A5V4d

Feverish illness in children
children with Streptococcus pneumoniae occult bacteraemia. Fewer cases of SBIs but not bacterial
meningitis were observed to develop in those children treated with antibiotics, compared with those
who were not (P = 0.003). Furthermore, both oral and parenteral antibiotics were found to be equally
effective in preventing SBI, which resulted in extremely low rates of complications observed in both
groups (pooled OR = 1.48 in each group). Similarly, in another EL 1+ RCT 157 which looked at the
effect of antibiotic treatment (amoxicillin) for acute otitis media in children between 6 months and
2 years, there was a reduced risk of 13% in the persistence of symptoms on day 4 in the amoxicillin
group compared with the group which did not take amoxicillin (risk difference 13%, 95% CI 1% to
25%). In addition, median duration of fever was 2 days in the amoxicillin group versus 3 days in the
placebo group (P = 0.004). Analgesic consumption was also higher in the group that went without
antibiotics during the first 10 days (4.1 versus 2.3 doses, P = 0.004). However, no significant
difference was observed in duration of pain or crying. No otoscopic differences were observed at
days 4 and 11, and hearing tests findings were similar in both groups at 6 weeks The researchers
concluded that, since seven to eight children aged 6–24 months with acute otitis media needed to be
treated with antibiotics to improve symptomatic outcome on day 4 in one child, the modest effect does
not justify the prescription of antibiotics at first visit.
Decreasing inappropriate antibiotic prescribing for children may also help decrease antibiotic
resistance. In Finland, after nationwide reductions in the use of macrolide antibiotics for outpatient
therapy, there was a significant decline in the frequency of erythromycin resistance among group A
streptococci. 158
Evidence summary
There is some evidence that oral antibiotics may decrease the risk of developing complications in
children with Streptococcus pneumoniae occult bactaeremia, but insufficient evidence to conclude
that it prevents bacterial meningitis.
There was no significant difference between children who were treated with oral or parenteral
antibiotics.
However, over 1000 children at risk of occult pneumococcal bacteraemia would need to be treated to
possibly reduce one case of meningitis. 159 There is evidence that campaigns to reduce the
prescription of oral antibiotics are associated with a reduction in antimicrobial resistance. 158
Health economics
There are very wide variations at both local and national levels in both rates and costs of antibiotic
prescribing, with little evidence of associated variations in morbidity from infections. A decrease in
inappropriate prescribing might also reduce antibiotic resistance. A decrease in inappropriate
antibiotic prescribing would provide a saving in the overall NHS prescribing costs and delay antibiotic
resistence. It is also possible that reduced antibiotic prescribing might increase the need or demand
for reassessment and hospital admission of a febrile child either during surgery hours or by out-ofhours
service providers, but while it would be possible to undertake research to assess the impact on
healthcare demand (and costs and savings) of changes in antibiotic prescribing for children with
suspected SBI, the GDG did not identify relevant data on this for the guideline.
GDG translation
The vast majority of well-appearing children (97%) with fever without cause do not have occult
bacteraemia, and they will therefore not benefit from empirical oral antibiotics.
Occult pneumococccal bacteraemia is likely to be reduced markedly after conjugate pneumococcal
vaccine was introduced in the routine UK immunisation schedule in September 2006.
Even for infections such as otitis media, the modest effect does not justify the prescription of
antibiotics at first visit (number needed to treat [NNT] = 7–8).
The GDG also recognised the risks of the unnecessary prescribing of antibiotics such as adverse side
effects and the development of antimicrobial resistance. The GDG also acknowledged the possibility
of cost savings.
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