What is the treatment approach for pediatric upper respiratory infections (URIs)?

Treatment of Pediatric Upper Respiratory Infections

Most pediatric URIs are viral and require only supportive care; antibiotics should be reserved exclusively for strictly defined bacterial infections (acute otitis media, acute bacterial sinusitis, and Group A streptococcal pharyngitis) confirmed by specific diagnostic criteria. 1, 2

Initial Assessment: Distinguishing Viral from Bacterial Infection

The critical first step is determining the likelihood of bacterial infection, as this fundamentally changes management 3, 1:

Viral URIs (Most Common)

• Supportive care only - no antibiotics indicated 1, 2
• Provide adequate hydration and fever management with appropriate antipyretics 1, 2
• Educate families on managing fever, preventing dehydration, and recognizing deterioration 1
• Avoid chest physiotherapy - it provides no benefit 1
• Review patient if deteriorating or not improving after 48 hours 1, 2

When to Consider Bacterial Infection

Apply stringent diagnostic criteria for three specific conditions that may warrant antibiotics 3, 1, 2:

Acute Otitis Media (AOM)

Diagnostic Criteria

Requires both middle ear effusion AND signs of inflammation 3, 1, 2:

• Moderate or severe bulging of tympanic membrane, OR
• Otorrhea not due to otitis externa, OR
• Mild bulging with ear pain or erythema of tympanic membrane 3, 1

Treatment Approach

• First-line: Amoxicillin 90 mg/kg/day 1, 2, 4
• Consider high-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) if antibiotics received in previous 4-6 weeks or moderate disease 1, 2
• Observation strategy ("wait and see") is appropriate for uncomplicated cases in children >2 years when adequate follow-up is ensured 1, 5
• Shorter courses (7 days vs. 10 days) may be appropriate for older children 1
• Number needed to treat is as few as 4 patients for symptom improvement 3

Acute Bacterial Sinusitis

Diagnostic Criteria

URI symptoms that are worsening, severe, OR persistent 3, 1, 2:

• Worsening: new or worsening fever, daytime cough, or nasal discharge after initial improvement 3
• Severe: fever ≥39°C with purulent nasal discharge for at least 3 consecutive days 3
• Persistent: nasal discharge or daytime cough >10 days without improvement 3, 1
• No routine imaging indicated 3, 1

Treatment Approach

• First-line: Amoxicillin with or without clavulanate 3, 1, 2
• Consider observation for patients with persistent symptoms only 1, 2
• Antibiotics improve symptoms at 3 and 14 days when bacterial infection is strictly defined 3

Group A Streptococcal Pharyngitis

Diagnostic Criteria

• Only test if ≥2 of the following present 3, 1, 2:
  • Fever
  • Tonsillar exudate/swelling
  • Swollen/tender anterior cervical nodes
  • Absence of cough
• Do NOT treat empirically - confirmation by rapid antigen detection test or throat culture required 3, 1, 2

Treatment Approach

• First-line: Amoxicillin or penicillin 3, 1, 2, 4
• Once-daily dosing of amoxicillin can be used 1
• Benefits include shortened symptom duration, prevention of rheumatic fever, and limiting secondary transmission 3
• Macrolides reserved for suspected Mycoplasma or Chlamydia pneumonia 1

Critical Cautions and Pitfalls

Antibiotic-Associated Harms

• Adverse events range from mild (diarrhea, rash) to life-threatening (anaphylaxis, Stevens-Johnson syndrome) 1
• Amoxicillin-clavulanate has higher rates of adverse events, particularly diarrhea, compared to amoxicillin alone 1
• Early-life antibiotic exposure may contribute to inflammatory bowel disease, obesity, eczema, and asthma 1
• No benefits when bacterial infection is not likely - only increased risk of harm 3

Common Prescribing Errors to Avoid

• Azithromycin is NOT first-line for any pediatric URI and may have inadequate coverage for common pathogens 1
• Antibiotics do NOT prevent complications like mastoiditis (AOM) or brain abscess (sinusitis) 3
• Inappropriate use drives antibiotic resistance at individual and community levels 1

Special Populations

• Amoxicillin should be taken at the start of a meal to minimize gastrointestinal intolerance 4
• Dosing modifications required for pediatric patients ≤12 weeks (3 months) due to incompletely developed renal function 4
• Monitor for drug interactions with oral anticoagulants (increased INR) and reduced efficacy of oral contraceptives 4