Antibiotic diversion poses serious health risks

The misuse of antibiotics has become an area of concern given the lack of new medications available to treat increasingly drug-resistant bacterial infections. Results of an anonymous survey presented at the 2018 AAP National Conference & Exhibition suggested that in many cases, parents will save leftover antibiotics that were prescribed to their children and share them with other children or adults. The practice is known as antibiotic diversion.

Of the nearly 500 parents who responded to the researchers’ questionnaire, 454 had leftover antibiotics, and 48.2% reported that they saved these medications. Almost three-quarters of parents (72.6%) who held onto the drugs diverted them, results showed.

“We knew that parents were reusing antibiotics. We knew they were saving antibiotics, but I think that we as researchers were pretty shocked by the number of people who were actually saving them,” Ruth Milanaik, DO, director of the neonatal and neurodevelopmental follow-up program at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and lead author of the study, told Infectious Diseases in Children. “For me, these findings say that this is a bigger problem than we think.”

Ruth Milanaik

Specifically, results from the study showed that antibiotics in liquid form were the most commonly diverted type (80.4%), followed by drops (73.8%), creams (69.7%) and tablets (55.6%). Surprisingly, 16% of parents admitted that they had given their children an antibiotic prescription that was prescribed for an adult.

Milanaik said many parents reported that they would save these medications for months or even years and then either readminister them to the child for whom they were initially prescribed or gave the drugs to siblings, unrelated children or adults. Survey results revealed that many parents even used their child’s leftover antibiotics for their own purposes (Table).

Dangers of antibiotic diversion

Richard F. Jacobs

Richard F. Jacobs, MD, professor emeritus at the University of Arkansas for Medical Sciences and Chief Medical Editor of Infectious Diseases in Children, stressed that children metabolize antibiotics differently at different ages.

“The ability to excrete or clear antibiotics is very different at specific ages,” he said in an interview. “That is why dosing indications are very specific. If parents are diverting antibiotics, especially from an older child to a younger child, there is a potential for overdose, which can increase the likelihood of toxicity or adverse events.”

Conversely, he said, older children who are given antibiotics that were prescribed to a younger sibling are at risk of being underdosed, which could further fuel antimicrobial resistance.

Giving a child an antibiotic without consultation from a health care provider can put them at risk — including allergic reactions.

According to study results published in the Journal of the Pediatric Infectious Diseases Society, antibiotics are the leading cause of ED visits for adverse drug events, or ADEs, in children. The researchers estimated that 69,464 ED visits (95% CI, 53,488-85,441) were made annually in the United States for antibiotic ADEs among children aged 19 years and younger between 2011 and 2015. Children aged 2 years and younger were admitted for 40.7% of ED visits for antibiotic ADEs, with 86.1% involving an allergic reaction.

A review published in the Journal of Pharmacology & Pharmacotherapeutics also suggested that antibiotics are one of the leading causes of ADEs. The researchers estimated that ADEs could cost up to $30.1 billion every year in the U.S.

A separate statistical brief published by the Healthcare Cost and Utilization Project highlighted an increasing number of ADEs occurring outside the hospital setting that lead to hospitalization. The researchers added that ADEs occurring outside the hospital had an average cost per stay of $13,308. Antibiotics were one of the most commonly reported causes of ADE-related hospital stays in the study.

According to Milanaik, the best person to prescribe antibiotics is a health care provider, not a parent. In most cases, parents are not aware of the indications.

“If you have an ear infection, that might not be the same as a throat infection, which might not be the same as an infection in your toe,” she said. “Parents need to understand that this is why doctors go to medical school, remain very current and up-to-date on research being done and what bacteria are commonly seen. This is why you should go to a doctor or clinician when you are not feeling well so they can prescribe the correct antibiotic at the correct dose if you need it.”

Role of education

Having leftover medications — and not just antibiotics — is common. One C.S. Mott Children’s Hospital National Poll on Child Health found that more than half of households held onto leftover pain medications prescribed to children. However, more than half of these parents were not told by their provider how to properly dispose of leftover medication.

“People are not finishing their courses of antibiotics the way they are supposed to be finishing them,” Milanaik said. “This can create bacterial resistance. Needless to say, if there are leftover antibiotics for whatever the reason, parents must be very careful to dispose of leftover antibiotics properly.”

The FDA states that all expired, unwanted or unused medications should be removed from the home as quickly as possible. Although certain medications can be flushed down the toilet, Jacobs stressed that this cannot be done with antibiotics. Flushing antibiotics down the toilet or washing them down the drain can contribute to antibiotic resistance in the environment, he said.

Many pharmacies, hospitals and law enforcement agencies collect medications in drop-boxes and dispose of them properly. Additionally, the FDA suggests that uncrushed tablets can be mixed with dirt, cat litter or used coffee grounds in a sealed plastic bag and disposed of with household trash.

Ideally, every course of antibiotics should be completed for the duration prescribed by health care providers. Jacobs said the results of Milanaik’s study were “alarming,” but they show an opportunity to educate parents and providers about the correct use of antibiotics.

Some national efforts to do just that are currently underway. For example, the CDC’s Get Smart: Know When Antibiotics Work program was created to educate parents of young children, the general public and outpatient health care providers about the dangers of antibiotic resistance and to improve antibiotic prescribing and use. Additional information can be found on the agency’s website. Furthermore, both the CDC and NIH have resources for the general public on how to properly dispose of medications.

“I think the key for physicians, nurses and pharmacists is to make sure that they clearly educate families on the duration of antibiotics, the indication of the antibiotics, side effects and adverse events to be observant for,” Jacobs said. – by Katherine Bortz

Disclosures: Jacobs and Milanaik report no relevant financial disclosures.

