The document discusses guidelines for antibiotic use in pediatric respiratory illnesses such as sinusitis, otitis media, and tonsillitis. It provides diagnostic criteria and treatment recommendations for these conditions, emphasizing watchful waiting and judicious antibiotic use. Key points include only prescribing antibiotics for certain cases of acute otitis media and sinusitis based on severity, using penicillin as first line treatment for strep throat, and not using imaging to diagnose acute bacterial sinusitis. The goal is to reduce unnecessary antibiotic use and prevent antibiotic resistance.

1. +
NICE Guidelines- Sinusitis et
Otitis Media:
When are antibiotics indicated?
Dr.sc.Gazmend BOJAJ, MD,
Ph.D, FCIML
Family Medicine Specialist
Ass. Clinical Professor
Heimerer University Pristina,
Kosovo

2. +
Antibiotic Resistance is Rising:
Regional Trends

3. +
Antibiotic Prescribing Rates

4. +
Think Before Ordering Antibiotics
Indiana’s antibiotic statistics are concerning
 Some of the highest resistance to antibiotics in the
nation
 In the category of the 2nd highest Antibiotic Prescribing
rates in the community (cdc.gov 2014)
Are you, as a prescriber, aware of the local
resistance patterns in Northwest Indiana?
 Local antibiogram
 How should it affect your prescribing for pediatric
respiratory infections?

5. +
Local Antibiogram

6. +
Guideline Based Care for Pediatric
Respiratory Illnesses
No antibiotics for
 Asthma/allergy
 Bronchitis
 Bronchiolitis
 Influenza
 URI/nasopharyngitis
Judicious use of
antibiotics for
 Acute Otitis Media
 Sinusitis
 GABS Pharyngitis
Upper Respiratory Pathogens
• Streptococcus pneumoniae
• Nontypeable Haemophilus influenzae
• Moraxella catarrhalis

7. + Acute Otitis Media (AOM)
Description
 Acute infection of the
middle ear
 Requires 3 components
1. Recent abrupt onset of
signs & symptoms
2. MEE confirmed with
pneumatic otoscopy
3. Middle ear inflammation
visualized or otalgia that
is interfering with
activities, including sleep
History
 Sudden, occurring with
other signs of illness
 High fever to 104 F
 Complaints of feeling
ill
 Pain in the ear (pulling
at ear)
 Sudden hearing loss in
the verbal child
 Vomiting/diarrhea
 Otorrhea

8. • Negative pressure draws fluid into the middle ear from
ET when child cries/sucks
• Pain results from the fluid pressure and can result in
effusion (glue ear)
• If effusion persists, conductive hearing loss can occur
Often occurs in conjunction with eustachian tube dysfunction

9. + Acute Otitis Media (AOM)
Physical exam
 Bulging membrane
 Does not move with insufflation
 If drainage is present, tympanic
membrane (TM) has been perforated
 Obscured or absent landmarks
 Red, yellow or purple color
Diagnostics
 Pneumatic otoscopy by NP
 Otoscopy usually not done til 4+ months
 Tympanocentesis in infants less than 2
months to identify the organism
 Should be done by otolaryngologist

10. + Acute Otitis Media (AOM)
Differential Diagnoses
 OME, mastoiditis, dental abscess, sinusitis, ET
dysfunction, TMJ dysfunction, peritonsillar abscess
 NOTE: infants less than 2 month should be worked up for
Fever Without Focus and not just treated for AOM
Management depends on age and severity
 Pain management for all
 Acetaminophen or ibuprofen (over 6 months)
 External use of heat or cold
 Observation if it is an option to reduce overuse of
antibiotics
 May be viral, especially with URI symptoms

11. + Watchful Waiting for AOM
Age Certain diagnosis Uncertain diagnosis
< 6mos Antibacterial therapy Antibacterial therapy
6mos to 2
years
Antibacterial therapy Antibacterial therapy if severe
Watchful waiting if non-severe
> 2 years Antibacterial therapy if severe
Watchful waiting if non-severe
Watchful waiting
• Watchful waiting for 48-72 hours with analgesia and a follow
up plan that includes
• Parent to call if no improvement
• Scheduled follow-up appointment
• Routine follow-up phone call to parent
• Antibiotic script to fill if no improvement
• If no improvement in 48-72 hours, confirm diagnosis and
initiate antibiotics

12. + Acute Otitis Media (AOM)
Use of Antimicrobials
Initial treatment at time of first exam or
after watchful waiting has failed
After no improvement on first antibiotic
Amoxicillin 80-90mg/kg/day, split BID
Alternate for allergy:
Cefdinir 14mg/kg/day, once or split BID
Cefuroxime 30mg/kg/day, split BID
Cefpodoxime 10mg/kg/day, split BID
Ceftriaxone 50mg/kg given IM X 3 days
Amoxicillin-clavulanate, 90mg/kg/day, split
BID
Alternate for allergy:
Ceftriaxone 50mg/kg given IM X 3 days
Clindamycin 30-40mg/kg/day, split TID
If amoxicillin used in the last 30 days,
Amoxicillin-clavulanate, 90mg/kg/day, split
BID
If failure of 2nd antibiotic
Clindamycin 30-40mg/kg/day, split TID
PLUS 3rd generation cephalosporin
Or tympanocentesis
Note there is no mention of Azithromycin: meta-analysis of 10 trials indicated
greater likelihood of clinical failure with macrolide (Courter at al, 2010)

