# Antimicrobial Stewardship in Pediatrics

## Overview

Antibiotic overuse is a major public health threat, with approximately 30-50% of outpatient antibiotic prescriptions in pediatrics being unnecessary or inappropriate. Children receive more antibiotic prescriptions per capita than any other age group. Most unnecessary prescriptions are for viral upper respiratory infections, viral pharyngitis, bronchitis, and non-specific cough. Antimicrobial stewardship (AMS) aims to optimize antibiotic use by selecting the right drug, right dose, right duration, and right indication. Resistance is rising across multiple organisms including MRSA, ESBL-producing Enterobacteriaceae, and drug-resistant pneumococcus.

## Principles of Antimicrobial Stewardship

The core principles are using antibiotics only when indicated and avoiding prescribing for viral infections; choosing narrow-spectrum agents when possible and reserving broad-spectrum antibiotics for documented need; optimizing dose and duration with evidence increasingly supporting shorter courses for many infections; using diagnostic tools such as rapid strep testing, procalcitonin, and viral PCR panels to guide decisions; reassessing at 48-72 hours to narrow or discontinue based on culture results and clinical response; and educating families by setting expectations about viral illness natural history and providing contingency plans such as "safety-net" prescriptions.

## Common Conditions and Evidence-Based Prescribing

| Condition | First-Line Antibiotic | Dose | Duration | Watchful Waiting Option |
|-----------|---------------------|------|----------|------------------------|
| AOM | High-dose amoxicillin | 80-90 mg/kg/day BID | 10 days (<2 yr); 5-7 days (≥2 yr) | Yes (≥2 yr, unilateral, non-severe) |
| Strep pharyngitis | Amoxicillin | 50 mg/kg/day once daily (max 1000 mg) | 10 days | No |
| CAP (outpatient) | High-dose amoxicillin | 90 mg/kg/day BID | 5-7 days | No (if bacterial suspected) |
| Acute sinusitis | Amoxicillin-clavulanate | 90/6.4 mg/kg/day BID | 10-14 days | Yes (≥2 yr, persistent symptoms only) |
| Bronchitis/bronchiolitis | None (viral) | N/A | N/A | N/A (antibiotics not indicated) |

### Acute Otitis Media (AOM)

#### Diagnosis

Accurate diagnosis is critical because AOM is frequently overdiagnosed. Diagnosis requires moderate-to-severe bulging of the tympanic membrane, new onset otorrhea not from otitis externa, or mild bulging with recent ear pain or TM erythema. Otitis media with effusion (OME) is not AOM and should not be treated with antibiotics. Pneumatic otoscopy showing decreased TM mobility is the most reliable physical finding.

#### Treatment

First-line therapy is high-dose amoxicillin at 80-90 mg/kg/day divided twice daily for 10 days in children under 2 years or 5-7 days in children 2 years and older with mild symptoms. Second-line therapy for treatment failure at 48-72 hours is amoxicillin-clavulanate at 90/6.4 mg/kg/day. For penicillin allergy, cefdinir, cefuroxime, or azithromycin (which is less effective for pneumococcus) may be used.

Watchful waiting (the observation option) is appropriate for children 2 years and older with unilateral non-severe AOM. Pain management (ibuprofen, acetaminophen) is prescribed along with a safety-net antibiotic prescription to fill in 48-72 hours if not improving. Studies show approximately 60% improve without antibiotics. The AAP 2013 guideline supports shared decision-making with parents.

#### Stewardship Points

Watchful waiting for AOM in children 2 years and older with mild symptoms reduces unnecessary antibiotic use by approximately 50%. Ensuring accurate diagnosis is paramount, as many "AOM" diagnoses are actually OME. Ear pain should be treated with analgesics regardless of whether antibiotics are prescribed.

### Streptococcal Pharyngitis

#### Diagnosis

Clinical scoring uses the Modified Centor/McIsaac criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough). Rapid antigen detection testing (RADT) has a sensitivity of 85-95% and specificity above 95%. If RADT is negative in a child, a throat culture (backup, with sensitivity above 95%) should be sent; the AAP recommends confirmatory culture in children. In adults, a negative RADT is sufficient without backup culture. Testing should not be performed in children under 3 years (rheumatic fever is exceedingly rare, and pharyngitis in this age group is almost always viral), in children with clear viral symptoms (cough, rhinorrhea, conjunctivitis, hoarseness), or in asymptomatic contacts (the carrier state does not require treatment).

