What is ‘judicious use of antibiotics’ and is it achievable in children?

Judicious use of antibiotics is promoted largely because of the threat of antibiotic-resistant pathogens. The most common reasons for antibiotic prescriptions in all ages are respiratory tract infections (RTIs). The most common patients to receive antibiotics are infants and young children, and among these, the commonest diagnosis for which antibiotics are prescribed is otitis media. Antibiotic resistance in the community is spread through selection of antibiotic-resistant respiratory flora submitted to antibiotic pressure during treatment of various acute diseases. Not all antibiotics are equal in their effect on promotion of antibiotic resistant organisms. Using the pneumococcus paradigm, azithromycin is the antibiotic with the highest promotion of resistance, due to its long half life and low extra-cellular concentration; followed by oral cephalosporins. Traditionally, “judicious use of antibiotics” is translated by most clinicians as “reducing antibiotic use”. However judicious use means much more than that. There is a need to consider all the following to successfully execute a judicious use of antibiotics (as summarized by Ball et al, Journal of Antimicrobial Chemotherapy 2002;49:31-40): 1) Treatment of bacterial infections only; 2) optimize treatment by diagnosis and severity assessment; 3) maximize bacterial eradication; 4) recognize local resistance prevalence; 5) utilize pharmacokinetics/pharmacodynamics for effective agents and dosage; and 6) integrate local resistance, efficacy and cost effectiveness. Judicious use is of utmost importance to assure retention of antibiotic susceptibility of respiratory pathogens.