It is Antibiotic Awareness week! It is a great time to renew our understandings and efforts regarding appropriate use of antibiotics, as inappropriate usage can lead to unnecessary resistance and adverse effects.  For 2025, the CDC’s theme is “Fighting Antimicrobial Resistance Takes All of Us”.

There are two easy ways we as pharmacists can help improve antibiotic usage for our youngest patients. 

• ️The first is to recommend/provide immunizations to help prevent the children from getting significant illnesses.
  1. Recommend/provide routine and seasonal childhood immunizations.
  2. In the fall, provide additional education to parents regarding seasonal immunizations that are appropriate for the infant/child’s age (e.g., RSV mab, influenza vaccine, COVID-vaccine)
• ‍‍Educate parents about what infections are most likely caused by viruses versus bacteria. When the kids are sick, it is good to explain to the parents that the best care for respiratory viruses (other than flu and COVID-19) is supportive management. The CDC has a nice summary here.  This often includes hydration and targeted symptom management with things such as antipyretics, honey (if > 12 months), and nasal saline.  It is important to educate parents that antibiotics will not help treat viral infections.  Explaining that by not using the antibiotics when they will not help, they will help save the antibiotics for the conditions when they are needed (e.g., group A streptococcal pharyngitis, otitis media in some cases).

 

As mentioned above, Flu and COVID-19 are two viral conditions that have specific treatments.  These treatments are reserved for those with severe disease or at high risk for severe disease.  For flu this includes all children who are less than 2-5 years old with oseltamivir.  While COVID-19 treatment recommendations are provided by the Infectious Diseases Society of America.

 

For more resources Go Purple and visit the USAAW Resources: https://www.cdc.gov/antimicrobial-resistance/communication-resources/usaaw.html

 

A recent article by Kaplan and colleagues was published in the Journal of Pediatric Infectious Diseases in November 2025 evaluating the pneumococcal serotypes and susceptibility of invasive pneumococcal disease in children.¹ In this article, the authors evaluated pediatric pneumococcal disease in children admitted to 8 hospitals across the United States from 2018 – 2023. These findings help us identify information on which pneumococcal diseases continue to occur despite vaccination, inform current empiric treatment strategies in children and help identify areas for targeted stewardship interventions.

Pneumococcal Disease and Conjugate Vaccine History

To fully understand this article, it is essential to understand the history of the pneumococcal disease and vaccination. Pneumococcal disease has significantly cased invasive infections in young and old as well as those with significant chronic conditions including immunocompromise. The incidence of these infections has been greatly reduced from ~ 25 per 100,000 in late 1990’s to < 10 per 100,000 in 2023.² This reduction has been primarily due to pneumococcal vaccination. In 2010, the pneumococcal conjugate 13 valent vaccine (PCV13) replaced the 7 valent vaccine (PCV7). A key advantage of this broadening was the coverage of serotype 19A, which was a major cause of severe, antibiotic resistant infections in young children.³ More recently, the 15 and 20 valent pneumococcal vaccines (PCV15, PCV20) were recommended for use in children in 2022 and 2023, respectively.^4-7

Study Key Findings

Despite overall numbers of invasive pneumococcal disease decreasing, breakthrough infections (e.g., those caused by PCV13 strains), do occur.  This study found that 30% of the cases were caused by PCV13 strains, particularly pneumonia and mastoiditis.¹. In contrast, infections such as bacteremia, meningitis, peritonitis, and bone and joint infections were more commonly caused by strains not covered by the PCV13 vaccine.¹ It is estimated that up to 23% of the isolates with non-PCV13 strains may be covered by the newer vaccines.¹

Fortunately, non-CNS isolates were reported to have low non-susceptibility rates to both penicillin (4%) and ceftriaxone (3%).  Of those that were resistant, they continued to be primarily caused by serotype 19A.  Concerningly, meningitis isolates that were tested using CNS breakpoints demonstrated higher rates of non-susceptibility with about 40% non-susceptible to penicillin and 10% to ceftriaxone (majority were serotypes 19A and 35B).¹  This suggests there is continued need to use combination empiric therapy for meningitis in children.

Pharmacist Considerations

For pharmacists, these findings reinforce empiric therapy recommendations.  Amoxicillin (or amoxicillin/clavulanate for mastoiditis) remains appropriate for most invasive pneumococcal infections in children (e.g., pneumonia, mastoiditis).  Unfortunately, neither penicillin nor ceftriaxone should be relied upon alone for empiric pneumococcal meningitis treatment, instead vancomycin still should be combined with ceftriaxone.

As broader spectrum PCVs (i.e., PCV15, PCV20) are now commonly used, ongoing surveillance for pneumococcal serotypes and resistances will be important to guide future antibiotic treatment recommendations.

