Antibiotics in URI

I. General Principles

• Majority Rule: >85–90% of pediatric URIs (Common cold, non-specific pharyngitis) are viral and self-limiting.
• Goal: Antibiotic therapy is strictly reserved for confirmed or highly suspected bacterial etiologies to prevent resistance and adverse effects.
• "Watchful Waiting": A key strategy in non-severe cases (especially AOM and Sinusitis), involving observation for 48–72 hours before starting antibiotics.

II. Acute Otitis Media (AOM)

Based on AAP 2013 Guidelines. Antibiotics are indicated based on age and severity.

1. Absolute Indications (Treat Immediately)

• Age < 6 months: Treat all cases.
• Severe Symptoms (Any Age):
  • Toxic appearance.
  • Moderate-to-severe otalgia for > 48 hours.
  • Temperature ≥ 39°C (102.2°F).
• Bilateral AOM in children < 2 years: Treat immediately (high risk of failure with observation).
• Otorrhea: Perforation with purulent discharge (at any age).

2. Relative Indications (Observation Option)

• Children 6 months to 2 years (Unilateral, Non-severe): Option to observe for 48–72 hours ("Safety Net" prescription).
• Children > 2 years (Non-severe): Observation is preferred. Antibiotics started only if symptoms worsen or fail to improve after 48-72 hours.

III. Acute Bacterial Rhinosinusitis (ABRS)

Distinguishing bacterial from viral rhinosinusitis is clinical. Antibiotics are indicated only if ONE of the following three criteria is met (AAP Guidelines):

1. Persistent Illness:
   • Nasal discharge (any quality) or daytime cough lasting > 10 days without improvement.
2. Severe Onset:
   • High fever (>39°C) AND purulent nasal discharge or facial pain for at least 3–4 consecutive days at the onset.
3. Worsening Course ("Double Sickening"):
   • Initial improvement of a viral URI followed by new fever, worsening cough, or discharge (typically around day 6–7).

IV. Acute Pharyngitis / Tonsillitis

Antibiotics are indicated ONLY for Group A Beta-Hemolytic Streptococcus (GABHS) to prevent Rheumatic Fever.

1. Diagnostic Criteria

• Clinical Scoring (Modified Centor / McIsaac Score):
  • Fever > 38°C (+1)
  • Absence of cough (+1)
  • Tender anterior cervical adenopathy (+1)
  • Tonsillar exudates/swelling (+1)
  • Age 3–14 years (+1)
• Action:
  • Score ≤ 2: Viral likely. No antibiotics.
  • Score ≥ 3: Test indicated.

2. Confirmed Indication

• Positive Rapid Antigen Detection Test (RADT).
• Positive Throat Culture.
• Note: Empirical treatment is generally discouraged unless testing is unavailable and clinical suspicion (Score >4) is very high in a Rheumatic-endemic area.

V. Pertussis (Whooping Cough)

• Indication: Suspected cases with prolonged cough (>14 days), paroxysms, or inspiratory whoop.
• Antibiotic: Macrolides (Azithromycin) are used to decrease transmission (most effective in catarrhal phase) and treat the patient.

VI. Deep Neck Space Infections

Absolute Indication for IV antibiotics (and often surgical drainage).

• Peritonsillar Abscess (Quinsy): Trismus, uvula deviation.
• Retropharyngeal Abscess: Neck stiffness, widening of prevertebral space on X-ray.
• Epiglottitis: Medical emergency (Ceftriaxone).

VII. Conditions Where Antibiotics are NOT Indicated

• Common Cold: Clear or mucopurulent discharge < 10 days.
• Bronchiolitis: Wheezing in < 2 years (Viral).
• Non-specific cough: Without specific bacterial signs.
• Green Snot: Purulent nasal discharge alone (without duration >10 days) is normal in the evolution of viral URI.

VIII. Summary of Drug Choice