Emily is a 2 year old girl brought to the emergency department with her mum, following two days of fever and poor intake. She has a temperature of 39°C and looks a little unhappy, but has no red flags for sepsis. On examination of her throat you see she has enlarged, red tonsils bilaterally with exudate. Her examination is otherwise normal. Should you prescribe her antibiotics?
What is the problem?
Respiratory tract infections (RTIs) in young children including tonsillitis, otitis media (OM), and lower respiratory tract infections (LRTIs), make up a significant portion of paediatric presentations in both primary and secondary care. There is a lot of confusion about when to treat, what to treat, and why. Currently the majority of these presentations end up in a prescription for antibiotics, which is a problem for many reasons, including:
- Antibiotics are rarely indicated for LRTI, Tonsillitis or OM
- Inappropriate antibiotic prescribing drives antibiotic resistance
- Inappropriate antibiotic prescribing drives future medicalised health behaviour
- Inappropriate antibiotic prescribing has a number of short-term risks, such as hypersensitivity reactions and GI upset
- Inappropriate antibiotic prescribing is associated with number of long-term risks due to microbiome dysbiosis, including increased risk of atopy, inflammatory and auto-immune conditions, obesity and more.
So why are we prescribing so many antibiotics? The cause is multifactorial; in order to reduce inappropriate antibiotic prescribing we need to address each of these.
Perception that parents are seeking antibiotics
It is a wide held belief that a desire for antibiotics is the motivation behind most presentations to the doctor for children with RTIs. As a matter of fact, this is not true for the majority of encounters. Parents bring their child to medical attention because they are uncertain as to the severity of their child’s illness, and they are frightened. They are generally looking for someone to reassure them.
The right way to manage the family when antibiotics are not appropriate, is not to dismiss the infection as ‘only viral’ (a term that parents hate). The right steps to take in your discussion are:
- Acknowledge their child feels poorly.
- Acknowledge this is difficult for their child, and for them as parents.
- Reassure them their child is safe, and there are no ‘red flags’; – remember what we consider severe (physiological derangement) is not the same as parents (behavioural impact).
- Explain that medical treatment is supportive and offer symptom management.
- If you need to, confirm antibiotics are neither necessary nor helpful, as it will not speed up recovery and only expose the child to unnecessary risk.
- Most importantly – provide illness specific information and safety net advice (ideally written information/leaflet).
There is good evidence that addressing parental concerns and providing information reduces re-presentation and antibiotic prescribing rates. You will find that most parents will just want to hear that their child is safe, and be happy that they don’t need to struggle to force disgusting medicine in to them for the next week.
Fear of ‘missing something’
Complications of RTIs in children do occur, including quinsy, mastoiditis, empyema etc. However, respiratory tract infections are very common, and complications are incredibly rare.
To put complications in context:
- The rate of quinsy after tonsillitis for <4 year olds is 1.59/10,000. The NNT to prevent a quinsy in all age groups is >4000.
- The rate of mastoiditis after otitis media for <4 year old is 1.33/10,000, and the NNT to prevent a mastoiditis in all age groups is >4000.
A very important contradiction in the treatment of respiratory tract infections, is that the cohort most likely to receive antibiotics (the under 5s, and especially under 3s) are the least likely to have a bacterial aetiology, and the least likely to develop complications.
Treating mild to moderate RTIs with antibiotics to prevent complications is not necessary, and in general, the younger the child, the less likely it is your treatment will do anything to prevent subsequent complications of their illness, and the more likely it will cause them harm.
When should I treat RTIs in children?
The paradigm has always been to target ‘bacterial’ causes of infection. Sadly, we know that clinically we are almost totally unable to distinguish between bacterial and viral aetiology.
Pus on tonsils? Meaningless.
Focal chest signs? Useless.
What about point of care testing? Whilst this seems like a good idea, and in theory should reduce antibiotic prescribing, in practice this approach has had very mixed results (e.g. rapid strep tests or flu tests). The main problem is people don’t entirely understand how to interpret the test results, treat even when the test would advise against, and end up treating positive tests which shouldn’t be treated.
We need to change the paradigm from trying to distinguish bacterial from viral infections to adopting a severity based approach to direct our treatment decisions. Even if mild to moderate disease is caused by bacteria, these infections still resolve on their own and antibiotics make little to no difference anyway.
Do not treat mild to moderate disease in children with RTIs, and do treat those with severe disease.
In practice, to guide people in determining severity:
Otitis media:
<6 months – treat all AOM (it is unusual in this group)
6 months – 2 years – treat if bilateral, or if unilateral and there is severe impact on function
2 years – treat if has the child has a perforated AOM with exudate, symptoms for >4 days, or is systemically unwell
Lower respiratory tract infection:
Consider antibiotics if there are persistent fevers >48 hours and signs of respiratory distress without signs of bilateral wheeze (strong predictor of viral aetiology).
