In the name of God

In the name of God

Judicious Antibiotic Therapy for Upper Respiratory Tract Infections

in Pediatrics

Dr. Hamid RahimiPediatric Infectious Disease Specialist

References

Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics – Pediatrics 2013

Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years – Pediatrics 2013

The Diagnosis and Management of Acute Otitis Media - Pediatrics 2013

Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America - Clinical Infectious Diseases 2012

More than 1 in 5 pediatric ambulatory visits to a physician result in an antibiotic prescription.

As many as 20% of antibiotic prescriptions are directed toward respiratory conditions for which they are unlikely to provide benefit.

Recent evidence shows that broad-spectrum antibiotic prescribing has increased and frequently occurs when either no therapy is necessary or when narrower-spectrum alternatives are appropriate.

Such overuse of antibiotics causes avoidable drug-related adverse events, contributes to antibiotic resistance, and adds unnecessary medical costs.

This is compounded by the fact that few new antibiotics to treat antibiotic-resistant infections are under development.

Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics Principle 1: Determine the likelihood of a bacterial

infection Principle 2: Weigh benefits versus harms of antibiotics Principle 3: Implement judicious prescribing

strategies

Principle 1: Determine the likelihood of a bacterial infection

Many aspects of the clinical history, symptoms, and signs of bacterial URIs overlap with or mirror those of viral infections or noninfectious conditions.

In the specific cases of AOM, acute bacterial sinusitis, and pharyngitis, there are well-established stringent criteria that aid in distinguishing bacterial from nonbacterial causes.

Principle 2: Weigh Benefits Versus Harms of Antibiotics

If a bacterial infection is determined to be likely, the next step is to compare the evidence about the benefits of antibiotic therapy for each condition to the potential for harms.

Relevant outcomes to consider for benefits include Cure rate Symptom reduction Prevention of complications, and secondary cases

Outcomes for harms include Antibiotic-related adverse events (eg, abdominal pain, diarrhea, rash), Clostridium difficile colitis Development of resistance Cost

Principle 3: Implement Judicious Prescribing Strategies

When evidence suggests that antibiotics may provide benefit, several aspects of judicious prescribing should be considered. Selecting an appropriate antibiotic agent that treats the

most likely pathogens Selecting the appropriate dose Treating for the shortest duration required Considering the role of observation and use of delayed

prescribing strategies.

Acute Otitis Media

Acute Otitis Media

The most common infection for which antibacterial agents are prescribed for children in the US

1/3 of office visits to pediatricians

Key Action Statements 1 Diagnosis of AOM

Acute purulent otorrhea is present and otitis externa has been excluded

Moderate to severe bulging of the TMMild bulging of the TM and …

Recent (less than 48 hours) onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal child) or

Intense erythema of the TM

Key Action Statements 1 Diagnosis of AOM

Clinicians should not diagnose AOM in children who do not have MEE (based on pneumatic otoscopy and/or tympanometry).

Normal TM

Moderate Bulging Severe Bulging

Mild bulging with intense erythema of the TM

Signs of middle-ear inflammation

Established acute otitis media

Predictive value of combinations of otoscopic findings in children with acute ear symptoms

Differential diagnosis

Other conditions Redness of tympanic membrane

AOM Crying Upper respiratory infection with congestion and inflammation of the mucosa lining

the entire respiratory tract Trauma and/or cerumen removal

Decreased or absent mobility of tympanic membrane AOM and OME Tympanosclerosis A high negative pressure within the middle ear cavity

Ear pain Otitis externa Ear trauma Throat infections Foreign body Temporomandibular joint syndrome

Management

NNT (Number Need to Treat)

NNT in AOM forAntibiotic therapy vs. control groups

≥2 y/o <2 y/o Overall

10 7 8 Pain, Fever, or both15 20 17 Unilateral AOM9 4 5 Bilateral AOM

3 Otorrhea

Rovers MM, Glasziou P, Appelman CL, et al. Antibiotics for acute otitis media: an individual patient data meta-analysis. Lancet. 2006;368(9545):1429–1435

NNT in AOM forantibiotic therapy vs. control groups

Antibiotics produced a small reduction in the number of children with pain 2 to 7 days after diagnosis.

