1he bas|cs of ranona| and prudent

annb|onc use for common ch||dhood

|nfecnons |n ambu|atory care
A8LC Lducauonal Croup

1
!ulla 8lellckl
Clanglacomo nlcollnl
MarLa 8omanengo
lrancols uubos
8ebecca Lundln

Educational Tool Contents
lnLroducuon
1he role of mlcroorganlsms ln Lhe human body
Mlcroorganlsms and Lhelr LreaLmenLs
noL all lnfecuons requlre speclc LreaLmenL
WhaL anubloucs do
Luropean ouLpauenL anublouc use
8elauonshlp beLween anublouc reslsLance and anublouc use
1he landscape of anublouc reslsLance ln Lurope: .coll
AspecLs of rauonal anublouc prescrlblng ln ouLpauenL care
ueallng wlLh common chlldhood lnfecuons presenung Lo
ambulaLory care provlders
harynglus
AcuLe ouus medla
CommunlLy acqulred pneumonla
Slnuslus
urlnary LracL lnfecuon
Skln and so ussue lnfecuon


2
IN1kCDUC1ICN
1he bas|cs of ranona| and prudent annb|onc use for common ch||dhood
|nfecnons |n ambu|atory care
3
The role of microorganisms
in the human body
300-600 dlerenL klnds of bacLerla Lhrlve on mucus
and food remnanLs ln Lhe mouLh (5tteptococcos,
oooetobes).
Some mlcroorganlsms llve on Lhe exLernal ear and skln
and consuLuLe lLs normal ora (ltoploolboctetlom
ocoes, 5topb eplJetmlJls, Mlctococcos).
A normal ora llves on Lhe lower parL of Lhe ureLhra
and Lhe female genlLal LracL (loctobocllll).
1he colon ls a holdlng Lank for bacLerla (10
12
-10
13
/ml)
LhaL paruclpaLe ln Lhe end sLages of food dlgesuon.


4
Microorganisms and their
treatments
3
Viruses Bacteria Fungi Parasites
Anuvlrals Annbacter|a|s (a|so
ca||ed annb|oncs)
AnumycobacLerlals
(speclcally acuve
agalnsL mycobacLerla)
Anufungals AnuparaslLal drugs
(acuve agalnsL
malarla and oLher
parasluc lnfecuons)
Anumlcroblal reslsLance ls Lhe ablllLy of a mlcroorganlsm Lo reslsL
Lhe acuons of anumlcroblal agenLs. lL ls a characLerlsuc of mlcro-
organlsms, noL pauenLs, and may or may noL be seen ln
con[uncuon wlLh dlsease ln a pauenL. 8eslsLance may also be
found when survelllance or envlronmenLal samples are analysed.
AdapLed from LCuC facLsheeL for experLs Anumlcroblal reslsLance"
MosL oen used ln
Lhe communlLy
and Lhe focus of
Lhese slldes
Not all infections require
specific treatment
MosL lnfecuons seen ln ambulaLory care are vlral
ln naLure (e.g. common cold, pharynglus, acuLe
ouus medla, u)
MosL of Lhese lnfecuons do noL requlre speclc
LreaLmenL (lndeed, oen Lhls ls noL avallable)
1he key declslon ls wheLher Lhe pauenL ls
presenung wlLh an lnfecuon LhaL ls (a) llkely Lo be
bacLerlal and (b) llkely Lo beneL from anublouc
LreaLmenL
6
AdapLed from LCuC facLsheeL for experLs Anumlcroblal reslsLance"
What antibiotics do
lf Lhere ls a bacLerlal lnfecuon caused by a
mlcroorganlsm suscepuble Lo Lhe chosen
anublouc, Lhe lnfecuon may be LreaLed
wlLh Lhe correcLly admlnlsLered anublouc
1he normal human ora wlll also be
modled, resulung ln some well-known
slde-eecLs such as dlarrhoea
Croups of reslsLanL bacLerla may be
selecLed and perslsL as colonlzlng
organlsms
1hese can cause lnfecuon ln Lhe same
pauenL or ln oLher conLacLs of LhaL
pauenL laLer
7
AdapLed from LCuC facLsheeL for experLs Anumlcroblal reslsLance"
Lcologlcal
pressure
Selecuon of
reslsLanL bacLerla
Colonlzauon of
lndlvlduals
Spread and
cross-
Lransmlsslon
beLween
humans, anlmals
and Lhe
envlronmenL
European outpatient
antibiotic use
Antibiotics are used very frequently in ambulatory
healthcare & very variably across Europe 8
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Relationship between
antibiotic resistance and
antibiotic use
Study of the
relationship between
penicillin use and
prevalence of penicillin
non-susceptible
S.pneumoniae in
Europe:
High observed levels of
antibiotic resistance are
associated with more
intensive antibiotic use
9
Coossens P eL al.1be loocet. 2003,363:379-387. 8eproduced wlLh permlsslon.
The landscape of antibiotic
resistance in Europe: E.coli
10
Anumlcroblal reslsLance survelllance ln Lurope 2011. LCuC 2012. 8eproduced wlLh permlsslon.
noLe varlauon ln
reslsLance Lo Lhlrd-
generauon
cephalosporlns
amongsL .coll
bloodsLream and
cerebrosplnal uld
lsolaLes ! ln some
counLrles Lhe uullLy of
cephalosporlns ln
LreaLmenL of .coll
lnfecuon may already
be llmlLed
Aspects of rational antibiotic
prescribing in outpatient care
lL ls ln Lhe lnLeresL of pauenLs Lo preserve
currenLly avallable anubloucs for fuLure use
auenLs musL recelve anubloucs LhaL Lhey need
aL Lhe rlghL ume, dose and durauon
A glven anublouc should be prescrlbed lf
Lhe lnfecuon ls mosL llkely caused by bacLerla
Lhe causauve bacLerla are llkely Lo be suscepuble Lo
Lhe anublouc of cholce
anublouc LreaLmenL ls Lhe only safe opuon Lo manage
Lhe pauenL
CaLherlng all relevanL lnformauon Lo address Lhe
above polnLs aL each pauenL encounLer ls crlucal
11
AdapLed from WPC reporL 1he evolvlng LhreaL of anumlcroblal reslsLance - Cpuons for acuon. 2012"
lurLher lnformauon: 8elevanL
anublouc prescrlpuon guldellnes
oLenually relevanL guldellnes ln Lngllsh may be found aL:
1he nauonal Culdellne Clearlnghouse run by Lhe uS ueparLmenL of
PealLh and Puman Servlces and Lhe Agency for PealLhcare 8esearch and
CuallLy (hup://guldellne.gov/)
1he Cllnlcal Culdellnes orLal run by Lhe nauonal PealLh and Medlcal
8esearch Councll, AusLralla (hup://www.cllnlcalguldellnes.gov.au/)
Cllnlcal Culdellnes provlded by Lhe nauonal lnsuLuLe for Cllnlcal
Lxcellence (nlCL) (hup://guldance.nlce.org.uk/CC)#
1he Scomsh lnLercolleglaLe Culdellnes neLwork run by PealLhcare
lmprovemenL Scouland (
hup://www.slgn.ac.uk/guldellnes/publlshed/lndex.hLml)
1he Cochrane 8evlews provlded by Lhe Cochrane Collaborauon (
hup://www.cochrane.org/)
ln addluon, you may be able Lo nd guldellnes for Lhe LreaLmenL of Lhe
common lnfecuons dlscussed ln Lhls sllde seL Lhrough your nauonal
paedlaLrlc or paedlaLrlc lnfecuous dlseases socleLy.
12
lurLher lnformauon: CounLry
speclc anublouc use and reslsLance
Lu counLry speclc daLa on anublouc use and reslsLance may be found aL:
1he Luropean Anumlcroblal 8eslsLance Survelllance neLwork (LA8S-neL)
run by Lhe Luropean CenLre for ulsease revenuon and ConLrol (LCuC)
(
hup://ecdc.europa.eu/en/acuvlues/survelllance/LA8S-neL/daLabase/
ages/daLabase.aspx)
1he Luropean Survelllance of Anumlcroblal Consumpuon neLwork (LSAC-
neL), also run by Lhe Luropean CenLre for ulsease revenuon and ConLrol
(LCuC) (
hup://www.ecdc.europa.eu/en/acuvlues/survelllance/LSAC-neL/
daLabase/ages/daLabase.aspx )
ln addluon, you may be able Lo nd lnformauon on nauonal, reglonal, or
hosplLal level anublouc use and reslsLance Lhrough your nauonal or
reglonal publlc healLh auLhorlLy or laboraLory or pharmacy deparLmenLs
wlLhln lndlvldual hosplLals.
13
DLALING WI1n CCMMCN CnILDnCCD
INILC1ICNS kLSLN1ING 1C
AM8ULA1Ck CAkL kCVIDLkS
1he bas|cs of ranona| and prudent annb|onc use for common ch||dhood
|nfecnons |n ambu|atory care
14
lnLroducLory remarks
1hls sllde seL lncludes dlscusslons on Lhe
managemenL of speclc common chlldhood
lnfecuons ln ambulaLory care
Whenever a speclc guldellne ls clLed, Lhls ls as
an example of a sLrucLured approach raLher Lhan
as an endorsemenL of LhaL parucular
recommendauon
users of Lhls sllde seL should be encouraged Lo
adhere Lo local guldellnes, wherever Lhese exlsL
8ecommendauons for speclc anublouc
LreaLmenLs lncluded ln Lhls sllde seL are used only
as examples, because rauonal anublouc cholces
may vary accordlng Lo local epldemlology
13
Common ch||dhood |nfecnons presennng to
ambu|atory care prov|ders
Infecnons covered |n s||de set
harynglus
AcuLe ouus medla
CommunlLy acqulred
pneumonla
Slnuslus
urlnary LracL lnfecuon
Skln and so ussue
lnfecuon

Structured approach
8roadly, for each lnfecuon Lhe
sllde seL conLalns lnformauon on
Case ouLllne
8ackground lnformauon
Cllnlcal assessmenL
8eneL of laboraLory Lesung
Chooslng a LreaLmenL sLraLegy
8lsk-beneL conslderauons for
anublouc LreaLmenL
roposed approach
16
nAkNGI1IS

8as|c know|edge on good c||n|ca| pracnce |n common |nfecnous
d|seases |n ch||dren
17
Dav|d can't eat today.
uavld, my 3 year old son auendlng pre-school, was always healLhy before
nephrouc syndrome was dlscovered abouL 2 monLhs ago. lor abouL Lhree
days he has had a bad sore LhroaL, especlally when he swallows, and l wonder
lf Lhls can be relaLed Lo hls kldneys, as he has been Laklng sLerolds for nearly 2
monLhs. Pls fever was 38.3'C Lhls mornlng. Pe ls noL eaung much"
18
Lver seen Lhese?
Cn c||n|ca| exam|nanon Dav|d |s
hot and you can fee| h|s cerv|ca|
|ymph nodes. ne has no s|gns of
tox|c|ty or resp|ratory d|stress.
n|s throat |s very red, w|th b|g
tons||s w|th exudate and
erythema.
8ackground lnformauon: harynglus
19
Pow can l
dlsungulsh
beLween Lhem?
Lp|dem|o|og|ca| Cnset haryngea| appearance Assoc|ated symptoms
-kare |n ch||dren < 3
years
-C|der age S-1S years
-W|nter-ear|y spr|ng