 

References

1. Kaplan SL, Barson WJ, Ling Lin P, et al. Invasive Pneumococcal Disease at Eight Children’s Hospitals in the United States, 2018-2023. Pediatr Infect Dis J. 2025
2. Centers for Disease Control and Prevention. Pneumococcal Disease Surveillance and Trends. Accessed November 11, 2025 https://www.cdc.gov/pneumococcal/php/surveillance/index.html
3. Centers for Disease Control and Prevention (CDC). Licensure of a 13-valent pneumococcal conjugate vaccine (PCV13) and recommendations for use among children – Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2010;59(9):258–261
4. Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine Among U.S. Children: Updated Recommendations of the Advisory Committee on Immunization Practices – United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(37):1174–1181
5. American Academy of Family Physicians. Immunization Schedules. Accessed November 13, 2025https://www.aafp.org/family-physician/patient-care/prevention-wellness/immunizations-vaccines/immunization-schedules.html
6. American Academy of Pediatrics, Committee on Infectious Diseases. Red Book : Report of the Committee on Infectious Diseases 2024 – 2027. AAP Immunization Schedule. Accessed November 14, 2025https://publications.aap.org/redbook/resources/15585
7. ACIP Updates: Recommendations for Use of 20-Valent Pneumococcal Conjugate Vaccine in Children – United States, 2023MMWR Morb Mortal Wkly Rep. 2023;72(39):1072

The Essential Role of Pharmacists in Pediatric COVID-19 Vaccination

Evidence shows that pharmacists played a key role in COVID-19 vaccines for patients of all ages, including children, during the peak of the pandemic. Specifically, in the first three years of the pandemic (12/2020 – 9/2023) pharmacists provided 13 – 57% of all pediatric COVID-19 vaccines.¹ Although most children receive most of their vaccines at their doctor’s office, survey data suggests about 15% (especially teens and those in cities) obtain routine vaccines from pharmacies.² The pharmacist is the most accessible healthcare provider, with 89% of American’s living within 5 miles of a pharmacy.³ Thus, pharmacies remain an essential access point for vaccines for children.

Making Sense of COVID-19 Vaccine Recommendations for Kids

In recent months, the rules for when one can and should recommend COVID-19 vaccines to children has become confusing. The Advisory Committee on Immunization Practices has voted and Centers for Disease Control and Prevention (CDC) have changed COVID-19 vaccine for those 6 months and older to a shared clinical decision recommendation.⁴ It is important that it remains recommended at least at this level, as this will allow it to be paid for by the VFC program.

Meanwhile, the American Academy of Pediatrics (AAP) has made a stronger statement clearly recommending the COVID-19 vaccine for all infants and children 6 months through 23 months of age, as well as those 2 through 18 years old who: are unvaccinated, are at high risk of severe COVID-19 disease, live in congregate settings, have household members at high risk of severe COVID-19 disease, or whose parent/guardian wishes to provide them with additional protection.⁵

It is important to note, although confusing, these vaccine recommendations are not in conflict but rather differ in emphasis. The AAP guidance more clearly states which children are at highest risk and should be recommended to receive the vaccine while the CDC allows for individual decision-making. Notably, the CDC report shows that children < 2 years of age are at one of the highest risks of being hospitalized from COVID-19 disease, second only to those > 75 years old.⁶ As such, it is clear why this age is a routine recommendation, per the AAP. The AAP provides clear evidence for each of their recommendations in their COVID-19 specific recommendations.⁷

Which Pediatric Patients are Pharmacists Authorized to Vaccinate Against COVID-19 in 2025-26?

Which of our pediatric patients can we as pharmacists provide the COVID-19 vaccine to?  That partially depends on which state one is practicing.  The 12^th PREP Act extension allows pharmacists in every state to continue to provide COVID-19 and flu vaccines down to 3 years of age, in accordance with ACIP/CDC recommendations.⁸  Beyond this federal authorization, vaccine administration regulations revert to each state’s law.  We published an updated chart with links in a recent JPPT article to help clarify these requirements and provide you with quick access to state-specifics.⁹

References

1. El Kalach R, Jones-Jack NH, Grabenstein JD, et al. Pharmacists’ answer to the COVID-19 pandemic: Contribution of the Federal Retail Pharmacy Program to COVID-19 vaccination across sociodemographic characteristics-United States. J Am Pharm Assoc (2003). 2025;65(1):102305
2. Kang Y, Zhang F, Vogt TM. Where do children get vaccinated in the U.S.? Parental experiences, attitudes, and beliefs about place of vaccination with a focus on pharmacies and schools. 2025;62:126801
3. Berenbrok LA, Tang S, Gabriel N, et al. Access to community pharmacies: A nationwide geographic information systems cross-sectional analysis. J Am Pharm Assoc (2003). 2022;62(6):1816–1822.e2
4. Centers for Disease Control and Prevention. Child and Adolescent Immunization Schedule by Age (Addendum updated August 7, 2025). Accessed September 20, 2025https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-age.html
5. American Academy of Pediatrics, Committee on Infectious Diseases. Red Book : Report of the Committee on Infectious Diseases 2024 – 2027. AAP Immunization Schedule. Accessed September 20, 2025https://publications.aap.org/redbook/resources/15585
6. Centers of Disease and Prevention. Updates to COVID-19 epidemiology. 2025. https://www.cdc.gov/acip/downloads/slides-2025-09-18-19/02-Srinivasan-covid-508.pdf
7. Committee on Infectious Diseases. Recommendations for COVID-19 Vaccines in Infants, Children, and Adolescents: Policy Statement. 2025
8. Health and Human Services Department. 12th Amendment to Declaration Under the Public Readiness and Emergency Preparedness Act for Medical Countermeasures Against COVID-19. 2024;89(238):99875–99883. https://www.federalregister.gov/documents/2024/12/11/2024-29108/12th-amendment-to-declaration-under-the-public-readiness-and-emergency-preparedness-act-for-medical#:~:text=The%20Public%20Readiness%20and%20Emergency%20Preparedness%20(PREP)%20Act%20authorizes%20the,relating%20to%2C%20or%20resulting%20from
9. Girotto JE, Warminski S, Oz T, Fly JH. Continuing as Partners in Immunization: Updates to Practice and Legislation for Pediatric Pharmacy Immunizations. J Pediatr Pharmacol Ther. 2025;30(5):691–695