They also concluded that most cases spontaneously remitted with no complications (NNT = 16).

Antibiotics were most beneficial in children younger than 2 years with bilateral AOM and in children with otorrhea.

Sanders S, Glasziou PP, DelMar C, Rovers M. Antibiotics for acute otitis media in children [review]. Cochrane Database Syst Rev. 2009;(2):1–43

Observation Option OR Wait & See protocol

Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children

In this protocol … Deferring antibacterial treatment of selected

children for 48 -72 hrs & limiting management to symptomatic relief

Key Action Statements 3 Management of AOM - Antibiotic Rx

The clinician should prescribe antibiotic therapy for … AOM (bilateral or unilateral) in children 6 months and older

with severe signs or symptoms (ie, moderate or severe otalgia or otalgia for >48 hours, or Temp ≥ 39°C)

Bilateral AOM in children younger than 24 months without severe signs or symptoms.

AOM in infant ≤6 months old

Key Action Statements 3 Management of AOM – Observation vs. Antibiotic Rx

The clinician should either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision-making with the parent(s)/caregiver for Unilateral AOM in children 6 months to 23 months of age

without severe signs or symptoms. AOM (bilateral or unilateral) in children 24 months or older

without severe signs or symptoms.

Key Action Statements 3 Management of AOM – Observation vs. Antibiotic Rx

When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms.

Observation

Observation is only appropriate when …Follow-up can be ensured and antibiotic therapy

initiated if symptoms persist or worsen

Specific follow-up system i.e. Reliable parent / caregiver Convenient obtaining medications if necessary

Observation

Antibiotics should be prescribed when the patient does not improve with observation for 48 to 72 hours

Adequate follow-up may include …1 - A parent-initiated visit or phone contact if symptoms

worsen or do not improve at 48 -72 hrs2 - A scheduled follow-up appointment in 48 -72 hrs3 - Giving parents an antibiotic prescription that can be filled

if illness does not improve in this time frame. “wait-and-see prescription” (WASP)

Selecting Effective antibiotic

Key Action Statements 4 Selecting Effective antibiotic

Clinicians should prescribe amoxicillin for AOM when a decision to treat with antibiotics has been made.

Clinicians should prescribe an antibiotic with additional β-lactamase coverage for AOM when child Has received amoxicillin in the past 30 days Has concurrent purulent conjunctivitis Has a history of recurrent AOM unresponsive to

amoxicillin.

Macrolides & Cefixime

Macrolides, such as erythromycin and azithromycin, have limited efficacy against both H influenzae and S pneumoniae.

Cefixime has limited efficacy against S pneumoniae

In last AAP recommendation not recommended for treatment of AOM.

Ceftriaxone

Although a single injection of ceftriaxone is approved by the US FDA for the treatment of AOM,

Results of a double tympanocentesis study (before and 3 days after single dose ceftriaxone) suggest that more than 1 ceftriaxone dose may be required to prevent recurrence of the middle ear infection within 5 to 7 days after the initial dose.

Clindamycin ± 3rd Generation Cephalosporin

Clindamycin alone (30–40 mg/kg per day in 3 divided doses) may be used for suspected penicillin-resistant S pneumoniae; however, the drug will likely not be effective for the multidrug-resistant serotypes.

Clindamycin lacks efficacy against H influenzae.

Key Action Statements 4 Selecting Effective antibiotic

Clinicians should reassess the patient if the caregiver reports that the child’s symptoms have worsened or failed to respond to the initial antibiotic treatment within 48 to 72 hours and determine whether a change in therapy is needed.

Duration of therapy

For children younger than 2 y/o and severe disease, a standard 10-day course is recommended

A 7-day course of oral antibiotic appears to be equally effective in children 2 to 5 years of age with mild or moderate AOM.

For children ≥ 6 years of age with mild to moderate disease 5 -7 days is appropriate

Follow-up of the Patient With AOM

There is little scientific evidence for a routine 10- to 14-day reevaluation visit for all children with an episode of AOM.

The physician may choose to reassess some children, such as young children with severe symptoms or recurrent AOM or when specifically requested by the child’s parent.