-Sudden onset sore throat
-a|n on swa||ow|ng
-resence of fever
-Absence of cough
-1ons|||o-har|ngea|
erythema (dark red)
-atchy exudate on tons||s
-Soh pa|ate petech|ae
-1ender anter|or aden|ns
-neadache
-Nausea, vom|nng,
abdom|na| pa|n
-Cerv|ca| aden|ns
-Scar|ann|form rash

Cllnlcal crlLerla more frequenLly meL ln bacLerlal lnfecuon
V|ra| aeno|ogy
1he mosL common (60-80)
ssoclaLed feaLures:
Con[uncuvlus
8hlnlus
Poarseness
Cough
ularrhoea
LxanLhema

kbloovltos, oJeoovltos, 8v,
otetovltos, n5v, lofoeozo
vltos, k5v, potolofoeozoe
vltos, cotooovltos,
metopoeomovltos
8acter|a| aeno|ogy
!" $%&'()(* + Group A
Strep (20-30 chlldren)
Cram posluve coccl
May be presenL ln Lhe
normal pharyngeal ora ln
chlldren
Several facLors of
vlrulence
Cther rare bacter|a
losoboctetlom (oJolesceots)
Nelssetlo
cotyoeboctetlo
Many sympLoms are slmllar,
lL ls noL easy Lo dlsungulsh
bacLerlal from vlral
sLrepLococcal lnfecuon only
on cllnlcal grounds
Speclc conslderauons wlLh Croup
A 5tteptococcos
CAS pharynglus ls a self-llmlLed lllness even wlLhouL A8 LreaLmenL
1ransmlsslon: CAS harynglus ls Lransmlued by dropleLs from person Lo
person, A8 LreaLmenL can sLop Lransmlsslon.
urulenL compllcauons: 8eLropharyngeal abscesses, perlLonslllar abscesses,
(qulnsy), Lamlerre's Syndrome are very rare (< 1)
Carrlers: CAS carrlers should noL be LreaLed wlLh anumlcroblal Lherapy, Lhey
are unllkely Lo spread CAS pharynglus or develop compllcauons.
non purulenL compllcauons
ScarleL fever
AcuLe posL-sLrepLococcal Clomerulonephrlus (lL ls noL prevenLed by anumlcroblal Lherapy!)
8heumauc fever (A8l) (sull leadlng cause of acqulred hearL dlsease ln chlldren ln parLs of Lhe world)
osL-sLrepLococcal reacuve arLhrlus
20
AccuraLe ldenucauon of sLrepLococcal pharynglus followed by A8
Lherapy can be lmporLanL for lmprovlng cllnlcal sympLoms and for
prevenuon of compllcauons, buL several facLs should be consldered
osslble dlagnosuc approaches Lowards acuLe
harynglus
Can be used when
no deLecuon LesL
ls avallable, buL
has low predlcuon
value for CAS
lnfecuon (33-30)
21
now can I make an |nformed dec|s|on on the use of annb|oncs |n ch||dren w|th acute pharyng|ns?
Can be very Lrlcky ln
a non-collaborauve
chlld, buL lf
performed correcLly
ls 90-93 sensluve
for deLecuon of CAS
noL lndlcaLed for chlldren
< 3 years , Lhose wlLh vlral
aeuology, or
asympLomauc household
conLacLs
C||n|ca| Cr|ter|a:
1he 4 CenLre CrlLerla:
1.lever and
2.1onslllar exudaLe
3.1ender
llnphoadenophaLy
4.Absence of cough
8apld anugen
deLecuon LesL
(8Au1)

1hroaL culLure
(can be used Lo verlfy
8Au1 LesL resulLs)
Anu-
sLrepLococcal
anubody uLres
are noL
recommended

Group A Strep-rap|d test (kAD1)
A8 treatment can be
proposed
Amoxlclllln
suscepublllLy: 100
Macrollde reslsLance:
2-20 by an eMux
pump mechanlsm
ueLecL Lhe membrane group
A speclc carbohydraLe
anugens.
_
_
_
_
_
No Annb|oncs
SympLomauc LreaLmenL
1he performance of Lhe LesL
depends on Lhe quanuLy of anugen
ln Lhe swab. A swabblng wlLh hlgh
charge of pus ls lmporLanL.
22
1hls ls CCCu pracuce,
we can avold lnapproprlaLe
admlnlsLrauon of A8!

8eneLs & 8lsks of A8 ln harynglus

23
8enehts of A8 |n pharyng|ns
A8 are an eecuve LreaLmenL for
bacLerlal harynglus caused by CAS
osluve 8Au1 are hlghly speclc for CAS
and allow LargeLed 8x .
8educuon of conLaglousness from 6-14d
Lo 24h for SLrep A pharynglus
8educuon of compllcauons
Lhe greaLesL burden of dlsease, parucularly
lnvaslve dlsease and posL-sLrepLococcal
sequelae, ls ln chlldren ln resource-poor areas.
8educuon of lnammaLory compllcauons
noL dlerenL beLween delayed or
lmmedlaLe A8 LreaLmenL
Anumlcroblal Lherapy ls of no proven
beneL as LreaLmenL due Lo organlsms
oLher Lhan CAS
lamlly & hyslclan reassurance

k|sks of A8 kx |n pharyng|ns

AdequaLe A8 LreaLmenL should follow
bacLerlologlcal conrmauon wlLh 8Au1 or
swab.
Cllnlcal crlLerla for CAS pharynglus are noL
cerLaln
lnapproprlaLe A8 8x for large numbers of
non-CAS pharynglus
naLural hlsLory of sympLoms ls Lowards a
sponLaneous resoluuon

uevelopmenL of anumlcroblal
reslsLance among common paLhogens
8lsk for A8 slde-eecLs
8ash
ularrhoea
Lxcesslve dlagnoses of allergy
A reasonable approach Lo uavld's sore LhroaL.
cooslJetloq uovlJs symptoms, oqe,
ooJ exomloouoo tesolts, l most
cooslJet o posslble CA5 lofecuoo. wbot
ote my oext steps?

" uavld ls febrlle and mum ls worrled
" uavld has [usL had a long LreaLmenL
wlLh sLerolds for Cn

" ?ou do noL wanL Lo prescrlbe
unnecessary LreaLmenL Lo hlm
" ?ou need a qulck answer for mum
and a solld plan for hls dlscharge


ou can use a kAD1 test !
24
?ou can perform a LhroaL swab for
coltote for pauenLs wlLh underlylng
condluons lf sLrep A LesL ls negauve
l can be reasonably condenL
uavld has a SLrepLococcal
harynglus
Clve anubloucs ln case of posluve coltote
_
Anublouc 8eglmens reccomended for Croup A
SLrepLococcal harynglus

23
luSA Culdellnes, 2012

lf you declde Lo prescrlbe anubloucs you should follow your local guldellnes.
20%30% in children [9, 10]. Accurate diagnosis of streptococ-
cal pharyngitis followed by appropriate antimicrobial therapy is
important for the prevention of acute rheumatic fever; for the
prevention of suppurative complications (eg, peritonsillar
abscess, cervical lymphadenitis, mastoiditis, and, possibly, other
invasive infections); to improve clinical symptoms and signs;
for the rapid decrease in contagiousness; for the reduction in
transmission of GAS to family members, classmates, and other
close contacts of the patient [11]; to allow for the rapid resump-
tion of usual activities; and for the minimization of potential
adverse effects of inappropriate antimicrobial therapy.
Although acute pharyngitis is one of the most frequent ill-
nesses for which pediatricians and other primary care physi-
cians are consulted, with an estimated 15 million visits per year
in the United States [10], only a relatively small percentage of
patients with acute pharyngitis (20%30% of children and a
smaller percentage of adults) have GAS pharyngitis. Moreover,
the signs and symptoms of GAS and nonstreptococcal pharyn-
gitis overlap so broadly that accurate diagnosis on the basis of
clinical grounds alone is usually impossible [12].
With the exception of very rare infections by certain other
bacterial pharyngeal pathogens (eg, Corynebacterium diphther-
iae and Neisseria gonorrhoeae) (Table 3), antimicrobial
therapy is of no proven benet as treatment for acute pharyn-
gitis due to organisms other than GAS. Therefore, it is ex-
tremely important that physicians exclude the diagnosis of
GAS pharyngitis to prevent inappropriate administration of
antimicrobials to large numbers of patients with nonstrepto-
coccal pharyngitis. Such therapy unnecessarily exposes pa-
tients to the expense and hazards of antimicrobial therapy.
Despite improvements in antimicrobial prescribing for chil-
dren and adults with acute pharyngitis, a substantial number
of patients continue to receive inappropriate antimicrobial
therapy [1315]. Inappropriate antimicrobial use for upper re-
spiratory tract infections, including acute pharyngitis, has
been a major contributor to the development of antimicrobial
resistance among common pathogens [15]. Estimated econom-
ic costs of pediatric streptococcal pharyngitis in the United
States range from $224 million to $539 million per year, in-
cluding indirect costs related to parental work losses [16].
In addition to acute disease, streptococcal pharyngitis is im-
portant because it can lead to the nonsuppurative postinfec-
tious disorders of acute rheumatic fever with and without
carditis, as well as to poststreptococcal glomerulonephritis. Al-
though acute rheumatic fever is now uncommon in most de-
veloped countries, it continues to be the leading cause of
acquired heart disease in children in areas such as India, sub-
Saharan Africa, and parts of Australia and New Zealand [17].
This guideline updates the 2002 practice guidelines of the
IDSA [1]. The following 5 clinical questions are addressed in
the guidelines:
(I) How should the diagnosis of GAS pharyngitis be
established?
Table 2. Antibiotic Regimens Recommended for Group A Streptococcal Pharyngitis
Drug, Route Dose or Dosage
Duration or
Quantity
Recommendation
Strength, Quality
a
Reference(s)
For individuals without
penicillin allergy
Penicillin V, oral Children: 250 mg twice daily or 3 times daily;
adolescents and adults: 250 mg 4 times daily or
500 mg twice daily
10 d Strong, high [125, 126]
Amoxicillin, oral 50 mg/kg once daily (max =1000 mg); alternate:
25 mg/kg (max =500 mg) twice daily
10 d Strong, high [8892]
Benzathine penicillin G,
intramuscular
<27 kg: 600 000 U; 27 kg: 1 200 000 U 1 dose Strong, high [53, 125, 127]
For individuals with
penicillin allergy
Cephalexin,
b
oral 20 mg/kg/dose twice daily (max =500 mg/dose) 10 d Strong, high [128131]
Cefadroxil,
b
oral 30 mg/kg once daily (max =1 g) 10 d Strong, high [132]
Clindamycin, oral 7 mg/kg/dose 3 times daily (max =300 mg/dose) 10 d Strong, moderate [133]
Azithromycin,
c
oral 12 mg/kg once daily (max =500 mg) 5 d Strong, moderate [97]
Clarithromycin,
c
oral 7.5 mg/kg/dose twice daily (max =250 mg/dose) 10 d Strong, moderate [134]
Abbreviation: Max, maximum.
a
See Table 1 for a description.
b
Avoid in individuals with immediate type hypersensitivity to penicillin.
c
Resistance of GAS to these agents is well-known and varies geographically and temporally.
IDSA Guideline for GAS Pharyngitis CID 2012:55 (15 November) e89

b
y

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,

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t
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p
:
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f
r
o
m

A course of 10 days of oral penlclllln v ls recommended ln vlew of rheumauc fever
prevenuon buL compllance ls very low
8enzaLhlne enlclllln C lnLramuscular can be used ln Lhose pauenLs unllkely Lo compleLe a
full course of LreaLmenL, buL ls very rare approach ln wesLern CounLrles.
AlLernauve reglmens wlLh comparable eecuveness are hlgh dose amoxlclllln Lwlce a day or
narrow specLrum cephalosporlns for 3-6 days.
?ou declde Lo lnluaLe anublouc LreaLmenL wlLh hlgh dose Amoxlclllln a
day for uavld for a week.
uavld's mum rlngs you aer 2 days. Pe ls much beuer and has been
afebrlle for a full day Loday. Pls appeuLe has come back and he ls much
happler.

