When to Use Antibiotics in Pediatric Patients with Colds, Cough, and Fever
Antibiotics should NOT be prescribed for children with common colds, nonspecific upper respiratory infections, or acute bronchitis, as these are viral conditions that do not benefit from antibiotic therapy. 1
Primary Principle: Most Cases Do Not Require Antibiotics
- The vast majority of colds, coughs, and fever in children are viral and resolve without antibiotics. 1
- Children with mild coughs and fevers should be managed at home with antipyretics (avoiding aspirin) and fluids, without antibiotics. 1
- Antibiotics are prescribed inappropriately 44% of the time for common colds and 75% for bronchitis in pediatric practice, despite lack of benefit. 2
Specific Conditions That MAY Require Antibiotics
Acute Otitis Media (AOM)
- Antibiotics are indicated when AOM is diagnosed based on established clinical criteria (presence of middle ear effusion with signs of acute inflammation). 1
- Observation without immediate antibiotics can be considered for children older than 2 years with nonsevere symptoms and unilateral disease. 1
Acute Bacterial Sinusitis
- Antibiotics should be prescribed only when specific clinical criteria are met: 1
- Persistent symptoms (nasal discharge or daytime cough) not improving by 10 days, OR
- Worsening symptoms (new/worsening fever, cough, or nasal discharge after initial improvement), OR
- Severe symptoms (persistent fever ≥39°C and purulent nasal discharge for at least 3 consecutive days). 1
Group A Streptococcal Pharyngitis
- Antibiotics should be prescribed ONLY after positive rapid antigen testing or throat culture - never based on clinical criteria alone. 1
- Do not diagnose or treat for streptococcal pharyngitis in children younger than 3 years, as it rarely occurs in this age group. 1
Community-Acquired Pneumonia
- Antibiotics are indicated when pneumonia is diagnosed clinically or radiographically. 3
- For children under 5 years: oral amoxicillin 90 mg/kg/day divided into 2-3 doses is first-line treatment. 3
- For children 5 years and older: macrolide antibiotics (erythromycin, clarithromycin, or azithromycin) are first-line due to higher prevalence of Mycoplasma pneumoniae. 3
High-Risk Situations Requiring Antibiotics
Children with fever >38.5°C, cough, AND any of the following features should receive antibiotics: 1
- Chronic comorbid disease (asthma, heart disease, immunocompromise)
- Breathing difficulties or respiratory distress
- Severe earache
- Vomiting >24 hours
- Drowsiness or altered consciousness
Children under 1 year of age with high fever and cough should be evaluated by a physician with a low threshold for antibiotic treatment if they worsen. 1
Red Flags Requiring Hospital Admission and Parenteral Antibiotics
Immediate hospitalization and IV antibiotics are indicated for: 1
- Signs of respiratory distress (markedly raised respiratory rate, grunting, intercostal recession)
- Cyanosis
- Oxygen saturation <92%
- Severe dehydration
- Altered conscious level
- Signs of septicemia (extreme pallor, hypotension, floppy infant)
Common Pitfalls to Avoid
- Do not prescribe antibiotics for mucopurulent rhinitis alone - this is a normal part of viral URI progression and does not indicate bacterial infection, even when lasting up to 2 weeks. 4
- Do not perform imaging for suspected sinusitis - many children with viral URI will have radiographic abnormalities that do not indicate bacterial infection. 1
- Do not test for streptococcal pharyngitis in children with cough and congestion - these symptoms suggest viral infection, not strep throat. 1
- Avoid prescribing antibiotics "just in case" - this contributes to antibiotic resistance and exposes children to unnecessary adverse effects including diarrhea, rash, and C. difficile infection. 1