13. + Penicillin Allergy and
Cephalosporins
There is often concern about ordering a
cephalosporin if the patient claims to have an
allergy to Penicillin
Terico and Gallagher (2014)
 Reviewed literature from 1950 to 2013
 Cross reactivity was less than 5%
Campagna et al (2012)
 Review
 Overall cross reactivity rate was about 1%

14. +
Allergies and Antibiotics
 True Allergy, Type 1, IgE-mediated, to Penicillin products
is over-reported
 About 10% of patients report an allergy
 Only about 1% will have a true allergy
 These may lose sensitivity after 10 years
 It is recommended that allergies be confirmed by an
allergist
 This can decrease the use of broad spectrum antibiotics
 Only 1-5% of children with a true Penicillin allergy will
also be allergic to cephalosporins
 www.cdc.gov/getsmart

15. + Acute Otitis Media (AOM)
 Treatment duration is age dependent
 < 2 years: 10 days
 2-5 years: 7 days
 > or = 6 years: 5-7 days
 Follow up exam 3-4 weeks after
 Refer to otolaryngology if antimicrobial failure occurs
Persistent AOM occurs when infection is still
present after full course of antibiotics
 Retreat with broader spectrum antibiotic
 Recurrent AOM is defined as
more than 3 bouts of AOM in
6 mos or 4 in 12 mos
 May have PETs placed

16. + Acute Otitis Media (AOM)
Prevention of AOM
 Prevnar 13 immunization (pneumococcal AOM)
 Attend day care with smaller enrollment
 Annual Flu vaccine if >6 month old (2 shot series for first )
 Xylitol chewing gum, 5-6 sticks per day
 Bacteriostatic effects against S. pneumoniae
 Exclusive Breastfeeding for the first 6 months (Ig’s)
 Avoid feeding the infant while lying down
 Avoid passive smoke

17. + Otitis Media with Effusion
Description
 Evidence of fluid without signs of acute infection
 Decreased mobility of TM which interferes
with sound conduction
 Common after AOM (clears in 3 months)
History
 If verbal, reports
 Popping in the ear/talking in a barrel
 Hearing loss
 Dizziness or poor balance
 If preverbal
 Poor language development

18. + Otitis Media with Effusion
Physical exam
 Asymptomatic and afebrile
 Exam is normal except for decreased TM mobility
 Dull opaque TM with no visible landmarks
 Retracted TM with landmarks
 TM with bulging , air bubbles
Management
 Watchful waiting for low risk since most resolve
spontaneously
 Monitor verbal skills and any learning difficulties
 Those at risk should be referred for further evaluation of
hearing, speech and language
 If skills are negatively effected, refer to otolaryngology

19. + Three organisms cause inflamed tonsils requiring
antibiotics
 GABHS
 Neisseria gonorrhoeae
 Corynebacterium diphtheriae
What helps
distinguish
between the
three?

20. + Acute Pharyngitis/Tonsillitis
VIRAL
 Most common: Adenovirus
 Classic features
 Hoarseness, mild cough
 CORYZA
 Conjunctivitis
 Diarrhea
 Rashes
 Gradual onset
 Low grade fever
 Diagnostic tests
 Only to r/o other conditions
 Management: supportive
BACTERIAL
 Most common: GABHS
 Classic features GABHS
 Uncommon under 2 yr
 Abrupt onset
 NO nasal symptoms/NO CORYZA
 Moderate to high fever
 Sore throat/dysphagia
 N/V, headache, abdominal pain
 Petechiae on soft palate
 Enlarged tonsils with exudate
 +cervical lymphs
 Scarlatiniform rash (Sandpaper)

21. + GABHS Tonsillitis
Diagnostic tests
 Rapid strep culture: 90-95% accurate
 Do not culture every child that presents with a sore throat
 They might be a carrier
 When to culture?
 Use the McIsaac criteria to help decide
 Temp > 38 C (100.4F)
 Tender anterior cervical nodes
 Sore throat
 Absence of cough
 Tonsillar swelling
 Age < 15 years and >2 years

22. +
GABHS Tonsillitis
Interpreting rapid strep results
 If result is negative but has + symptoms, plate it
 If positive, treat
 but remember they could be a carrier
 Other possible lab
 Antistreptolysin O titer (ASO)
 Confirms past GABHS infection
 Confirmed diagnosis is important for treatment
 Prevent complications (RF or PSGN)
 Prevent horizontal transmission

23. +
GABHS Tonsillitis
Antibiotics are needed to prevent
 Rheumatic fever
 Spread of infection
 24 hour rule for school
 Suppurative complications

