What is the recommended treatment for pediatric patients with upper respiratory infections (URI)?

Treatment of Upper Respiratory Infections in Pediatric Patients

Most upper respiratory tract infections (URIs) in children are viral in origin and require only supportive care, with antibiotics indicated only for specific bacterial infections diagnosed using stringent clinical criteria. 1, 2

Diagnostic Approach

• Apply stringent diagnostic criteria to identify specific bacterial URIs that may benefit from antibiotic therapy 1, 2
• For Acute Otitis Media (AOM): Diagnosis requires middle ear effusion AND signs of inflammation (moderate/severe bulging of tympanic membrane, or mild bulging with ear pain or erythema) 2
• For Acute Bacterial Sinusitis: Diagnosis based on URI symptoms that are worsening, severe, or persistent (>10 days) 2, 3
• For Group A Streptococcal (GAS) Pharyngitis: Only test if at least 2 of the following are present: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, or absence of cough 2

Management of Viral URIs

• Supportive care is the mainstay of treatment for viral URIs 1, 2, 4
• Provide adequate hydration and fever management with appropriate antipyretics 2
• Families of children cared for at home need information on managing fever, preventing dehydration, and identifying any deterioration 1
• Saline nasal drops may help relieve congestion 4
• Antihistamines appear to relieve only symptoms potentiated by allergy 4
• Chest physiotherapy is not beneficial and should not be performed 1

Antibiotic Management for Bacterial URIs

Acute Otitis Media (AOM)

• First-line treatment: Amoxicillin (90 mg/kg/day) 2, 5
• Consider high-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) for children who received antibiotics in previous 4-6 weeks or have moderate disease 2, 3
• Consider observation strategy ("wait and see") for selected uncomplicated cases in children older than 2 years when adequate follow-up can be ensured 2, 3
• Switch to ceftriaxone if amoxicillin regimen fails within 48-72 hours 3

Acute Bacterial Sinusitis

• First-line treatment: Amoxicillin or amoxicillin-clavulanate 2, 3
• Consider observation for patients with persistent symptoms only 2
• For treatment failure, consider amoxicillin-clavulanate, cefpodoxime proxetil, or ceftriaxone 3

Group A Streptococcal Pharyngitis

• Only treat after confirmation by rapid antigen detection test or throat culture 2, 3
• First-line treatment: Amoxicillin or penicillin 2, 3
• Macrolide antibiotics should be used if either mycoplasma or chlamydia pneumonia is suspected 1

Duration of Therapy and Follow-up

• Shorter courses of therapy (e.g., 7 days vs. 10 days) may be appropriate for older children with AOM 2
• Once-daily dosing of amoxicillin can be used for GAS pharyngitis 2
• Children treated at home should be reviewed if deteriorating or not improving after 48 hours on treatment 1, 2
• If a child remains febrile or unwell 48 hours after admission with pneumonia, re-evaluation is necessary with consideration given to possible complications 1

Cautions and Considerations

• Antibiotic-associated adverse events range from mild (diarrhea, rash) to severe (Stevens-Johnson syndrome) to life-threatening (anaphylaxis) 1
• Amoxicillin-clavulanate has higher rates of adverse events (particularly diarrhea) compared to amoxicillin alone 1
• Antibiotic exposure early in life may disrupt microbial balance, potentially contributing to long-term adverse health effects like inflammatory bowel disease, obesity, eczema, and asthma 1
• Azithromycin is not a first-line antibiotic for any pediatric URI and may have inadequate coverage for common pathogens causing AOM and sinusitis 1
• Inappropriate antibiotic use contributes to antibiotic resistance at both individual and community levels 1