Why do we care about antibiotics?
As paediatricians, antibiotics are one of the most common classes of medications that we will end up prescribing. When we do this correctly, antibiotics can save lives. However, prescribing unnecessary antibiotics increases the risk of antimicrobial resistance while exposing children to potential side effects. This blog post aims to help familiarise you with some of the most common reasons for prescribing antibiotics in the paediatric emergency department.
Acute otitis media
A 12-month-old with Trisomy 21 presents with a low-grade fever, irritability, and poor feeding. His parents describe him pulling at his ears, and following a thorough examination, you identify that both tympanic membranes are bulging and red.
Acute otitis media is an infection of the middle ear common in children. It often follows an upper respiratory tract infection as the secretions from a coryzal illness can make the middle ear an ideal environment for colonisation by viruses and bacteria.
Symptoms typically include low-grade fever, earache, and pulling at the ears. However, symptoms may also be non-specific, including irritability, headache, poor feeding, vomiting, or diarrhoea. The diagnosis is clinical and can be made by directly visualising erythema or bulging of the tympanic membrane.
Treatment is mainly symptomatic with analgesia. Serious complications (such as intratemporal or intracranial infection) are rare with or without antibiotics. Antibiotics should be considered in children younger than two years with infections in both ears or suppurative acute otitis media. Children at high risk of complications (age <6 months, craniofacial malformations, trisomy 21, and immunodeficiency) should receive immediate antibiotics and be considered for admission.
In children with mild otitis media and risk factors, expectant observation and delayed antibiotic prescriptions are associated with better parent/caregiver satisfaction. When antibiotics are indicated, the treatment of choice is amoxicillin, which should be continued for five to seven days.
Debate and discussion – Are antibiotics required?
Antibiotic prescribing practice is variable. A Cochrane review of randomised control trials compared antibiotics to placebo for children with acute otitis media. Antibiotics were found to have no early effect on pain, and without antibiotics, most cases in high-income countries spontaneously resolved.
For every 14 children treated with antibiotics, one had an adverse effect such as vomiting, diarrhoea, or rash. The take home is that antibiotics should be reserved for children at higher risk of complications, and an expectant observational approach is appropriate for children with mild disease and an absence of risk factors.
Tonsillitis
A 3-year-old girl presents with a two-day history of fever and reduced oral intake. A thorough examination demonstrates tender lymph nodes at the front of her neck and swollen pus-filled tonsils.
Tonsilitis is an infection of the tonsils which is usually viral but can also be bacterial, with Group A β-hemolytic streptococcus (GAβHS) being the most common bacterial organism. Acute onset of fever, painful swallowing, tender cervical lymph nodes, and severe tonsillar inflammation or exudate may suggest a bacterial cause. These features are incorporated into clinical prediction rules that can help guide antibiotic prescribing, as children with low scores using prediction rules are likely to have a viral cause. These include FeverPAIN, Centor and its modified version McIsaac.
In geographical areas with low rates of invasive GAβHS, antibiotics are reserved for high-risk children only. For example, the RCH Melbourne guideline recommends antibiotics only for Aboriginal and Torres Strait Islanders, Maori and Pacific Islanders, those with a personal or family history of rheumatic fever or rheumatic heart disease, or immunosuppressed children.
A throat culture is the gold standard for confirming a bacterial infection. However, results may take some time and, as such, rapid point-of-care tests are increasingly used. Beware of false positives from colonisation of the throat with streptococcus.
When antibiotics are indicated, penicillins, macrolides and cephalosporins are all effective, with the suggested duration of treatment ranging from 5-10 days.
Debate and discussion – Can scoring systems help determine treatment?
Most guidelines acknowledge the use of scoring systems. However, even the maximum scores of the Centor, FeverPAIN, and McIsaac scores give probabilities of GAβHS of 56%, 65%, and 68%, respectively.
The take home is that scoring systems can help guide decision-making, but if scores are used, their usefulness is in ruling out, rather than ruling in, GAβHS.
Community-acquired pneumonia
A 4-year-old presents with fever, vomiting, and cough. On examination, there is an increased work of breathing, and you can hear crackles at the base of his right lung.
Community-acquired pneumonia (CAP) is an acute lower respiratory tract infection. It can be either viral or bacterial. Infection is characterised by fever, cough, increased work of breathing, and focal crackles on auscultation.
Although traditionally prescribed, antibiotics may not be necessary for mild infections. When antibiotics are required, amoxicillin remains the treatment of choice, and a short course of 3-5 days is preferred, especially for uncomplicated CAP. Four recent large randomised control trials (CAP-IT, SAFER, SCOUT-CAP, ARTIC PC) have all supported shorter courses of antibiotics. Amoxicillin is the first-line antibiotic of choice in children without penicillin allergy.
Another common belief is that IV antibiotics are better than oral antibiotics. This is true in life-threatening conditions such as sepsis. However, when children do not have features of sepsis, oral antibiotics are equally effective. As such, oral antibiotics should be offered when they can be tolerated.
Debate and discussion – Are intravenous antibiotics necessary in admitted children?
