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Antibiotics in the paediatric emergency department

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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.

Karageorgos, S.; Hibberd, O.; Mullally, P.J.W.; Segura-Retana, R.; Soyer, S.; Hall, D., on behalf of the Don’t Forget the Bubbles. Antibiotic Use for Common Infections in Pediatric Emergency Departments: A Narrative Review. Antibiotics 2023, 12, 1092.

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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Davidson L, Foley DA, Clifford P, Blyth CC, Bowen AC, Hazelton B, et al. Infectious complications and optimising infection prevention for children with cochlear implants. J Paediatr Child Health. 2022 Jun;58(6):1007–12.

Frost HM, Bizune D, Gerber JS, Hersh AL, Hicks LA, Tsay SV. Amoxicillin Versus Other Antibiotic Agents for the Treatment of Acute Otitis Media in Children. J Pediatr. 2022 Dec;251:98-104.e5.

Overview | Otitis media (acute): antimicrobial prescribing | Guidance | NICE [Internet]. NICE; [cited 2022 Dec 28]. Available from: https://www.nice.org.uk/guidance/ng91

Spurling GK, Del Mar CB, Dooley L, Clark J, Askew DA. Delayed antibiotic prescriptions for respiratory infections. Cochrane Acute Respiratory Infections Group, editor. Cochrane Database Syst Rev [Internet]. 2017 Sep 7 [cited 2022 Dec 28];2022(8). Available from: http://doi.wiley.com/10.1002/14651858.CD004417.pub5

Suzuki HG, Dewez JE, Nijman RG, Yeung S. Clinical practice guidelines for acute otitis media in children: a systematic review and appraisal of European national guidelines. BMJ Open. 2020 May;10(5):e035343.

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Venekamp RP, Schilder AGM, van den Heuvel M, Hay AD. Acute middle ear infection (acute otitis media) in children. BMJ. 2020 Nov 18;m4238.

Tonsillitis

Baker MG, Gurney J, Oliver J, Moreland NJ, Williamson DA, Pierse N, et al. Risk Factors for Acute Rheumatic Fever: Literature Review and Protocol for a Case-Control Study in New Zealand. Int J Environ Res Public Health. 2019 Nov 15;16(22):4515.

Banerjee S, Ford C. Clinical Decision Rules and Strategies for the Diagnosis of Group A Streptococcal Infection: A Review of Clinical Utility and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2018 [cited 2022 Dec 28]. (CADTH Rapid Response Reports). Available from: http://www.ncbi.nlm.nih.gov/books/NBK532209/

Cohen JF, Pauchard JY, Hjelm N, Cohen R, Chalumeau M. Efficacy and safety of rapid tests to guide antibiotic prescriptions for sore throat. Cochrane Acute Respiratory Infections Group, editor. Cochrane Database Syst Rev [Internet]. 2020 Jun 4 [cited 2022 Dec 28];2020(6). Available from: http://doi.wiley.com/10.1002/14651858.CD012431.pub2

Dodd HK, Atkinson A. 1572 The use of centor and/or FeverPain scoring criteria to determine antibiotic prescribing in acute sore throat according to NICE NG84 guideline. In: Abstracts [Internet]. BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health; 2021 [cited 2022 Dec 28]. p. A418.2-A419. Available from: https://adc.bmj.com/lookup/doi/10.1136/archdischild-2021-rcpch.726

Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012 Jun 11;172(11):847–52.

Freer J, Ally T, Brugha R. Impact of Centor scores on determining antibiotic prescribing in children. Int J Health Care Qual Assur. 2017 May 8;30(4):319–26.

Overview | Sore throat (acute) in adults: antimicrobial prescribing | Guidance | NICE [Internet]. NICE; [cited 2022 Dec 28]. Available from: https://www.nice.org.uk/guidance/ng84

Ralph AP, Noonan S, Wade V, Currie BJ. The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease. Med J Aust. 2021 Mar;214(5):220–7.

