‫الهيئة العامة للرعاية الصحية‬

‫فرع االقصر‬

‫نموذج تعليمات المضادات الحيوية‬

Pediatric Outpatient Treatment Recommendations

Antibiotic prescribing guidelines establish standards of care, focus quality
improvement efforts, and improve patient outcomes. The table below summarizes the
most recent principles of appropriate antibiotic prescribing for children obtaining care
in an outpatient setting for the following six diagnoses: acute rhinosinusitis, acute
otitis media, bronchiolitis, pharyngitis, common cold, and urinary tract infection.

Condition Epidemiology Diagnosis Management

Acute Sinusitis may be Halitosis, fatigue, f a bacterial infection is

caused by viruses or headache, decreased established:
sinusitis 1, 2
bacteria, and appetite, but most
antibiotics are not physical exam findings
guaranteed to help are non-specific and do
even if the causative not distinguish bacterial
agent is bacterial. from viral causes.
A bacterial diagnosis may
be established based on
the presence of one of
the following criteria:
 Persistent
symptoms without
improvement: nasal
discharge or
daytime cough >10
days.
 Worsening
symptoms:
 Watchful waiting for
up to 3 days may be
offered for children
with acute bacterial
sinusitis with
persistent symptoms.
Antibiotic therapy
should be prescribed
for children with acute
bacterial sinusitis with
severe or worsening
disease.
 Amoxicillin or
amoxicillin/clavulanate
remain first-line
therapy.
 Recommendations for
 ‫الهيئة العامة للرعاية الصحية‬
‫فرع االقصر‬

worsening or new treatment of children

onset fever, with a history of type I
daytime cough, or hypersensitivity to
nasal discharge penicillin vary. 1, 2

after initial  In children who are

improvement of a vomiting or who
viral URI. cannot tolerate oral
 Severe symptoms: medication, a single
fever ≥39°C, dose of ceftriaxone
purulent nasal can be used and then
discharge for at can be switched to
least 3 consecutive oral antibiotics if
days. improving. 1

Imaging tests are no  For further

longer recommended for
uncomplicated cases.
recommendations on
alternative antibiotic
regimens, consult the
American Academy of
Pediatrics or the
1

Infectious Diseases
Society of
America guidelines.
2

Acute otitis -AOM is the most Definitive diagnosis -Mild cases with unilateral
common childhood requires either symptoms in children 6-23
media infection for which months of age or unilateral
antibiotics are -Moderate or severe or bilateral symptoms in
(AOM) 3-5
prescribed. bulging of tympanic children >2 years may be
membrane (TM) or new appropriate for watchful
-4-10% of children onset otorrhea not due to waiting based on shared
with AOM treated otitis externa. decision-making.
with antibiotics
experience adverse -Mild bulging of the TM -Amoxicillin remains first line
effects.
4 AND recent (<48h) onset therapy for children who
of otalgia (holding,
 ‫الهيئة العامة للرعاية الصحية‬
‫فرع االقصر‬

tugging, rubbing of the have not received amoxicillin

ear in a nonverbal child) within the past 30 days.
or intense erythema of
the TM. -Amoxicillin/clavulanate is
AOM should not be recommended if amoxicillin
diagnosed in children has been taken within the
without middle ear past 30 days, if concurrent
effusion (based on purulent conjunctivitis is
pneumatic otoscopy present, or if the child has a
and/or tympanometry). history of recurrent AOM
unresponsive to amoxicillin.

-For children with a non-

type I hypersensitivity to
penicillin: cefdinir,
cefuroxime, cefpodoxime, or
ceftriaxone may be
appropriate choices.

-Prophylactic antibiotics are

not recommended to reduce
the frequency of recurrent
AOM.

