What are the risks of frequent antibiotic use in the pediatric population?

From the Guidelines

Frequent antibiotic use in children poses significant risks, including the development of antibiotic resistance, disruption of the gut microbiome, and increased risk of adverse events, and therefore, antibiotics should only be prescribed when truly necessary for bacterial infections. The primary concerns with frequent antibiotic use in children include the development of antibiotic resistance, where bacteria evolve to withstand medications like amoxicillin, azithromycin, and cephalosporins that were previously effective 1. Children who receive multiple courses of antibiotics, particularly broad-spectrum agents, are at higher risk for disrupting their gut microbiome, which can lead to immediate side effects such as diarrhea, abdominal pain, and Clostridioides difficile infections 1. This microbiome disruption may have long-term consequences, potentially contributing to conditions like asthma, allergies, inflammatory bowel disease, and obesity 1.

Some of the key risks associated with antibiotic use in children include:

• Development of antibiotic resistance
• Disruption of the gut microbiome
• Adverse events such as diarrhea, abdominal pain, and Clostridioides difficile infections
• Long-term consequences such as asthma, allergies, inflammatory bowel disease, and obesity
• Specific antibiotic-related risks, such as cardiac arrhythmias with macrolides, effects on developing cartilage with fluoroquinolones, and permanent staining of developing teeth with tetracyclines in children under 8 years 1.

To minimize these risks, healthcare providers should:

• Prescribe antibiotics only when truly necessary for bacterial infections
• Use narrow-spectrum antibiotics when possible
• Prescribe the shortest effective duration (typically 5-7 days for most common infections)
• Consider watchful waiting for conditions like mild otitis media that often resolve without antibiotics 1.

It is essential to apply stringent clinical criteria to establish the diagnosis of a bacterial infection and to use therapy only when the diagnosis and potential benefits are well established 1. The careful application of these criteria has the potential to mitigate overuse of antibiotics for pediatric URIs 1.

Overall, the benefits and harms of antibiotic use must be carefully weighed, and antibiotics should only be prescribed when the potential benefits outweigh the potential harms 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of azithromycin and other antibacterial drugs, azithromycin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. The safety and effectiveness of amoxicillin for the treatment of upper respiratory tract infections, and infections of the genitourinary tract, skin and skin structure and lower respiratory tract have been established in pediatric patients.

The risks of frequent antibiotic use in the pediatric population include the development of drug-resistant bacteria. Antibiotics such as azithromycin and amoxicillin should only be used to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.

• Development of drug-resistant bacteria: using antibiotics frequently can lead to the development of bacteria that are resistant to the antibiotic, making it less effective in treating infections.
• Sensitization of infants: amoxicillin use by nursing mothers may lead to sensitization of infants.
• Delayed elimination: because of incompletely developed renal function in neonates and young infants, the elimination of amoxicillin may be delayed. 2 3

From the Research

Risks of Frequent Antibiotic Use in Pediatric Population

The frequent use of antibiotics in the pediatric population poses several risks, including:

• Antibiotic resistance, which is a major public health concern 4
• Disruption of the gut microbiota, leading to changes in metabolic function and increased susceptibility to colonization by pathogenic microorganisms 5
• Increased risk of adverse long-term health outcomes, such as:
  • Atopic dermatitis 6
  • Allergic symptoms 6
  • Food allergies 6
  • Allergic rhinoconjunctivitis 6
  • Wheezing 6
  • Asthma 6
  • Increased weight gain or overweight 6
  • Obesity 6
  • Juvenile idiopathic arthritis 6
  • Psoriasis 6
  • Autism spectrum disorders 6
  • Neurodevelopment disorders 6

Mechanisms of Antibiotic Resistance

The mechanisms of antibiotic resistance are complex and involve various factors, including:

• Overuse and misuse of antibiotics 4
• Genetic mutations in bacteria 5
• Horizontal gene transfer between bacteria 5
• Selection pressure imposed by antibiotic use 5

Importance of Antibiotic Stewardship

Antibiotic stewardship is crucial in reducing the risks associated with frequent antibiotic use in the pediatric population 4, 7. This includes:

• Prescribing antibiotics only when necessary
• Using the appropriate antibiotic, dose, and duration of therapy
• Monitoring antibiotic use and resistance patterns
• Implementing infection control measures to reduce the spread of antibiotic-resistant microorganisms

Impact of Antibiotic Exposure on the Microbiome

Antibiotic exposure can have a profound impact on the developing microbiome of children, leading to:

• Disruption of the balance between different microbial communities 5
• Changes in metabolic function and immune system development 5, 7
• Increased susceptibility to colonization by pathogenic microorganisms 5