Randel A, Infectious Disease Society of America. IDSA Updates Guideline for Managing Group A Streptococcal Pharyngitis. Am Fam Physician. 2013 Sep 1;88(5):338–40.

Roggen I, van Berlaer G, Gordts F, Pierard D, Hubloue I. Centor criteria in children in a paediatric emergency department: for what it is worth. BMJ Open. 2013;3(4):e002712.

Shapiro DJ, Barak-Corren Y, Neuman MI, Mandl KD, Harper MB, Fine AM. Identifying Patients at Lowest Risk for Streptococcal Pharyngitis: A National Validation Study. J Pediatr. 2020 May;220:132-138.e2.

Tonsillitis – Symptoms, diagnosis and treatment | BMJ Best Practice US [Internet]. [cited 2022 Dec 28]. Available from: https://bestpractice.bmj.com/topics/en-us/598

Willis BH, Coomar D, Baragilly M. Comparison of Centor and McIsaac scores in primary care: a meta-analysis over multiple thresholds. Br J Gen Pract. 2020 Apr;70(693):e245–54.

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.

Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children With Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial | Infectious Diseases | JAMA | JAMA Network [Internet]. [cited 2023 Jan 3]. Available from: https://jamanetwork.com/journals/jama/fullarticle/2785716

Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax. 2011 Oct 1;66(Suppl 2):ii1–23.

Li HK, Agweyu A, English M, Bejon P. An Unsupported Preference for Intravenous Antibiotics. PLOS Med. 2015 May 19;12(5):e1001825.

Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America | Clinical Infectious Diseases | Oxford Academic [Internet]. [cited 2023 Jan 3]. Available from: https://academic.oup.com/cid/article/53/7/e25/424286

Rojas‐Reyes MX, Rugeles CG. Oral antibiotics versus parenteral antibiotics for severe pneumonia in children. Cochrane Database Syst Rev [Internet]. 2006 [cited 2023 Jan 3];(2). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004979.pub2/full

The CAP-IT Trial: Amoxicillin Dose and Duration in Children with Community-Acquired Pneumonia – REBEL EM – Emergency Medicine Blog [Internet]. [cited 2023 Jan 5]. Available from: https://rebelem.com/the-cap-it-trial-amoxicillin-dose-and-duration-in-children-with-community-acquired-pneumonia/

Williams DJ, Creech CB, Walter EB, Martin JM, Gerber JS, Newland JG, et al. Short- vs Standard-Course Outpatient Antibiotic Therapy for Community-Acquired Pneumonia in Children: The SCOUT-CAP Randomized Clinical Trial. JAMA Pediatr. 2022 Mar 1;176(3):253–61.

Pre-septal cellulitis

Al-Nammari S, Roberton B, Ferguson C. Should a child with preseptal periorbital cellulitis be treated with intravenous or oral antibiotics? Emerg Med J. 2007 Feb 1;24(2):128–9.

Bae C, Bourget D. Periorbital Cellulitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Dec 28]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470408/

Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. Int J Pediatr Otorhinolaryngol. 2008 Mar;72(3):377–83.

Ibrahim LF, Hopper SM, Orsini F, Daley AJ, Babl FE, Bryant PA. Efficacy and safety of intravenous ceftriaxone at home versus intravenous flucloxacillin in hospital for children with cellulitis (CHOICE): a single-centre, open-label, randomised, controlled, non-inferiority trial. Lancet Infect Dis. 2019 May;19(5):477–86.

James V, Mohamad Ikbal MF, Min NC, Chan YH, Ganapathy S. Periorbital Cellulitis in Paediatric Emergency Medicine Department Patients. Ann Acad Med Singapore. 2018 Oct;47(10):420–3.

Lee S, Yen MT. Management of preseptal and orbital cellulitis. Saudi J Ophthalmol. 2011 Jan;25(1):21–9.