Anublouc 8eglmens recommended for CAS
harynglus
26
8eferences
Shulman S1 eL al. Cllnlcal racuce Culdellne for Lhe dlagnosls and
managemenL of group A sLrepLococcal pharynglus: 2012 updaLe by Lhe
lnfecuous ulseases SocleLy of Amerlca. cllo lofect uls 2012 nov 13,33(10):
1279-82.

27
ACU1L C1I1IS MLDIA
1he bas|cs of ranona| and prudent annb|onc use for common ch||dhood
|nfecnons |n ambu|atory care
28
Iames has a fever and |s refus|ng food.
Iomess motbet btloqs bet oloe mootb-
olJ soo to yoot o[ce eotly oo MooJoy
motoloq. nls fevet splkeJ lo tbe ptevloos
ofetoooo bot lotet be boJ o qooJ meol.
ne woke op ot 2 om ctyloq ooJ llule
coolJ be Jooe to colm blm. ne foolly
coolJ qo bock to sleep ofet beloq qlveo
o Jose of 5 ml lotocetomol. lo tbe
motoloq be tefoseJ bls mllk ooJ
oppeoteJ testless ooJ posslbly bot
oqolo.
oo koow Iomes, be bos oo ptevloos
meJlcol ptoblems. nls mom tepotts tbot
be wos teceotly lottoJoceJ loto o Joy
cote ootsety fot tbtee bolf-Joys o week.
Lxamlnauon
lrrlLable, wlLh normal consclousness,
noL smlllng.
Slgns of upper alrway lnfecuon.
1'=38.9'C
no resplraLory slgns, normal general
examlnauon.
Mum helps you and you manage Lo
check hls ears. 1hls ls whaL you see:
(le oLoscopy)


29
8ackground lnformauon: acuLe ouus medla
PlghesL lncldence
among chlldren beLween
6 monLhs and 2 years of
age

8y 3 years of age, 80 of
chlldren have had aL
leasL one eplsode of
acuLe ouus medla
30
ACM ls Lhe mosL commonly reporLed lndlcauon for anublouc LreaLmenL ln chlldren
# 1here ls serlous problem wlLh over-dlagnosls and overprescrlblng of A8 for ACM ln chlldren
reclse mlcroblologlc dlagnosls requlres a sample of mlddle ear uld
# Mlddle ear uld sampllng ls noL posslble
naLural hlsLory of Lhe ma[orlLy of ACM eplsodes ls a sponLaneous resoluuon of paln and fever ln 3-7 days
# ls anublouc LreaLmenL necessary?
8are buL serlous suppurauve compllcauons of ACM can occur (masLoldlus, hearlng loss, menlnglus)
# lncldence ln chlldren ls noL lnuenced by lnlual LreaLmenL wlLh anubacLerlal agenLs
Lplsodes of upper resplraLory vlral
lnfecuon (adenovlrus, rhlno,
lnuenza, 8Sv) oen precede or
are concurrenL wlLh developmenL
of ACM

Mlddle ear uld paLhogens ln ACM:
5tteptococcos poeomooloe &
nemopbllos lofoeozoe (80-83)
Motoxello cotottolls (3-10)
5tteptococcos lyoqeoes (3)
What shou|d I cons|der |n the approach to a ch||d w|th suspected acute onns med|a?
now can I make an |nformed dec|s|on on the use of annb|oncs |n ch||dren w|th
suspected acute onns med|a ?
A poss|b|e strategy for treanng Iames.
1. Check h|story of
acute onset
Cta|g|a
Irr|tab|||ty
Iever
Lxcess|ve cry|ng

1he symptoms are
ohen aspec|hc

2 Check tympan|c
membrane for s|gns of:
Mlddle-ear euslon (MLL)
lullness or bulglng of 1M
LlmlLed or absenL moblllLy of
1M
Alr-uld level behlnd Lhe 1M
CLorrhea
Mlddle-ear lnammauon
ulsuncL eryLhema of 1M
ulsuncL oLalgla
coo yoo Jl[eteouote AOM ftom
OM ?
nlCL
AA CMA Culdellnes 2013
3. Assess and check for
s|gn of severe |||ness or
presence of suppuranve
comp||canons




4. 1reat pa|n w|th
aracetamo| or Ibuprofen
fo||ow|ng |oca| gu|de||nes
for pa|n management,
adequate dose and age
appropr|ate |nd|canons
1hls ls whaL !ames' mum has reporLed
CML (Cnns Med|a w|th Lus|on) ls a
sLerlle lnammaLory sLaLe of Lhe mlddle
ear LhaL resolves sponLaneously, A8 are
noL approprlaLe or beneclal ln Lhls case
lf Lhls ls
presenL, refer
Lhe chlld
accordlngly
31
1) Pow llkely ls Lhls Lo be a real acuLe ouus medla? Iocus on 1M: musL be cloudy,
bulglng wlLh lmpalred moblllLy
2) l am reasonably condenL !ames has ACM, should l prescrlbe an anublouc?
" now o|d |s the ch||d? ?oung chlld (< 6 monLhs or < 2 years) or
bllaLeral ACM, oLhorrea
" nas pa|n and fever been assessed? and adequaLely LreaLed?
" Can the ch||d be adequate|y superv|sed? lnform Lhe parenLs
regardlng Lhe LreaLmenL plan and expecLed lllness progresslon
" nas adequate fo||ow up appo|ntment been agreed upon?

32
# Cbservanon w|thout use of annbacter|a| agents (or de|ayed A8
prescr|b|ng) |s an opnon for se|ected ch||dren w|th uncomp||cated
ACM
8uL lL ls lmporLanL Lo conslder and welghL Lhe presence of oLher facLors
LhaL mlghL lnuence your declslon how Lo LreaL Lhe ACM:
A poss|b|e strategy for treanng Iames.
Anublouc cholce for ACM
33
AA Culdellnes, 2013

lf you declde Lo prescrlbe anubloucs you should follow your local guldellnes.
1he followlng Lables are Lhe reccomended anubacLerlal agenLs ln Lhe AA Culdellnes for ACM publlshed ln 2013.
compared with the regular dose.
151153
Hoberman et al
154
reported superior
efcacy of high-dose amoxicillin-
clavulanate in eradication of S pneu-
moniae (96%) from the middle ear at
days 4 to 6 of therapy compared with
azithromycin.
The antibiotic susceptibility pattern for
S pneumoniae is expected to continue
to evolve with the use of PCV13,
a conjugate vaccine containing 13
serotypes of S pneumoniae.
133,155,156
Widespread use of PCV13 could po-
tentially reduce diseases caused by
multidrug-resistant pneumococcal
serotypes and diminish the need for
the use of higher dose of amoxicillin
or amoxicillin-clavulanate for AOM.
Some H inuenzae isolates produce
-lactamase enzyme, causing the iso-
late to become resistant to penicillins.
Current data from different studies
with non-AOM sources and geographic
locations that may not be comparable
show that 58% to 82% of H inuenzae
isolates are susceptible to regular-
and high-dose amoxicillin.
130,147,148,157,158
These data represented a signicant
decrease in -lactamaseproducing H
inuenzae, compared with data repor-
ted in the 2004 AOM guideline.
Nationwide data suggest that 100% of M
catarrhalis derived from the upper re-
spiratory tract are -lactamasepositive
but remain susceptible to amoxicillin-
clavulanate.
159
However, the high rate of
spontaneous clinical resolution occur-
ring in children with AOM attributable
to M catarrhalis treated with amoxicil-
lin reduces the concern for the rst-line
coverage for this microorganism.
145,146
AOM attributable to M catarrhalis rarely
progresses to acute mastoiditis or in-
tracranial infections.
102,160,161
Antibiotic Therapy
High-dose amoxicillin is recommended
as the rst-line treatment in most
patients, although there are a number
of medications that are clinically ef-
fective (Table 5). The justication for
the use of amoxicillin relates to its
effectiveness against common AOM
bacterial pathogens as well as its
safety, low cost, acceptable taste, and
narrow microbiologic spectrum.
145,151
In children who have taken amoxicillin
in the previous 30 days, those with
concurrent conjunctivitis, or those
for whom coverage for -lactamase
positive H inuenzae and M catarrhalis
is desired, therapy should be initiated
with high-dose amoxicillin-clavulanate
(90 mg/kg/day of amoxicillin, with 6.4
mg/kg/day of clavulanate, a ratio of
amoxicillin to clavulanate of 14:1, given
in 2 divided doses, which is less likely to
cause diarrhea than other amoxicillin-
clavulanate preparations).
162
Alternative initial antibiotics include
cefdinir (14 mg/kg per day in 1 or 2
doses), cefuroxime (30 mg/kg per day
in 2 divided doses), cefpodoxime (10
mg/kg per day in 2 divided doses), or
ceftriaxone (50 mg/kg, administered
intramuscularly). It is important to
note that alternative antibiotics vary in
their efcacy against AOM pathogens.
For example, recent US data on in vitro
susceptibility of S pneumoniae to cef-
dinir and cefuroxime are 70% to 80%,
compared with 84% to 92% amoxicillin
efcacy.
130,147149
In vitro efcacy of
cefdinir and cefuroxime against H
inuenzae is approximately 98%, com-
pared with 58% efcacy of amoxicillin
and nearly 100% efcacy of amoxicillin-
clavulanate.
158
A multicenter double
tympanocentesis open-label study of
TABLE 5 Recommended Antibiotics for (Initial or Delayed) Treatment and for Patients Who Have Failed Initial Antibiotic Treatment
Initial Immediate or Delayed Antibiotic Treatment Antibiotic Treatment After 4872 h of Failure of Initial Antibiotic Treatment
Recommended First-line
Treatment
Alternative Treatment
(if Penicillin Allergy)
Recommended
First-line Treatment
Alternative
Treatment
Amoxicillin (8090 mg/ kg per
day in 2 divided doses)
Cefdinir (14 mg/kg per day
in 1 or 2 doses)
Amoxicillin-clavulanate
a
(90 mg/kg per
day of amoxicillin, with 6.4 mg/kg
per day of clavulanate in 2
divided doses)
Ceftriaxone, 3 d Clindamycin
(3040 mg/kg per day in 3
divided doses), with or without
third-generation cephalosporin
or Cefuroxime (30 mg/kg per
day in 2 divided doses)
or Failure of second antibiotic
Amoxicillin-clavulanate
a
(90 mg/kg
per day of amoxicillin, with 6.4 mg/kg
per day of clavulanate [amoxicillin to
clavulanate ratio, 14:1] in 2
divided doses)
Cefpodoxime (10 mg/kg per
day in 2 divided doses)
Ceftriaxone (50 mg IM or IV for 3 d) Clindamycin (3040 mg/kg per day
in 3 divided doses) plus
third-generation cephalosporin
Tympanocentesis
b
Ceftriaxone (50 mg IM or IV
per day for 1 or 3 d)
Consult specialist
b
IM, intramuscular; IV, intravenous.
a
May be considered in patients who have received amoxicillin in the previous 30 d or who have the otitis-conjunctivitis syndrome.
b
Perform tympanocentesis/drainage if skilled in the procedure, or seek a consultation from an otolaryngologist for tympanocentesis/drainage. If the tympanocentesis reveals
multidrug-resistant bacteria, seek an infectious disease specialist consultation.
c
Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to be associated with cross-reactivity with penicillin allergy on the basis of their distinct chemical structures.
See text for more information.
PEDIATRICS Volume 131, Number 3, March 2013 e983
FROM THE AMERICAN ACADEMY OF PEDIATRICS
by guest on May 18, 2013 pediatrics.aappublications.org Downloaded from
k|sks & benehts of annb|onc use |n ACM
8enehts
1he LreaLmenL ls always emplrlcal
lamlly reassurance
Can be safe Lo prescrlbe emplrlcally even
among lnfanLs and chlldren < 2 years
k|sks
Anublouc LreaLmenL has no eecL for :
8educlng paln on day 1
revenung suppurauve compllcauons
Acceleraung resoluuon of mlddle ear uld
unwanLed A8 slde-eecLs
ularrhoea
vomlung
8ashes
Allergy/Anaphylaxls
lncreased A8 reslsLance ln communlLy
Plgher raLe of LreaLmenL fallure
use of low dosage dose or lncorrecL
course
1-8osenfeld, Laryngoscope 2003
2-Llule , 8r ! Cen racL 2006
3-Splro uM, !AMA 2006
4-Coker, !AMA 2010
34
A reasonable approach Lo !ames's
problem.










