6657 Peds Week 4: Pediatric Infectious Disease and Antibiotic
Stewardship: Acute Otitis Media, Otitis Media with Effusion, Acute Bacterial
Sinusitis, Pharyngitis, Viral URIs, Antibiotic Allergy, Pneumococcal
Vaccination, Influenza Prevention, RSV Management, Antiviral
Therapeutics, PrEP, and TB: Clinical Diagnosis, Evidence-Based Treatment,
Risk Stratification, Pneumatic Otoscopy, Tympanometry, Beta-Lactam
Pharmacology, Penicillin Allergy Delabeling, Antibiotic Resistance,
Observation Strategies, Delayed Prescribing, Adverse Drug Effects,
Microbiome Disruption, Immunization Efficacy, High-Risk Infant Care,
Palivizumab Prophylaxis, Pediatric Antimicrobial Guidelines, Centor Criteria,
Rapid Antigen Testing, Clinical Decision-Making Exam Questions Verified
and Provided with A+ Graded Rationales Latest Updated 2026
Outpatient abx use and need for increased antibiotic stewardship effors
ABX use, regardless of whether it is warranted, is a primary factor in the development of resistance
Majority of abx health care expenditure are due to prescribing in outpatient settings - much of this
prescribing is inappropriate, at least 30% of abx use in outpatient settings is unnecessary
What is driving inappropriate antibiotic prescribing?
Patient satisfaction
Time constraints
Diagnostic uncertainty
Externalized responsibility (problem as being one driven by physicians other than themselves,
particularly physicians from other specialties)
Antibiotic allergy in peds
Up to 10% of the US population is labeled as penicillin allergic, 5 million children
Most cutaneous symptoms that are interpreted as drug allergy are likely viral induced or due to a drug-
virus interaction, and they usually do not represent a long-lasting, drug-specific, adaptive immune
response to the antibiotic that a child received
,Most antibiotic allergy labels acquired in childhood are carried into adulthood, the over-labeling of abx
allergy is a liability that leads to unnecessary long-term health care costs, risks, and abx resistance
No systemic approach to address abx allergy during routine office visits, and allergy labels persist into
adult hood
childhood allergy labels
75% of children diagnosed with pcn allergy were labeled before their third birthday, and never undergo
an allergy evaluation to address the diagnosis
when children are tested and/or undergo drug challengeing, >90% are able to tolerate the antibiotic
even when they diagnosis of drug allergy is excluded by such procedures, not only parents but many
providers are still resistant to drug allergy delabeling
Prescription costs are 30 to 40% higher in pts with suspected pcn allergy
Summary - principles of judicious abx use for URIs in peds
Abx are prescribed in over 20% of pediatric ambulatory office visits which accounts for nearly 50 million
abx prescriptions in the US
URIs are a common cause of inappropriate abx use
About 10 million abx prescribed for resp conditions provide no benefit
Abx overuse results in drug-related adverse effects, abx resistance, and unnecessary medical costs
Key factors r/t abx prescribing
Reducing overuse and ensuring appropriate agents are prescribed
Difficult to distinguish btw viral and bacterial URIs
Clinical guidelines offer stringent and validated critical criteria
Application of criteria may mitigate overuse for pediatric URIs
General recommendations from the American academy of pediatrics pertain to healthy children without
underlying medical conditions
, principle I
Determine the likelihood of a bacterial infection - the clinical presentation of signs and symptoms of a
viral infection will commonly mimic the clinical presentation of a bacterial infection
Well-established diagnostic criteria have been developed for common bacterial infections - acute otitis
media, acute bacterial sinusitis, pharyngitis
acute otitis media criteria
Signs and symptoms: bulging with or without tympanic membrane (TM) erythema, otalgia, otorrhea,
irritability, fever
Diagnostic findings through otoscopic exam: middle ear effusion, moderate to severe bulging of TM,
new onset otorrhea (not associated with otitis externa), mild bulging with ear pain or erythema of TM
considerations for abx use - Acute otitis media
Severity - severe otalgia, otalgia lasting > 48 hours, temp > 39 C
Laterality - bilateral involvement, age < 23 months
Watchful waiting is reasonable for older patients with non-severe unilateral disease
considerations for abx use - acute bacterial sinusitis
Diagnostic criteria - persistent and non-improving, nasal discharge or daytime cough with no
improvement within 10 days
Worsening - worsening or new onset of fever, daytime cough, or nasal discharge after improvement of
viral UPR
Severity - persistent fever (>39C), purulent nasal discharge for at least 3 days
considerations for antibiotic use - acute pharyngitis
Group A beta-hemolytic streptococcus (GABHS) must be considered
Stewardship: Acute Otitis Media, Otitis Media with Effusion, Acute Bacterial
Sinusitis, Pharyngitis, Viral URIs, Antibiotic Allergy, Pneumococcal
Vaccination, Influenza Prevention, RSV Management, Antiviral
Therapeutics, PrEP, and TB: Clinical Diagnosis, Evidence-Based Treatment,
Risk Stratification, Pneumatic Otoscopy, Tympanometry, Beta-Lactam
Pharmacology, Penicillin Allergy Delabeling, Antibiotic Resistance,
Observation Strategies, Delayed Prescribing, Adverse Drug Effects,
Microbiome Disruption, Immunization Efficacy, High-Risk Infant Care,
Palivizumab Prophylaxis, Pediatric Antimicrobial Guidelines, Centor Criteria,
Rapid Antigen Testing, Clinical Decision-Making Exam Questions Verified
and Provided with A+ Graded Rationales Latest Updated 2026
Outpatient abx use and need for increased antibiotic stewardship effors
ABX use, regardless of whether it is warranted, is a primary factor in the development of resistance
Majority of abx health care expenditure are due to prescribing in outpatient settings - much of this
prescribing is inappropriate, at least 30% of abx use in outpatient settings is unnecessary
What is driving inappropriate antibiotic prescribing?