McMullan BJ, Andresen D, Blyth CC, Avent ML, Bowen AC, Britton PN, et al. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. Lancet Infect Dis. 2016 Aug;16(8):e139–52.

Okonkwo ACO, Powell S, Carrie S, Ball SL. A review of periorbital cellulitis guidelines in Fifty-One Acute Admitting Units in the United Kingdom. Clin Otolaryngol. 2018 Apr;43(2):718–21.

Wong SJ, Levi J. Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018 Jul;110:123–9.

Urinary tract infections

‘t Hoen LA, Bogaert G, Radmayr C, Dogan HS, Nijman RJM, Quaedackers J, et al. Update of the EAU/ESPU guidelines on urinary tract infections in children. J Pediatr Urol. 2021 Apr;17(2):200–7.

Alghounaim M, Ostrow O, Timberlake K, Richardson SE, Koyle M, Science M. Antibiotic Prescription Practice for Pediatric Urinary Tract Infection in a Tertiary Center. Pediatr Emerg Care [Internet]. 2019 Feb 28 [cited 2022 Dec 28];Publish Ahead of Print. Available from: https://journals.lww.com/00006565-900000000-98209

Autore G, Bernardi L, La Scola C, Ghidini F, Marchetti F, Pasini A, et al. Management of Pediatric Urinary Tract Infections: A Delphi Study. Antibiotics. 2022 Aug 18;11(8):1122.

Boon HA, Struyf T, Bullens D, Van den Bruel A, Verbakel JY. Diagnostic value of biomarkers for paediatric urinary tract infections in primary care: systematic review and meta-analysis. BMC Fam Pract. 2021 Dec;22(1):193.

Boon HA, Verbakel JY, De Burghgraeve T, Bruel AV den. Clinical prediction rules for childhood urinary tract infections: a cross-sectional study in ambulatory care. BJGP Open. 2022 Jun;6(2):BJGPO.2021.0171.

Brady PW, Conway PH, Goudie A. Length of Intravenous Antibiotic Therapy and Treatment Failure in Infants With Urinary Tract Infections. Pediatrics. 2010 Aug 1;126(2):196–203.

Glissmeyer EW, Korgenski EK, Wilkes J, Schunk JE, Sheng X, Blaschke AJ, et al. Dipstick screening for urinary tract infection in febrile infants. Pediatrics. 2014 May;133(5):e1121-1127.

McTaggart S, Danchin M, Ditchfield M, Hewitt I, Kausman J, Kennedy S, et al. KHA-CARI guideline: Diagnosis and treatment of urinary tract infection in children: Urinary tract infection in children. Nephrology. 2015 Feb;20(2):55–60.

Roberts KB, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011 Sep 1;128(3):595–610.

Shaikh N, Hoberman A, Hum SW, Alberty A, Muniz G, Kurs-Lasky M, et al. Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children. JAMA Pediatr. 2018 Jun 1;172(6):550–6.

Shaikh N, Mattoo TK, Keren R, Ivanova A, Cui G, Moxey-Mims M, et al. Early Antibiotic Treatment for Pediatric Febrile Urinary Tract Infection and Renal Scarring. JAMA Pediatr. 2016 Sep 1;170(9):848.

Authors

  • Owen Hibberd is an Emergency Medicine Trainee in Cambridge, currently studying on the QMUL PEM MSc. Interested in Paediatric Emergency Medicine, Pre-Hospital Emergency Medicine and Medical Education. He/him.

  • Spyridon is a Paediatric Resident in Athens, interested in Paediatric Emergency Medicine, reducing antibiotic use in paediatric patients and in Medical Education. Currently studying on the QMUL PEM MSc. He/him.

  • Dani Hall is a PEM consultant in Dublin, member of the DFTB executive team and senior clinical lecturer on the Queen Mary University of London and DFTB PEM MSc. Dani is passionate about advocating for children and young people, and loves good coffee, a good story and her family. She/her.

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