1. Pediatric Infectious Disease Specialist
In the name of God
Judicious Antibiotic Therapy for Upper Respiratory Tract Infections in Pediatrics
Dr. Hamid Rahimi
Pediatric Infectious Disease Specialist

2. 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

3. 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.

4. 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.

5. 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

6. 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.

7. 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

8. 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.

9. Acute Otitis Media

10. 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

11. Key Action Statements 1 Diagnosis of AOM
Acute purulent otorrhea is present and otitis externa has been excluded
Moderate to severe bulging of the TM
Mild 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

12. 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).

13. Normal TM

14. Moderate Bulging
Severe Bulging

15. Signs of middle-ear inflammation
Mild bulging with intense erythema of the TM

16. Established acute otitis media

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

18. 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

19. Management
NNT (Number Need to Treat)

20. NNT in AOM for Antibiotic therapy vs. control groups
≥2 y/o
<2 y/o
Overall 10 7 8
Pain, Fever, or both 15 20 17
Unilateral AOM 9 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

21. NNT in AOM for antibiotic 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

22. 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 hrs & limiting management to symptomatic relief

23. 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

24. Key Action Statements 3 Management of AOM – Observation vs
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.

25. Key Action Statements 3 Management of AOM – Observation vs
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.

26. 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

27. 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 hrs
2 - A scheduled follow-up appointment in hrs
3 - Giving parents an antibiotic prescription that can be filled if illness does not improve in this time frame. “wait-and-see prescription” (WASP)

28. Selecting Effective antibiotic

29. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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

38. 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.

39. Antibiotic therapy in Treatment Failure

40. Microbiology of AOM

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

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

43. In daily clinical practice…
Amoxicillin - Clavul. 90mg/kg
Ceftriaxone ×1 – 3 dose
Clindamycin + Cefixime
Amoxicillin 90mg/kg
Azithromycin
Clarithromycin
Cefixime
Cotri-Erythro
Cefuroxime
Amoxicillin - Clavul.30mg/kg
Amoxicillin 30 – 45 mg/kg

44. For getting a ratio of amoxicillin to clavulanate of 14:1
Co-Amoxiclave + Amoxicillin
156/ /250
1/3 2/3
Farmentin BD + Faramox
228/ /400
1/ /2

45. In daily clinical practice…
Month of year ( mehr vs. farvardin)
Previous antibacterial treatment

46. In daily clinical practice…

47. In daily clinical practice…
Previous (First line) antibacterial treatment Failure
Amoxicillin - Clavul. 90mg/kg
Amoxicillin 30mg/kg
Azithromycin
Cefixime
Cotri-Erythro
Cefuroxime
Azithromycin
Clarithromycin
Cefixime
Cotri-Erythro
Cefuroxime
Amoxicillin - Clavul. 30mg/kg
Amoxicillin - Clavul. 90mg/kg
Amoxicillin 90mg/kg

48. Acute Bacterial Sinusitis

49. 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

50. Classification of Bacterial Sinusitis
Acute bacterial sinusitis (ABS)
Infection lasting < 30 days, symptoms resolve completely
Subacute bacterial sinusitis
Infection lasting between 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

51. Factors Predisposing to Sinusitis
Mucosal Swelling
Mechanical Obstruction
Systemic 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

52. Causative factors - URTI
Approximately 60-80% of bacterial sinus infections
Day-care centre should be as small and clean as possible

53. 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

54. 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

55. 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 fumes
Cold air / Dry air

56. Viral Upper Respiratory Tract Infections

57. ABS Symptoms Persistent rhinorrhea
Cough particularly is troublesome at night
Occasionally vomiting
Fever
Periorbital swelling
Malodorous breath

58. 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

60. Clinical Presentations

61. 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;
Severe onset, ie, concurrent fever (temperature ≥39°C) and purulent nasal discharge for at least 3 consecutive days.

62. 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

63. Key Action Statement 2A
Clinicians should not obtain imaging studies (plain films, CT, MRI, or ultrasonography) to distinguish acute bacterial sinusitis from viral URI.

64. 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.

65. Management

66. Spontaneous resolution in 30 - 70% of children …
Also high rate of spontaneous resolution in adults
Meta-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

67. Key Action Statement 3 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)

68. Key Action Statement 3 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).

69. Key Action Statement 3 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.

70. Key Action Statement 3 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)

71. Key Action Statement 3

73. Key Action Statement 4
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).

74. Key Action Statement 4
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.

75. Key Action Statement 4
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

76. Key Action Statement 4
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.

77. 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

78. Key Action Statement 4
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.

79. 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.

80. 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.

82. 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.

83. Pharyngitis

84. Incidence
One of the most common complaint leading older children and adults to acutely seek medical care
10% of all general practice consultations
2nd most common diagnosis in the pediatric age group

85. Classification Nasopharyngitis Pharyngitis or tonsilopharyngitis
Illness with nasal symptoms
Mostly viral etiologies
Pharyngitis or tonsilopharyngitis
Illness without nasal symptoms
Many etiologies

86. 12 - 40% in children and 5 - 10% in adults
Causes
Viral (70-80%)
Group A beta-haemolytic streptococcus GAS
% in children and % in adults

87. 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)

88. Pharyngitis - 1 Etiology Bacterial Group A β-hemolytic streptococci
Group C & G β-hemolytic streptococci
Arcanobacterium haemolyticum
Mycoplasma Pneumonia
N. gonorrhea
Corynebacterium diphteriae
Anaerobes …

89. Pharyngitis - 2 Viral Causes Adenovirus
Influenza & Parainfluenza Virus
EBV
Entrovirus
Herpes virus

90. Pharyngitis - 3 Non-infectious illness Aphthous stomatitis PFAPA
Behcet syndrome
Kawasaki disease
Stevens-Johnson syndrome

91. GAS Pharyngitis
15 – 30 % pharyngitis in pediatric BUT only % in adults
Prescription of antibiotics for pharyngitis in adults in US
3/4 cases of pharyngitis

92. Clinical features associated with pharyngitis

93. Clinical Scoring

94. 6th Item Clinical Scoring System (1)
Age (5 to 15 years)
Season (late fall, winter, early spring)
Physical examination of acute pharyngitis (erythema, edema, and/or exudates)
Tender, enlarged (>1 cm) Ant. cervical lymph nodes
Moderate fever (38.4º - 40º C)
No usual signs & symptoms of viral URTI (i.e. cough, coryza, and nasal congestion)

95. 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)

96. Pharyngitis – GAS
NOTE: Only approximately 15% of all patients with GAS pharyngitis have a classic presentation So It is impossible to diagnose streptococcal sore throat on clinical grounds alone

97. Centor criteria

98. Centor criteria Tonsillar exudates
Tender anterior cervical lymphadenopathy
Absence of cough
History of temperature of at least 38 0C
In adults
 3criteria
75% sensitivity and 75% specificity versus culture
Positive Predictive Value (PPV) is %
IF < 1-2 criteria
Negative Predictive Value ( NPV ) is 80%

100. Pharyngitis GAS - Laboratory Investigations
Throat culture
Rapid Antigen Tests (RAT)
Anti-streptolysin O (ASO) titres

101. Pharyngitis – GAS Culture Imperfect 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

102. Management

103. 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 .

104. 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.

105. 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.

110. 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.

111. 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

112. Adjunctive therapy may be useful in the management of GAS pharyngitis.
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.

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

114. 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.

115. 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.

116. Thanks for your attention.