Best Practices for Limiting Antibiotic Use in Pediatric Head and Neck Infections
Author: Christine Zink, MD
Inappropriate antibiotic prescribing has become commonplace in the US. In pediatric patients, up to 30% of antibiotics may be inappropriately prescribed, which is not only costly for the patient but can also lead to side effects and even severe illnesses like Clostridium difficile infection.
Read on to garner a more in-depth view of the appropriate prescribing guidelines for acute otitis media, pharyngitis, and rhinosinusitis in pediatric patients and the evidence behind the recommendations. Here are the key takeaways:
- The American Academy of Pediatrics stresses an accurate diagnosis of acute otitis media before prescribing antibiotics1
- Antibiotic therapy for acute otitis media is recommended for pediatric patients with unilateral severe otitis media or those with bilateral disease1
- Pediatric patients with nonsevere acute otitis media might be better served with observation1
- The Infectious Diseases Society of America stresses appropriate diagnosis of group A streptococcal pharyngitis through rapid antigen detection before prescribing antibiotics3
- To limit the detection of noninfectious colonization and overuse of antibiotics, testing for group A streptococcal pharyngitis is not recommended in children or adults with acute pharyngitis and clinical features that suggest a viral etiology3
- Most pediatric patients with upper respiratory infection symptoms have a viral illness, and antibiotics should not be prescribed6
Acute Otitis Media
The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians provide recommendations for the management of uncomplicated acute otitis media (AOM) in pediatric patients between the ages of six months and 12 years.1 They stress a strict definition of acute otitis media, including1:
- Moderate to severe bulging of the tympanic membrane or new onset otorrhea not due to acute otitis externa
- Mild bulging of the tympanic membrane and less than 48 hours of ear pain or intense erythema of the tympanic membrane
Clinicians should not diagnose AOM in pediatric patients who do not have a middle ear effusion.1
Antibiotics vs. Observation
Antibiotic therapy for AOM is mainly recommended for pediatric patients (under age 2) with:
- Severe unilateral AOM
- Bilateral disease without severe signs or symptoms
Antibiotic therapy for AOM is recommended for older pediatric patients (over age 2) with:
- Severe unilateral AOM
Symptoms of severe disease include either1:
- Moderate to severe pain for at least 48 hours
- Temperature of at least 39°C (102.2°F)
Pediatric patients with nonsevere AOM might be better served with observation and close follow-up based on joint decision-making between the clinician and parent(s)/caregiver.1
Evidence Behind Recommendations
These recommendations are based on an extensive literature review comparing antibiotic therapy versus placebo for AOM. After using stringent diagnostic criteria for AOM, researchers determined that approximately half of young children experienced resolution of symptoms when treated with a placebo.1 The evidence also showed that utilizing observation as initial management in properly selected children did not increase suppurative complications, such as mastoiditis.1 Essentially, 4,800 patients would need to be treated with antibiotics to prevent one case of mastoiditis.1
However, clinicians must use the initial observation recommendation in a situation with appropriate follow-up in case a pediatric patient develops persistent or worsening symptoms that require antibiotic therapy.
The recommendation for initial observation and consideration of antibiotics for pediatric patients with persistent or worsening symptoms has been reaffirmed in a more recent Cochrane Database Systematic Review conducted in 2015. Five randomized controlled trials that included 1,149 pediatric patients were analyzed in the part of the study that compared immediate antibiotic therapy with expectant observation.2 Researchers found2:
- No difference in pain at three to seven days
- No difference in the number of pediatric patients with abnormal tympanometry findings at four weeks
- No increase in tympanic membrane perforations or recurrent AOM
- No serious complications in either the antibiotic or the expectant observation group
However, pediatric patients who received immediate antibiotics had a significantly increased risk of vomiting, diarrhea, and rash compared to those in the observation group.2 The analysis also showed that the group to benefit the most from immediate antibiotic therapy was young pediatric patients (under age 2) with bilateral AOM and those with both AOM and otorrhea.2
Treatment Strategy When Antibiotics Are Appropriate
When antibiotics are prescribed, generally, amoxicillin is the recommended first-line therapy. If a pediatric patient received amoxicillin in the last 30 days, has concurrent, purulent conjunctivitis, or has a history of recurrent AOM unresponsive to amoxicillin, additional beta-lactamase coverage is suggested.1
Acute pharyngitis is a common cause of sore throat, and bacterial infection can sometimes lead to complications such as acute rheumatic fever, peritonsillar abscess, or invasive disease.3 However, only 20 to 30% of patients with acute pharyngitis have a concerning bacterial cause (group A streptococcal infection).3 There is much debate about the best way to diagnose and treat acute group A streptococcal (GAS) pharyngitis, and different organizations have different guidelines.
