, Volume 55, Issue 6, pp 779–790 | Cite as

Practical Considerations When Treating Children with Antimicrobials in the Outpatient Setting

Disease Management


Over the past decade new antimicrobial agents have been introduced used to treat common paediatric infectious diseases such as acute otitis media and sinusitis. These agents vary with respect to their mechanism of action, dosage and duration of therapy, cost, taste and type of adverse effects. More recently, there has been concern about the overuse of antibiotics and increasing bacterial resistance, particularly Streptococcus pneumoniae, to these agents.

Dosage and duration of therapy, cost, taste, and adverse effects play important roles in determining success or failure of antimicrobial medications in paediatric patients. Use of potential alternatives and adjuncts to antimicrobial treatment, such as vaccination, control of environmental risk factors, surgical techniques and alternative medical therapies may also be employed, and the practitioner must ascertain if their paediatric patients are being treated by any of these methods. Rather than listing the therapeutic challenges for all common outpatient paediatric infectious diseases, acute otitis media (accounting for over 50% of the antimicrobial prescriptions dispensed in childhood) is used to illustrate each issue.

Clinicians are faced with a growing number of possible antimicrobial choices; concomitantly, there is increasing concern that these agents are overused. When prescribing antimicrobial agents, we need to be familiar with what we can do to optimise the care we provide. By avoiding inappropriate or trivial use of antimicrobials, we can preserve and even strengthen our armamentarium against disease. Simple strategies can improve compliance with therapeutic regimens and improve parental satisfaction.


