Rana Hamdy, MD

Pediatricians tend to be more judicious in prescribing antibiotics than our colleagues in adult medicine, but there remains much room for improvement in ambulatory pediatrics. Reducing therapy to the shortest effective duration may be one of the highest-yield practice changes to decrease unnecessary antibiotic exposure in pediatric patients.

Antibiotic resistance is a growing threat to public health, and antibiotic use (prescribed for a wide variety of pediatric illnesses such as common respiratory disorders) is the primary driving factor that leads to resistance. Many pediatricians may have been taught that not completing a prescribed course could lead to antibiotic resistance. In fact, it is longer exposure to antibiotics that exerts greater selective pressure on bacteria, increasing the risk of resistance.

Adverse drug events (ADEs) are another important consideration in the mission to reduce unnecessary antibiotic use. The findings of one study showed that almost half of all emergency department visits for ADEs in children were due to antibiotics.

 In one study across a large primary care pediatric network, 29% of all antibiotic courses prescribed for acute respiratory tract infection resulted in an ADE.

 In the inpatient setting, each additional day of antibiotic use has been shown to be associated with a 7% increased risk of developing an antibiotic-related ADE.

 Longer duration of therapy is also an important risk factor for 

Therapy should be prescribed for the shortest effective duration. For some indications, that means 0 days. This article discusses several childhood illnesses and recommended durations for antibiotics, which are summarized in the accompanying Table.

Acute otitis media (AOM) is the most common indication for antibiotics in children,

 and 95% of children with AOM are prescribed antibiotics.

 However, most children with AOM will improve without antibiotics.

 The number of patients needed to treat for symptomatic benefit after 2 to 3 days is 20,

 whereas the number needed to harm with an antibiotic-related ADE is 4.

 For this reason, the 2013 American Academy of Pediatrics (AAP) clinical practice guidelines recommend watchful waiting for children older than 6 months with mild to moderate unilateral AOM.

 Findings have shown that for most children with AOM given antibiotics, there is no difference in treatment failure between those who receive 5 days and those who receive 7 or more days of therapy.

 When antibiotics are prescribed, high-dose amoxicillin remains the first-line antibiotic treatment for AOM.

Group A streptococcal (GAS) pharyngitis is the second most common indication for antibiotics in ambulatory pediatrics. Although the standard recommended antibiotic duration for confirmed GAS pharyngitis remains 10 days,

 the greatest opportunity for antibiotic stewardship in this setting lies in testing for GAS pharyngitis only when indicated; this reduces the likelihood of identifying and treating false positives that represent chronic pharyngeal GAS colonization in patients with viral pharyngitis. Because 20% of healthy, asymptomatic children can be chronic pharyngeal GAS carriers at any given time,

 it is important to test only when there is a high pretest probability for GAS vs viral pharyngitis. This means not testing when a patient has viral upper respiratory infection symptoms including cough, rhinorrhea, congestion, conjunctivitis, and hoarseness or in a child younger than 3 years who has a low likelihood of GAS pharyngitis.

In the past year, the results of 2 multi-institutional, randomized controlled trials showed no difference in treatment failure or recurrence of infection in children who received short-course (5 days) vs long-course (10 days) antibiotics. High-dose amoxicillin remains the first-line antibiotic treatment for community-acquired pneumonia believed to be bacterial.

Skin and soft-tissue infections are unique in that clinical improvement is easily visible, so antibiotic duration can easily be tailored based on clinical improvement. Clinical practice guidelines from the Infectious Diseases Society of America recommend 5 days of antibiotics for cellulitis.

 For an extensive case, if evidence of active infection remains after 5 days of therapy, then the course should be extended. On the other hand, for a more minor skin infection, if clinical resolution is shown after 3 days of therapy, then antibiotics could be discontinued. For abscesses without surrounding cellulitis, the guidelines recommend incision and drainage alone, without additional need for antibiotics.