?ou revlew !ames 2 days laLer. Pe ls much beuer and has been LreaLed wlLh
only araceLamol for abouL 24 hours and hls dlsLress has dlsappeared.
33
?ou conslder !ames ls only 9 monLhs old, hls LemperaLure ls 38.3C now and
hls mum appears very concerned for hls dlsLress. ?ou are cerLaln LhaL !ames
has ACM buL aL presenL hls condluon ls noL severe and you have ume Lo
observe Lhe slLuauon. ?ou reassure and explaln Lo hls mum whaL you Lhlnk
and LhaL she needs Lo glve hlm araceLamol regularly. neverLheless, you
declde Lo dlscharge hlm wlLh an anublouc prescrlpuon (Amoxlclllln aL 80 mg/
kg/24 hours) and lnsLrucL hls mum LhaL lf sympLoms do noL lmprove wlLhln 2
days, she can call you and a dlerenL LreaLmenL can be agreed upon.
!ames mum asks lf anyLhlng can be done Lo prevenL furLher eplsodes of ACM, can
you advlse her on Lhls?
8eferences
1he dlagnosls and managemenL of acuLe ouus medla.
Amerlcan Academy of edlaLrlcs subcommluee on
managemenL of acuLe ouus medla. leJlottlcs. 2013 lebruary,
uCl: 10.1342/peds.2012-3488
8esplraLory LracL lnfecuons - anublouc prescrlblng. nlCL
cllnlcal guldellnes 69, lssued !uly 2008
Wald L8. AcuLe ouus medla and acuLe bacLerlal slnuslus. cllo
lofect uls 2011 May,32(Suppl 4):S277-83.
Wald L8, uemurl C. Anublouc 8ecommendauons for AcuLe
Cuus Medla and AcuLe 8acLerlal Slnuslus ln 2013 - 1he
Conundrum. leJlott lofect uls I 2013 !an 21. [Lpub ahead of
prlnL]
36
CCMMUNI1 ACUIkLD
NLUMCNIA
1he bas|cs of ranona| and prudent annb|onc use for common ch||dhood
|nfecnons |n ambu|atory care
37
AlberL has a bad cough.
A|bert's father br|ngs h|s 12 years o|d boy to your auennon. Pe wanLs AlberL
Lo be assessed because he has been coughlng for ve days now. Pe was
orlglnally dlagnosed wlLh a vlral lnfecuon by hls regular docLor, who
suggesLed salbuLamol and sLerold lnhalers, whlch AlberL has needed before.
AlberL has many allergles, mosLly Lo foodsLus and pollen. Pe llkes Lo play
fooLball, and he had conunued Lo be able Lo play unul yesLerday, when he
developed a hlgh fever and Lhe cough goL worse, on 2 occaslons resulung ln
AlberL havlng Lo Lhrow up.

?ou examlne AlberL, who ls auenuve and able Lo co-operaLe wlLh Lhe
examlnauon. Powever, you noLe LhaL hls resplraLory raLe ls 32/mln and he ls
sllghLly ouL of breaLh aer undresslng. Pe also has a LemperaLure of 39.2C.
?ou hear crackles over Lhe rlghL lung and nd AlberL's oxygen saLurauon Lo be
93 ln room alr. Pls LhroaL ls normal and he does noL have a cold. ?ou feel
AlberL has communlLy-acqulred pneumonla (CA).

38
8ackground lnformauon:
CommunlLy acqulred pneumonla
39
vlruses (20-43)
lnuenza vlrus
aralnuenzae vlrus
8Sv
8hlnovlrus
Adenovlrus
Coronavlrus
LnLerovlrus
8ocavlrus
MeLapneumovlrus

8acLerla
1yplcal
5tteptococcos poeomooloe
5tteptococcos qtoop A
5topbylococcos ooteos
(n. lofoeozoe & M.
cotbottolls)
ALyplcal
Mycoplosmo poeomooloe
cblomyJlo poeomooloe
8otJetello pettossls
neonates 1m-3m 4m-Sy Sy-1Sy
SLrep 8
Cram neg bacllll
(L. coll)
Chlamydla Lrachomaus
SLrepLococcus pneumonlae
vlruses
8ordeLella perLussls
vlruses
SLrepLococcus pneumonlae
Mycoplasma pneumonlae
Mycoplasma pneumonlae
SLrepLococcus pneumonlae
Chlamydla pneumonlae
vlruses
Curr Cpln ulm
Med 2003
In ch||dren, CA
|s most
common|y due
to v|ra|
|nfecnon, but
can be bacter|a|
w|th d|erent
pathogens
|mportant at
d|erent ages
A mlcroorganlsm ls ldenued ln less Lhan 10 of cases
WhaL ls pneumonla?
40
lu5A cAl qolJelloe, 2011
neumonla ls an acuLe or chronlc lnammauon of
Lhe lung caused by lnfecuon. 8acLerla, vlruses,
fungl or paraslLes can cause pneumonla.
1he mosL lmporLanL crlLerla for dlagnosls are
cllnlcal slgns and sympLoms

neumonla denluons:
very sensluve: e.g. fever and cough ! for
epldemlologlc conslderauons
very speclc: e.g. cllnlcal sympLoms and slgns
+ radlologlc documenLauon / mlcroblologlc
conrmauon ! dened by governmenL
regul aLory agencl es f or approval of
anumlcroblals Lo LreaL pneumonla
Lower resplraLory LracL lnfecuon (L81l) can be
synonymous wlLh CA when dened ln a way LhaL
ls cllnlcally orlenLed, Lo asslsL pracuuoners wlLh
dlagnosls and managemenL.

In some stud|es, v|ra|
aeno|og|es of CA have
been documented |n up
to 80 of ch||dren
younger than 2 years.
1he d|snncnons
between typ|ca| -
bacter|a|, atyp|ca| -
bacter|a| and v|ra| cases
are d|mcu|t. Laboratory
tests and chest
rad|ography cou|d he|p
but are not conc|us|ve.
Pow llkely ls Lhls Lo be a
communlLy acqulred pneumonla?
More dlrecLly relevanL Lo
evaluaung severlLy of dlsease ln
CA ls Lhe slmple measuremenL of
oxygen saLurauon by pulse
oxlmeLry.

41
lu5A cAl qolJelloe, 2011
AlberL has some slgns of dlsLress, 8y denluon
he suers from CA.
CA |n ch||dren |s dehned as
the presence of s|gns and
symptoms of pneumon|a |n
a prev|ous|y hea|thy ch||d
caused by an |nfecnon that
has been acqu|red outs|de
of the hosp|ta|.
ulagnosuc approach Lowards CA
anent w||| be managed as outpanent
Conslder
lnuenza vlrus and oLher vlral LesL, LesLs for
Mycoplosmo (dependlng on age and cllnlcal
slgns)! Lo help dellneaLe aeuology
ulse oxlmeLry! rule ouL need for
hosplLallsauon
robably noL necessary
8lood culLures
SpuLum! chlldren are rarely able Lo
expecLoraLe
neumococcal urlnary anugen ! oen false -
posluve
CompleLe blood cell counL and acuLe -phase
reacLanLs
8ouune chesL radlographs
42
lu5A cAl qolJelloe, 2011
anent w||| be managed |n hosp|ta|
Conslder
lnuenza vlrus and oLher vlral LesL, LesLs for
Mycoplosmo (dependlng on age)! Lo help dellneaLe
aeuology
ulse oxlmeLry ! conrm need for hosplLallsauon
8lood culLures ! hlgher raLes of bacLeraemla lf
unwell
SpuLum! lf chlld ls able Lo expecLoraLe
CompleLe blood cell counL and acuLe -phase
reacLanLs ! Lo assess response Lo Lherapy
8ouune chesL radlographs or ulLrasound! Lo
assess for pleural euslon
robably noL necessary
neumococcal urlnary anugen ! oen false -
posluve
CA |s a c||n|ca| d|agnos|s, therefore no further tesnng |s
requ|red to |dennfy CA. nowever, some further eva|uanon and
tests may be he|pfu| to determ|ne appropr|ate CA management
lf you manage AlberL as an ouLpauenL, he may noL need any furLher LesLs.
uoes Lhls chlld wlLh CA requlre
hosplLal admlsslon?
1. Chlldren and lnfanLs who have moderaLe Lo severe CA, as dened by several
facLors, lncludlng resplraLory dlsLress and hypoxemla (susLalned perlpheral oxygen
saLurauon <=90 aL sea level) should be hosplLallzed for managemenL ln a semng
where skllled paedlaLrlc nurslng care can be provlded.
2. lnfanLs less Lhan 3-6 monLhs of age wlLh suspecLed bacLerlal CA (buL also
frequenLly Lhose wlLh vlral aeuology) are llkely Lo beneL from hosplLallzauon,
especlally when Lhere are feedlng problems.
3. Chlldren and lnfanLs wlLh suspecLed or documenLed CA caused by a paLhogen
wlLh lncreased vlrulence, such as communlLy-assoclaLed meLhlclllln-reslsLanL
SLaphylococcus aureus (CA-M8SA) should be hosplLallzed. 1hese chlldren wlll be
generally very unwell and remaln so desplLe LreaLmenL wlLh anubloucs.
4. Chlldren and lnfanLs for whom Lhere ls concern abouL careful observauon aL home
or who are unable Lo comply wlLh Lherapy or unable Lo be followed up should be
hosplLallzed.
43
lu5A cAl qolJelloe, 2011
1here are some s|tuanons when adm|ss|on to hosp|ta| shou|d be
cons|dered |n a ch||d w|th CA.
lL looks llke AlberL can be managed aL home. 1he mosL common reasons
for admlsslon are hypoxaemla and feedlng dlmculues/refusal Lo drlnk.
CA - a sLraLegy Lo deLermlne
wheLher LreaLmenL ls requlred
Dec|de on where to manage the panent: based on cllnlcal
severlLy of sympLoms and pauenL characLerlsucs
Cho|ce of d|agnosnc test: lf you declde Lo manage pauenL
aL home posslbly 1) no blood sample, 2) vlral anugen, 3)
no -ray.
lf bacLerlal aeuology ls felL llkely (see nexL sllde) and vlral
anugen Lesung (lf relevanL ln your area) ls negauve,
anublouc LreaLmenL should be glven
S.pneumonlae conunues Lo be Lhe mosL common cause of
bacLerlal pneumonla and Lherefore should be covered
ln some pauenLs may need Lo conslder a macrollde lf aLyplcal
bacLerla are suspecLed
koute of treatment: oral
Duranon of treatment should be beLween 7 Lo 10 days,
buL local guldellnes may vary
Io||ow-up:
lf posslble revlew pauenL on anublouc LreaLmenL
wlLhln 48-72 hours
Change LreaLmenL and refer Lo hosplLal lf worsenlng
44
lu5A cAl qolJelloe, 2011
ul[eteououoo of boctetlol ooJ vltol cAl lo
cbllJteo, uoo et ol. leJlott lot. 2009
LlmlLed role for blood LesLs ln screenlng
(C8, C1, W8C, LS8) buL lf all or mosL
of Lhese are elevaLed bacLerlal aeuology
ls hlghly probable
Cn Lhe basls of hls cllnlcal slgns
AlberL ls mosL llkely Lo have
dlsease caused by Lyplcal bacLerla.
1herefore Lhe LreaLmenL should
cover Lhese rsL and foremosL.
AlberL can be managed aL home.
?ou Lake a full blood counL and
C8, boLh of whlch are elevaLed.
1esung for lnuenza ls negauve.
?ou are noL able Lo perform an -
ray aL your pracuce.
Anublouc cholce for CA - a sLraLegy
43
I|rst ||ne A8 treatment
no A8 Lherapy requlred + sLrlcL
follow-up (even wlLh vlral
lnfecuon chlldren can geL unwell)
Amoxlclllln or equlvalenL,
conslder macrollde rsL lf 3yo

