals are good people who strive to provide the best care possible for their patients, I accept that there is room for improvement and pediatric medicine is certainly no exception.
In fact, one of the characteristics that best distinguishes conventional from so-called alternative medicine is the simple fact that we systematically attempt to recognize and correct our errors on an individual and system wide level. That we evolve in the light of new and better evidence, albeit sluggishly as a rule rather than an exception, allows me to sleep at night. There is no quality control in alternative medicine. There are only shifting trends in the marketing of nonsense to the curious, desperate, and gullible.
One of the most recognized areas where improvement is needed in regular medicine is in the use of antibiotics. For too long we have been cavalier when it comes to prescribing antibiotics in situations where supportive care and appropriate observation would suffice, and too liberal with our use of broad spectrum agents. In fact, up to half of all antibiotic prescriptions are unnecessary according to the CDC. Based on my own clinical experience, admittedly anecdotal as it is, this seems about right. As a hospitalist, once a child arrives on the inpatient unit I probably discontinue more antibiotic courses than I start.
Over the past few years there has been a significant increase in the awareness of this problem, however. Many hospitals have even dedicated resources and personnel to antibiotic stewardship programs in order to study patterns of antibiotic use in their facility, design protocols to reduce antibiotic misuse, and to even enforce their implementation. It is a sad reality that inappropriate practice is sometimes best addressed by restricting a physician’s ability to order certain tests or medications, or to at least set up enough hoops to jump through to make them think twice about it.
The best way to improve care, however, is through education and guidance, often in the form of practice guidelines published by reputable organizations such as the American Academy of Pediatrics. In 2011, the Pediatric Infectious Disease Society and Infectious Disease Society of America published guidelines on the management of pneumonia in children. As with most new guidelines, pediatricians have been slow to change their practice, but new data presented at IDWeek 2015 revealed a more nuanced pattern.
Pneumonia, which kills more young children around the world than any other condition, is also one of the most common infections diagnosed in the pediatric population in the United States. It can be caused by a variety of viral, bacterial, and even fungal pathogens, and despite the overwhelming success of the childhood vaccination program, pneumonia remains a leading cause for admission to the hospital. Well over 100,000 children are hospitalized because of pneumonia each year, and many more cases are treated in an outpatient setting. It is also the leading indication for antibiotic use among hospitalized children.
The 2011 pediatric pneumonia guidelines, which gave evidence-based recommendations on numerous aspects of medical management of children with lower respiratory infections, put considerable emphasis on antibiotic choices. Based on the latest antibiotic resistance data, for example, the drug amoxicillin was preferred as the first line agent when treating children in the office, urgent care or emergency department, while the intravenous drug ampicillin was recommended for children requiring hospital admission. These medications are much more narrow in coverage yet as effective if not more so than other popular choices, in particular oral 3rd generation cephalosporins like cefdinir (Omnicef) and the parenteral (i.e. IV or intramusclar) antibiotic ceftriaxone (Rocephin). And when it comes to antibiotic use, the more narrow the coverage the better since this reduces the opportunity for resistance and the development of complications..
In the study presented at IDWeek 2015, researchers compiled data from pediatric pneumonia admissions to hospitals across the United States in 2013, particularly looking at antibiotic prescribing patterns. The study consisted of a retrospective cross-sectional analysis of admissions to over 323 hospitals, 49 of which were identified as children’s hospitals, which was defined as a facility where more than 75% of the admissions, not counting newborns, were children. In this study, 15,495 cases of pediatric pneumonia requiring admission were identified, with a bit over 9,000 of the admissions being to children’s facilities.
So what did they find? In general, children’s hospitals were more likely to adhere more closely to the guidelines than community, non-children’s facilities. But the overall numbers were terrible, with not even half (46%) of the patients admitted to hospitals specializing in pediatric care receiving appropriate antibiotics for their pneumonia. Only 15% of pediatric admissions to non-children’s hospitals got guideline therapy. And this was after weeding out high risk patients and patients with a complicated pneumonia that would be more likely to justify use of a more broad spectrum antibiotic.
Conclusion
Ignoring evidence and refusing to update clinical practice is one of the hallmarks of quackery. Conventional medicine must always work to avoid sinking to such depths. Unfortunately, because the practice of medicine is ultimately a human endeavor, there will always be challenges. And although new data such as this is upsetting, I stand by my trust in the overall process.
Medicine is hard and the human mind is complicated. The reasons why we are slow to adopt new guidelines even years after their publication, or why we continue to throw antibiotics at viral infections, while somewhat understandable are still extremely frustrating. I wrote a post on this subject over two years ago and I am no more able to fully wrap my head around it today than I was back then.
Organizations like the AAP and Pediatric Infectious Disease Society will continue to do their part, as will hospitals and committed, science-based pediatricians. I will continue to do my best to practice according to the evidence and to model this approach for the medical students and resident physicians under my guidance. Parents and patients can help us do a better job by becoming better informed and taking a more active role when possible. I don’t believe that the response to this newly presented information should be to avoid non-children’s hospitals if your child has pneumonia, however. But it should serve as a reminder that it is always okay to ask questions, and even to question the recommendations of a treating physician or other healthcare professional.