What we’re looking for here is pneumonia, and frankly this one of the hardest diagnoses to make in children until it is severe. Focal chest signs are a terrible predictor of bacterial pneumonia in children (see this excellent review
by JAMA), and are only useful where there is reduced air entry for detecting effusion/empyema.
Children who are hypoxic obviously need admission with oxygen therapy, but recommendations are use a cut off of O2Â of sats <85% in air, or complicated disease to warrant IV antibiotics instead of oral.
Tonsillitis:
Tonsillitis should be treated in those with the highest chance of GAS:
Treat if there is a FeverPAIN score of ≥4* (Fever, Purulent exudate, Attends within 3 days, severe Inflammation, No cough or coryza)
*If you are able to write delayed prescriptions, some guidelines would advocate this for a score of 2–3.
Importantly – this score is only validated in >3 year olds, and younger children (<5 years) are far less likely to have bacterial infectionsÂ
Tonsillitis/pharyngitis is the exception to the severity based prescribing paradigm. There is a reason for particularly wanting to treat group A Strep (GAS) tonsillitis in children, which is preventing spread to those susceptible to invasive infections (mainly the elderly). Therefore, we use a rule which aimed at identifying those with the highest chance of having GAS. Also, please note that about half the children whose throat swab is positive for GAS are just carriers, so this alone is not an indication to treat.
Important caveats
As always, it should be noted that there are groups for whom these rules don’t apply, and lower threshold for prescribing antibiotics should be adopted.
This is true for indigenous populations in countries such as Australia and New Zealand, who are at higher risk of long-term hearing loss due to chronic/recurrent otitis media, and importantly are very high risk for developing rheumatic fever following group A strep infections. They should almost always be prescribed antibiotics for tonsillitis and AOM. This is no longer the case in the UK. For reasons which are unclear, current GAS circulating strains are non-rheumatogenic, and antibiotic treatment is no longer necessary for prevention of rheumatic fever in the UK.
That said, currently circulating GAS strains may be responsible for increased rates of invasive GAS disease, especially in infants and the frail and elderly exposed to children with scarlet fever.
Other groups with lower threshold for antibiotics include those with immunodeficiencies, long term chronic health problems increasing susceptibility to bacterial chest infections such as chronic lung disease and neurodisability, and patients who have previously suffered complications from RTIs.
The bottom line
The default position for treating RTIs in children should be NO antibiotics
The decision to give antibiotics should be based on severity, not perceived likelihood of bacterial aetiology
There are special groups for whom lower thresholds for antibiotics are appropriate, and many of these patients would benefit from review by senior decision makers
Reassurance, high quality information, and safety netting are the mainstay of treatment
Hi Ben, thanks so much for your comment. You are right to identify there is little individual patient benefit from treating based on FeverPAIN score (although one should note, the inclusion of a criteria for presentation within 3 days is actually to identify those most likely to benefit symptomatically – but I digress…).
The decision to treat in this scenario depends on your philosophical stance on the desired outcome of treatment. The individual stands little to gain. Giving antibiotics is in order to prevent spread of GAS to populations who are most vulnerable to invasive disease (primarily the elderly). This is a theoretical benefit, as to my knowledge there is no specific evidence that treating sore throats reduces invasive GAS in the elderly, however we do know we have seen a resurgence in the past few years of more invasive phenotypes of GAS in the UK.
Many people would agree with your stance of withholding treatment for those who are not in the high risk categories, as you state. It all depends on your philosophy!
Thanks,
Ally
Thanks so much for a wonderful post and a great summary of a lot of evidence regarding common infections in children.
Can I clarify your thoughts on treating GAS Tonsillitis in kids? My understanding from this article is that you recommend to treat if FeverPain score is > or = to 4, but I’m not sure what the patient benefit is.
The advice from our Australian therapeutic guidelines is :
‘Streptococcal pharyngitis and tonsillitis are usually self-limiting. Antibiotics shorten the duration of symptoms by less than 1 day, but at day 7 there is no difference in improvement between patients treated with and without antibiotics. This small benefit of antibiotic therapy must be balanced against the potential harms (eg diarrhoea, rash or more serious hypersensitivity reactions, bacterial resistance). Empirical antibiotic therapy is recommended for the following high-risk patient groups to prevent nonsuppurative complications of Streptococcus pyogenes infection (eg acute rheumatic fever, poststreptococcal glomerulonephritis ):
patients aged 2 to 25 years from populations with a high incidence of acute rheumatic fever (eg Aboriginal and Torres Strait Islander Australians living in rural or remote settings, Maori and Pacific Islander people)Â [Note 1]
patients of any age with existing rheumatic heart disease
patients with scarlet fever”
The link in this article to dftb’s tonsillitis article acknowledges the NNT to prevent any strep related complication is so astronomically high that unless you’re in one of these at risk populations, why treat?
I have changed my practice to essentially treat all my indigenous patients when they have an OM or Tonsillitis, but to almost never treat my caucasian patients in a metropolitan area.
Curious what your thoughts are?