Adis International Limited Otitis Medium Acute Otitis Medium Cefixime Cefpodoxime 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bergus GR, Levy BT, Levy SM, et al. Antibiotic use during the first 200 days of life. Arch Fam Med 1996; 5: 523–6PubMedCrossRefGoogle Scholar
  2. 2.
    Otitis Media Guideline Panel. Managing otitis media with effusion in young children. Pediatrics 1994; 94: 766–73Google Scholar
  3. 3.
    Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first seven years of life in children in Greater Boston: a prospective, cohort study [comment]. J Infect Dis 1989; 160: 83–94PubMedCrossRefGoogle Scholar
  4. 4.
    Nelson WL, Kennedy DL, Lao CS, et al. Outpatient systemic antiinfective use by children in the United States 1977 to 1986. Pediatr Infect Dis J 1988; 7: 505–9PubMedCrossRefGoogle Scholar
  5. 5.
    Kennedy DL, Forbes MB. Drug therapy for ambulatory pediatric patients in 1979. Pediatrics 1982; 70: 26–9PubMedGoogle Scholar
  6. 6.
    McCaig LF, Hughes JM. Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA 1995; 273: 214–9PubMedCrossRefGoogle Scholar
  7. 7.
    Paradise JL, Rockette HE, Colborn DK, et al. Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics 1997; 99: 318–33PubMedCrossRefGoogle Scholar
  8. 8.
    Chambers HF, Sande MA. Chapter 43. Antimicrobial agents: general considerations. In: Hardman JG, Limbird LE, editorsin-chief. Goodman and Gilman’s the pharmacological basis of therapeutics. 9th ed. New York: McGraw Hill, 1996: 1029–56Google Scholar
  9. 9.
    Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A metaanalysis. BMJ 1997; 314: 1526–9PubMedCrossRefGoogle Scholar
  10. 10.
    Rosenfeld RM, Post CJ. Meta-analysis of antibiotics for the treatment of otitis media with effusion. Otolaryngol Head Neck Surg 1992; 106: 378–86PubMedGoogle Scholar
  11. 11.
    Klein JO, Bluestone CD. Management of otitis media in the era of managed care. Adv Pediatr Infect Dis 1997; 12: 351–68Google Scholar
  12. 12.
    Berman S. Otitis media in developing countries. Pediatrics 1995; 96: 126–31PubMedGoogle Scholar
  13. 13.
    Froom J, Culpepper L, Jacobs M, et al. Antimicrobials for acute otitis media? A review from the International Primary Care Network. BMJ 1997; 315: 98–102PubMedCrossRefGoogle Scholar
  14. 14.
    de Melker FA, Kuyvenhoven MM. Management of upper respiratory tract infections in Dutch family practice. J Fam Pract 1994; 38: 350–7Google Scholar
  15. 15.
    Stephenson J. Icelandic researchers are showing the way to bring down rates of antibiotic-resistant bacteria. JAMA 1996; 275: 175PubMedCrossRefGoogle Scholar
  16. 16.
    Drugs for treatment of acute otitis media in children [editorial]. Med Lett Drugs Ther 1994; 36: 19–21Google Scholar
  17. 17.
    Kunin CM. The responsibility of the infectious disease community for the optimal use of antimicrobial agents. J Infect Dis 1985; 151: 388–98PubMedCrossRefGoogle Scholar
  18. 18.
    Harrison CJ. Perspectives on newer oral antimicrobials: what do they add? Pediatr Infect Dis J 1995; 14: 436–44PubMedCrossRefGoogle Scholar
  19. 19.
    McCracken GH. Emergence of resistant Streptococcus pneumoniae: a problem in pediatrics. Pediatr Infect Dis J 1995; 14: 424–8PubMedCrossRefGoogle Scholar
  20. 20.
    Craig WA, Andes D. Pharmacokinetics and pharmacodynamics of antibiotics in otitis media. Pediatr Infect Dis J 1996; 15: 255–9PubMedCrossRefGoogle Scholar
  21. 21.
    Green SM, Rothrock SG. Single-dose intramuscular ceftriaxone for acute otitis media in children. Pediatrics 1993; 91: 23–39PubMedGoogle Scholar
  22. 22.
    Lorlertratna N, Cunningham CK. Erythromycin and beyond: using macrolide antibiotics. Contemp Pediatr 1997; 14: 27–55Google Scholar
  23. 23.
    Hoberman A, Paradise JL, Burch DJ, et al. Equivalent efficacy and reduced occurrence of diarrhea from a new formulation of amoxicillin/clavulanate potassium (Augmentin®) for treatment of acute otitis media in children. Pediatr Infect Dis J 1997; 16: 463–70PubMedCrossRefGoogle Scholar
