Application of Judicious Antibiotic Principles for Pediatric URIs

PrinciplesAOMAcute Bacterial SinusitisAcute Pharyngitis
Principle 1: Determine the likelihood of a bacterial infectionRequires middle ear effusion and signs of inflammation:URI symptoms that are either worsening, severe, or persistentDiagnosis of GAS pharyngitis requires confirmation by rapid testing or culture
• moderate or severe bulging of TM; or• Worsening symptoms: worsening or new onset fever, daytime cough, or nasal discharge after improvement of viral URI• Only test if 2 of the following are present: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, absence of cough
• otorrhea not due to otitis externa; or• Severe symptoms: fever ≥39°C, purulent nasal discharge• Do not treat empirically
• mild bulging of TM with ear pain or erythema of TM• Persistent symptoms without improvement: nasal discharge or daytime cough >10 d
No role for routine imaging
Principle 2: Weigh benefits versus harms of antibioticsBenefits: for strictly defined AOM, NNT of as few as 4 patients to achieve improvements in symptomsBenefits: for strictly defined bacterial sinusitis, antibiotics improve symptoms at 3 and 14 dBenefits: for confirmed GAS, antibiotics shorten symptom duration, prevent rheumatic fever and may limit secondary transmission.
• no significant benefits in preventing complications such as mastoiditis• no evidence that antibiotic therapy prevents complications such as brain abscess• Limited evidence that therapy prevents complications such as PTA
 First-line therapyAmoxicillin with or without clavulanateAmoxicillin with or without clavulanateAmoxicillin or penicillin
Harms: for all conditions, no benefits to therapy when bacterial infection is not likely. Increased risk of adverse events including diarrhea, dermatitis, C difficile colitis, antibiotic resistance
Principle 3: Implement judicious prescribing strategies• Consider watchful waiting for older patients (>2 y), those with unilateral disease and without severe symptoms• Consider watchful waiting for patients with persistent symptoms only• Once daily dosing of amoxicillin
• Shorter-duration therapy (7 d)
Not recommended: azithromycin and oral third-generation cephalosporins are generally not recommended for these conditions attributable to S pneumoniae resistance.