The rising incidence of bacterial resistance to common antibiotics, particularly, multi-drug resistant pneumococci, has prompted the need to use antibiotics judiciously in pediatric practice. Antibiotics are the second leading class of drugs prescribed, according to the National Ambulatory Medical Care Surveys, with the majority of such prescriptions being for respiratory infections. Children are the principal recipients of a disproportionate number of these prescriptions. Many of these antibiotics are unnecessarily prescribed for viral infections such as the common cold. In a pediatric practice in Memphis, Tennessee, 43% of children with uncomplicated upper respiratory tract infections or asthma were prescribed antibiotics. In a Kentucky study, 60% of patients were prescribed antibiotics for the common cold. In a Canadian study from Saskatchewan, 85% of antibiotics prescribed for respiratory tract infections in children less than 5 years of age were considered inappropriate.

Reducing antibiotic prescribing has been advocated as one way to protect patients against resistant infections. A national North American campaign has been developed to assist both the general public and prescribing physicians in understanding antibiotic resistance an in identifying specific situations in which unnecessary antibiotic use could be curtailed without compromising patient care.

In order to improve antibiotic prescribing by physicians, a thorough review of current physician prescribing patterns must be understood (Table 1). Physicians surveyed on the misuse of antibiotics for the treatment of upper respiratory tract infections in children provide a number of reasons for their pattern of prescribing antibiotics. Their diagnostic uncertainty in differentiating bacterial from viral infections plays a major role - preferring to overtreat a viral infection than miss treating a bacterial one. They believe that antibiotics are safe, may be effective for viral infections, lessen the severity of viral illnesses, shorten the duration of viral illnesses and prevent secondary bacterial infection. Other physicians report a reluctance to reduce inappropriate prescribing because of the concern that patients will simply obtain antibiotics from colleagues whose routine practice may differ substantially from their own.

For some physicians, the constraints of daily practice make it easier to prescribe antibiotics rather than to take the time to discuss with the patient or parent the implications of antibiotic avoidance and symptom management. Many doctors maintain that parents continue to expect that an antibiotic will be prescribed where a pattern has been established over several years. "Friday medicine" is unique. Many physicians practice differently on Fridays than on any other day of the week because of their reduced coverage on weekends and because they may want to protect and prevent their patients from using other doctors or walk-in clinics. Antibiotics are often prescribed on Fridays "in case" it is needed in the event that the child's symptoms get worse over the weekend.

Socio-economic pressures also play a role in antibiotic overprescriptions with concern about lost income from work missed while attending to a sick child at home. Antibiotics will often be prescribed in the hope that they will be rapidly effective and allow children to return to daycare or school, thereby allowing their parents to get back to work sooner. Many parents and physicians believe that an antibiotic may prevent the need and cost for a return doctor's visit, including further time lost from work, if the child does not get better.

It is important to recognize that doctors who overprescribe antibiotics are not necessarily "bad doctors". They believe they are doing their best, consistent with their view of what is appropriate care for their patients. Re-education, using evidence to support the appropriate use of antibiotics, is necessary in order to effect a change in physician behavior and their antibiotic prescribing patterns.

Most upper respiratory tract infections are viral in origin and the use of antibiotics will NOT significantly benefit the patient. Based on studies dating back to the 1940’s, the potential efficacy of antibiotic therapy in the treatment of presumed respiratory viral infections has not been substantiated. A review on the question whether prevention of bacterial complications could be achieved with prophylactic antibiotics, concluded the following:

Antibiotics administered prophylactically in a double-blind study in a private pediatric practice involving 781 children with assumed viral URI, did not reduce the incidence of bacterial complications. In another study of children with upper respiratory tract infections where bacterial and viral pathogens were cultured by nasopharyngeal swabs, there was no difference in the response of children who were treated with antibiotics compared to those who were not. In both groups, there was no difference in the mean duration of fever, the failure to improve the development of complications or the persistence of bacterial pathogens in the nasopharynx.

In the first instance, parents need to be educated using a handout like the one provided (see Parent Hand out). This brief and succinct outline will provide a basis for further discussion with the physician regarding the appropriate use of antibiotics. Many parents are already aware of the fact that antibiotics have been overprescribed by physicians and are very accepting of the new strategy that physicians are using.

There are four major indications for the use of antibiotics in children with upper respiratory tract infections. The following specific recommendations can be made:

1. Otitis media. Acute otitis media (ear pain) associated with fluid (pus in the middle ear) must be distinguished from otitis media with effusion (middle ear fluid without symptoms). Middle ear effusion does not require antibiotics. Acute otitis media should be treated with antibiotics in all children under two years of age. In selected children over 2 years of age, who are at low risk for serious sequelae (Table 2), treatment with analgesia and observation for 24 to 48 hours may be sufficient and antibiotics need only be prescribed if symptoms persist or get worse. There is good evidence that 80% of ear infections will resolve spontaneously and only approximately 20% of children with continued pain will ultimately require antibiotic treatment.
2. Sore throats. The majority of sore throats are caused by viruses and do not require antibiotics. Generally, antibiotic treatment should not be prescribed without laboratory confirmation on a Group A streptococcus infection. A positive rapid streptococcus antibody test done in the office is highly specific and may be used as confirmation of the streptococcus infection for which antibiotics should be prescribed. In the absence of a rapid strep test or a negative strep test, a throat culture should be used. Not all children require throat swabs, in particular, those children with a viral-like illness, who have a sore throat accompanied by a cough, cold, runny nose or congestion, do not require a throat swab.
3. Sinus infections. Parents need to know that sinusitis is rare in childhood and that the presence of a green-yellow nasal discharge does not necessary imply secondary bacterial infection. The natural course for an upper respiratory tract infection with rhinitis is that a clear running nose will become yellow-green for a few days during the middle of a cold then revert back to a clear runny nose as the cold subsides. Generally, waiting seven to ten days of a persistent purulent rhinitis or productive cough without improvement is recommended before treating children for sinusitis with antibiotics. Treatment should be initiated sooner if the child has a high fever, looks unwell, has facial pain or severe headache.
4. Coughs and Colds. These are caused by viruses and last for up to two weeks. They do not require antibiotics. With the development of pneumonia, there is often fever that develops late in the illness. The children often become irritable and cranky or lethargic and sleepy, may refuse to eat or drink and on examination, may have features suggestive of pneumonia but may just have tachypnoea and even grunting in the younger child. These children should obviously be treated with antibiotics.

Older than 2 years of age

The significant worldwide increase in antibiotic resistant bacteria has made it imperative that we only use antibiotics when properly indicated. Antibiotics are among the most important drugs available in our society. We as physicians together with you as parents must become more responsible in using antibiotics wisely.