Rob Steele, MD (Host): [00:00:00] Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy Kansas City. Before we introduce our guest, I want to remind you to claim your CME credits after listening to our episode, visit cmkc.link/CMEpodcast and click the claim CME to get your credits.

Today, we are joined by Dr. Rana El Feghaly to talk about appropriate antibiotic use in the primary care setting. Dr. El Feghaly is a Pediatric Infectious Disease Specialist at Children's Mercy Kansas City, and she serves as the Director of Infectious Disease Clinical Services and the Outpatient Antibiotic Stewardship Program. Dr. El Feghaly has won numerous awards throughout her career and is an elected fellow of the Pediatric Infectious Disease Society of America, and the Society of Pediatric Research. She also leads an international collaborative of over 59 pediatric [00:01:00] institutions focusing on improving antimicrobial stewardship in the ambulatory settings. Dr. El Feghaly, thank you for joining us today.

Rana El Feghaly, MD,: Thank you for having me here, Dr. Steele.

Host: I heard one of the things that you're doing is ticking off each of the 50 states that you're visiting. How many do you have left to go?

Rana El Feghaly, MD,: Ten more to go. Almost there.

Host: All right. Fantastic. Well, we'll talk about some antimicrobial stewardship, and maybe even touch on states as we get there. I'll tell you, why don't we start off at a high level? When should antibiotics be the answer? If you're talking with the primary care pediatrician, and talking about antibiotics, when should they be the answer? When should they not be the answer?

Rana El Feghaly, MD,: Well, this sounds like a simple question, doesn't it? But the answer is actually quite complex. I'll try to answer it without taking the whole podcast on this question. Now, it goes without saying that diagnoses that are viral in origin will not respond to antibiotics, and those that are bacterial will usually respond, right? [00:02:00] But that's easier said than done. In predominantly bacterial entities, like urine infection or skin and soft tissue infection, this could be an easy distinction. But viral infection can be very difficult to differentiate from bacterial infections in common respiratory infections, which are by large the most common causes of infections we see in children.

There's a few things that I wanted to talk to you about where there's clinical findings that can help, right? One thing for pharyngitis, if the child has a cough, congestion, runny nose, diarrhea, chances that this is group A strep is very low, and you can avoid testing or treating. If the child does not have any viral symptoms with pharyngitis, it could be strep, but it also still could be a viral infection, so it's essential to test first before you treat, because even viruses can present with sore throat and fever alone.

Now, for pneumonia, if you identify crackles on lung exam, it could be bacterial. If you have wheezing, it's more consistent with viral. Sinusitis really [00:03:00] is a pretty tricky diagnosis. It has very set criteria, as many of our listeners know, that you either have prolonged or worsening symptoms for 10 days or more, or severe symptoms for at least three days. But maybe keeping in mind that sinusitis that is bacterial in origin is actually pretty rare in children. And the vast majority of rhinosinusitis we see in the community is actually viral. And then, bronchitis in older children and adults is also important to remember, these are all viral, right?

Hopefully, these clinical findings can help our listeners to kind of differentiate between bacterial and viral. And I know they do that on a regular basis. But I'm also going to add that there are entities such as otitis media or sinusitis, as I mentioned, that could be either. But there are still opportunities to watch possible bacterial infection without antibiotics. This is especially true, for example, with otitis media, where the resolution rate without antibiotic is very high, even when it's caused by a bacteria like Moraxella catarrhalis or Haemophilus [00:04:00] influenzae. So, I hope I answered your question, even if it's a slightly convoluted way.

Host: No, I think it was fantastic. As a primary care pediatrician, I think you covered all, you know, the key upper respiratory bases that often antibiotics are not used appropriately. You know, I can tell you, you're preaching a little bit to the choir, because my dad is a retired pediatric infectious disease specialist. So when I went to practice, I was hammered in with antimicrobial stewardship, just from my family going into practice. But once I did get into practice, I can tell you, you know, sometimes it's hard to have that conversation with the family, because those families are often expecting something before they leave the office. Do you have any pearls of wisdom for the primary care pediatrician on how to appropriately speak to the families about the appropriate utilization of antibiotics?

Rana El Feghaly, MD,: This is an awesome question, and I do get asked that question quite often. And interestingly, Dr. Steele, although I'm a pediatric infectious diseases doctor, I actually do moonlight in the urgent [00:05:00] care. So, I do have to have those conversations.

Host: You've been in the real world with us.