-For further
recommendations on
alternative antibiotic
regimens, consult the
American Academy of
Pediatrics guidelines. 3

Pharyngitis 4, 6
-Recent guidelines -Clinical features alone do -Amoxicillin and penicillin V
aim to minimize not distinguish between remain first-line therapy.
unnecessary GAS and viral pharyngitis.
antibiotic exposure -For children with a non-
 ‫الهيئة العامة للرعاية الصحية‬
‫فرع االقصر‬

by emphasizing
appropriate use of -Children with sore throat type I hypersensitivity to
rapid antigen plus 2 or more of the penicillin: cephalexin,
detection test following features should cefadroxil, clindamycin,
(RADT) testing and undergo a RADT test: clarithromycin, or
subsequent azithromycin are
-absence of cough recommended.
treatment .
-presence of tonsillar -For children with an
-During the winter
exudates or swelling immediate type I
and spring, up to
20% of hypersensitivity to penicillin:
-history of fever
asymptomatic clindamycin, clarithyomycin,
children can be or azithroymycin are
-presence of swollen and
colonized with recommended.
tender anterior cervical
group A beta- lymph nodes
-Recommended treatment
hemolytic
course for all oral beta
streptococci (GAS), -age < 15 years
lactams is 10 days.
leading to more
false positives from -Testing should generally
RADT-testing and not be performed in
increases in children < 3 years in
unnecessary whom GAS rarely causes
antibiotic exposure. pharyngitis and
rheumatic fever is
-Streptococcal uncommon.
pharyngitis is
primarily a disease -In children and
of children 5-15 adolescents, negative
years old and is rare RADT tests should be
in children < 3 years. backed up by a throat
culture; positive RADTs
do not require a back-up
culture.

Common -The course of most -Viral URIs are often -Management of the
uncomplicated viral characterized by nasal common cold, nonspecific
 ‫الهيئة العامة للرعاية الصحية‬
‫فرع االقصر‬

cold or non- URIs is 5-7days. discharge and congestion URI, and acute cough illness
Colds usually last or cough. Usually nasal should focus on
specific around 10 days. discharge begins as clear symptomatic relief.
and changes throughout Antibiotics should not be
upper -At least 200 viruses the course of the illness. prescribed for these
can cause the conditions.
respiratory common cold. -Fever, if present, occurs
early in the illness. -There is potential for harm
tract and no proven benefit from
over-the-counter cough and
infection cold medications in children
< 6 years. These substances
(URI) 4,7 are among the top 20
substances leading to death
in children <5 years.

-Low-dose inhaled
corticosteroids and oral
prednisolone do not
improve outcomes in
children without asthma.

Bronchiolitis 8
 ronchiolitis is  Bronchiolitis occurs  Usually patients
the most in children<24 worsen between 3-5
common months and is days, followed by
lower characterized by improvement.
respiratory rhinorrhea, cough,  Antibiotics are not
tract infection wheezing, helpful and should not
in infants. tachypnea, and/ or be used.
 It is most increased  Nasal suctioning is
often caused respiratory effort. mainstay of therapy.
by respiratory  Routine laboratory  Neither albuterol nor
syncytial virus tests and radiologic nebulized racemic
but can be studies are not epinephrine should be
caused by recommended, but administered to

‫فرع االقصر‬
many other a chest x-ray may
respiratory be warranted in
viruses. atypical disease
(absence of viral  There is no evidence
symptoms, severe
distress, frequent
recurrences, lack of
improvement).
 There is no role for
Urinary tract -UTIs are common in -fever and or strong-
children, affecting smelling urine are
infections 8% of girls and 2% common.
of boys by age 7.
(UTIs) 8, 9 -In school-aged children,
-The most common dysuria, frequency, or
causative pathogen urgency are common.
is E. coli, accounting
for approximately -A definitive diagnosis
85% of cases. requires both a urinalysis
suggestive of infection
and at least 50,000
CFUs/mL of a single
uropathogen from urine
obtained through
catheterization or
suprapubic aspiration
(NOT urine collected in a
bag) for children 2–24
‫الهيئة العامة للرعاية الصحية‬
infants and children
with bronchiolitis who
are not hospitalized.
to support routine
suctioning of the
lower pharynx or
larynx (deep
suctioning).
corticosteroids,
ribavirin, or chest
physiotherapy in the
management of
bronchiolitis.
-intial antibiotic
treatment should be
based on local
antimicrobial
susceptibility patterns.
-Suggested agents
include
TMP/SMX,amoxicillin/
clavulanate,cefixime,
or cephalexin in
children 2- 24 months.
-Duration of therapy
should be 7 – 14 days.
-Antibiotic treatment
of asymptomatic
bacteriuria in children
 ‫الهيئة العامة للرعاية الصحية‬
‫فرع االقصر‬

months. is not recommended.

