Pediatric Infections in Outpatient Settings-Review of Recent Evidence

Pediatric infections in India-Overview

Shedding light on the frequently encountered pediatric infections reported in India, recent studies have reported a high prevalence (50–64%) of respiratory infections; associated with concerning morbidity and even mortality. (1,2) Statistics reveal that India is among the most burdened countries regarding total pediatric pneumonia incidence and related childhood mortality. (2) Studies further highlight that respiratory tract infections, followed by acute gastroenteritis (diarrhea) and urinary tract infections, are some of the most common bacterial infections among Indian children between 1 month to 5 years. (3)

Diagnosing Pediatric Bacterial Infections: A Consistent Dilemma- Overlapping symptoms of bacterial infections with various viral, fungal, and parasitic infections, coupled with low resource settings for laboratory infrastructure and human capacity, especially in developing countries, complicates clinical diagnosis. Given such circumstances, physicians and pediatricians in OPDs often rely heavily on empirical therapy to initiate a fight against pediatric infections. (1)

Antibiotics, the cornerstones of bacterial infectious diseases, are an essential part of pediatric medical care in OPDs, and children get prescribed these more frequently. (4) Antibiotic prescribing in primary care also varies significantly across doctors, being dictated by diagnostic ambiguity, cost, availability of drugs, parent expectations, workloads, and difficulties in effective doctor-patient communication. (5)

Recent Clinical Updates on Managing Pediatric Infections -A Physician’s Guide

The scarcity of pediatric clinical trials on the use of antibiotics has resulted in a continuing dearth of evidence-based expert consensus. With a strikingly high prevalence of inappropriate antibiotic prescriptions in hospitals and the community globally, the focus has now been put on the appropriate and safe use of these antimicrobial agents across infections. (4)

Analyzing the scope of Antibiotics-Importance of an Initial Empirical therapy

• When an infection is suspected, but the actual pathogen is yet to be identified, empiric treatment is recommended. Based on the recognized signs and symptoms, it comprises the administration of a broad-spectrum antibiotic; and is implemented while awaiting the lab tests, which can take several days. (4)
• On the other hand, definite therapy, usually with a narrow-spectrum antibiotic, can begin when the pathogenic microorganism has already been identified or established. (4)
• Recommendations highlight that the price and availability of antibiotics will also influence the choice. Accurate diagnosis is crucial as it lowers the expense and side effects of antibiotic therapy while preventing the development of antibiotic resistance. (4)

Importance of appropriate antibiotic dosing - Pediatric medication dosage is more complicated than adults' and should ideally reflect the child's age and weight. Antibiotic dose errors could lead to iatrogenic sequels in children. While sub-therapeutic antibiotic administration can result in treatment failure and contribute to antimicrobial resistance, excessive dosing can increase the frequency and severity of side effects and toxicity. (5)

Managing infections in children -Scope of Amoxicillin

Amoxicillin, by its spectrum of action against various micro-organisms, is one of the frequently used antibiotics, particularly in primary healthcare settings. The FDA-approved uses of Amoxicillin in children are ear, nose, and throat infections in pediatric patients (upper respiratory tract infections like tonsillitis, pharyngitis, and otitis media); lower respiratory tract infections, acute bacterial sinusitis, skin and skin structure infections, and urinary tract infections. (6)

Amoxicillin has been included in the ACCESS category of antibiotics by the WHO, which justifies its effectiveness in treating various diseases while posing little threat of resistance. (7)

The Indian Council of Medical Research (ICMR), in the latest Antimicrobial Guidelines 2022, recommend the following suggestions on the usage of Amoxicillin: (8)

• Bacterial sinusitis: Amoxicillin is the first choice of treatment in mild bacterial sinusitis in children 10-14 days.
• Acute otitis media: Children between 2 and 5 years with mild disease can be treated for 7 days, and those above 5 years with 5-7 days of therapy.
• Pediatric community-acquired pneumonia (CAP): For children aged > 1 month, Amoxicillin is the first choice of therapy.
• Urinary tract infection (UTI) in Children: The guideline recommended Amoxicillin as the first choice of therapy in cystitis, and the treatment regime can be for 5-7 days.

In addition, Amoxicillin is recommended as the second/alternate therapy for Streptococcal pharyngitis for a treatment duration of 10 days.

