Case Study 2: Antibiotic Stewardship in a Pediatric Patient with Pneumonia

Full Answer Section

• Antibiotic Options:
  • Amoxicillin (high-dose)
  • Amoxicillin-clavulanate
  • Ceftriaxone (for more severe cases or when oral therapy is not tolerated)
  • Macrolides (e.g., azithromycin) if atypical pneumonia is suspected.

2. Appropriate Antibiotic Regimen:

• First-Line Therapy:
  • High-dose amoxicillin is the recommended first-line treatment for uncomplicated pediatric CAP.
  • Dosing: 90 mg/kg/day, divided into two doses.
  • Route: Oral.
  • Frequency: Twice daily.
• Rationale:
  • Amoxicillin has a narrow spectrum, targeting S. pneumoniae effectively.
  • High-dose therapy helps overcome potential resistance.
  • Oral administration is preferred for outpatient treatment.

3. Antibiotic Resistance and Stewardship:

• Risk of Resistance:
  • Overuse and inappropriate use of antibiotics contribute to the development of antibiotic resistance.
  • Recurrent ear infections may increase the risk of resistance to common antibiotics.
• Importance of Stewardship:
  • Using narrow-spectrum antibiotics when appropriate.
  • Avoiding unnecessary antibiotic use for viral infections.
  • Educating parents on the importance of completing the full course of antibiotics.
  • Ensuring the correct dosage is used.
  • Avoiding broad spectrum antibiotics unless absolutely necessary.
• In this case, because of the reoccurring ear infections, it is very important to make sure that the parent understands the importance of completing the full course of antibiotics.

4. Monitoring:

• Clinical Signs and Symptoms:
  • Resolution of fever.
  • Improved breathing (reduced respiratory rate, decreased work of breathing).
  • Decreased cough and sputum production.
  • Improved appetite and activity level.
• Laboratory Findings:
  • If a chest radiograph was initially performed, a follow-up radiograph may be considered if symptoms persist.
  • A CBC may be useful to monitor white blood cell counts.

5. Adjustments:

• Failure to Respond:
  • If the patient does not improve within 48–72 hours, consider:
    • Resistance to amoxicillin.
    • Atypical pneumonia (consider adding a macrolide).
    • Complications (e.g., empyema).
    • Need for hospitalization and parenteral antibiotics (e.g., ceftriaxone).
• Adverse Effects:
  • If the patient develops diarrhea or rash, consider:
    • Switching to amoxicillin-clavulanate or another appropriate antibiotic.
    • Managing symptoms (e.g., probiotics for diarrhea).
    • If a severe allergic reaction occurs, cease the medication immediately, and treat the reaction.

6. Parent Counseling:

• Key Teaching Points:
  • Administer the antibiotic exactly as prescribed, at the correct dose and frequency.
  • Complete the entire course of antibiotics, even if the child feels better.
  • Do not save leftover antibiotics for future illnesses.
  • Report any side effects to the healthcare provider.
  • Encourage rest and fluids.
  • Use acetaminophen or ibuprofen for fever and discomfort (as directed by the healthcare provider).
  • Explain the difference between viral and bacterial infections, and why antibiotics are not used for viruses.
  • Explain the importance of follow up appointments.

Sample Answer

Let's address this pediatric CAP case with a focus on appropriate antibiotic selection, dosing, and resistance concerns.

1. Likely Pathogens and Antibiotic Options:

• Most Likely Pathogens:
  • Streptococcus pneumoniae (most common)
  • Mycoplasma pneumoniae (especially in school-aged children)
  • Chlamydophila pneumoniae
  • Respiratory viruses (e.g., respiratory syncytial virus, influenza) can also be a cause, or a co-infection.