8equlres hosplLallsauon

Amoxlclllln or equlvalenL


Conslder assessmenL ln hosplLal
Most probab|e cause
vlruses
lnvesugaLe for Mycoplosmo,
lofoeozo A/8, 5. poeomooloe
5. poeomooloe, 5. pyoqeoes,
conslder 5. ooteos ln case of
necrouzlng pneumonla/abscess
5. poeomooloe, 5. pyoqeoes

5. poeomooloe, 5. pyoqeoes
resentanon
8llaLeral pneumonla, well chlld
wlLh slgns of vlral lnfecuon
(pharynglus, runny nose, wheezlng,
dlarrhoea eLc.)
8llaLeral pneumonla,
moderaLely unwell
8llaLeral pneumonla, severely
unwell

Lobar/segmenLal pneumonla,
mlld

Lobar/segmenLal pneumonla,
moderaLe Lo severe
8toJley. lluI 2002
lu5A cAl qolJelloe, 2011
Duranon of treatment must be of 7 - 10 days
8lsks & 8eneLs of anublouc use ln
CA
46
k|sks of A8 |n CA
unnecessary A8 LreaLmenL ln
chlldren wlLh vlral CA
unnecessary broad-specLrum
anublouc LreaLmenL ln chlldren
mosL llkely Lo have 5.poeomooloe
lnfecuon responslve Lo penlclllln
rescrlblng errors resulung ln
lnadequaLe LreaLmenL
unwanLed A8 slde-eecLs
ularrhoea
vomlung
8ashes
Allergy/Anaphylaxls
Selecuon of reslsLanL bacLerla
8lsk of re-consulLauon for an
lnfecuon caused by a reslsLanL
mlcroorganlsm
8enehts of A8 |n CA
ln bacLerlal CA A8 are eecuve
LreaLmenL. 1here are no beneLs
ln case of vlral CA, buL
dlsungulshlng vlral and bacLerlal
CA can be dlmculL.
ln Lyplcal 5.poeomooloe lobar
pneumonla A8 LreaLmenL may
prevenL suppurauve
compllcauons
lamlly & hyslclan reassurance,
however revlew ls lmporLanL Lo
monlLor progress
A reasonable approach Lo AlberL's
problem.
?ou explaln Lo AlberL and hls faLher LhaL you suspecL CA. ?ou feel LhaL AlberL
would beneL from anubloucs and LhaL Lhe sympLoms and slgns are noL
severe enough Lo requlre an admlsslon Lo hosplLal. When you perform a rapld
screen for lnuenza, Lhe LesL comes back negauve. Lucklly, and desplLe hls
many allergles, AlberL's faLher conrms LhaL he has had penlclllln anubloucs
prevlously wlLhouL any sympLoms suggesuve of allergy. 1herefore you
propose Lo sLarL an oral anublouc LreaLmenL, chooslng as rsL llne amoxlclllln.
?ou also suggesL Lo dlsconunue Lhe lnhalauons for now. ?ou warn AlberL LhaL
he may experlence some dlarrhoea, buL LhaL he should hopefully feel beuer
wlLhln a few days. ?ou ask Lo see AlberL agaln ln a couple of days Lo assess hls
progress and Lo revlew your LreaLmenL.
?ou revlew AlberL 2 days laLer. Pe ls much beuer and has been afebrlle for a
day alLhough sull coughlng. 1here ls no wheezlng on ausculLauon. ?ou
propose Lo go on wlLh anublouc LreaLmenL for anoLher 3 days. ?ou ask
AlberL's faLher Lo conLacL you lf he geL worse agaln and you reassure boLh
LhaL Lhe cough should evenLually seule down.
47
8eferences

Slnanlous CA, Slnanlous AC. CommunlLy acqulred pneumonla ln
chlldren. cott Oplo lolm 2003 May,11(3):218-23
8radley !S eL al. 1he managemenL of communlLy-acqulred
pneumonla ln lnfanLs and chlldren older Lhan 3 monLhs of age:
cllnlcal pracuce guldellnes by Lhe edlaLrlc lnfecuous ulseases
SocleLy and Lhe lnfecuous ulseases SocleLy of Amerlca. clu AJvooce
Access publlshed AugusL 301, 2011
uon eL al. ulerenuauon of bacLerlal and vlral CA ln chlldren,
leJlott lot. 2009 leb,31(1):91-6
8radley !S. ManagemenL of communlLy-acqulred pedlaLrlc
pneumonla ln an era of lncreaslng anublouc reslsLance and
con[ugaLe vacclnes. lluI, 2002 !un,21(6):392-8



48
ACU1L knINCSINUSI1IS
1he bas|cs of ranona| and prudent annb|onc use for common ch||dhood
|nfecnons |n ambu|atory care
49
Sophla has rhlnorrhoea, headache and cough.
Soph|a's mother br|ngs her 8 year o|d daughter to your auennon. Sophla has
been complalnlng abouL perslsLenL, Lhlck nasal dlscharge, nasal congesuon,
headache and cough for 13 days now. 1he cough ls worse aL nlghL buL Lhere ls
no wheezlng. Lvery day, ln Lhe aernoon, she has a LemperaLure splke of
38.2C. She doesn'L vomlL and has no rashes or oLher sympLoms. 1here are no
slgns of referred nasal forelgn bodles. no allergy or oLher lllnesses are
menuoned by Sophla's moLher.

?ou examlne Sophla, who ls breaLhlng well, wlLhouL slgns of dyspnoea, no
fever aL Lhe momenL. ?ou don'L nd any eye abnormallues, her Lympanlc
membranes are clear. She has nasal congesuon wlLh Lhlck yellow purulenL
mucus ln Lhe posLerlor nasal pharynx. She has mlld Lenderness Lo palpauon of
her maxlllary slnuses. Per oral pharynx ls non eryLhemaLous. Per breaLh ls
malodorous. She has no obvlous denLal carles or paln on Lapplng of her LeeLh.
?ou feel Sophla has an acuLe slnuslus.
30
WhaL ls slnuslus?
31
lu5A 8octetlol ocote tblooslooslus qolJelloe, 2012
AcuLe rhlnoslnuslus ls dened as an lnammauon of Lhe mucosal llnlng of Lhe
nasal passage and paranasal slnuses lasung up Lo 4 weeks.


Acote boctetlol slooslus lo cbllJteo. ue Motl, NIM 2012
lL can be caused by varlous lnclung facLors lncludlng allergens, envlronmenLal
lrrlLanLs, and lnfecuon by vlruses, bacLerla, or fungl.

A vlral aeuology assoclaLed wlLh a upper resplraLory LracL lnfecuon (u8l) or Lhe
common cold ls Lhe mosL frequenL cause of acuLe rhlnoslnuslus
8ackground lnformauon: acuLe slnuslus
ApproxlmaLely 80 of eplsodes
of acuLe bacLerlal slnuslus are
preceded by a vlral u8l
32
Aeuologles of A88S:
5. poeomooloe(20-J0X)
n. lofoeozoe (J0X)
M. cotottbolls (8-11X)

Less commonly also:
5. ooteos, 5. pyoqeoes
no growLh ln 30
1o declde wheLher Lo LreaL Sophla for slnuslus, furLher evaluauon needs Lo Lake place
1he prevalence of a bacLerlal
l n f e c u o n d u r l n g a c u L e
r hl nos l nus l us ( A88S ) l s
esumaLed Lo be 2-10,
whereas vlral causes accounL
for 90-98
Anubloucs are frequenLly prescrlbed for pauenLs presenung wlLh sympLoms of
acuLe rhlnoslnuslus, belng Lhe h leadlng lndlcauon for anumlcroblal
prescrlpuons by physlclans ln omce pracuce
lu5A 8octetlol ocote tblooslooslus qolJelloe, 2012 Acote boctetlol slooslus lo cbllJteo. ue Motl, NIM 2012
Pow llkely ls Lhls Lo be a A88S?
lmaglng sLudles cannoL
dlsungulsh lnammauon
caused by vlruses from LhaL
caused by bacLerla
33
Sophla has perslsLenL sympLoms. lL seems Lo be
a bacLerlal lnfecuon
Cverprescrlpuon of
anubloucs ls a ma[or
concern ln Lhe
managemenL of acuLe
rhlnoslnuslus, largely due
Lo Lhe dlmculLy ln
dlerenuaung A88S from a
vlral u8l (upper resplraLory
lnfecuon)
lu5A 8octetlol ocote tblooslooslus qolJelloe, 2012
C||n|ca| Cr|ter|a for the D|agnos|s of
A8S: 3 pauerns of onset

erslsLenL sympLoms
nasal congesuon, rhlnorrhea, or cough 10
days' durauon wlLhouL lmprovemenL

Severe sympLoms
1emperaLure 38.3C for 3-4 days
urulenL rhlnorrhea for 3-4 days

Worsenlng sympLoms
8eLurn of sympLoms aer lnlual resoluuon
new or recurrenL fever, lncrease ln
rhlnorrhea, or lncrease ln cough
Acote boctetlol slooslus lo cbllJteo. ue Motl, NIM 2012
34
ulagnosuc approach Lowards Slnuslus
1he d|agnos|s of Acute bacter|a| s|nus|ns |n ch||dren |s c||n|ca|
and based on h|story, w|th the use of the cr|ter|a ||sted |n the
prev|ous s||de

?ou don'L need any furLher LesLs Lo conrm Sophla's slnuslus.
lmaglng sLudles (plaln-lm radlography, compuLed Lomography, magneuc
resonance lmaglng M8l, and ulLrasonography) show slgns of slnus
lnammauon buL are noL recommended ln pauenLs wlLh uncompllcaLed
lnfecuon, glven Lhe low speclclLy of Lhese sLudles. CulLures are noL lndlcaLed.
lmaglng may be useful ln rullng ouL a dlagnosls of slnuslus when Lhe ndlngs are
normal. C1 or M8l ls warranLed ln pauenLs wlLh sympLoms or slgns suggesung
compllcaLed slnuslus (e.g., severe headache, selzures, focal neurologlc declLs, perl-
orblLal oedema, or abnormal lnLraocular muscle funcuon) and may show dralnable uld
collecuons wlLhln Lhe cranlum or Lhe orblL
Acote boctetlol slooslus lo cbllJteo. ue Motl, NIM 2012
Slnuslus - a sLraLegy Lo deLermlne
wheLher LreaLmenL ls requlred
D|agnosnc approach: ln uncompllcaLed cases, we don'L
perform radlologlcal lmaglng or mlcroblologlcal LesL.


