What is the first-line treatment for pediatric patients with bacterial upper respiratory infections (URI)?

From the Guidelines

The first-line treatment for pediatric patients with bacterial upper respiratory infections (URI) is amoxicillin, typically dosed at 90 mg/kg/day in 2 doses. This recommendation is based on the most recent and highest quality study available, which prioritizes morbidity, mortality, and quality of life as the outcome 1.

Key Considerations

• The dosage of amoxicillin may vary depending on the specific infection and local susceptibility data, but 90 mg/kg/day in 2 doses is the recommended starting point.
• For children with penicillin allergy, alternatives include azithromycin (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2–5) or other oral cephalosporins such as cefpodoxime, cefprozil, or cefuroxime, provided under medical supervision 1.
• It's essential to note that most URIs are viral in nature and do not require antibiotics, and bacterial URIs should be diagnosed based on specific criteria such as persistent symptoms beyond 10-14 days, severe symptoms, or worsening symptoms after initial improvement.
• Supportive care is crucial regardless of etiology and includes adequate hydration, rest, and appropriate pain management with acetaminophen or ibuprofen for fever and discomfort.
• Antibiotics should be used judiciously to prevent antimicrobial resistance, and treatment should be completed for the full prescribed duration even if symptoms improve earlier to ensure complete eradication of the bacterial infection.

Additional Guidance

• For children who are vomiting, cannot take oral medications, or are not likely to take the initial antibiotic doses as prescribed, intravenous or intramuscular ceftriaxone (50 mg per kg once) can be given, and after clinical improvement, the treatment can be changed to oral therapy 1.
• Children with hypersensitivity to amoxicillin can be treated with alternative antibiotics, and the choice of antibiotic should be individualized based on the specific clinical scenario and local resistance patterns.

From the FDA Drug Label

Amoxicillin for oral suspension is indicated in the treatment of infections due to susceptible (ONLY β-lactamase–negative) isolates of Streptococcusspecies. (α-and β-hemolytic isolates only), Streptococcus pneumoniae, Staphylococcusspp., or Haemophilus influenzae. Upper Respiratory Tract Infections of the Ear, Nose, and Throat: The first-line treatment for pediatric patients with bacterial upper respiratory infections (URI) is amoxicillin 2.

• The medication is effective against susceptible strains of Streptococcus species, Streptococcus pneumoniae, Staphylococcus species, and Haemophilus influenzae.
• It is essential to note that amoxicillin should only be used to treat infections that are proven or strongly suspected to be caused by bacteria.
• Treatment should be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic, or evidence of bacterial eradication has been obtained.

Alternatively, azithromycin 3 can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy, such as in the case of pharyngitis/tonsillitis caused by Streptococcus pyogenes.

From the Research

First-Line Treatment for Pediatric Patients with Bacterial Upper Respiratory Infections (URI)

• The first-line treatment for pediatric patients with bacterial upper respiratory infections (URI) is typically an antibiotic, with the specific choice depending on the suspected causative pathogen and local resistance patterns 4.
• For uncomplicated acute bacterial rhinosinusitis, amoxicillin is often used as first-line therapy, with dosages of 45 mg/kg/d being common 4, 5.
• In cases where the patient is allergic to amoxicillin, second- or third-generation oral cephalosporins may be used as first-line therapy, with clarithromycin or clindamycin being alternative options 4.
• High-dose amoxicillin-clavulanate (90 mg/kg/d of the amoxicillin component) may be recommended for high-risk children, such as those in day care or who have recently received antibiotics 4, 5.

Antibiotic Options for Pediatric URI

• Amoxicillin is a commonly used antibiotic for pediatric URI, with a wide range of activity against common pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 4, 6.
• Cephalexin is another antibiotic that has been used to treat upper respiratory tract infections in children, although its effectiveness against Haemophilus influenzae is limited 7.
• Other antibiotics, such as cefdinir, cefpodoxime proxetil, and cefuroxime axetil, may also be used to treat pediatric URI, depending on the specific circumstances and local resistance patterns 4.

Duration of Antibiotic Treatment

• The optimal duration of antibiotic treatment for pediatric URI is not always clear, with different studies suggesting different lengths of treatment 6, 8.
• A systematic review and meta-analysis found that a 5-day course of amoxicillin was as effective as a 10-day course for uncomplicated community-acquired pneumonia in children 8.
• However, other studies have suggested that longer courses of antibiotics may be necessary in certain cases, such as in high-risk children or those with more severe infections 4, 5.