Clinically, acute pharyngitis can be misdiagnosed as a bacterial infection leading to the overuse of antibiotic therapy. To combat overprescribing, the Infectious Diseases Society of America (IDSA) updated its guidelines in 2012, and they stress appropriate diagnosis of GAS pharyngitis to guide proper treatment.3
The IDSA recommends testing for GAS pharyngitis by rapid antigen detection test (RADT) or culture before initiating therapy since it is difficult to differentiate GAS from viral pharyngitis clinically.3 In addition, a throat culture in patients with a negative RADT should only be performed in children and adolescents and is not necessary in adults due to the low incidence of GAS and subsequent acute rheumatic fever.3
That being said, testing for GAS pharyngitis is not recommended in children or adults with acute pharyngitis and clinical features that suggest a viral etiology.3 Symptoms of a viral cause include:
- Oral ulcers
Inappropriate use of diagnostic testing for GAS can lead to overprescribing of antibiotics since children can be carriers of the bacteria. Furthermore, testing for GAS is not recommended in children under three years because acute rheumatic fever and streptococcal pharyngitis are rare in this age group.3
Antibiotics Vs. No Antibiotics
Similar to the variability in practice patterns on diagnosing GAS pharyngitis, there is debate on whether antibiotics are truly necessary for pharyngitis, particularly in adult populations. The evidence can be challenging to tease apart because many studies do not differentiate viral versus bacterial pharyngitis. Overall, patients with GAS pharyngitis generally have symptom improvement 24 hours faster when treated with antibiotics.4 A large Cochrane Database Systematic Review of 12,835 patients performed in 2013 showed that antibiotics used for the treatment of sore throat (not differentiated into bacterial versus viral etiologies) showed symptom improvement approximately 16 hours faster with antibiotics compared to those without antibiotics.5 The incidence of suppurative and nonsuppurative complications was low in all studies.4,5
Standard Treatment Practice
Even though practice guidelines vary, the standard of care is antibiotic treatment for confirmed GAS pharyngitis, particularly in pediatric patients. When the diagnosis of GAS has been made and antibiotics are necessary, the first-line treatment recommendation is penicillin or amoxicillin.3 Patients with a penicillin allergy can be treated with cephalexin, cefadroxil, clindamycin, azithromycin, or clarithromycin.3
Maintaining consistency with other guidelines regarding diagnosing and managing head and neck infections, the AAP has developed specific diagnostic criteria to guide treating rhinosinusitis in pediatric patients between one and 18 years of age.6 Most pediatric patients with upper respiratory infection (URI) symptoms have a viral illness. The nasorespiratory symptoms usually peak at about days three to six and then begin to improve.6 However, a small proportion (6-7%) of patients will develop bacterial sinusitis.6
The guidelines state that a clinical diagnosis of acute bacterial sinusitis can be made if the pediatric patient has one of the following6:
- Persistent nasal discharge or daytime cough for more than ten days without improvement
- Worsening nasal discharge, daytime cough, or fever after initial improvement
- Severe onset with purulent nasal discharge for at least three consecutive days and a fever greater than or equal to 39°C (102.2°F). These children are often ill-appearing
These guidelines are in line with a diagnosis of bacterial sinusitis in adults. Adhering to strict diagnostic criteria reduces overprescribing of antibiotics for viral URIs.
American Academy of Pediatrics Guideline Updates: 2001 vs. 2013
One meaningful change to note when evaluating the 2013 versus 2001 AAP guidelines for managing rhinosinusitis is that the updated guidelines allow three days of additional observation for pediatric patients with persistent illness.6 Previously, the AAP recommended that all children diagnosed with acute bacterial sinusitis after ten days of persistent symptoms be treated with antibiotics.6 The updated guidelines allow for continued outpatient observation for an additional three days, if appropriate, with the institution of antibiotics if symptoms persist after that time.
This recommendation only applies to patients with persistent symptoms and uncomplicated disease and does not apply to those with worsening symptoms after initial improvement or severe disease at onset. Patients with severe disease or worsening symptoms are more likely to have a bacterial etiology simply because the pattern of illness is not consistent with an acute viral URI.6 Randomized-controlled trials support antibiotics in these cases.
The AAP allows for continued observation in patients with uncomplicated persistent symptoms because evidence suggests that many will improve independently, and the risk of suppurative complications is low.6 However, only three to five patients need to be treated for persistent ten-day symptoms with antibiotics to show improvement in their disease.6 If a patient is to be observed, it is essential to use shared-decision making with the parent(s)/caregiver to ensure appropriate follow-up three days later.
Treatment Strategy When Antibiotics Are Appropriate
The first-line recommendation is amoxicillin with or without clavulanate if antibiotics are prescribed. Patients with a severe penicillin allergy can be treated with cefdinir, cefuroxime, or cefpodoxime.6
The next time you encounter a pediatric patient with a head and neck infection (otitis media, pharyngitis, rhinosinusitis), consider limiting the use of antibiotics. The American Academy of Pediatrics stresses limited antibiotic use in their Choosing Wisely Campaign.7 You should, too. Listen here to learn more about the risks of inappropriate prescribing. Visit Pri-Med for more CME/CE opportunities.
- 1. Siddiq S, Grainger J. The diagnosis and management of acute otitis media: American Academy of Pediatrics Guidelines 2013. Arch Dis Child Educ Pract Ed. 2015;100(4):193-197.
2. Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015;2015(6):CD000219.
3. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2014 May;58(10):1496. Dosage error in article text]. Clin Infect Dis. 2012;55(10):e86-e102.
4. Mustafa Z, Ghaffari M. Diagnostic methods, clinical guidelines, and antibiotic treatment for group a streptococcal pharyngitis: a narrative review. Front Cell Infect Microbiol. 2020;10:563627.
5. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2013;2013(11):CD000023.
6. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.
7. American Academy of Pediatrics. Ten things physicians and patients should question. Choosing Wisely website. Accessed October 20, 2022. https://www.choosingwisely.org/societies/american-academy-of-pediatrics/