Guidelines of Prescribing Antibiotics

Antibiotics are commonly prescribed unnecessarily for colds, the flu, coughs and bronchitis, and viral sore throats, etc.

Boy taking a spoonful of medicine
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Overuse Is a Big Problem

This overuse of antibiotics can lead to unwanted side effects, including diarrhea and allergic reactions. Perhaps even more importantly, the overuse of antibiotics is leading to more bacteria gaining the ability to resist antibiotics. These antibiotic-resistant bacteria are more difficult to treat, often require stronger antibiotics, and can cause life-threatening infections.

You can help prevent the problem of antibiotic-resistant bacteria by making sure your child only takes an antibiotic when he needs it and then takes it as prescribed. Understanding the latest antibiotic treatment guidelines for ear infections and sinus infections, which include options to observe your child without antibiotics, might also help decrease the overuse of antibiotics.

Antibiotics for Ear Infections

Ear infections are the most common condition for which antibiotics are prescribed in children.

Guidelines that were released in 2004 have helped to decrease some of those prescriptions, as they recommended an "observation option" for some children with ear infections. These children who could safely be observed for two to three days without treatment with an antibiotic included those who were at least 2-years-old and had mild symptoms.

In an updated guideline from the AAP, this "observation option" has now been extended to infants as young as 6-months-old. Keep in mind that observation without antibiotics is still only a good option for those children with:

  • Ear infection in just one ear (unilateral) or children who are at least 2-years-old with mild symptoms and an ear infection in both ears (bilateral)
  • an ear infection without ear drainage (otorrhea)
  • Mild symptoms, including those who have only mild ear pain, a temperature less than 102.2 degrees F (39 degrees C)
  • The availability of a follow-up treatment plan if a child's symptoms worsen or don't get better in 2 to 3 days
  • Parents who agree to a plan to observe without antibiotic treatment

For children with an ear infection who aren't a good candidate for observation, especially those with severe symptoms, then a prescription for antibiotics is still recommended.

Which Antibiotics?

If your child hasn't been on antibiotics in the past 30 days and he isn't allergic, then he will likely be prescribed high-dose amoxicillin. Other options include high-dose amoxicillin-clavulanate (Augmentin XR), cefdinir (Omnicef), cefpodoxime (Vantin), cefuroxime (Ceftin), or one to three days of ceftriaxone (Rocephin) shots.

The latest guidelines also added newer alternative treatment plans for when first-line treatments have failed, including ceftriaxone shots and 3 days of clindamycin either with or without a third-generation cephalosporin antibiotic (cefdinir, cefuroxime, cefpodoxime, etc.). A combination of clindamycin and a third-generation cephalosporin antibiotic is also a good option for these children.

Antibiotics for Sinus Infections

While antibiotics have long been recommended for the treatment of sinusitis in children, they are also often misused when children have uncomplicated viral upper respiratory tract infections. Treatment guidelines that came out in 2001 worked to help minimize this overuse of antibiotics by providing clinical criteria for diagnosing sinusitis. After all, to properly treat an infection, you have to first diagnose it properly. If your child has a runny nose that is caused by the common cold, then he doesn't have a sinus infection and doesn't need an antibiotic prescription.

That guideline was recently updated, and like the ear infection guidelines now includes an observation option for select children. It still starts with a recommendation that sinusitis be diagnosed properly though, including that to be diagnosed with acute sinusitis, a child either have persistent symptoms (a runny nose and/or daytime cough for more than 10 days without improvement), worsening symptoms after they had started to get better, or severe symptoms for at least 3 days.

For those children with persistent symptoms, instead of just prescribing antibiotics right away, another option can be watching the child for 3 more days without antibiotics to see if he gets better. If he doesn't get better, gets worse, and for those children who are initially diagnosed with sinusitis and severe symptoms or who are already getting worse, then a prescription for antibiotics is still recommended.

Recommended antibiotics for sinus infections in the latest AAP guidelines include:

  • High-dose augmentin (recent antibiotic use)
  • High-dose amoxicillin (first-line treatment)
  • Standard dose amoxicillin (children over age 2-years who aren't in daycare)
  • 1-3 daily ceftriaxone shots (won't take or tolerate oral the initial dose of antibiotics) to be followed by a 10-day course of one of these oral antibiotics once they are getting better

Like ear infections, children with sinusitis can also be treated with cefdinir, cefuroxime, or cefpodoxime. And if there is no improvement after 3 days (72 hours), your child's antibiotic might need to be changed to one of the others, especially if he started out on amoxicillin.