#### Treatment

First-line therapy is amoxicillin at 50 mg/kg/day (maximum 1000 mg) once daily for 10 days, or penicillin V for 10 days. For penicillin allergy, cephalexin (if not an anaphylactic allergy), azithromycin, or clindamycin may be used. The goals of treatment are preventing rheumatic fever (the primary goal), reducing suppurative complications, shortening symptom duration, and reducing transmission. Positive throat cultures in asymptomatic carriers should not be treated, as carriers do not develop rheumatic fever and are minimally contagious.

#### Stewardship Points

Antibiotics should not be prescribed for sore throat without a positive RADT or culture. Clinical diagnosis alone without testing leads to overtreatment, as the positive predictive value of clinical criteria alone is only 50-70%. Azithromycin resistance in GAS is increasing (15-20% in some regions), so it should not be first-line.

<image>Decision algorithm for antibiotic prescribing in pediatric pharyngitis showing clinical assessment (Modified Centor criteria), RADT testing with backup throat culture for children, treatment with first-line amoxicillin for positive results, and clear guidance to withhold antibiotics for negative tests and viral presentations</image>

### Community-Acquired Pneumonia (CAP)

#### Diagnosis

The clinical picture includes fever, cough, tachypnea, increased work of breathing, crackles, and decreased breath sounds. Chest X-ray is not routinely recommended for outpatient management of suspected uncomplicated CAP but is indicated for hospitalized patients, treatment failure, or complicated pneumonia. Blood cultures are not routinely needed for outpatient CAP but should be obtained for hospitalized patients. Viral testing may reduce unnecessary antibiotics, as a positive viral panel in a well-appearing child with mild pneumonia supports observation.

#### Treatment

For outpatient presumed bacterial pneumonia, amoxicillin at 90 mg/kg/day divided twice daily for 5-7 days is recommended per PIDS/IDSA guidelines. Shorter courses of 5 days are supported by recent evidence for uncomplicated CAP. High-dose amoxicillin covers most penicillin-intermediate pneumococcus. For suspected atypical pneumonia (school-age child, gradual onset, prominent cough), azithromycin is given at 10 mg/kg on day 1 followed by 5 mg/kg on days 2-5. For inpatient treatment, ampicillin at 150-200 mg/kg/day IV is first-line for a fully immunized child. Azithromycin is added if atypical infection is suspected. Vancomycin or clindamycin is added if there is concern for empyema or MRSA. Empyema or parapneumonic effusion requires drainage (chest tube, VATS) plus IV antibiotics.

#### Stewardship Points

Amoxicillin (not amoxicillin-clavulanate or broad-spectrum cephalosporins) is first-line for uncomplicated outpatient CAP. Five-day courses are increasingly supported for uncomplicated cases, with the traditional 10 days likely being unnecessary. Routine CXR for outpatient CAP should be avoided because it does not change management and may lead to unnecessary antibiotic escalation.

### Acute Sinusitis

#### Diagnosis

Persistent symptoms are defined as nasal discharge or cough for 10 or more days without improvement and represent the most important diagnostic criterion. Severe onset involves fever of 39C or higher with purulent nasal discharge for 3 or more consecutive days. Worsening (double-sickening) is improvement followed by new fever or increased nasal symptoms. Most children with "sinusitis symptoms" have viral URI, and the 10-day persistence criterion helps distinguish bacterial sinusitis.

#### Treatment

First-line therapy is amoxicillin-clavulanate at 90/6.4 mg/kg/day twice daily for 10-14 days. Watchful waiting is allowed by the AAP for children 2 years and older with persistent symptoms (not severe onset or worsening), with follow-up in 72 hours.

#### Stewardship Points

Most "sinusitis" in children is viral URI, and applying the 10-day criterion prevents vast overtreatment. Imaging (sinus X-ray, CT) is not recommended for uncomplicated sinusitis because sinus opacification is present in most children with viral URI.

### Acute Bronchitis/Bronchiolitis

Antibiotics are not indicated for acute bronchitis (a viral cough illness) or bronchiolitis. Bronchitis in children is almost always viral. This is one of the most common conditions for which antibiotics are inappropriately prescribed.

## Diagnostic Tools Supporting Stewardship

### Rapid Strep Testing

Point-of-care RADT enables real-time decision-making and avoids empiric antibiotics for pharyngitis without testing.