For simple cystitis (ie, symptomatic urinary tract infection with pyuria and positive urine culture but with- out symptoms suggesting pyelonephritis, such as flank pain, costovertebral angle tenderness, or fever), it has long been known that for adult patients, short courses of antibiotics (1-3 days, depending on antibiotic choice) are sufficient.

 Pediatric guidelines recently adopted these standards to shift recommendations to short courses (3 days).

For pyelonephritis, the AAP’s 2011 guidelines recommend a range of 7 to 14 days. More recent data show that a 7-day course for pyelonephritis results in similar outcomes, including infection recurrence or treatment failure, with lower rates of ADEs compared with longer courses.

When prescribing antibiotics, the first consideration is whether antibiotics are indicated: How certain is the diagnosis (eg, otitis media with effusion vs AOM, viral vs bacterial pneumonia)? Is this a condition (eg, AOM, sinusitis) for which watchful waiting is a safe option? When antibiotics are definitely indicated, the shortest effective duration must be prescribed to minimize harm to patients.

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Follow best practices when prescribing antibiotics in the pediatric population

Less is more: Use the shortest effective duration of antibiotics

Between 2000 and 2014, 493 outbreaks linked to treated recreational water were reported to the Centers for Disease Control and Prevention (CDC), resulting in 27,219 cases of infections and 8 deaths.

 Additional outbreaks have been reported in connection with untreated fresh and marine water. Pediatricians should be ready to recognize and treat these infections and to appropriately advise families on safe water practices.

Signs and symptoms of recreational water illness

The most common recreational water illness is gastrointestinal disease, particularly diarrhea. When a child sick with diarrhea enters a body of water, small bits of fecal material that naturally remain on the body even when visibly clean can contaminate surrounding water. Another individual who swallows that water may become sick. 

, a protozoan, is the most commonly identified organism in water illnesses, likely because it can tolerate chlorine and survive for long periods. Although most bacterial and viral organisms are rapidly killed in properly disinfected water, they may survive in improperly disinfected or untreated water. Other pathogens implicated in diarrheal illnesses following recreational water exposure include bacteria (

), viruses (norovirus), and other parasites (

). Giardia cysts survive in mountain streams, where water-dwelling mammals such as beavers can contaminate water, leading to the nickname of “beaver fever.”

 Skin infections can also occur following recreational water activities. 

can form a biofilm on surfaces of pools and hot tubs. After prolonged skin exposure, infections such as folliculitis can occur. Folliculitis can present as a bumpy, red, itchy rash, or you may see pustules or blisters around a hair follicle. Organisms in water can also infect wounds, surgical sites, and areas of recent piercings, leading to cellulitis and deeper soft tissue infections. 

, present in certain coastal waters especially when water temperatures are warmer, can cause severe, even life-threatening, rapidly progressing wound infections including necrotizing fasciitis that require timely recognition and treatment. More indolent skin infections following water exposure may be caused by nontuberculosis mycobacterium (NTM) such as 

 Also known as “swimmer’s ear,” this occurs when contaminated water stays in an individual’s ear for a prolonged period, providing an opportunity for bacteria to thrive in this moist, warm environment. Children with otitis externa usually have pain with tugging of the ear or placement of pressure on the tragus. The ear may be red and swollen and drainage may be present. Otitis externa can be caused by several organisms, but 

 is an environmental bacteria found in water and soil that can lead to pneumonia via inhalation of aerosols from contaminated water. Outbreaks have occurred from contaminated mists generated by cooling towers, showers, faucets, decorative fountains, and grocery store mist machines.

Most diarrheal illnesses caused by exposure to waterborne organisms are self-limited and can be appropriately managed with supportive care. With certain infections, such as cryptosporidiosis, symptoms may persist for several days and up to 2 weeks. Children with severe diarrhea leading to significant dehydration or children with com- promised immune systems may require therapy. In those scenarios, evaluation with stool studies is war- ranted to identify a causative organism. Therapy is then directed to the identified cause.

