When Darlene Barkman would take her daughter to the pediatrician for an earache, sore throat, or cough, she says, “I would always think, is this the strongest antibiotic you can give me? Because I really want this infection to get knocked out.” Her now-15-year-old daughter, a survivor of both leukemia and pediatric stroke, had already experienced more than her share of medical problems. 

Any parent can identify with Barkman’s desire to see her child get well quickly. However, the “strongest” antibiotic might not always be the best choice for treating respiratory infections. The broad-spectrum medications can lead to unnecessary side effects and their widespread use may reduce their power to fight future severe infections in all patients.

“We want to use antimicrobials to treat diseases in the best way possible without creating collateral damage,” says PCORI awardee Jeffrey Gerber, MD, PhD, an infectious diseases specialist and director of the Antimicrobial Stewardship Program at the Children’s Hospital of Philadelphia. He has teamed with other researchers and healthcare stakeholders, including Barkman, in a study that interviewed several thousand parents whose children recently received antibiotic prescriptions for respiratory infections. The goal was to learn whether children with infections who get broad-spectrum antibiotics do better—or worse—than those treated with narrower-spectrum drugs.

Widespread and Inconsistent Prescribing

Antibiotics are by far the most common medications taken by US children; some 70 million receive prescriptions for antibiotics each year. An estimated half of children who visit a pediatrician for a respiratory infection—usually strep throat or an ear or sinus infection—come away with a prescription for an antibiotic. Today, doctors less frequently prescribe antibiotics for viral infections, which don’t respond to these medications.

Most bacterial respiratory infections are caused by only a few species. Narrow-spectrum drugs target the most common of these species, and so are currently recommended by the American Academy of Pediatrics as first-line treatments. However, clinicians often prescribe broader-spectrum agents. It is unclear whether there is an advantage to either class of medication to treat infections or to reduce side effects, such as hives and diarrhea. Furthermore, with overuse of an antibiotic, bacteria become resistant, rendering the drug less useful for future disease control. “We need to preserve the broader-spectrum agents for infections that are severe or resistant to other drugs, or both,” Gerber says.

Despite the guidelines, some clinicians are increasingly prescribing newer, broad-spectrum drugs, reaching for a sledgehammer when a tack hammer might do.

Currently, studies show, prescribing patterns vary widely. “At one pediatric practice, 90 percent of the prescribing is narrow spectrum,” Gerber says. “A practice across the street is prescribing 50 percent narrow spectrum. We don’t know why. But we know that parents and pediatricians want more information to help them balance the risks and benefits of different antibiotics.”

Asking Parents What Matters

So Gerber and his collaborators began a study to provide that information. First, the team needed to know which outcomes were of most concern to patients’ families. In 109 extensive interviews with parents at their children’s doctor visits across Philadelphia, researchers asked such questions as, “What concerns you most about your child’s symptoms?” and “When your child is ill, how does it impact your family’s daily life?”

Gerber’s team heard some expected answers: parents worried about their children’s suffering, them missing school, and missing work. One major concern did surprise the research team: restoring children’s—and parents’—ability to get a good night’s sleep. “We hadn’t really thought about sleep,” Gerber says. “I’m not sure why I didn’t because I have kids.”

Barkman and other members of the team’s family advisory council helped shape the phone survey in other ways. For example, they told the researchers to be considerate of families’ time. “You also need to make sure that families understand why you’re asking these questions,” says Barkman, a former teacher and now a family consultant at the Children’s Hospital of Philadelphia.

Working with parents and families to develop research plans “opens your eyes,” Gerber says. “In medicine, we too often assume that we know what people want and what outcomes are important. But working with the family stakeholders was a constant reminder to reframe our thinking, to put ourselves in their shoes and think about what it’s like to be a patient or a parent.”

Call and Call and Call

Gerber’s team has been phoning families across Philadelphia. “We are trying to get an equal number of children who received narrow-spectrum antibiotics and broad-spectrum antibiotics across each of the three conditions,” he says. To find families interested in participating in the study, he says, “we call and call and call.”

The team has interviewed more than 3,000 parents of children who had received antibiotic prescriptions for respiratory infections. Five and 14 days after a child’s office visit, researchers are phoning parents to find out how the child is doing. The interviewers ask about symptoms and side effects such as hives or diarrhea, whether the family needed to return to the doctor for a different prescription, and whether children and parents were getting enough sleep and were back on normal daytime schedules. The team will correlate the families’ responses with the type of antibiotic prescribed.

The researchers hypothesize that children who receive the broad-spectrum drugs will do no better than those who receive the narrower ones. “Potentially, some adverse effects such as diarrhea might be worse with the newer antibiotics,” Gerber says.

Of course, the results may instead show that for certain infections, broad-spectrum drugs work better, or that kids receiving one type of drug may experience more hives but also miss less school.

“The phone calls get us that rich, patient-centered information that you can’t get from electronic health records,” Gerber observes. Nuances in the study’s results should allow doctors and parents to make more-personalized treatment decisions based on the medical findings and what’s most important to the family.

“We hope to get clear-enough data to help inform practice moving forward,” Gerber says.

Posted: August 25, 2016; Updated: February 9, 2018