### Procalcitonin

Procalcitonin is a biomarker for bacterial infection, and normal values help safely withhold antibiotics. It is useful in febrile infants (PECARN), pneumonia (guiding antibiotic initiation and duration), and sepsis (guiding de-escalation). Limitations include that it is not universally available, it rises with some viral infections, and there is a learning curve for interpretation.

### Respiratory Viral Panels (PCR)

Identifying a viral etiology reduces antibiotic prescribing. However, viral-bacterial co-infection occurs, and a positive viral panel does not entirely exclude bacterial superinfection. These panels are most useful in hospitalized children with respiratory illness.

<image>Antimicrobial stewardship strategies for common pediatric infections showing appropriate antibiotic choices, duration, and watchful waiting options for AOM (amoxicillin, 5-10 days, observation for mild cases >= 2 years), pharyngitis (amoxicillin, 10 days, test-only-treat approach), CAP (amoxicillin, 5-7 days, no routine CXR), and sinusitis (amoxicillin-clavulanate, 10-14 days, 10-day persistence criterion)</image>

## Strategies to Combat Antibiotic Overuse

### Provider-Level

Strategies include clinical decision support tools in the EHR, audit and feedback on prescribing patterns, delayed or safety-net prescribing (providing a prescription with instructions to fill only if not improving in 48-72 hours), and peer comparison reports.

### Patient/Family-Level

Strategies include education about viral illness natural history (average URI lasts 7-10 days; cough lasts 2-3 weeks), explanation of why antibiotics are not needed and can cause harm (diarrhea, allergic reactions, C. difficile, resistance), provision of symptomatic relief recommendations (honey for cough in children 1 year and older, saline nasal spray, acetaminophen or ibuprofen), and setting specific follow-up expectations.

### Institutional-Level

Antimicrobial stewardship programs are required by the Joint Commission for hospitals. Antibiograms displaying local resistance patterns guide empiric therapy. Formulary restrictions on broad-spectrum agents and institutional guidelines for common infections (AOM, pharyngitis, UTI, pneumonia) are additional strategies.

## Clinical Pearls

The most effective stewardship intervention is accurate diagnosis, as many unnecessary antibiotics stem from misdiagnosis (OME treated as AOM, viral URI treated as sinusitis, viral pharyngitis treated as strep). Watchful waiting for AOM in children 2 years and older is safe, evidence-based, and reduces antibiotic exposure by approximately 50%. Antibiotics should never be prescribed for pharyngitis without a positive strep test because clinical diagnosis alone has unacceptable false-positive rates. High-dose amoxicillin (80-90 mg/kg/day) is the appropriate dose for AOM and CAP, as standard-dose amoxicillin is insufficient for intermediate-resistance pneumococcus. A positive viral PCR panel in a child with respiratory symptoms supports withholding antibiotics, especially if the child is well-appearing and improving. Delayed or safety-net prescriptions are an excellent compromise: families feel supported, but 60-70% never fill the prescription.

## Key Controversy: Watchful Waiting for AOM in Children >= 2 Years

The AAP 2013 guideline supports observation without antibiotics for non-severe, unilateral AOM in children 2 years and older. Adoption has been slow due to parental expectations, time pressure, and diagnostic uncertainty. Studies show approximately 60% of AOM resolves without antibiotics, and the number needed to treat to prevent one case of persistent symptoms is 7-20. Pain management is essential whether or not antibiotics are prescribed and is often undertreated. Barriers include access to follow-up, parental health literacy, and provider comfort with shared decision-making. Solutions include structured education materials, safety-net prescriptions, and follow-up phone calls in 48-72 hours. Watchful waiting represents the single highest-impact stewardship intervention in pediatric primary care.

## References
- Lieberthal AS, et al. The Diagnosis and Management of Acute Otitis Media (AAP Clinical Practice Guideline). Pediatrics. 2013;131(3):e964-e999.
- Shulman ST, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis (IDSA). Clin Infect Dis. 2012;55(10):e86-e102.
- Bradley JS, et al. The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age (PIDS/IDSA Guidelines). Clin Infect Dis. 2011;53(7):e25-e76.
- Wald ER, et al. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1-18 Years (AAP). Pediatrics. 2013;132(1):e262-e280.
- Gerber JS, et al. Effect of an Outpatient Antimicrobial Stewardship Intervention on Broad-Spectrum Antibiotic Prescribing by Primary Care Pediatricians. JAMA. 2013;309(22):2345-2352.
- Kronman MP, et al. Optimizing Antimicrobial Stewardship in the Pediatric Emergency Department. Curr Opin Pediatr. 2016;28(6):631-637.