Patient satisfaction
Time constraints
Diagnostic uncertainty
Externalized responsibility (problem as being one driven by physicians other than themselves,
particularly physicians from other specialties)
Antibiotic allergy in peds
Up to 10% of the US population is labeled as penicillin allergic, 5 million children
Most cutaneous symptoms that are interpreted as drug allergy are likely viral induced or due to a drug-
virus interaction, and they usually do not represent a long-lasting, drug-specific, adaptive immune
response to the antibiotic that a child received
,Most antibiotic allergy labels acquired in childhood are carried into adulthood, the over-labeling of abx
allergy is a liability that leads to unnecessary long-term health care costs, risks, and abx resistance
No systemic approach to address abx allergy during routine office visits, and allergy labels persist into
adult hood
childhood allergy labels
75% of children diagnosed with pcn allergy were labeled before their third birthday, and never undergo
an allergy evaluation to address the diagnosis
when children are tested and/or undergo drug challengeing, >90% are able to tolerate the antibiotic
even when they diagnosis of drug allergy is excluded by such procedures, not only parents but many
providers are still resistant to drug allergy delabeling
Prescription costs are 30 to 40% higher in pts with suspected pcn allergy
Summary - principles of judicious abx use for URIs in peds
Abx are prescribed in over 20% of pediatric ambulatory office visits which accounts for nearly 50 million
abx prescriptions in the US
URIs are a common cause of inappropriate abx use
About 10 million abx prescribed for resp conditions provide no benefit
Abx overuse results in drug-related adverse effects, abx resistance, and unnecessary medical costs
Key factors r/t abx prescribing
Reducing overuse and ensuring appropriate agents are prescribed
Difficult to distinguish btw viral and bacterial URIs
Clinical guidelines offer stringent and validated critical criteria
Application of criteria may mitigate overuse for pediatric URIs
General recommendations from the American academy of pediatrics pertain to healthy children without
underlying medical conditions
, principle I
Determine the likelihood of a bacterial infection - the clinical presentation of signs and symptoms of a
viral infection will commonly mimic the clinical presentation of a bacterial infection
Well-established diagnostic criteria have been developed for common bacterial infections - acute otitis
media, acute bacterial sinusitis, pharyngitis
acute otitis media criteria
Signs and symptoms: bulging with or without tympanic membrane (TM) erythema, otalgia, otorrhea,
irritability, fever
Diagnostic findings through otoscopic exam: middle ear effusion, moderate to severe bulging of TM,
new onset otorrhea (not associated with otitis externa), mild bulging with ear pain or erythema of TM
considerations for abx use - Acute otitis media
Severity - severe otalgia, otalgia lasting > 48 hours, temp > 39 C
Laterality - bilateral involvement, age < 23 months
Watchful waiting is reasonable for older patients with non-severe unilateral disease
considerations for abx use - acute bacterial sinusitis
Diagnostic criteria - persistent and non-improving, nasal discharge or daytime cough with no
improvement within 10 days
Worsening - worsening or new onset of fever, daytime cough, or nasal discharge after improvement of
viral UPR
Severity - persistent fever (>39C), purulent nasal discharge for at least 3 days
considerations for antibiotic use - acute pharyngitis
Group A beta-hemolytic streptococcus (GABHS) must be considered