Antibiotic therapy in Treatment Failure

Microbiology of AOM

Predicted treatment failure rates based on PD breakpoints for expected pathogens in low- or high-

risk AOM

Predicted treatment failure rates based on PD breakpoints for expected pathogens in low- or high-

risk AOM

In daily clinical practice…

Amoxicillin 30 – 45 mg/kg

Amoxicillin - Clavul. 90mg/kgCeftriaxone ×1 – 3 doseClindamycin + Cefixime

AzithromycinClarithromycin

CefiximeCotri-ErythroCefuroxime Amoxicillin -

Clavul.30mg/kg

Amoxicillin 90mg/kg

Co-Amoxiclave + Amoxicillin 156/325 125/250 1/3 2/3

Farmentin BD + Faramox 228/456 200/400 1/2 1/2

For getting a ratio of amoxicillin to clavulanate of 14:1


Month of year ( mehr vs. farvardin)

Previous antibacterial treatment



Previous (First line) antibacterial treatment Failure

Amoxicillin 30mg/kg

Amoxicillin - Clavul. 90mg/kg

AzithromycinCefixime

Cotri-ErythroCefuroxime

AzithromycinClarithromycin

CefiximeCotri-ErythroCefuroxime



Amoxicillin 90mg/kg

Acute Bacterial Sinusitis

Scope of Problem

3rd most common diagnosis for which antibiotics are prescribed

Abnormalities of the paranasal sinuses are common during the course of an uncomplicated cold (up to 87%).

Viral URIs secondary bacterial sinusitis 0.5 -2% in adults & 5% in children

Classification of Bacterial Sinusitis

Acute bacterial sinusitis (ABS) Infection lasting < 30 days, symptoms resolve completely

Subacute bacterial sinusitis Infection lasting between 30-90 days, yet resolves completely

Recurrent Episodes of <30 days duration with intervals of 10 days without symptoms

>3 episodes in a 6-month period, or >4 episodes in one year Each episodes respond briskly to antibiotic therapy

Chronic sinusitis Symptoms lasting >90 days Some guidelines add treatment failure + a positive imaging study

Factors Predisposing to Sinusitis

Mucosal Swelling Mechanical ObstructionSystemic Disorder Choanal atresia

Viral upper respiratory tract infection Deviated septum

Allergic inflammation Nasal polyps

Cystic fibrosis Foreign body

Immune disorders Tumour

Immotile cilia Ethmoid bulla

Local Insult

Facial trauma

Swimming, diving

Drug-induced rhinitis

Gastroesophageal reflux

Causative factors - URTI

Approximately 60-80% of bacterial sinus infections

Day-care centre should be as small and clean as possible

Causative factors - Allergy

Approximately 15% of bacterial sinus infections

80% of children with RS have a family history of allergy, (general population 15% - 20%)

50% of sinusitis is closely associated with asthma

50% of children with chronic sinusitis have some element of allergy

Causative factors - Allergy

Allergy Should be considered in all children with … A history of allergic signs and symptoms

(watery rhinorrhea, pruritus, sneezing, transverse nasal crease, allergic shiners, frequent rashes)

Seasonal patterns of infection Specific allergen reactions

(dust, pet dander, particular foods) Strong family history of allergy or asthma

Causative factors - Airway pollutants

Airway pollutants can have direct irritant effects on the nasal and sinus mucosa.

The most significant irritant in RS is environmental tobacco smoke.

Car exhaust, diesel fumesCold air / Dry air

Viral Upper Respiratory Tract Infections

ABS Symptoms

Persistent rhinorrheaCough particularly is troublesome at nightOccasionally vomitingFever Periorbital swellingMalodorous breath

Physical Findings

In general, the diagnosis of ARS depends on clinical presentation alone, correlated with physical findings … Mucopurulent nasal discharge

Anterior rhinoscopy with an otoscope Highest positive predictive value

Swelling of nasal mucosa Mild erythema Facial pain (unusual in children) Periorbital swelling Malodorous breath

Key Action Statement 1

Clinicians should make a presumptive diagnosis of acute bacterial sinusitis when a child with an acute URI presents with the following: Persistent illness, ie, nasal discharge (of any quality) or

daytime cough or both lasting more than 10 days without improvement;

OR Worsening course, ie, worsening or new onset of nasal

discharge, daytime cough, or fever after initial improvement;OR

Severe onset, ie, concurrent fever (temperature ≥39°C) and purulent nasal discharge for at least 3 consecutive days.

