When Are Antibiotics Needed for URI in Children? CME/CE

News Author: Norra MacReady
CME Author: Laurie Barclay, MD

CME/CE Released: 12/03/2013; Valid for credit through 12/03/2014

Clinical Context

Because most upper respiratory tract infections (URIs) are caused by viruses, antibiotic treatment is generally not needed. A clinical report describes antibiotic prescribing strategies for bacterial URIs in children, including acute otitis media (AOM), acute bacterial sinusitis, and group A streptococcal (GAS) pharyngitis.

Three principles for judicious antibiotic prescribing are using strict diagnostic criteria, considering the benefits and harms of antibiotic treatment, and understanding situations when antibiotics may not be needed. Although these principles can help guide implementation of recommendations from recent clinical guidelines regarding antibiotic prescribing strategies for bacterial URIs in children, Hersh and colleagues suggest that they may apply more broadly to antibiotic prescribing in general.

Study Synopsis and Perspective

Effective use of antibiotics to treat pediatric URIs rests on 3 basic principles: accurate diagnosis, consideration of risks vs benefits, and recognizing when antibiotics may be contraindicated, according to a clinical report by the Committee on Infectious Diseases of the American Academy of Pediatrics.

Of the nearly 50 million pediatric antibiotic prescriptions written annually, as many as 10 million of those "are directed toward respiratory conditions for which they are unlikely to provide benefit," lead author Adam L. Hersh, MD, PhD, and fellow committee members write in an article published in the December issue of Pediatrics. Often this occurs because it is hard to distinguish bacterial infections, which respond to antibiotics, from viral infections, which do not.

The report emphasizes "the importance of using stringent and validated clinical criteria when diagnosing ...AOM, acute bacterial sinusitis, and pharyngitis caused by ...GAS, as established through clinical guidelines," the authors write.

The first principle of judicious antibiotic prescribing is to determine the presence of a bacterial infection. For example, with AOM, this requires an otoscopic examination to observe characteristic inflammatory changes in the tympanic membrane plus bulging of the membrane or new-onset otorrhea not attributable to otitis externa, or mild bulging of the tympanic membrane accompanied by intense erythema or pain of recent onset. Acute bacterial sinusitis is diagnosed from persistent, worsening, or severe symptoms. Pharyngitis resulting from GAS can be diagnosed by taking a throat culture to identify the organism.

Following these diagnostic guidelines can help clinicians rule out the common cold, nonspecific URI, and bronchitis, which are viral in origin and will not respond to antibiotics, the authors write.

The second principle is to weigh the benefits against the harms of antibiotics. In the case of AOM, the evidence suggests that although at least 50% of patients may get well without antibiotics, antibiotics hasten recovery and are especially helpful for patients who are younger or have bilateral or severe disease. The evidence for using antibiotics to treat acute bacterial sinusitis is limited and mixed, and the role of the drugs in preventing complications such as orbital cellulitis or intracranial abscess also is unproven. Nevertheless, the American Academy of Pediatrics recommends antibiotics for children with clinical features of acute bacterial sinusitis, especially when the symptoms are worsening or severe. As for GAS pharyngitis, good evidence suggests that antibiotics can shorten symptom duration, although their effect on limiting fever is less clear, and they may reduce horizontal transmission. Antibiotics also may prevent suppurative complications of GAS pharyngitis such as peritonsillar abscess.

The harms of antibiotics can potentially outweigh these benefits, the authors warn. Most of the clinical trials reviewed have used amoxicillin or amoxicillin-clavulanate, which have been associated with adverse events ranging from mild (eg, diarrhea and rash), to severe (eg, Stevens-Johnson syndrome), to life-threatening cardiac and anaphylactic reactions. What is more, a growing body of evidence suggests that antibiotic use early in life may upset the normal microbial balance in the intestine and other organs, possibly setting the child up for lifelong health problems, including inflammatory bowel disease, obesity, eczema, and asthma. "Application of stringent diagnostic criteria and use of therapy only when the diagnosis and potential benefits are well established is essential to minimizing the impact of antibiotic overuse on resistance in individuals and within communities," the authors write.

Principle 3 is implementation of judicious prescribing strategies, including selection of the antibiotic most likely to eliminate the infecting organism, using an appropriate dose, and treating for the shortest duration possible. The committee suggests that clinicians consider a "wait-and-see" approach before prescribing antibiotics, especially for older patients with mild to moderate AOM or sinusitis. They also recommend an assessment of the child's overall antibiotic exposure.

These principles "can be used to amplify messages from recent clinical guidelines for local guideline development and for patient communication; they are broadly applicable to antibiotic prescribing in general," the authors conclude.

The authors have disclosed no relevant financial relationships.

Pediatrics. 2013;132:1146-1154.

Study Highlights

• The first principle of judicious antibiotic prescribing for pediatric URIs is to determine the likelihood of a bacterial infection.
  • For AOM, diagnosis of a bacterial cause requires middle ear effusion and signs of inflammation, with moderate or severe bulging of the tympanic membrane; otorrhea not the result of otitis externa; mild bulging of the tympanic membrane with ear pain; or erythema of the tympanic membrane.
  • For acute bacterial sinusitis, diagnosis of a bacterial cause requires URI symptoms that are worsening, severe, or persistent.
  • These include worsening or new-onset fever, daytime cough, or nasal discharge after improvement of viral URI.
  • Severe URI symptoms include fever of at least 39°C or purulent nasal discharge.
  • Persistent URI symptoms without improvement include nasal discharge or daytime cough lasting longer than 10 days.
  • There is no role for routine imaging in diagnosis of acute bacterial sinusitis.
  • Diagnosis of GAS pharyngitis requires confirmation by rapid testing or culture.
  • Testing for GAS pharyngitis should be done only if 2 of the following conditions are present: fever, tonsillar exudate or swelling, swollen or tender anterior cervical nodes, and absence of cough.
  • Presumed GAS pharyngitis should not be treated empirically.
• The second principle of judicious antibiotic prescribing for pediatric URIs is to consider the benefits vs the harms of antibiotics.
  • For strictly defined AOM, the number needed to treat for a reduction in symptoms is as low as 4 patients.
  • However, antibiotic treatment of AOM offers no significant benefits in preventing complications such as mastoiditis.
  • For strictly defined bacterial sinusitis, antibiotics relieve symptoms at 3 and 14 days, but no evidence exists that antibiotics prevent complications such as brain abscess.
  • For confirmed GAS pharyngitis, antibiotics shorten symptom duration, prevent rheumatic fever, and may reduce secondary transmission.
  • However, evidence is limited that antibiotics may prevent GAS complications such as peritonsillar abscess.
  • Recommended first-line therapy is amoxicillin with or without clavulanate for AOM or bacterial sinusitis, and amoxicillin or penicillin for GAS pharyngitis.
  • For all 3 conditions, the harms of antibiotics are the lack of benefit from therapy when bacterial infection is not likely; and an increased risk for adverse events, including diarrhea, dermatitis, Clostridium difficile colitis, and antibiotic resistance.
• The third principle is to implement judicious antibiotic prescribing strategies for pediatric URIs.
  • For AOM, watchful waiting may be considered for patients older than 2 years, and for those with unilateral disease and without severe symptoms.
  • For AOM, shorter-duration therapy (7 days) may also be an option.
  • For bacterial sinusitis, watchful waiting may be considered for patients with persistent symptoms only.
  • For GAS pharyngitis, treatment may be limited to once-daily dosing of amoxicillin.
  • Azithromycin and oral third-generation cephalosporins are generally not recommended for these conditions attributable to Streptococcus pneumoniaeresistance.