24. +
GABHS Treatment
 Penicillin
 PO: 250mg BID if <27kg or 500mg BID if >27kg
 IM: single dose 600,000units <27kg or 1.2 million >27kg
 Amoxicillin, 50mg/kg/day for 10 days
 Single daily dose
 Maximum 1,000mg
 Cephalexin (Keflex) 40-50mg/kg/day, split BID
 Maximum 500mg BID
 Cefadroxil (Duricef) 30mg/kg/day
 Maximum 1 gram

25. +
If Penicillin Allergic
 Cephalexin (Keflex) 40-50mg/kg/day, split BID
 Maximum 500mg BID
 If immediate Type 1 hypersensitivity
 Clindamycin 20mg/kg/day, split TID
 Maximum 600mg/dose (1.8gm/day)
 Consider a macrolide, but may be up to 20%
resistance (Redbook, 2015)
 Azithromycin 12mg/kg/day for 5 days
 Maximum 500mg

26. + GABHS Tonsillitis
What if the child doesn’t improve on the
antibiotic?
 Treatment failure versus new infection
 Look at the time frame
 Viral infection
 Look at the time frame
 Carrier status
 Culture between episodes to determine if still positive
when asymptomatic
 Eradication needed if transferring to others
 Clindamycin 20-30mg/kg/day, split TID X 10 days
 Maximum 300mg/dose

27. + Acute Purulent Rhinitis
 Often, result of a superinfection from common
cold
 Classic features
 URI with purulent yellow-green discharge for 3 + days
 If viral origin, usually worse in morning
 Diagnostic tests
 To r/o other causes (Foreign Body)
 Management
 Watchful waiting approach if from URI
 Clear nasal passages as needed (saline, bulb,..)
 Return if not cleared in 10-14 days and then consider antibiotic
 Likely cause is sinusitis

28. + Sinusitis
Inflammation and secondary infection of para-
nasal sinuses
 URI symptoms that last > 10 days
 Ethmoidal sinus: present at birth and pneumatized
 Can occur as early as 6 months
 Frontal sinus: develop around 7 years
 Usually occurs around age 10 yearss
Category of Sinusitis Timeframe of respiratory symptoms
Acute sinusitis More than 10 days but less than 30 days
Subacute sinusitis More than 30 days, up to 12 weeks
Recurrent sinusitis Recurrent acute episodes of <4 weeks in duration but
separated by symptom-free intervals of at least 10 days
Chronic sinusitis More than 12 weeks

29. + Acute Sinusitis: diagnosis
 Major Criteria
 Facial congestion and/or
fullness
 Fever
 Purulent rhinorrhea or
post nasal drip
 Facial pain or pressure
 Nasal obstruction
 Hyposmia or anosmia
 Minor Criteria
 Headache
 Halitosis
 Fatigue
 Dental pain
 Cough
 Otalgia and or
aural/fullness
Timeframe of >10 days but <30 days
AND
Two Major or One Major with two Minor

30. + Acute Sinusitis
Diagnostic Tests: New 2013 AAP Guidelines
 Should NOT use imaging to determine acute bacterial
sinusitis from viral sinusitis
 Includes Xray, CT, MRI, and ultrasound
 Inflammation is seen with viral along with bacterial
 Should be a Clinical Diagnosis
 Presumptive Acute Bacterial Sinusitis occurs if any of
the 3 occur:
 Persistent illness
 10-30 days w/o improvement, cough
 Worsening course
 Improvement followed by sudden worsening
 Severe onset
 39C (102.2F), purulent nasal discharge, looks ill

31. + Acute Sinusitis
 Management (AAP 2013 guidelines)
 60-80% resolve without antibiotics in 4 weeks (viral)
 Is the patient high or low risk?
 Antibiotics for bacterial sinusitis
 First line: Amoxicillin
 If > 2yrs, no day care, no antibiotics in past 4 wks: 45 mg/kg/day,
split BID
 If high risk of resistance, use high dose of 80-90mg/kg/day,
split BID
 If < 2yrs, in day care or recent antibiotics: use amoxicillin-
clavulnate 80-90mg/kg/day, split BID
 If penicillin allergic
 Cefdinir(Omnicef), cefuroxime(Ceftin), cefpodoxime (Vantin)
 Consider otolaryngology if persistent or fail treatment

32. +
How Long to Treat for Sinusitis?
10, 14, 21, 28 days?
“Optimal duration has nt received systematic
study” (Wald 2013)
AAP, 2013
 10 days or 7 days after improvement
 Majority improve in 3 days
Infectious Disease Society, 2012
 5 to 7 days

33. + Additional Sinusitis Care
Remember to include
 Saline nasal spray or drops
 Liquifies secretions
 Decreases crusting near the sinus ostia
 Topical decongestants
 Decreases tissue edema and nasal resistance
 Enhances drainage of secretions from sinus ostia
 Corticosteroids
 Helpful in chronic sinusitis or concurrent allergic rhinitis
 No evidence for acute sinusitis

34. + Antibiotic Stewardship in
Outpatient Prescribing
 Know the organism
 Know the resistance in your area
 Display a Commitment in the office
 Track prescribing in the practice
 Educate the patient/parent about the harms of
antibiotic treatment