1he role of anublouc Lherapy ln acuLe bacLerlal slnuslus ls
conLroverslal, wlLh few sLudles provldlng dlscordanL
resulLs. Anubloucs Lo be suggesLed lf sLrong suspecL of
bacLerlal aeuology
nasal sallne washes or sprays don'L provlde subsLanual
rellef from sympLoms
lnLranasal glucocorucolds provlde only sllghL rellef
AnuhlsLamlnes and decongesLanLs have been shown Lo
be of no beneL
koute of treatment: oral
I|rst ||ne treatment: AmoxlclavulanaLe
Duranon of treatment : 10 - 14 days
Io||ow-up:
33
Cn Lhe basls of her cllnlcal slgns
Sophla ls mosL llkely Lo have
dlsease caused by usual bacLerla.
1herefore Lyplcal rsL-llne
anublouc LreaLmenL should be
suggesLed.
Sophla can be managed aL home.
?ou don'L need Lo perform any
furLher LesL, lncludlng nasal swab
culLure or C1 or M8l
8lsks & 8eneLs of anublouc use ln Slnuslus
4-Abovoo-5olotooto, cocbtooe 2008
5-cott Oplo lofect uls 2012
6-lu5A, cllo lofect uls 2012
1-Cotbou, IAMA 2012
2-8ocbet, Atcb loteto MeJ 200J
J-oooq, loocet 2008
*NN1, oombet oeeJeJ to tteot
8enehts of A8: Sma|| A8 emcacy
demonstrated on appropr|ate|y
|dennhed panents
S,6
erslsLenL sympLoms (nasal dlscharge or cough for 10
days wlLhouL lmprovemenL),
C8 acuLely worsenlng sympLoms (nasal dlscharge or
dayume cough worsenlng aer 3-6 days wlLh new onseL
fever, headache or worsenlng ln nasal dlscharge aer
LranslenL lmprovemenL),
C8 severe sympLoms (LemperaLure 39'C and purulenL
nasal dlscharge or faclal paln for aL leasL 3-4 consecuuve
days).
ln Lhose cases A8 are LhoughL Lo decrease boLh Lhe
durauon and Lhe severlLy of sympLoms and poLenually
prevenL suppurauve compllcauons
llrsL-llne LreaLmenL
6

Amoxlclllln/clavulanaLe 10 days
Amoxlclllln 10-14 days
Second-llne agenLs
ClarlLhromycln 14 days
AzlLhromycln 3 days
1rlmeLhoprlm-sulfameLhoxazole 10 days
Cllndamycln + C2C or C3C (for en allergy)

36
k|sks of A8: |mportant |nd|v|dua||y
and for the commun|ty
use of unnecessary A8 for Lhe LreaLmenL of non
bacLerlal lnfecuon
8lsk for A8 slde-eecLs
8ash, ularrhoea, Lxcesslve dlagnoses of allergy
Selecuon & dlssemlnauon of AM8 reslsLance
8e-consulLauons for slde-eecLs and reslsLanL
bacLerla relaLed lnfecuons
unnecessary cosLs
lL ls esumaLed LhaL unnecessary A8 LreaLmenLs ln
acuLe slnuslus cosL .
Among pauenLs wlLh acuLe rhlnoslnuslus, a 10-day
course of amoxlclllln compared wlLh placebo dld noL
reduce sympLoms aL day 3 of LreaLmenL.
1
AdulL pauenLs ln general pracuce wlLh cllnlcally
dlagnosed acuLe rhlnoslnuslus experlenced
no advanLage wlLh amoxlclllln-clavulanaLe
more llkely Lo experlence adverse eecLs.
2

ln a meLa-analysls of 9 randomlzed conLrolled Lrlals
(n=2347):
Lhe mean nn1 pauenLs wlLh A8 was 13 (93 Cl, 7
Lo 190) before one addluonal pauenL beneLs from
A8 LreaLmenL.
3

64 to 80 of panents were cured at 14 days even
w|thout annb|onc treatment.
3,4

ModeraLe sympLom severlLy does noL dlsungulsh a
bacLerlal from a vlral lnfecuon
A reasonable approach Lo Sophla's
problem.
?ou explaln Lo Sophla and her moLher your dlagnosls of slnuslus and lLs
suspecLed bacLerlal orlgln. ?ou feel LhaL Sophla would beneL from anubloucs
and LhaL she can be LreaLed aL home. ?ou explaln LhaL lL's noL useful Lo
perform an x-8ay or a C1 scan for a beuer dlagnosls. ?ou ask Sophla's
moLher abouL any allergy Lo anubloucs and you propose Lo sLarL an oral
anublouc LreaLmenL, chooslng as rs-llne hlgh dose amoxlclllln plus clavulanlc
acld. ?ou also suggesL noL Lo glve sLerolds, nasal washes, decongesLanLs or
oLher drugs. ?ou warn Sophla LhaL she may experlence some dlarrhoea, buL
LhaL she should hopefully feel beuer wlLhln a few days. ?ou ask Lo see Sophla
agaln ln Len days Lo assess her progress.

?ou revlew Sophla 10 days laLer. She ls much beuer and has been wlLhouL
cough, rhlnorrhea and headache for 2 days. ?ou propose Lo sLop wlLh
anublouc LreaLmenL.
37
8eferences
Chow AW eL al. luSA Cllnlcal racuce Culdellne for AcuLe 8acLerlal 8hlnoslnuslus ln
Chlldren and AdulLs. clu Advance Access publlshed March 20, 2012
ue Murl C eL al. AcuLe bacLerlal slnuslus ln Chlldren. NIM 2012,367:1128-34
Carbuu !M eL al. Amoxlclllln for acuLe rhlnoslnuslus: a randomlzed conLrolled Lrlal.
IAMA 2012 leb 13,307(7):683-92
8ucher PC eL al. LecL of amoxlclllln-clavulanaLe ln cllnlcally dlagnosed acuLe
rhlnoslnuslus: a placebo-conLrolled, double-bllnd, randomlzed Lrlal ln general
pracuce. Atcb loteto MeJ 2003 Aug 11-23,163(13):1793-8
?oung ! eL al. Anubloucs for adulLs wlLh cllnlcally dlagnosed acuLe rhlnoslnuslus: a
meLa-analysls of lndlvldual pauenL daLa. loocet 2008 Mar 13,371(9616):908-14
Ahovuo-SaloranLa. Anubloucs for acuLe maxlllary slnuslus. cocbtooe 2008 Apr 16,
(2):Cu000243
Mandal 8 eL al. 8ole of anubloucs ln slnuslus. cott Oplo lofect uls 2012 Apr,23(2):
183-92

38
UkINAk 1kAC1 INILC1ICN
1he bas|cs of ranona| and prudent annb|onc use for common ch||dhood
|nfecnons |n ambu|atory care
39
Suzle ls auendlng wlLh a fever.
Suz|e's mother br|ngs 7 month-o|d Suz|e to your omce. She has come Lo see
you, because Suzle has had a fever up Lo 39.3 'C for Lhe lasL 2 days. She ls
refuslng her feeds and has vomlLed several umes. Per moLher has noL noLed
any dlarrhoea, whlch she was expecung because Suzle's older slsLer had a bad
Lummy Lhe prevlous week. Suzle has noL been qulLe herself Lhose lasL Lwo
days. uesplLe havlng occaslonally wanLed Lo play a llule, she seemed freul
and cllngy. 1he famlly wenL Lo see an emergency omce physlclan when Lhe
vomlung sLarLed. Pe was unable Lo nd a source for Lhe fever, buL found
Suzle Lo be qulLe well ln herself. Pe suggesLed araceLamol and frequenL
lnLake of slps of elecLrolyLe soluuon, Lhlnklng LhaL Lhls mlghL be a vomlung
bug. Suzle's moLher ls brlnglng her ln, because she worrles as Lhlngs are noL
lmprovlng.
?ou examlne Suzle and nd her auenuve, buL noL very playful. She has a
LemperaLure of 38.8'C, pulse raLe of 148/mln and resplraLory raLe of 23/mln.
Per hands and feeL are warm and she looks plnk. 1here are no slgns of
dehydrauon and Suzle's fonLanel ls so and level. 1he resL of Lhe examlnauon
ls normal. ?ou suspecL Suzle has a urlnary LracL lnfecuon.
60
8ackground lnformauon: communlLy-
acqulred urlnary LracL lnfecuon
In prev|ous|y hea|thy
ch||dren, U1I |s a
bacter|a| d|sease most
common|y due to
|nfecnon by Gram-
neganve bac||||
61
Many enLerobacLerlaceae lsolaLes (. coll, klebslello spp., otetoboctet spp.) are now reslsLanL Lo
commonly used anubloucs. lor example, reslsLance of . coll Lo
amoxlclllln ls mosLly Loo hlgh (40-60) Lo recommend Lhls A8 as a rsL llne u1l
LreaLmenL.
co-amoxlclav varles from 0 Lo 30 .
LS8L produclng enLerobacLerlaceae are lncreaslngly lsolaLed drlven by buL also llmlung Lhe
usefulness of cephalosporlns.
LnLerococcl are naLurally reslsLanL Lo all cephalosporlns.
scbetlcblo coll (80-85X)
ltoteos mltobllls (5-10X)
klebslello poeomooloe (5X)