Rana El Feghaly, MD,: Exactly, right. So, I will start by discussing a really good communication strategy that you could use if antibiotics are not indicated, but you feel like the parent is coming in wanting something, wanting an antibiotic. There's this Dialogue Around Respiratory Illness treatment or DART approach that was developed by Mangione-Smith's lab. And they did a lot of studies and identified that if a parent wants antibiotics, and you determine they're not necessary, you got to use these four components to your discussion with the family.

You want to start by reviewing your physical exam finding. For example, as you're examining the ear, you say, "Well, the ears look good. There's no signs of ear infection. The lungs are clear. There's no signs of pneumonia." Then, you deliver the diagnosis. "Your child has a really bad cold." After that, you want to deliver a two-part treatment recommendation, and it's very important to start with the negative recommendation first and follow it by a positive recommendation. They even say it's a [00:06:00] good idea to use something like on one hand so that nobody interrupts you before you say on the other hand. So, you can say something like, "On one hand, antibiotics are not going to treat a virus. But on the other hand, these are some things you can use in your house that might help your kid feel better. acetaminophen for fever, a humidifier, honey if they're older than one year for cough, those sorts of things that can help their child feel better, because parents really want their child to feel better. For the most part, they don't necessarily need an antibiotic. They just want to make sure that they're doing things to help their child. And finally, finish with providing a contingency plan. "If they're not better within 48 hours, please give me a call."

There are multiple other studies that have looked into this. There's another great paper by Dr. Szymczak and colleagues. It's called "I Never Get Better Without an Antibiotic": Antibiotic Appeals and How to Respond. And these are for patients that are coming in really demanding an antibiotic and different types of approaches to how to address their [00:07:00] concerns. And I really would recommend that you take a look at it. It's from 2021.

Host: Oh, that's a great recommendation. I was not familiar with that. I'll have to check that one out myself. For the primary care pediatrician who now has truly diagnosed a bacterial process, so has gone through the rigorous process of identifying an actual bacterial process that's going on that needs to be addressed with an antibiotic. Can you give some additional advice on choosing the correct antibiotic, dose, duration, all the things that are necessary to appropriately treat but not overtreat.

Rana El Feghaly, MD,: Yeah, absolutely. That's a great question. You want to choose the right antibiotic at the right dose for the right duration. Knowing when not to prescribe an antibiotic is awesome, but also knowing which antibiotic to prescribe and for how long is also very important. Of course, you need to be familiar with the drugs of choices for your infections.

I would say typically amoxicillin is going to be a great drug for many respiratory infections. A few pearls, [00:08:00] azithromycin is almost never the answer, except for atypical community-acquired pneumonia. Resistance rate among Strep pneumo, Moraxella, Haemophilus, which are, as you guys know, the most common cause of respiratory infections, are extremely high.

Another pearl I would say that knowing that cefdenir is not superior to amoxicillin in otitis media or pneumonia. There's actually studies that show that cefdenir doesn't concentrate very well in the lung and it doesn't reach that level where it's supposed to be able to kill the strep pneumo. So, trying to avoid cefdenir, except if a patient has penicillin allergy, in settings such as otitis media and pneumonia are important. Knowing, for example, that cefdenir is not superior to cefalexin for UTI. At least here at Children's Mercy, our antibiogram shows that our cefalexin susceptibility rates among E. coli from the urine is quite high. So, we can get away with using cefalexin for most patients with urine infections. And we don't need to go to something broader, such as cefdenir or even trimethoprim sulfa.

And bottom [00:09:00] line, you want to stick to the narrowest antibiotic, but also knowing that using broad antibiotics when needed is okay. It's okay to use doxy when you suspect a tick-borne illness. Even if the kid is younger, there's been studies showing that teeth staining is not as big of a problem with doxycycline. It's okay to use levofloxacin if you have, for example, a Pseudomonas UTI, because that's your only oral option, right? So, there are some times where being broad is okay. I don't want our listeners to be scared to go broad because I see that sometimes that people don't want to go on antibiotics that are broader because they're worried. But trying to reserve those antibiotics for the time when they're absolutely necessary.

Now, dose is also important. There's often confusion with high and regular dose amox I usually say that the high dose should typically be reserved when you're treating strep pneumo or when you're treating difficult to get to infections like MSK infections. We know that a regular dose for three days is all one needs for a bite prophylaxis, which brings us to the [00:10:00] duration. I often see prolonged antibiotic courses of 10 days for pneumonia or skin and soft tissue infections, cystitis. There's evidence suggesting that five days is effective in treating almost all pediatric infections. Pneumonia, UTI, sinusitis, SSTIs, most cases of otitis media can be treated with a five to seven-day course. So, trying to think about the shortest duration that can treat the bacterial infection is an essential part of managing those infections.