Differential diagnosis

The main consideration is the distinction between viral URI or allergic inflammation and secondary bacterial infection of the paranasal sinuses.

Others Allergic or non-allergic rhinitis with or without

reactive airways disease Nasal foreign body Pertussis

Key Action Statement 2A

Clinicians should not obtain imaging studies (plain films, CT, MRI, or ultrasonography) to distinguish acute bacterial sinusitis from viral URI.

Key Action Statement 2B

Clinicians should obtain a contrast-enhanced CT scan of the paranasal sinuses and/or an MRI with contrast whenever a child is suspected of having orbital or central nervous system complications of acute bacterial sinusitis.

Management

Spontaneous resolution in 30 - 70% of children …Also high rate of spontaneous resolution in adultsMeta-analysis of 9 DBT

The NNT For rhinosinusitis-like complaints was 15 For purulent discharge in the pharynx was 8

Patients who were older, reported symptoms for longer, or reported more severe symptoms also took longer to cure but were no more likely to benefit from antibiotics than other patients.

No clinical signs/symptoms that justify treatment even after 7-10 days of symptoms


Initial Management of Acute Bacterial Sinusitis “Severe onset & worsening course” acute bacterial

sinusitis. The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course (signs, symptoms, or both)


Initial Management of Acute Bacterial Sinusitis “Persistent illness.” The clinician should either

prescribe antibiotic therapy OR offer additional outpatient observation for 3 days to children with persistent illness (nasal discharge of any quality or cough or both for at least 10 days without evidence of improvement).


Initial Management of Acute Bacterial Sinusitis “Persistent illness” outpatient observation

Factors that might influence this decision include …. symptom severity the child’s quality of life recent antibiotic use previous experience or outcomes with acute bacterial sinusitis cost of antibiotics, ease of administration caregiver concerns about potential adverse effects of

antibiotics, persistence of respiratory symptoms, or development of complications.


Initial Management of Acute Bacterial Sinusitis “Persistent illness” antibiotic therapy in 1st visit if …

Children who received antibiotic therapy in the previous 4 weeks

those with concurrent bacterial infection (eg, pneumonia, suppurative cervical adenitis, group A streptococcal pharyngitis, or acute otitis media)

those with actual or suspected complications of acute bacterial sinusitis

those with underlying conditions (asthma, cystic fibrosis, immunodeficiency, previous sinus surgery, or anatomic abnormalities of the upper respiratory tract)



Clinicians should prescribe amoxicillin ± clavulanate as first-line treatment when a decision has been made to initiate antibiotic treatment of acute bacterial sinusitis. For children aged 2 years or older with uncomplicated acute bacterial

sinusitis that is mild to moderate in degree of severity who do not attend child care and who have not been treated with an antimicrobial agent within the last 4 weeks, amoxicillin is recommended at a standard dose of 45 mg/kg per day in 2 divided doses.

Patients presenting with moderate to severe illness as well as those younger than 2 years, attending child care, or who have recently been treated with an antimicrobial may receive high-dose amoxicillin-clavulanate (80–90 mg/kg per day of the amoxicillin component with 6.4 mg/kg per day of clavulanate in 2 divided doses with a maximum of 2 g per dose).


A single 50-mg/kg dose of ceftriaxone, given either intravenously or intramuscularly, can be used for children who are vomiting, unable to tolerate oral medication, or unlikely to be adherent to the initial doses of antibiotic.

If clinical improvement is observed at 24 hours, an oral antibiotic can be substituted to complete the course of therapy. Children who are still significantly febrile or symptomatic at 24 hours may require additional parenteral doses before switching to oral therapy.