Antibiotics for Sore Throats

This is an easy one. Kids very rarely need antibiotics when they have a sore throat unless they have a group A streptococcal (strep) infection. Because sore throats (pharyngitis) are most commonly caused by viral infections, a strep test should be done to confirm the diagnosis before antibiotics are prescribed.

If a child does have strep throat, then antibiotic treatment might include:

  • Penicillin V
  • Standard dose amoxicillin
  • Benzathine penicillin G (a penicillin shot)

Children with a penicillin allergy can be treated with a first-generation cephalosporin, such as cephalexin (Keflex) or cefadroxil (Duricef), clindamycin, azithromycin (Zithromax), or clarithromycin (Biaxin). They can also use a third-generation cephalosporin, such as Cefdinir.

Antibiotics for Bronchitis

It will come as a surprise to many parents that the AAP Red Book states that a "nonspecific cough illness/bronchitis in children, regardless of duration, does not warrant antimicrobial treatment."

Keep in mind that acute bronchitis can cause a cough, which may be productive, and it can last for up to three weeks. And again, the use of antibiotics is not recommended to treat acute bronchitis.

Your child may still be prescribed an antibiotic if he has a prolonged cough that is lasting for 10 to 14 days or more and your healthcare provider suspects that it is caused by one of these bacteria:

  • Bordetella parapertussis
  • Mycoplasma pneumoniae
  • Chlamydophila pneumoniae

Most importantly, since antibiotics are commonly overused to treat bronchitis, ask if your child really needs an antibiotic when he has a cough.

Antibiotics for Skin Infections

While rashes and other skin conditions are common in children, fortunately, most don't require treatment with antibiotics. Some do, though, and with the rise in resistant bacteria, it is important that your child with a skin infection is prescribed the right antibiotic.

Skin and soft tissue infections can include:

  • Cellulitis Without Purulent (Pus) Drainages: little worry for MRSA, so a regular anti-staph and/or anti-strep antibiotic can be used, such as cephalexin or cefadroxil.
  • Cellulitis With Purulent (Pus) Drainage: antibiotics that treat MRSA, including clindamycin, TMP-SMX (Bactrim), tetracycline (children who are at least 8-years-old), or linezolid.
  • Abscess: antibiotics that treat MRSA, including clindamycin, trimethoprim-sulfamethoxazole (Bactrim), tetracycline (children who are at least 8-years-old), or linezolid.
  • Impetigo: mupirocin 2% topical ointment or an oral antibiotic for extensive cases (cephalexin or cefadroxil).

A simple abscess might be treated without antibiotics if it can be drained, is not getting worse, and the child has mild symptoms. A more serious abscess might require hospitalization, surgical drainage, and IV antibiotics.

Bactrim, which is commonly used to treat MRSA, does not treat the beta-hemolytic streptococci bacteria, which can also cause some skin infections. That makes it important that your healthcare provider not prescribe Bactrim if she doesn't suspect that your child has MRSA.

Antibiotics for Diarrhea

Parents don't usually expect an antibiotic prescription when their kids have diarrhea. In addition to the fact that diarrhea is often caused by viral infections, parasites, and food poisoning, etc., even when it is caused by bacteria, you don't necessarily need antibiotics.

In fact, in some situations, antibiotics can make your child with diarrhea worse.

  • Salmonellosis: Diarrhea caused by the Salmonella bacteria commonly goes away on its own. Antibiotics may make your child be contagious for a longer period of time.
  • Shigellosis: Diarrhea caused by the Shigella bacteria may go away on its own, but severe cases may require treatment with antibiotics. Recommended antibiotics for Shigella infections include azithromycin and ceftriaxone if resistance to more routine antibiotics, such as amoxicillin and trimethoprim-sulfamethoxazole is suspected.
  • E. Coli Infections: Diarrhea caused by E. coli typically goes away on its own. If treated with antibiotics, some, like Shiga toxin-producing E. coli (STEC), can put your child at risk for HUS (Hemolytic Uremic Syndrome - a potentially life-threatening condition that includes anemia and kidney failure).
  • Campylobacteriosis: Diarrhea caused by the Campylobacter bacteria only requires treatment with azithromycin if a child has severe symptoms.
  • Clostridioides difficile: People who take antibiotics are at risk for a C. diff infection, which causes diarrhea, and typically needs to be treated with an antibiotic like metronidazole.

Since antibiotics usually aren't needed for most infections that cause diarrhea, and can, in fact, cause diarrhea themselves, as with other infections, be sure to ask your healthcare provider if your child really needs them. Antibiotics aren't always the answer when your child is sick or when you visit the healthcare provider.

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By Vincent Iannelli, MD
 Vincent Iannelli, MD, is a board-certified pediatrician and fellow of the American Academy of Pediatrics. Dr. Iannelli has cared for children for more than 20 years.