  24. 24.
    Mandel EM, Casselbrant ML, Rockette HE, et al. Efficacy of 20-versus 10-day antimicrobial treatment for acute otitis media. Pediatrics 1995; 96: 5–13PubMedGoogle Scholar
  25. 25.
    Health insurance for children, private insurance coverage continues to deteriorate [report to US senate]. US General Accounting Office/Health, Education and Human Services Division 1996 Jun 17; 96–129Google Scholar
  26. 26.
    Berman S, Byrns P, Bondy J, et al. Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric Medicaid population. Pediatrics 1997; 100: 585–92PubMedCrossRefGoogle Scholar
  27. 27.
    Detar E, Mori G, Beaman D, et al. Cost and wastage of antibiotic suspensions: a comparative study for various weight groups. Pediatr Infect Dis J 1997; 16: 619–22PubMedCrossRefGoogle Scholar
  28. 28.
    Steele RW, Estrada B, Begue RE, et al. A double-blind taste comparison of pediatric antibiotic suspensions. Clin Pediatr 1997; 36: 193–9CrossRefGoogle Scholar
  29. 29.
    Deniers DM, Schotik Chan D, Bass JW. Antimicrobial drug suspensions: a blinded comparison of taste of twelve common pediatric drugs including cefixime, cefpodoxime, cefprozil and loracarbef. Pediatr Infect Dis J 1994; 13: 87–9CrossRefGoogle Scholar
  30. 30.
    Samulak KM, El-Chaar GM, Rubin LG. Randomized, double blind comparison of brand and generic antibiotic suspensions: I. A study of taste in adults. Pediatr Infect Dis J 1996; 15: 14–7PubMedCrossRefGoogle Scholar
  31. 31.
    Matsui D, Lim R, Tschen T, et al. Assessment of palatability of β-lactamase-resistant antibiotics in children. Arch Pediatr Adolesc Med 1997; 151: 599–602PubMedCrossRefGoogle Scholar
  32. 32.
    Dagan R, Shvartzman P, Liss Z. Variation in acceptance of common oral antibiotic suspensions. Pediatr Infect Dis J 1994; 13: 686–90PubMedCrossRefGoogle Scholar
  33. 33.
    Bauchner H, Klein J. Parental issues in selection of antimicrobial agents for infants and children. Clin Pediatr 1997 Apr; 36: 201–5CrossRefGoogle Scholar
  34. 34.
    Kramer MS, Hutchinson TA, Flegel KM, et al. Adverse drug reactions in general pediatric outpatients. J Pediatr 1985; 106: 305–10PubMedCrossRefGoogle Scholar
  35. 35.
    Becker MH, Drachman RH, Kirscht JP. Predicting mothers’ compliance with pediatric medical regimens. J Pediatr 1972; 81: 843–54PubMedCrossRefGoogle Scholar
  36. 36.
    Maiman LA, Becker MH, Liptak GS, et al. Improving pediatricians’ compliance-enhancing practices. Am J Dis Child 1988; 142: 773–9PubMedGoogle Scholar
  37. 37.
    Holloway RL, Rogers JC, Gershenhorn SL. Differences between patient and physician perceptions of predicted compliance. Fam Pract 1992; 9: 318–22PubMedCrossRefGoogle Scholar
  38. 38.
    Young P, Wasserman R, McAullife T, et al. Why families change pediatricians. Am J Dis Child 1985 Jul; 139: 683–6PubMedGoogle Scholar
  39. 39.
    Wasserman RC, Inui TS, Barriatua RD, et al. Pediatric clinicians’ support parents makes a difference: an outcome-based analysis of clinician-parent interaction. Pediatrics 1984; 14: 1047–53Google Scholar
  40. 40.
    Ben-Sira Z. Affective and instrumental components in the physician-patient relationship: an additional dimension of interaction theory. J Health Soc Behav 1980; 21: 170–80PubMedCrossRefGoogle Scholar
  41. 41.
    Wandstrat TL, Kaplan B. Pharmacoeconomic impact of factors affecting compliance with antibiotic regimens in the treatment of acute otitis media. Pediatr Infect Dis J 1997; 16: S27–9PubMedCrossRefGoogle Scholar
  42. 42.
    McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication accurately. Pediatrics 1997; 100: 330–3PubMedCrossRefGoogle Scholar
  43. 43.
    Cockburn J, Gibberd RW, Reid AL, et al. Determinants of noncompliance with short term antibiotic regimens. BMJ 1987; 295: 814–8PubMedCrossRefGoogle Scholar
  44. 44.
    Lima J, Nazarian L, Charney E, et al. Compliance with shortterm antimicrobial therapy: some techniques that help. Pediatrics 1976; 57: 383–6PubMedGoogle Scholar
  45. 45.