The treatment of patients with presumed allergy to penicillin …

non–type 1 (late or delayed, >72 hours) hypersensitivity reaction Cefuroxime

serious type 1 immediate or accelerated (anaphylactoid) reaction Cefuroxime OR clindamycin (or linezolid) and cefixime Levofloxacin


Pneumococcal and H influenzae surveillance studies have indicated that resistance of these organisms to Cotrimoxazole and azithromycin is sufficient to preclude their use for treatment of acute bacterial sinusitis in patients with penicillin hypersensitivity.

Second-and third-generation oral cephalosporins are no longer recommended for empiric monotherapy of ABRS due to variable rates of resistance among S. pneumoniae.

Combination therapy with a third-generation oral cephalosporin (cefixime) plus clindamycin may be used as second-line therapy for children with non–type I penicillin allergy or from geographic regions with high endemic rates of PNS S. pneumoniae


The optimal duration of antimicrobial therapy for patients with acute bacterial sinusitis has not received systematic study. Recommendations based on clinical observations have varied widely, from 10 to 28 days of treatment. An alternative suggestion has been made that antibiotic therapy be continued for 7 days after the patient becomes free of signs and symptoms.

Key Action Statement 5A

Clinicians should reassess initial management if there is either a caregiver report of worsening (progression of initial signs/symptoms or appearance of new signs/symptoms) OR failure to improve (lack of reduction in all presenting signs/symptoms) within 72 hours of initial management.

Key Action Statement 5B

If the diagnosis of acute bacterial sinusitis is confirmed in a child with worsening symptoms or failure to improve in 72 hours, then clinicians may change the antibiotic therapy for the child initially managed with antibiotic OR initiate antibiotic treatment of the child initially managed with observation.

No Recommendation (Adjuvant Therapy)

Potential adjuvant therapy for acute sinusitis might include intranasal corticosteroids, saline nasal irrigation or lavage, topical or oral decongestants, mucolytics, and topical or oral antihistamines.

A recent Cochrane review on decongestants, antihistamines, and nasal irrigation for acute sinusitis in children found no appropriately designed studies to determine the effectiveness of these interventions.

Pharyngitis

Incidence

One of the most common complaint leading older children and adults to acutely seek medical care

10% of all general practice consultations2nd most common diagnosis in the pediatric

age group

Classification

Nasopharyngitis Illness with nasal symptoms Mostly viral etiologies

Pharyngitis or tonsilopharyngitis Illness without nasal symptoms Many etiologies

Causes

Viral (70-80%)

Group A beta-haemolytic streptococcus GAS12 - 40% in children and 5 - 10% in adults

Nasopharyngitis

Viral infections >>> During cold weather months

Rhinorrhea and congestion may be more prominent than sore throat

Only pharyngeal erythema except adenovirus( follicular & exudative pharyngitis )

Mild or no cervical adenopathy Lower respiratory tract & GI sign & symptoms

Acute & self-limited ( 4 – 10 days)

Pharyngitis - 1

Etiology Bacterial

Group A β-hemolytic streptococci Group C & G β-hemolytic streptococci Arcanobacterium haemolyticum Mycoplasma Pneumonia N. gonorrhea Corynebacterium diphteriae Anaerobes …

Pharyngitis - 2

Viral Causes Adenovirus Influenza & Parainfluenza Virus EBV Entrovirus Herpes virus

Pharyngitis - 3

Non-infectious illness Aphthous stomatitis PFAPA Behcet syndrome Kawasaki disease Stevens-Johnson syndrome

GAS Pharyngitis

15 – 30 % pharyngitis in pediatric BUT only 5- 10 % in adults

Prescription of antibiotics for pharyngitis in adults in US 3/4 cases of pharyngitis

Clinical features associated with pharyngitis

Clinical Scoring

6th Item Clinical Scoring System (1)

1) Age (5 to 15 years)

2) Season (late fall, winter, early spring)

3) Physical examination of acute pharyngitis

(erythema, edema, and/or exudates)

4) Tender, enlarged (>1 cm) Ant. cervical lymph nodes

5) Moderate fever (38.4º - 40º C)

6) No usual signs & symptoms of viral URTI (i.e. cough, coryza, and nasal congestion)