The misuse of antibiotics has become an area of concern given the lack of new medications available to treat increasingly drug-resistant bacterial infections. Results of an anonymous survey presented at the 2018 AAP National Conference & Exhibition suggested that in many cases, parents will save leftover antibiotics that were prescribed to their children and share them with other children or adults. The practice is known as antibiotic diversion.

Of the nearly 500 parents who responded to the researchers’ questionnaire, 454 had leftover antibiotics, and 48.2% reported that they saved these medications. Almost three-quarters of parents (72.6%) who held onto the drugs diverted them, results showed.

“We knew that parents were reusing antibiotics. We knew they were saving antibiotics, but I think that we as researchers were pretty shocked by the number of people who were actually saving them,” Ruth Milanaik, DO, director of the neonatal and neurodevelopmental follow-up program at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and lead author of the study, told Infectious Diseases in Children. “For me, these findings say that this is a bigger problem than we think.”

Ruth Milanaik

Specifically, results from the study showed that antibiotics in liquid form were the most commonly diverted type (80.4%), followed by drops (73.8%), creams (69.7%) and tablets (55.6%). Surprisingly, 16% of parents admitted that they had given their children an antibiotic prescription that was prescribed for an adult.

Milanaik said many parents reported that they would save these medications for months or even years and then either readminister them to the child for whom they were initially prescribed or gave the drugs to siblings, unrelated children or adults. Survey results revealed that many parents even used their child’s leftover antibiotics for their own purposes (Table).

Dangers of antibiotic diversion

Richard F. Jacobs

Richard F. Jacobs, MD, professor emeritus at the University of Arkansas for Medical Sciences and Chief Medical Editor of Infectious Diseases in Children, stressed that children metabolize antibiotics differently at different ages.

“The ability to excrete or clear antibiotics is very different at specific ages,” he said in an interview. “That is why dosing indications are very specific. If parents are diverting antibiotics, especially from an older child to a younger child, there is a potential for overdose, which can increase the likelihood of toxicity or adverse events.”

Conversely, he said, older children who are given antibiotics that were prescribed to a younger sibling are at risk of being underdosed, which could further fuel antimicrobial resistance.

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Giving a child an antibiotic without consultation from a health care provider can put them at risk — including allergic reactions.

According to study results published in the Journal of the Pediatric Infectious Diseases Society, antibiotics are the leading cause of ED visits for adverse drug events, or ADEs, in children. The researchers estimated that 69,464 ED visits (95% CI, 53,488-85,441) were made annually in the United States for antibiotic ADEs among children aged 19 years and younger between 2011 and 2015. Children aged 2 years and younger were admitted for 40.7% of ED visits for antibiotic ADEs, with 86.1% involving an allergic reaction.

A review published in the Journal of Pharmacology & Pharmacotherapeutics also suggested that antibiotics are one of the leading causes of ADEs. The researchers estimated that ADEs could cost up to $30.1 billion every year in the U.S.

A separate statistical brief published by the Healthcare Cost and Utilization Project highlighted an increasing number of ADEs occurring outside the hospital setting that lead to hospitalization. The researchers added that ADEs occurring outside the hospital had an average cost per stay of $13,308. Antibiotics were one of the most commonly reported causes of ADE-related hospital stays in the study.

According to Milanaik, the best person to prescribe antibiotics is a health care provider, not a parent. In most cases, parents are not aware of the indications.

“If you have an ear infection, that might not be the same as a throat infection, which might not be the same as an infection in your toe,” she said. “Parents need to understand that this is why doctors go to medical school, remain very current and up-to-date on research being done and what bacteria are commonly seen. This is why you should go to a doctor or clinician when you are not feeling well so they can prescribe the correct antibiotic at the correct dose if you need it.”

Role of education

Having leftover medications — and not just antibiotics — is common. One C.S. Mott Children’s Hospital National Poll on Child Health found that more than half of households held onto leftover pain medications prescribed to children. However, more than half of these parents were not told by their provider how to properly dispose of leftover medication.

“People are not finishing their courses of antibiotics the way they are supposed to be finishing them,” Milanaik said. “This can create bacterial resistance. Needless to say, if there are leftover antibiotics for whatever the reason, parents must be very careful to dispose of leftover antibiotics properly.”

PAGE BREAK

The FDA states that all expired, unwanted or unused medications should be removed from the home as quickly as possible. Although certain medications can be flushed down the toilet, Jacobs stressed that this cannot be done with antibiotics. Flushing antibiotics down the toilet or washing them down the drain can contribute to antibiotic resistance in the environment, he said.

Many pharmacies, hospitals and law enforcement agencies collect medications in drop-boxes and dispose of them properly. Additionally, the FDA suggests that uncrushed tablets can be mixed with dirt, cat litter or used coffee grounds in a sealed plastic bag and disposed of with household trash.

Ideally, every course of antibiotics should be completed for the duration prescribed by health care providers. Jacobs said the results of Milanaik’s study were “alarming,” but they show an opportunity to educate parents and providers about the correct use of antibiotics.

Some national efforts to do just that are currently underway. For example, the CDC’s Get Smart: Know When Antibiotics Work program was created to educate parents of young children, the general public and outpatient health care providers about the dangers of antibiotic resistance and to improve antibiotic prescribing and use. Additional information can be found on the agency’s website. Furthermore, both the CDC and NIH have resources for the general public on how to properly dispose of medications.

“I think the key for physicians, nurses and pharmacists is to make sure that they clearly educate families on the duration of antibiotics, the indication of the antibiotics, side effects and adverse events to be observant for,” Jacobs said. – by Katherine Bortz

Disclosures: Jacobs and Milanaik report no relevant financial disclosures.