-Urinalysis is suggestive -Febrile infants

of infection with the
presence of pyuria
(leukocyte esterase or ≥5
WBCs per high powered
field), bacteriuria, or
nitrites.
-Nitrites are not a
sensitive measure for UTI
in children and cannot be
used to rule out UTIs.
undergo
ultrasonography.
-Please see the
American Academy of
Pediatrics guidelines
for further details of
establishing the
likelihood of UTI.9

-The decision to assess

for UTI by urine testing
for all children 2-–24
months with unexplained
fever is no longer
recommended and
should be based on the
child’s likelihood of UTI.
Please see the American
Academy of Pediatrics
guidelines for further
details of establishing the
likelihood of UTI.99
 ‫الهيئة العامة للرعاية الصحية‬
‫فرع االقصر‬

References
1. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the
diagnosis and management of acute bacterial sinusitis in children aged 1 to 18
yearsexternal icon. Pediatrics. 2013;132(1):e262-80.
Available at: http://pediatrics.aappublications.org/content/early/2013/06/19/
peds.2013-1071external icon
2. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute
bacterial rhinosinusitis in children and adults external icon. Clin Infect Dis.
2012;54(8):e72-e112.
Available at: https://academic.oup.com/cid/article/54/8/1041/364141/Executive-
Summary-IDSA-Clinical-Practice-Guidelineexternal icon
3. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management
of acute otitis mediaexternal icon. Pediatrics. 2013;131(3):e964-99.
Available at: http://pediatrics.aappublications.org/content/early/2013/02/20/
peds.2012-3488external icon
4. Hersh AL, Jackson MA, Hicks LA, et al. Principles of judicious antibiotic
prescribing for upper respiratory tract infections in pediatrics external
icon. Pediatrics. 2013;132(6):1146-54.
Available at: http://pediatrics.aappublications.org/content/132/6/1146?
rss=1external icon
5. Coker TR, Chan LS, Newberry SJ, et al. Diagnosis, microbial epidemiology, and
antibiotic treatment of acute otitis media in children: A systematic
reviewexternal icon. JAMA. 2010;304(19):2161-9.
Available at: http://jamanetwork.com/journals/jama/fullarticle/186896 external
icon
6. Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the
diagnosis and management of group A streptococcal pharyngitis: 2012 update
by the Infectious Diseases Society of America external icon. Clin Infect Dis.
2012;55(10):e86–102.
Available at: https://academic.oup.com/cid/article/55/10/e86/321183/Clinical-
Practice-Guideline-for-the-Diagnosis-and external icon
7. Fashner J, Ericson K, Werner S. Treatment of the common cold in children and
adultsexternal icon. Am Fam Physician. 2012;86(2):153-9.
Available at: http://www.aafp.org/afp/2012/0715/p153.htmlexternal icon
 ‫الهيئة العامة للرعاية الصحية‬
‫فرع االقصر‬

8. Ralston SL, Lieberthal AS, Meissner HC, et al. American Academy of Pediatrics.
Clinical practice guideline: the diagnosis, management, and prevention of
bronchiolitisexternal icon. Pediatrics. 2014 Nov;134(5):e1474-502.
Available
at: http://pediatrics.aappublications.org/content/134/5/e1474.long external icon
9. Subcommittee on Urinary Tract Infection, Steering Committee on Quality
Improvement and Management, Roberts KB. Urinary tract infection: Clinical
practice guideline for the diagnosis and management of the initial UTI in febrile
infants and children 2 to 24 monthsexternal icon. Pediatrics. 2011;128(3):595–
610.
Available at: http://pediatrics.aappublications.org/content/early/2011/08/24/
peds.2011-1330external icon
10.White B. Diagnosis and treatment of urinary tract infections in children external
icon. Am Fam Physician. 2011;83(4):409-15.
Available at: http://www.aafp.org/afp/2011/0215/p409.htmlexternal icon

‫مدير الوحدة‬ ‫صيدلى أول‬ ‫المدير الطبى‬