Chapter Summary: Short course antibiotics for common infections

When it comes to treating pediatric infections, many of us default to prescribing a 10 day course of antibiotics. Join Parul and Sol as they discuss which common infections can actually be effectively treated with a shorter duration of antibiotics.

Pearls:

• Pediatric physicians tend to default antibiotic prescriptions to 10 days but in many cases guidelines suggest that shorter courses are safe and effective
• CDC report linked here
• Skin and Soft Tissue Infections
• Most common organisms: MRSA, MSSA, GAS
• Abscesses more often staph
• Cellulitis more often GAS
• Antibiotic choice based on most likely organism and resistance patterns
• Generally, choices include clindamycin, TMP-SMX, linezolid for MRSA; 1st generation cephalosporin for MSSA and/or GAS
• Treatment can be for 5 days; can be extended longer if the symptoms are not improving
• Abscesses without surrounding cellulitis can be drained and no antibiotics are needed
• Acute Otitis Media
• Typically treating strep pneumo with high dose amoxicillin (90 mg/kg/day)
• Again, depends on local susceptibilities 
• Differing courses depending on age group
• Kids < 2 yo = treatment for 10 days
• Kids 2-5 yo = treatment for 7 days
• Kids 6 yo and older = treatment for 5 days
• Community Acquired Pneumonia
• Typical organisms are strep pneumo in younger children or mycoplasma in the school age and older children
• Treatment duration for CAP with likely strep pneumo
• High dose amoxicillin TID (need TID dosing to penetrate lung tissue) for 5-7 days 
  
  

Editor’s Note:  Centers differ on the maximum dose per day.  For example, USCF and Children’s Hospital Minnesota suggest daily max doses of 2 grams/day; while noting that the absolute amoxicillin max dose per day is 4 grams/day.

• Treatment for CAP with likely mycoplasma
• Azithromycin for 5 days

• Urinary Tract Infections/Simple Cystitis
• Most common organisms E. coli and enteric gram negatives
• In sexually active females, have to think about Staph Saprophyticus
• Enterococcus can be seen in more complicated cystitis
• Antibiotic choice depends on local resistance patterns
• Commonly 1st, 2nd, 3rd generation cephalosporins are used
• Older than 12
• TMP-SMX: 3 day course
• Fluoroquinolone: 3 day course
• Nitrofurantoin: 5 day course
• Beta-lactam/Cephalexin (for example): 3-7 day course
• In adolescent females with first time cystitis who might be sexually active, coverage for S. Saprophyticus will be important (TMP-SMX/Fluoroquinolone) 
• Younger than 12
• Duration of therapy is debatable
• Current trend: 5 day course of antibiotics, some data leading toward recommending 3-5 day course for first time uncomplicated simple cystitis in slightly older children
• Pyelonephritis requires a longer course of antibiotics (7-10 days)
• Appropriate 10 day treatment
• Streptococcal Pharyngitis
• Amoxicillin 50 mg/kg/day with a max of 1,000-1,200 mg/day
• Sinusitis
• 10-14 day course of antibiotics
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References:

1. Azzarone G, et al. Cystitis. Pediatr Rev. 2007;28(12):474-476. PMID: 18055650
2. Gupta K, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-e120. PMID: 21292654
3. King LM, et al. Duration of outpatient antibiotic therapy for common outpatient infections, 2017. Clin Infect Dis. 2021;72(10):e663-e666.  PMID: 32936884
4. Lieberthal AS, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999. PMID: 23439909
5. Messinger AI, et al. Management of Pediatric Community-acquired Bacterial Pneumonia. Pediatr Rev. 2017;38(9):394-409. PMID: 28864731
6. Michael M, et al. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev. 2003;(1):CD003966. PMID: 12535494
7. Pernica JM, et al. Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia: The SAFER Randomized Clinical Trial. JAMA Pediatr. 2021;175(5):475-482. PMID: 33683325
8. Stevens DL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-e52. PMID: 24973422