Less commonly also:
otetococcos spp
otetoboctet spp
lseoJomooos oetoqlooso
5topbylococcos ooteos
ke|evant bacter|o|og|ca| |nformanon for treatment
1o declde wheLher Lo LreaL Suzle for u1l, furLher evaluauon needs Lo Lake place
Pow llkely ls Lhls Lo be urlnary LracL
lnfecuon?
62
When young
ch||dren rema|n
febr||e w|thout
deve|op|ng
symptoms strong|y
suggesnve of an
a|ternanve
d|agnos|s, U1I
shou|d be
cons|dered and
ru|ed out
Suzle has several rlsk
facLors for u1l
nlCL u1l ln chlldhood guldellne 2007
AA u1l guldellne 2011
Conslder Lhe dlagnosls of
febrlle u1l (whlch can be
pyelonephrlus) ln case of:
unexplalned sepsls,
parucularly ln chlldren
less Lhan 24 monLhs
unexplalned fever for
48h
Conslder Lhe dlagnosls of
cysuus ln case of:
lnconunency,
haemaLurla, urgency of
mlcLurluon
Low welghL galn,
vomlung, decreased
feedlng ln bables
1hls applles Lo Suzle.
And then?
1. urlne dlpsuck ! LeukocyLe
esLerase (LL) and nlLrlLe Lesung
helps Lo ldenufy u1l
2. urlne mlcroscopy ! yurla and
bacLerlurla are suggesuve of u1l
3. urlne culLure! wlll conrm u1l,
ldenufy causauve organlsm and
allow for anublouc Lherapy Lo
be adapLed accordlngly
ulagnosuc approach Lowards
suspecLed u1l
1o assess whether a U1I |s present co||ect an
uncontam|nated ur|ne samp|e
63
nlCL u1l ln chlldhood guldellne 2007
AA u1l guldellne 2011
Suzle's urlne dlpsuck ls posluve for LL buL
negauve for nlLrlLe, you are unable Lo
perform urgenL mlcroscopy ln your pracuce.
C1ICNS for appropr|ate ur|ne samp||ng
Clean-caLch ! usually accepLable,
requlres pauence and musL be clean
caLch!
Supra-publc asplrauon or ln-ouL bladder
caLheLerlzauon ! may noL be
accepLable Lo parenLs, can be dlmculL lf
provlder has llule experlence of
procedure
A urlne bag should be a lasL resorL !
resulLs may noL be lnLerpreLable
WhaL consuLuLes a u1l?
1he accuraLe dlagnosls of u1l may prevenL renal
compllcauons and wlll reduce overLreaLmenL. ln
some semngs ln Lurope lL may noL be felL necessary
Lo obLaln urlnary culLure for cerLaln age groups lf LL
and nlLrlLe are posluve on dlpsuck.
64
1o conhrm U1I the comb|nanon of 1) symptomanc ch||d, 2)
abnorma| ur|ne d|psnck]m|croscopy and 3) a pos|nve cu|ture |s
requ|red
WhaL consuLuLes a posluve
urlne culLure?
ulerenL cuL-os for growLh
are applled
AA: 30,000 cfu/ml
nlCL: 100,000 cfu/ml

ulerenL cuL-os may be ln
use for dlerenL Lypes of urlne
sample

CrowLh should lnvolve a
uropaLhogen (see background)
Suzle's urlne resulLs are suggesuve for u1l. 1aklng a urlne
culLure wlll help you Lo conrm or rule ouL Lhe dlagnosls of
u1l.
nlCL u1l ln chlldhood guldellne 2007
AA u1l guldellne 2011
u1l LreaLmenL - a sLraLegy for
chooslng LreaLmenL
Dec|d|ng on need for referra|: lf serlous lllness ls suspecLed or Lhe pauenL ls very
young (e.g. <3 monLhs) referral Lo secondary care should be consldered
Determ|ne |ocanon: Cllnlcal evaluauon Lo dlerenuaLe cysuus and upper urlnary
LracL lnfecuon (pyelonephrlus) - generally wlLh fever and loln paln lndlcaung
upper urlnary LracL lnfecuon
Cho|ce of annb|onc: 1hls ls deLermlned by 1) common paLhogens, 2) local
reslsLance pauerns (lf avallable) and 3) avallablllLy of local guldellnes
koute of treatment: Cral and lnLravenous are equally emcaclous, buL may be of
dlerenL beneL cllnlcally
Duranon of treatment should be beLween 7 Lo 14 days for upper u1l and 3 Lo 3
days for lower u1l
63
uesplLe a nlLrlLe negauve dlpsuck you may wanL Lo sLarL Suzle on
anubloucs emplrlcally, because she has been unwell for a llule whlle.
Cnce U1I |s h|gh|y ||ke|y or |s conhrmed, annb|onc treatment |s
necessary wh||e awa|nng cu|tures
Anublouc cholce for u1l- a sLraLegy
66
Some treatment cho|ces.
Cral lnLravenous
Amoxlclllln-clavulanlc
acld
Cerlaxone
1rlmeLhoprlm-
sulfameLhoxazole
CefoLaxlme
Cexlme Ceazldlme
Cedpodoxlme CenLamlcln
Cephalexln 1obramycln
Cefuroxlme axeul lperaclllln
AA u1l guldellne 2011
lor Suzle may wanL Lo conslder
Amoxlclllln - clavulanlc acld ln areas of
low reslsLance or an oral cephalosporln
8eneLs & 8lsks of anublouc use ln u1l
67
k|sks of A8 |n U1I
unnecessary A8 LreaLmenL lf u1l
noL formally dlagnosed
unnecessary broad-specLrum
anublouc LreaLmenL when a
urlnary culLure has noL been
performed
rescrlblng errors resulung ln
lnadequaLe LreaLmenL
unwanLed A8 slde-eecLs
ularrhoea
vomlung
8ashes
Allergy/Anaphylaxls
Selecuon of reslsLanL bacLerla
8lsk of re-consulLauon for an
lnfecuon caused by a reslsLanL
mlcroorganlsm
8enehts of A8 |n U1I
Slmple screenlng LesLs are
avallable wlLh good sensluvlLy for
u1l
A mlcroblologlcal dlagnosls and
Lherefore ldenucauon of clear
lndlcauon for LreaLmenL can
usually by made
A8 are an eecuve LreaLmenL for
u1l and may avold suppurauve
compllcauons of Lhe dlsease
Long-Lerm renal damage may be
reduced lf u1ls are prompLly and
aggresslvely LreaLed
lamlly & hyslclan reassurance,
buL wlLh opuon Lo dlsconunue lf
dlagnosls ls noL conrmed
A reasonable approach Lo Suzle's
problem.
lL ls agreed Lo evaluaLe Suzle for posslble u1l. 1he opuons for obLalnlng a
urlne sample are dlscussed wlLh Suzle's mum. ?ou feel LhaL a u1l ls qulLe
llkely. 1herefore you suggesL Lo Suzle's moLher Lo perform an ln-ouL caLheLer.
urlne dlpsuck ls posluve for LL buL negauve for nlLrlLe. ?ou Lherefore send o
a sample for culLure and declde Lo sLarL Suzle on oral anublouc LreaLmenL,
chooslng Lhe anublouc accordlng Lo your local guldellnes for LreaLmenL of
u1l. ?ou ask Lo see Suzle agaln ln a couple of days Lo assess her progress and
Lo revlew your LreaLmenL wlLh culLure and sensluvlLy resulLs. ?ou arrange for
furLher lmaglng accordlng Lo your nauonal u1l guldellnes. ?ou lnsLrucL Suzle's
moLher Lo conLacL you or her local emergency deparLmenL lmmedlaLely ln
case of perslsLenL vomlung or any deLerlorauon.

?ou revlew Suzle 3 days laLer. She ls much beuer and has been afebrlle for
around 36 hours. Per urlne culLure has shown 1,000 cfu/ml mlxed growLh.
?ou Lherefore declde Lo sLop anublouc LreaLmenL aL Lhls polnL. ?ou ask
Suzle's moLher Lo conLacL you should she geL worse agaln over Lhe course of
Lhe nexL days.
68
8eferences
nauonal lnsuLuLe for PealLh and Cllnlcal Lxcellence, u. CC 34
urlnary LracL lnfecuon: dlagnosls, LreaLmenL and long-Lerm
managemenL of urlnary LracL lnfecuon ln chlldren. lssued AugusL
2007. Accesslble aL hup://www.nlce.org.uk/CC034
Amerlcan Academy of edlaLrlcs. Subcommluee on urlnary 1racL
lnfecuon and SLeerlng Commluee on CuallLy lmprovemenL and
ManagemenL. urlnary 1racL lnfecuon: Cllnlcal racuce Culdellne for
Lhe ulagnosls and ManagemenL of Lhe lnlual u1l ln lebrlle lnfanLs
and Chlldren 2 Lo 24 MonLhs. edlaLrlcs, orlglnally publlshed onllne
AugusL 28, 2011, uCl: 10.1342/peds.2011-1330. Accesslble aL
hup://pedlaLrlcs.aappubllcauons.org/conLenL/early/2011/08/24/
peds.2011-1330
69
SkIN AND SCI1 1ISSUL INILC1ICN
1he bas|cs of ranona| and prudent annb|onc use for common ch||dhood
|nfecnons |n ambu|atory care
70
1om has a rash.
1om's dad br|ngs 3 year-o|d 1om to your omce. Pe and 1om have come Lo
see you, because 1om has developed a rash over Lhe lasL 2 days. 1hls has
sLarLed wlLh some reddlsh spoLs around 1om's mouLh whlch have gradually
enlarged and become crusLy. 1om's parenLs have also nouced addluonal
spoLs and crusung on hls Lummy. 1om ls oLherwlse healLhy and has no known
allergles. 1om's dad ls worrled, because alLhough he ls very well, Lhe leslons
are spreadlng. 1he famlly have applled a baslc cream wlLhouL any
lmprovemenL. When speclcally asked wheLher 1om has complalned of paln
or lLchlng, 1om's faLher says he has nouced 1om ls plcklng aL Lhe rash, buL
does noL seem Lo be oLherwlse boLhered by lL.

When you examlne 1om,
Lhls ls whaL you see:
71
8ackground lnformauon: communlLy-
acqulred skln & so ussue lnfecuon
Sk|n rashes are a frequent
prob|em |n neonata| and
paed|atr|c panents. Most
of them are ben|gn and
se|f-||m|nng.
72
2. vlral rashes
Chlckenpox (veslcles) arvovlrus 819
Pv (warLs, verrucae) oxvlrus (Molluscum)
Measles Mumps
PPv3/PPv6 Coxsacklevlrus (PlM)
1. non-speclc rashes, e.g. maculopapular
erupuons, urucarla
3. lungal rashes
1lnea corposls 1lnea pedls
1lnea caplus lLyrlasls rosacea
4. 8ashes relaLed Lo paraslLe lnfesLauons
Peadllce
Scables
non-bacLerlal aeuology
Commonly: 5tteptococcos pyoqeoes or
5topbyloccos ooteos

