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Promoting Appropriate Antibiotic Use in Children

Stemming the tide of antibiotic resistance: Recommendations by the CDC /AAP to promote appropriate antibiotic use in children.*

CDC/AAP Principles of Appropriate Antibiotic Use

Otitis Media

1. Classify episodes of OM as acute otitis media (AOM) or otitis media with effusion (OME). Only treat proven AOM.
2. Antibiotics are indicated for treatment of AOM, however, diagnosis requires
   • Documented middle ear infection.
   • Signs or symptoms of acute local or systemic illness.
3. Don't prescribe antibiotics for initial treatment of OME
   • Treatment may be indicated if bilateral effusions persist for three months or more.

Rhinitis and Rhinitis

1. Antibiotics should not be given for viral rhinosinusitis.
2. Mucopurulent rhinitis (thick, opaque, or discolored nasal discharge) frequently accompanies viral rhinosinusitis. It is not an indication for antibiotic treatment unless it persists without improvement for more than 10-14 days.

Sinusitis:

1. Diagnose as sinusitis only in the presence of:
   • Prolonged nonspecific upper respiratory signs and symptoms (e.g. rhinorrhea and cough without improvement for more than 10-14 days)
   • More severe upper respiratory tract signs and symptoms (e.g. fever greater than 39 C, facial swelling, facial pain).
2. Initial antibiotic treatment of acute sinusitis should be with the most narrow-spectrum agent which is active against the likely pathogens.

Pharyngitis 

1. Diagnose as group A streptococcal pharyngitis using a laboratory test in conjunction with clinical and epidemiological findings.
2. Antibiotics should not be given to a child with pharyngitis in the absence of diagnosed group A streptococcal infection.
3. A penicillin remains the drug of choice for treating group A streptococcal pharyngitis. 

Cough Illness and Bronchitis 

1. Cough illness/bronchitis in children rarely warrants antibiotic treatment.
2. Antibiotic treatment for prolonged cough (more than 10 days) may occasionally be warranted:
   • Pertussis should be treated according to established recommendations.
   • Mycoplasma pneumoniae infection may cause pneumonia and prolonged cough (usually in children older than 5 years); a macrolide agent (or tetracycline in children 8 years or older) may be used for treatment.
   • Children with underlying chronic pulmonary disease (not including asthma) may occasionally benefit from antibiotic therapy for acute exacerbations.

When parent demand antibiotics

• Provide educational materials and share your treatment rules to explain when the risks of antibiotics outweigh the benefits.
• Build cooperation and trust:
  • Don't dismiss the illness as "only a viral infection"
  • Give parents a realistic time course for resolution
  • Explicitly plan treatment of symptoms with parents
  • Prescribe analgesics and decongestants, if applicable 

References
*Dowell SF, Editor. Principals of judicious use of antimicrobial agents for children's upper respiratory tract infections. Pediatrics. Vol 1. January 1998 Supplement.