, is usually self-limited and does not require treatment. However, more extensive infections of skin, wounds, and surgical areas following recreational water exposure may require systemic antibiotic therapy. When possible, cultures should be sent from the infected site to inform treatment decisions. Empiric treatment may be determined by the type of water exposure because different organisms can be found in treated, fresh, brackish, or salt water.

In addition, common skin organisms may also be the causative pathogens, unrelated to water exposure. Examples of antibiotic regimens are clindamycin or a first-generation cephalosporin (eg, cephalexin) for coverage of skin organisms plus a fluoroquinolone (eg, ciprofloxacin) for coverage of commonly found water organisms such as Pseudomonas. Doxycycline should be considered in cases of exposure to brackish or salt water for treatment of 

. If an NTM infection is suspected, biopsy and culture can help confirm the diagnosis and guide therapy. Treatment for NTM infection often involves use of multiple agents for a prolonged period. Infectious diseases consultation would be warranted.

In otherwise healthy children, acute otitis externa can be treated with topical antibiotic otic drops, such as ciprofloxacin, for 7 to 10 days.

 However, in immunocompromised children, children with diabetes, and healthy children with involvement of surrounding tissues, systemic treatment should be used. Because these infections may be polymicrobial, with 

 being the most common causative organisms, broad empiric therapy is warranted for severe cases.

Advising families on practices to prevent infections from exposure to recreational water is essential. Both the American Academy of Pediatrics

 offer recommendations for safe water practices.

Below are key tips to provide to families:

Regularly test home pools for appropriate chlorine or bromine concentrations.

Avoid recreational water when ill with diarrhea. After receiving a diagnosis of cryptosporidiosis, avoid swimming for an additional 2 weeks.

Avoid exposing open wounds to recreational water, including following recent surgery or piercings.

Practice water hygiene such as showering before entering recreational water, regularly bringing children to the bathroom, and checking diapers of young children to avoid water contamination.

Keep ears as dry as possible during swimming (such as with use of a bathing cap), and dry ears thoroughly following water exposure.

In addition, children who are immunocompromised should take extra precautions to avoid exposure to possibly contaminated water.

Although recreational water infections are on the rise,

 awareness of these infections allows for recognition and appropriate treatment. Importantly, pediatricians can play a key role in advising families how to best avoid infection by following safe water practices.

1. Hlavsa MC, Cikesh BL, Roberts VA, et al. Outbreaks associated with treated recreational water — United States, 2000-2014. 

2018;67(19):547-551. doi:10.15585/mmwr.mm6719a3

2. Vanden Esschert KL, Mattioli MC, Hilborn ED, et al. Outbreaks associated with untreated recreational water — California, Maine, and Minnesota, 2018-2019. 

 2020;69(25):781-783. doi:10.15585/mmwr.mm6925a3

3. Carrillo-Marquez M. Otitis externa. In: Cherry J, Demmler-Harrison GJ, Kaplan SL, Steinbach MJ, Hotez PJ, eds. 

Feigin and Cherry’s Textbook of Pediatric Infectious Diseases.

4. Prevention of illnesses associated with recreational water use. In: Kimberlin DW, ed. 

Red Book: 2018 Report of the Committee on Infectious Diseases.

 American Academy of Pediatrics; 2018:201-204.

5. Swimming and Ear Infections. Centers for Disease Control and Prevention. Updated June 3, 2020. Accessed April 29, 2021. 

https://www.cdc.gov/healthywater/swimming/swimmers/rwi/ear-infections.html

As summer approaches, many children will spend time playing in pools, water parks, lakes, rivers, and oceans. Several serious types of infections, although relatively infrequent, have been associated with recreational water activities.

Rana Hamdy, MD

Articles

Less is more: Use the shortest effective duration of antibiotics

Common recreational water illnesses in children