Although IV antibiotics are routinely prescribed, the belief that they are superior to oral antibiotics may not be evidence-based. Many oral antibiotics have high bioavailability.
Two large RCTs (APPIS and PIVOT) have recently compared treatment with oral or IV antibiotics for children with CAP. These RCTs demonstrated no difference in treatment failure between groups. The take home is that although IV antibiotics are key in sepsis management, oral antibiotics are equally as effective as IV antibiotics for children without critical illness.
Pre-septal cellulitis
A 3-year-old girl presents with a swollen and red left eye. She has a low-grade fever, and her parents describe a recent coryzal illness. The eye is unaffected, and, on examination, she has a full range of eye movements.
Pre-septal cellulitis (also called peri-orbital cellulitis) is a soft tissue infection around the eye and in front of the orbital septum.
Pre-septal cellulitis often presents with a gradual onset of eyelid swelling, erythema, and low-grade fever. The eye itself is not affected. Features such as a toxic appearance, a bulging eye (proptosis), or painful eye movements may point towards post-septal cellulitis (orbital cellulitis), which can lead to devastating consequences (such as blindness or even cerebral abscess).
Without treatment, pre-septal cellulitis may progress to post-septal cellulitis. As such, all patients should be treated with antibiotics. Due to the rise of MRSA, guidelines commonly recommend trimethoprim-sulfamethoxazole (TMP-SMX) and clindamycin.
Children over one year of age with mild symptoms can be treated as an outpatient with oral antibiotics, whilst children under one or those with more severe symptoms should be admitted for IV antibiotics. A clinical review within 24-48 hours is recommended for children treated at home, and treatment duration is usually 5-7 days (but may be longer if the cellulitis is ongoing).
Debate and discussion – Can intravenous antibiotics be given at home?
Conventionally IV antibiotics have been limited to in-hospital use. However, the Intravenous ceftriaxone at home versus intravenous flucloxacillin in hospital for children with cellulitis” (CHOICE) randomised control trial challenged this dogma. It included a subgroup of children with pre-septal cellulitis.
It found that home treatment with intravenous ceftriaxone was not inferior to hospital treatment with intravenous flucloxacillin. The take-home is that there is an emerging role for outpatient IV antibiotic therapy in appropriate patients.
Urinary tract infections
A 2-year-old with fever, vomiting, and reduced urine output. She cries when you palpate her lower abdomen. A urine dip demonstrates the presence of leukocytes.
Urinary tract infections can occur in the lower (cystitis) or upper urinary tract (pyelonephritis). Older children may present with painful urination or urinary retention; however, in younger children, symptoms may be non-specific. A urinary tract infection should be considered in children with fever with an obvious cause.
A urine culture is the gold standard for investigation; however, results can take time. In contrast, urine dipstick analysis is a low-cost and simple method of detecting UTIs. The two most useful markers of a UTI are leukocytes (white cells in the urine) and nitrites (breakdown products produced by bacteria). Leukocytes are more sensitive (meaning a lack of leukocytes makes a UTI unlikely), whilst nitrites are more specific (meaning the presence of nitrites strongly suggests a UTI, but a lack of nitrites does not exclude a UTI). Clinicians should be aware of false positive samples, which are common and often occur due to errors in the collection method.
Infections can be uncomplicated or complicated. Recognising features of complications infections can help with decision-making around the route of antibiotics and duration. Infections are more likely to be complicated in:
- neonates
- abdominal and/or bladder mass
- kidney and urinary tract anomalies
- urosepsis
- organisms other than Escherichia coli
- atypical clinical course, including an absence of clinical response to antibiotics within 72 hours
- renal abscess
Most children can be managed with oral antibiotics, and IV antibiotics should be reserved for those with high-risk factors:
- younger than 2-3 months
- urogenital anatomical alteration
- complicated infections
- unable to tolerate oral therapy
- ill-appearing
Short courses of 3-5 days may be sufficient for older children with cystitis and no fever. In younger children, a longer course of 7-10 days is recommended, and those with an upper urinary tract infection may require up to 14 days.
Debate and discussion – Can scoring systems determine who needs a urine sample?
There are several different scoring systems, such as UTIcalc, Gorelick, and Duty Score, aimed at helping to decide which children require a urine sample. Although sensitivity ranges from 75-98% with different scoring systems, specificity is low, ranging from 8-16%.
The take home is that these scoring systems result in a low threshold to collect urine, which may be useful in children under two, where symptoms are usually non-specific.
References
Acute otitis media
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Tonsillitis
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Community-acquired pneumonia
Addo-Yobo E, Anh DD, El-Sayed HF, Fox LM, Fox MP, MacLeod W, et al. Outpatient treatment of children with severe pneumonia with oral amoxicillin in four countries: the MASS study. Trop Med Int Health TM IH. 2011 Aug;16(8):995–1006.
Addo-Yobo E, Chisaka N, Hassan M, Hibberd P, Lozano JM, Jeena P, et al. Oral amoxicillin versus injectable penicillin for severe pneumonia in children aged 3 to 59 months: a randomised multicentre equivalency study. The Lancet. 2004 Sep 25;364(9440):1141–8.
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Pre-septal cellulitis
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Urinary tract infections
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