Host: Fantastic advice. You know, it's the right antibiotic at the right dose at the right duration. And I appreciate you going through that, because I think those are really key points, particularly for the primary care pediatrician who's seeing this almost on a daily basis, certainly at this time of year where we're in the winter viral season and we may have some of those secondary infections that occur and then also those times when there aren't secondary infections and it's just viral and we need to just treat it expectantly.

You had mentioned the antibiogram that we have here at Children's Mercy Kansas City. [00:11:00] Is that a resource or are there other sort of up-to-date local resources that help in choosing those antibiotics that the primary care pediatricians can use?

Rana El Feghaly, MD,: Yeah, absolutely. We do have multiple resources available at Children's Mercy. I'm sure most of your listeners are familiar with the evidence-based practice website. This is really an awesome, awesome website that has these clinical pathways developed by our evidence-based practice group, updated on a regular basis, and they're available to everybody. So even if you Google Children's Mercy EBP, it will open up these pathways. And you can go and check all of the information that's in there.

We also have an outpatient antibiotic handbook that many of your listeners may be familiar with, because we've been working on this and updating it for multiple years now. Our antibiotic Handbook is available online on our antimicrobial stewardship website, and we update it every year. It's also available to [00:12:00] everybody. So if you look up antimicrobial stewardship at Children's Mercy, you can go to that website, and there's a lot of information for clinicians, and the handbook is one of them. In that handbook, we actually have the updated antibiogram in there. But in addition to that, we have multiple of the clinical pathways. We have most common infections that you can see, like otitis media, pneumonia, sinusitis, UTI, SSTI. They're all in there with the drugs of choices for the infection; alternatives, if the patient has allergy to penicillin. We have the max doses for these antibiotics. And we have a lot of additional information that can be helpful for prescribers.

If our listeners do want a printed version, please let our provider relation group know. We do print a few. We disseminate them here at Children's Mercy, but we also can print some more and send them your way if you are interested in a small pocket size version. In addition to that, we have our Wise Use of [00:13:00] Antibiotic Articles in the link newsletter. If you are not receiving the link newsletter, please let us know. This is a really awesome newsletter that has a lot of updated information that goes out every month to pediatricians and pediatric prescribers all over the metro area. And then, like I said, if you guys are more interested in more information, reach out to me, or I'll also include the DART module I mentioned earlier, at least the link to the website and Dr. Szymczak's paper. We can add them on to the information available through the podcast as well.

Host: Great. Dr. El Feghaly, that's a great summarization of the great resources that we have available to the primary care pediatricians, so we can make those available, and they are available online. Thank you so much for highlighting those. We've come to the end of our podcast. I have to ask you one last question, or actually maybe it's a series of a couple of questions that really have to do with your travels. You're traveling to all 50 states and, you know, each state has its state [00:14:00] flower, its state tree, you're familiar with that. Were you aware that there are two states that have a state microbe. Can you believe that?

Rana El Feghaly, MD,: I had no idea.

Host: It's true. Oregon and New Jersey both have state microbe. Now, Oregon's state microbe is a brewer's yeast, which is Saccharomyces. And I do not recommend any antimicrobials for that because I like beer, and so we'll go ahead and keep that one around. But New Jersey is where Streptomyces was discovered, and so Streptomyces is the state microbe for New Jersey. So, my question for you, aside from just the use of streptomycin, which I think is still used for tuberculosis, have you been to New Jersey, one? And two, if you have, what was your memory of going to that state?

Rana El Feghaly, MD,: Well, yeah, I've been to New Jersey a few times because, you know, I lived in upstate New York for a little while, so the East Coast I kind of covered during my life there. The one memory I would say when I went to New Jersey, I was [00:15:00] younger. So, we went to-- I'm trying to remember the name, the area right next to the sea that has a lot of casinos for some reason--

Host: Oh, yeah. Atlantic City.

Rana El Feghaly, MD,: Atlantic City. That's the city that sticks to my head the most.

Host: Yeah. Okay. Well, that's a great memory. So, the next time you go, you'll just have to remember that streptomycin was discovered in New Jersey with the Streptomyces microbe, and it is the state microbe. So, the next time you go in, you can go to that state and check it out.

Rana El Feghaly, MD,: That is awesome news. Thank you.

Host: Shout out to all our listeners in New Jersey. Very good. Okay. Well, Dr. El Feghaly, I really appreciate your time with us today. As a reminder, claim your CME credit for listening to our show today. This has been another episode of Pediatrics in Practice, a CME podcast. See you next time.