    Finney JW, Friman PC, Rapoff MA, et al. Improving compliance with antibiotic regimens for otitis media. Am J Dis Child 1985; 139: 89–95PubMedGoogle Scholar
  46. 46.
    Williams RL, Maiman LA, Broadbent DN, et al. Educational strategies to improve compliance with an antibiotic regimen. Am J Dis Child 1986: 140: 216–20PubMedGoogle Scholar
  47. 47.
    Giebink GS. Childhood sinusitis: pathophysiology, diagnosis, and treatment. Pediatr Infect Dis J 1994; 13: S55–8PubMedCrossRefGoogle Scholar
  48. 48.
    Isaacson G. Sinusitis in childhood. Pediatr Clin North Am 1996; 43: 1297–318PubMedCrossRefGoogle Scholar
  49. 49.
    Pichichero ME. Assessing the treatment alternatives for acute otitis media. Pediatr Infect Dis J 1994; 134: S27–34Google Scholar
  50. 50.
    Hathaway TJ, Katz HP, Dershewitz RA, et al. Acute otitis media: who needs posttreatment follow-up? Pediatrics 1994; 94: 143–7PubMedGoogle Scholar
  51. 51.
    Berman S. Current concepts: otitis media in children. N Engl J Med 1995; 332: 1560–5PubMedCrossRefGoogle Scholar
  52. 52.
    Swanson JA, Hoecker JL. Otitis media in young children. Mayo Clin Proc 1996; 71: 179–83PubMedCrossRefGoogle Scholar
  53. 53.
    Bluestone CD. Modern management of otitis media. Pediatr Clin North Am 1989; 36: 1371–87PubMedGoogle Scholar
  54. 54.
    Swartz MN. Use of antimicrobial agents and drug resistance. N Engl J Med 1997; 337: 491–2PubMedCrossRefGoogle Scholar
  55. 55.
    Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997; 278: 901–4PubMedCrossRefGoogle Scholar
  56. 56.
    Mainous III AG, Hueston WJ, Clark JR. Antibiotics and upper respiratory infection: do some folks think there is a cure for the common cold? J Fam Pract 1996; 42: 357–61Google Scholar
  57. 57.
    Seppala H, Klaukka T, Vuopio-Varkila J, et al. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Engl J Med 1997; 337: 441–6PubMedCrossRefGoogle Scholar
  58. 58.
    Casiano RR. Azithromycin and amoxicillin in the treatment of acute maxillary sinusitis. Am J Med 1991; 91 Suppl. 3A: 27S–30SPubMedCrossRefGoogle Scholar
  59. 59.
    Green M, Wald ER. Emerging resistance to antibiotics: impact on respiratory infections in the outpatient setting. Ann Allergy Asthma Immunol 1996; 77: 167–75PubMedCrossRefGoogle Scholar
  60. 60.
    Owen MJ, Anwar R, Nguyen HK, et al. Efficacy of cefixime in the treatment of acute otitis media in children. Am J Dis Child 1993; 147: 81–6PubMedGoogle Scholar
  61. 61.
    Rawling SW Household and families. In US Bureau of the Census: current population reports. Series P23-189: population profile of the United States, 1995. Washington, DC: US Government Printing Office, 1995Google Scholar
  62. 62.
    Hernandez D, Saluter A, O’Brien C. We the American children. In: US Bureau of the Census: WE-10. Washington, DC: US Government Printing Office, 1993 SepGoogle Scholar
  63. 63.
    Hamm RM, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met? J Fam Pract 1996; 43: 56–62PubMedGoogle Scholar
  64. 64.
    Ruuskanen O, Heikkinen T. Otitis media: etiology and diagnosis. Pediatr Infect Dis J 1994; 13: S23–6PubMedCrossRefGoogle Scholar
  65. 65.
    Bluestone CD. Surgical management of otitis media: current indications and role related to increasing bacterial resistance. Pediatr Infect Dis J 1994; 13: 1058–63PubMedCrossRefGoogle Scholar
  66. 66.
    Casselbrant ML, Kaleida PH, Rockette HE, et al. Efficacy of antimicrobial prophylaxis and of tympanostomy tube insertion for prevention of recurrent acute otitis media: results of a randomized clinical trial. Pediatr Infect Dis J 1992; 11: 278–86PubMedCrossRefGoogle Scholar
  67. 67.
    Schmidt MA. Healing childhood ear infections — prevention, home care, and alternative treatment. Berkeley (CA): North Atlantic Books, 1996Google Scholar

Copyright information

© Adis International Limited 1998

Authors and Affiliations

  1. 1.Division of General Paediatrics, Boston Medical Center/Maternity 415Boston University School of MedicineBostonUSA

Personalised recommendations