8arely: n. lofoeozoe, l. oetoqlooso,
Anaerobes and oLhers
8acLerlal aeuology
Pow llkely ls Lhls Lo be bacLerlal SS1l?
1o dehne whether a sk|n |nfecnon |s ||ke|y to be due to bacter|a,
the rash must be c|ass|hed further on the bas|s of c||n|ca|
features |nc|ud|ng d|str|bunon and assoc|ated symptoms
73
Lpldermls
uermls
SweaL gland
SubcuLaneous layer
lascla
Muscle
8aslc anaLomy of skln
sLrucLures
lmpeugo sLaphylococcal scaled skln syndrome
ecLhyma cellullus
folllcullus furuncle carbuncles
Lpldermls: malnly
5.pyoqeoes, some
5.ooteos
uermls: malnly
5.pyoqeoes, some
5.ooteos
ueeper skln
sLrucLures: malnly
5.ooteos, some
5.pyoqeoes
ulagnosuc approach Lowards SS1l
8ecause aeno|og|ca| d|agnos|s |n suspected bacter|a| SS1I |s
genera||y d|mcu|t and unnecessary |n ch||dren w|th m||d symptoms,
the key to management |s assessment of d|sease sever|ty
74
SLevens eL al. Clu 2003, 41:1373-406
Ind|cators of severe]system|c d|sease
noLe: Conslder wheLher feaLures of Loxlc
shock are presenL ! lf so, lmmedlaLe
referral Lo hosplLal ls warranLed
anent w||| be managed as outpanent
need for furLher evaluauon & hosplLal
admlsslon musL be carefully consldered
Conslder
Local reslsLance pauerns Lo dene
cholce of anublouc
Swab lf Lhere ls pus or any exudaLe LhaL
ls easlly accesslble
robably noL necessary
Any furLher Lesung
1om appears well and can probably be
managed as an ouLpauenL
unusual SS1l
Superclal, uncompllcaLed
lnfecuon (lncludes lmpeugo,
erlslpelas and cellullus)
necrouslng lnfecuon, lnfecuons
assoclaLed wlLh blLes and anlmal
conLacL, surglcal slLe lnfecuons
lnfecuons ln Lhe
lmmunocompromlsed hosL.
73
In certa|n s|tuanon SS1I can be caused by unusua| organ|sms and
caunon |s necessary |n dec|d|ng on further management and
treatment
8ed ags ln SS1l
lnfecuon llkely Lo lnvolve unusual
organlsm and requlre lnpauenL LreaLmenL
SysLemlc sympLoms and slgns
especlally fever, Lachycardla,
hypoLenslon
Severe paln
SS1l ln assoclauon wlLh anlmal or
human blLes (1eLanus sLaLus musL be
checked!)
PlsLory of Lravel
Surglcal slLe lnfecuons
lmmunocompromlsed hosL
luSA classlcauon of SS1l
SLevens eL al. Clu 2003, 41:1373-406
1om does noL have any red ags and ls
unllkely Lo have unusual SS1l
Speclc conslderauons when
Lreaung superclal SS1l
1ype of SS1l: lmpeugo may be LreaLed Loplcally, cellullus and eryslpelas
wlll need sysLemlc LreaLmenL
Abscess formauon: Abscesses, furuncles and carbuncles may need
lnclslon and dralnage and can subsequenLly usually be managed
wlLhouL anubloucs
Locauon: lmpeuglnous leslons on Lhe eyellds or near Lhe mouLh may
be dlmculL Lo LreaL Loplcally
LxLenL of dlsease: more exLenslve dlsease LhaL needs Lo be rapldly
conLrolled requlres sysLemlc LreaLmenL
Local reslsLance prevalence: Where M8SA ls common, LreaLmenL
cholces may have Lo be adapLed accordlngly
76
Cnce SS1I |s deemed h|gh|y ||ke|y to be bacter|a|, annb|onc
treatment |s necessary, but a few add|nona| cons|deranons are
requ|red to determ|ne treatment cho|ce
1om has muluple leslons.
Chooslng anubloucs for SS1l -
conslderauons of bug/drug comblnauon
1he most common bacter|a| pathogens |n SS1I (!"$%&'()(* and
!",-.(-*) must be cons|dered when choos|ng annb|oncs for SS1I
77
5.pyoqeoes
100 penlclllln sensluve
Macrollde reslsLance: 2-20 by an eMux pump mechanlsm
AssoclaLed Loxln producuon posslble can be lnLerrupLed uslng cllndamycln or
rlfamplcln
5.ooteos
enlclllln ls lneecuve slnce mosL 5.ooteos are penlcllllnase producers
encllllnase reslsLanL beLa-lacLams such as llucloxaclllln are usually eecuve
ln communlLy acqulred SS1l ln Lurope
M8SA ls rare ln Lurope and should be consldered only for pauenLs comlng
from counLrles wlLh hlgh CA-M8SA lncldence
ke|evant bacter|o|og|ca| |nformanon for treatment
SS1l - chooslng anublouc LreaLmenL
Cho|ce of annb|onc depends on the type of SS1I, |ts d|str|bunon
and spread, ava||ab|||ty of d|erent annb|oncs and formu|anons,
||ke|y causanve organ|sms and known |oca| res|stance pauerns
78
D|sease Annb|onc Comment
Impengo enlcllllnase-reslsLanL A8, such as
llucloxaclllln
Macrolldes, such as LryLhromycln
Cllndamycln


Amoxlclllln/Clavulanlc acld
Muplrocln (Loplcal)


S.pyogenes and S.aureus may be reslsLanL
Cen acuve agalnsL M8SA, poLenual of reslsLance ln
eryLhromycln-reslsLanL sLralns, lnduclble reslsLance
ln M8SA ls a rlsk

lf llmlLed number of leslons and approprlaLe locauon
Ce||u||ns]
Lrys|pe|as
enclllln
enlcllllnase-reslsLanL A8, such as
llucloxaclllln
Cllndamycln
Amxoclllln/Clavulanlc acld
1eLracycllnes, such as uoxycycllne
Cnly lf classlcal eryslpelas


See above

noL ln persons <8 years of age, may be consldered ln
M8SA
SLevens eL al. Clu 2003, 41:1373-406
1hese are Lhe anubloucs LhaL one
may wanL Lo conslder for 1om.
8eneLs & 8lsks of anublouc use ln SS1l
79
k|sks of A8 |n SS1I
unnecessary A8 LreaLmenL , e.g.
for locallsed abscesses/furuncles
unnecessary broad-specLrum or
oral anublouc LreaLmenL
1reaLmenL of rashes LhaL are noL ln
facL due Lo bacLerlal lnfecuon (e.g.
fungl, oLher aeuology
unwanLed A8 slde-eecLs
ularrhoea
vomlung
8ashes
Allergy/Anaphylaxls
Selecuon of reslsLanL bacLerla
8lsk of re-consulLauon for an
lnfecuon caused by a reslsLanL
mlcroorganlsm
8enehts of A8 |n SS1I
A cllnlcal dlagnosls ls usually
posslble
Cen Loplcal LreaLmenL ls
approprlaLe
1reaLmenL wlLh anubloucs may
prevenL spread of conLaglous SS1l,
e.g. lmpeugo, Lo oLhers
A8 are an eecuve LreaLmenL for
bacLerlal SS1l
lamlly & hyslclan reassurance
A reasonable approach Lo 1om's
problem.
?ou explaln Lo 1om's dad LhaL you feel Lhe rash ls Lyplcal of lmpeugo, a
bacLerlal lnfecuon of Lhe skln. 8ecause you feel condenL ln your dlagnosls
and you know LhaL M8SA ls rare ln your area, you declde noL Lo Lake a swab.
?ou propose Lo LreaL 1om wlLh oral amoxlclllln/clavulanlc acld on accounL of
muluple leslons. ?ou advlse 1om's dad LhaL he should noL auend day care or
any oLher chlldhood group acuvlues for aL leasL 24 hours aer Lhe sLarL of
LreaLmenL. 1om's faLher wlll conLacL you ln case of lack of lmprovemenL,
dlmculLy ln admlnlsLerlng Lhe medlcauon or any worsenlng ln 1om's
condluon.

?ou nexL see 1om for a regular vacclnauon appolnLmenL. Pls moLher Lells you
Lhe rash qulckly dlsappeared aer sLarung anubloucs, buL LhaL 1om had
developed a blL of dlarrhoea durlng anublouc LreaLmenL. 1hls sLopped aer
Lhe course was nlshed.
80
8eferences
SLevens uL eL al. racuce Culdellnes for Lhe dlagnosls and
managemenL of skln and so-ussue lnfecuons. clu 2003 nov,
41: 1373 -1406

81
AL Lhe end .
. when parenLs demand anubloucs
82
Lncourage acnve management of the |||ness
plan LreaLmenL of sympLoms wlLh parenLs.
descrlbe Lhe expecLed normal ume course of Lhe
lllness and Lell parenLs Lo come back lf Lhe
sympLoms perslsL or worsen.
8e conhdent w|th the recommendanon to use
a|ternanve treatments
rescrlbe analgeslcs and decongesLanLs, lf
approprlaLe.
Lmphaslze Lhe lmporLance of adequaLe nuLrluon
and hydrauon.
Conslder provldlng care packages" wlLh non-
anublouc Lheraples.

1a|k about annb|onc use at mandatory we|| ch||d
v|s|ts
Start the educanona| process |n the wa|nng room
vldeoLapes, posLers, and oLher maLerlals are avallable.

Invo|ve omce personne| |n the educanona|
process
Use the CDC]AA pamph|ets and pr|nc|p|es to
support your treatment dec|s|ons
rov|de educanona| mater|a|s
share your LreaLmenL rules Lo explaln A8s rlsks and
beneLs.
Cer educauonal maLerlals on Lhe dlerences beLween
vlruses and bacLerla.

Ask parents why they fee| the|r ch||d need an A8

De|ayed prescr|pnon
Ask your pauenLs Lo walL some ume wlLhouL a prescrlpuon,
and Lo call back aer LhaL ume lf Lhey are sull experlenclng
sympLoms

Lxp|a|n that unnecessary A8s can be harmfu|
1ell parenLs LhaL unnecessary anubloucs CAn be harmful,
by promoung reslsLanL organlsms ln Lhelr chlld and Lhe
communlLy.
Slde eecLs
Selecuon of secondary reslsLanL organlsms
uo noL decrease Lhe lengLh of Lhe dlsease
ls noL acuve on paln or on a vlrus-relaLed fever

Share the facts: spend some nme educanng
your panents about why A8s are not he|pfu|
aga|nst v|ruses
bacLerlal lnfecuons can be cured by anubloucs, buL vlral
lnfecuons never are
Lreaung vlral lnfecuons wlLh anubloucs Lo prevenL bacLerlal
lnfecuons does noL work.
8u||d cooperanon and trust
lurLher lnformauon: 8elevanL
anublouc prescrlpuon guldellnes
oLenually relevanL guldellnes ln Lngllsh may be found aL:
1he nauonal Culdellne Clearlnghouse run by Lhe uS ueparLmenL of
PealLh and Puman Servlces and Lhe Agency for PealLhcare 8esearch and
CuallLy (hup://guldellne.gov/)
1he Cllnlcal Culdellnes orLal run by Lhe nauonal PealLh and Medlcal
8esearch Councll, AusLralla (hup://www.cllnlcalguldellnes.gov.au/)
Cllnlcal Culdellnes provlded by Lhe nauonal lnsuLuLe for Cllnlcal
Lxcellence (nlCL) (hup://guldance.nlce.org.uk/CC)#
1he Scomsh lnLercolleglaLe Culdellnes neLwork run by PealLhcare
lmprovemenL Scouland (
hup://www.slgn.ac.uk/guldellnes/publlshed/lndex.hLml)
1he Cochrane 8evlews provlded by Lhe Cochrane Collaborauon (
hup://www.cochrane.org/)
ln addluon, you may be able Lo nd guldellnes for Lhe LreaLmenL of Lhe
common lnfecuons dlscussed ln Lhls sllde seL Lhrough your nauonal
paedlaLrlc or paedlaLrlc lnfecuous dlseases socleLy.
83
lurLher lnformauon: CounLry
speclc anublouc use and reslsLance
Lu counLry speclc daLa on anublouc use and reslsLance may be found aL:
1he Luropean Anumlcroblal 8eslsLance Survelllance neLwork (LA8S-neL)
run by Lhe Luropean CenLre for ulsease revenuon and ConLrol (LCuC)
(
hup://ecdc.europa.eu/en/acuvlues/survelllance/LA8S-neL/daLabase/
ages/daLabase.aspx)
1he Luropean Survelllance of Anumlcroblal Consumpuon neLwork (LSAC-
neL), also run by Lhe Luropean CenLre for ulsease revenuon and ConLrol
(LCuC) (
hup://www.ecdc.europa.eu/en/acuvlues/survelllance/LSAC-neL/
daLabase/ages/daLabase.aspx )
ln addluon, you may be able Lo nd lnformauon on nauonal, reglonal, or
hosplLal level anublouc use and reslsLance Lhrough your nauonal or
reglonal publlc healLh auLhorlLy or laboraLory or pharmacy deparLmenLs
wlLhln lndlvldual hosplLals.
84