6 Clinical Scoring System (2)

If all 6 criteria Throat culture 85 % positive for GAS

BUT if even a single feature is absent … predictive value of the streptococcal score

falls to 50% ( No better than chance alone)

Pharyngitis – GAS

NOTE:Only approximately 15% of all patients with

GAS pharyngitis have a classic presentationSo

It is impossible to diagnose streptococcal sore throat on clinical grounds alone

Centor criteria

Centor criteria

Tonsillar exudatesTender anterior cervical lymphadenopathyAbsence of coughHistory of temperature of at least 38 0C

In adults 3criteria

75% sensitivity and 75% specificity versus culture Positive Predictive Value (PPV) is 40 - 60%

IF < 1-2 criteria Negative Predictive Value ( NPV ) is 80%

Pharyngitis GAS - Laboratory Investigations

Throat cultureRapid Antigen Tests (RAT)Anti-streptolysin O (ASO) titres

Pharyngitis – GAS

CultureImperfect Gold standard for the diagnosis

Late, carrier vs. infection

Rapid antigen detection test ( RADT ) Very specific, 80-90% sensitive

Recommendation in children:RADT as an initial screen

RADT is Positive RADT is negative Treatment Throat culture

Management

I. How Should the Diagnosis of GAS Pharyngitis Be Established?

Swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis except when overt viral features like rhinorrhea, cough, oral ulcers, and/or hoarseness are present.

In children and adolescents, negative RADT tests should be backed up by a throat culture . Positive RADTs do not necessitate a back-up culture because they are highly specific .

I. How Should the Diagnosis of GAS Pharyngitis Be Established?

Routine use of back-up throat cultures for those with a negative RADT is not necessary for adults in usual circumstances.

Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis as they reflect past but not current events.

II. Who Should Undergo Testing for GAS Pharyngitis?

Testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiological features that strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness, and oral ulcers).

Diagnostic studies for GAS pharyngitis are not indicated for <3 y/o.

Follow-up post treatment throat cultures or RADT are not recommended routinely but may be considered in special circumstances.

Diagnostic testing or empiric treatment of asymptomatic household contacts of patients with acute streptococcal pharyngitis is not routinely recommended.

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III. What Are the Treatment Recommendations for Patients With a Diagnosis of GAS

Pharyngitis?

Patients with acute GAS pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days).

Based on their narrow spectrum of activity, infrequency of adverse reactions, and modest cost, penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents.

Treatment of GAS pharyngitis in penicillin-allergic individuals should include a first generation cephalosporin (for those not anaphylactically sensitive) for 10 days, clindamycin or clarithromycin for 10 days, or azithromycin for 5 days.

With antimicrobial therapy, most throat cultures become negative within 24 hours and it is presumed that the patient is no longer contagious and may return to day care, school, or work

IV. Should Adjunctive Therapy With NSAIDs, Acetaminophen, Aspirin, or Corticosteroids Be Given to

Patients Diagnosed With GAS Pharyngitis?

Adjunctive therapy may be useful in the management of GAS pharyngitis. If warranted, use of an analgesic/antipyretic agent such as

acetaminophen or an NSAID for treatment of moderate to severe symptoms or control of high fever associated with GAS pharyngitis should be considered as an adjunct to an appropriate antibiotic .

Aspirin should be avoided in children. Adjunctive therapy with a corticosteroid is not

recommended.

Common Cold, Nonspecific URI, Acute Cough Illness, Acute Bronchitis

Symptoms of the common cold, nonspecific URI, and bronchitis may overlap with or mirror those of bacterial URIs and can include cough, congestion, and sore throat. Collectively, these viral conditions account for millions of office visits per year.

Acute bronchitis, in particular, is a cough illness that is diagnosed during more than 2 million pediatric office visits annually, and antibiotics are prescribed more than 70% of the time.

Application of diagnostic clinical criteria for AOM, sinusitis, and pharyngitis should aid clinicians in excluding these conditions.

Management of the common cold, nonspecific URI, acute cough illness, and acute bronchitis should focus on symptomatic relief. Antibiotics should not be prescribed for these conditions.

Thanks for your attention.

Date post:	24-Feb-2016
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