Study testimonials: Affirming the position of Amoxicillin in Pediatric Infections-

• Clinical Benefit in Pneumonia- Indian Experience: To assess the efficacy of three days versus five days of treatment with oral amoxicillin for curing non-severe pneumonia in children, a study was undertaken with 2188 children from India aged 2-59 months. The clinical cure rates with three days and five days of treatment were 89.5% and 89.9%, respectively, confirming that treatment with oral amoxicillin for three days was as effective as for five days in children with non-severe pneumonia. (9)
• Pediatric Tonsillopharyngitis: To assess the bacteriological and clinical effectiveness of amoxicillin as the first-line medication for the management of pediatric tonsillopharyngitis, prospective observational research was carried out. Children who participated in the study had beta-hemolytic streptococcal (GABHS) tonsillopharyngitis that had developed suddenly. Results revealed that Children who received amoxicillin experienced bacteriological and clinical cure rates of 76 per cent and 84 per cent, respectively, thus indicating a significant level of clinical effectiveness. (10)
• Sensitivity Edge Indian Data Over Other Commonly Used Antimicrobial Agents: In a major study, Mehta S et al. 2020 concluded that among the susceptibility patterns of Azithromycin, Cefuroxime, Doxycycline, and amoxicillin, only amoxicillin was more active (95.8 %) than doxycycline, azithromycin, and cefuroxime against Streptococcus spp. (11)

Final Key Pointers for Physicians-

• Infectious illnesses are the primary cause of death in children. Antibiotics are vital in managing pediatric bacterial infections.
• Physicians may like to be mindful of the clinical aspects of initiating an empirical therapy to effectively manage bacterial infections frequently observed in pediatric OPDs. When isolating the organism is challenging, empiric antibiotics can be used against the suspected pathogens. Treatment is directed to a more rational usage of antibiotics when specialized diagnostic tests are done and the results are correctly interpreted.
• Amoxicillin, supported by ample evidence and guidelines, occupies a prominent position in managing commonly encountered infections in children.
• Finally, the practitioner would like to be abreast of the most recent recommendations to help better manage pediatric infections.

References:

1. Pathak, A., Upadhayay, R., Mathur, A., Rathi, S., & Lundborg, C. S. (2020). Incidence, clinical profile, and risk factors for serious bacterial infections in children hospitalized with fever in Ujjain, India. BMC infectious diseases, 20(1), 1-11.

2. Hasan, M. M., Saha, K. K., Yunus, R. M., & Alam, K. (2022). Prevalence of acute respiratory infections among children in India: Regional inequalities and risk factors. Maternal and Child Health Journal, 1-9.

3. Saikia, D., & Sharma, R. K. (2018). A study of pattern of some common infections in children one month to five years of age. Int J ContempPediatr, 5, 1983-9.

4. Karataş, Y., & Zakir, K. H. A. N. (2021). Antibiotic usage in the pediatric population: The need for effective role of parents and prescribers. Güncel Pediatri, 19(1), 135-140.

5. Rann O, Sharland M,Long P, et al. Did the accuracy of oral amoxicillin dosing of children improve after British National Formulary dose revisions in 2014?National cross-sectional survey in England. BMJ Open 2017;7:e016363. doi:10.1136/ bmjopen-2017-016363

6. Akhavan BJ, Khanna NR, Vijhani P. Amoxicillin. [Updated 2021 Aug 17]. In:StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK482250/

7. World Health Organization. ( 2017) . WHO model list of essential medicines, 20thlist ( March 2017, amended August 2017) ? World Health Organization.https://apps.who.int/iris/handle/10665/273826

8. Indian Council of Medical Research. Treatment Guidelines for Antimicrobial Use in Common Syndrome. 2022. https://amrtg.icmr.org.in/redirect.html. [Access 18th January 2023]

9. Three days versus five-day treatment with amoxicillin for non-severe pneumonia in young children: a multicentre randomized controlled trial. BMJ, 328(7443), 791–0. doi:10.1136/bmj.38049.490255.de

10. Curtin-Wirt C, Casey JR, Murray PC, Cleary CT, Hoeger WJ, Marsocci SM,Murphy ML, Francis AB, Pichichero ME. Efficacy of penicillin vs. amoxicillin in children with group A beta-hemolytic streptococcal tonsillopharyngitis. Clin Pediatr(Phila). 2003 Apr;42(3):219-25. doi: 10.1177/000992280304200305. PMID:12739920.

11. Suyog C Mehta et al, Susceptibility Pattern of Doxycycline in Comparison to azithromycin, Cefuroxime and Amoxicillin against Common Isolates: A Retrospective Study Based on Diagnostic Laboratory Data, Journal of The Association of Physicians of India 2020;68:59-63