Upper and Lower Respiratory Tract Infections

upper RTIs

- acute otitis media (AOM)

- acute bacterial rhinosinusitis (ABRS)

- pharyngitis

- acute exacerbation of COPD (AECOPD)

acute otitis media (AOM)

- infection of the middle ear

- occurs with rapid onset of signs and symptoms of inflammation of middle ear

otitis media with effusion (OME)

presence of fluid in the middle ear without signs and symptoms of acute ear infection

peak age prevalence of AOM

6-18 months

Why are children at risk for AOM?

- microbiome diversity (higher nasal carriage of viral/bacterial pathogens)

- anatomy (short and horizontal Eustachian tubes)

- social and environmental factors (smoke exposure, day care attendance, siblings

diagnosis of AOM

- no gold standard

- present with bulging of tympanic membrane and new onset (within 48 hours) of non-specific clinical findings

non-specific clinical findings for AOM

- otorrhea

- otalgia, rubbing/tugging/holding

- irritability, crying, poor appetite

- rhinorrhea

- change in sleep or behavior patterns

- fever

definitive AOM findings

bulging tympanic membrane

common pathogens in AOM

- Gram-positive: Strep. pneumoniae

- Gram-negative: H. influenzae, Moraxella catarrhalis

uncomplicated AOM

AOM without otorrhea

nonsevere AOM

AOM with the presence of mild otalgia and a temp below

severe AOM

AOM with the presence of moderate to severe otalgia or fever equal to or higher than 39C

watchful waiting in AOM

- observation with close follow-up

- "wait and see"

watchful waiting of AOM in children 6-24 months

unilateral AOM and mild symptoms

watchful waiting of AOM in children older than 2 years

unilateral or bilateral AOM and mild symptoms

indications to initiate antibiotic therapy for AOM

- pain for >48 hours

- otorrhea regardless of age

- severe symptoms (dehydration, hypotension, decreased pallor, ned for IV fluids)

- 6 months to 2 years old with bilateral AOM

antibiotic therapy

6 months to 2 years with AOM + severe symptoms or AOM + otorrhea

antibiotic therapy

>2 years with AOM + severe symptoms or AOM + otorrhea

antibiotic therapy

antibiotic therapy

6 months to 2 years with bilateral AOM without otorrhea

antibiotic therapy

>2 years with bilateral AOM without otorrhea

consider watchful waiting

antibiotic therapy

6 months to 2 years with unilateral AOM without otorrhea

consider watchful waiting

>2 years with unilateral AOM without otorrhea

consider watchful waiting

antibiotics of choice for AOM

- amoxicillin

- amoxicillin-clavulanate

dose of amoxicillin for AOM

90 mg/kg/day divided q12h

dose of amoxicillin-clavulanate for AOM

90 mg/kg/day + 6.4 mg/kg/day divided q12h

considerations for use of amoxicillin-clavulanate

- >20% prevalence of beta-lactamase positive H. influenzae or Moraxella catarrhalis

- concurrent conjunctivitis

- beta-lactam use in previous 30 days

alternative agents of treatment for AOM in penicillin-allergic patients

- cefuroxime

- cefpodoxime

- cefdinir

- ceftriaxone

dose of cefuroxime for AOM

30 mg/kg/day divided q12h

dose of cefpodoxime for AOM

10 mg/kg/day divided q12h

dose of cefdinir for AOM

14 mg/kg/day divided q12-24h

dose and duration of ceftriaxone for AOM

50mg IM daily for 1-3 days

duration of therapy for AOM in patients

10 days

duration of therapy for AOM in patients 2-5 years with mild to moderate presentation

7 days

duration of therapy for AOM in patients >6 years with mild to moderate presentation

5-7 days

duration of therapy for severe AOM

10 days

treatment failure of AOM

failure of 48-72 hours of initial therapy

agents to use for AOM in the case of initial treatment failure

- amoxicillin-clavulanate 90 mg/kg/day + 6.4 mg/kg/day divided q12h (if initially treated with high-dose amoxicillin)

- ceftriaxone 50mg IM or IV daily for 3 days (if initially treated with amoxicillin-clavulanate or oral cephalosporin)

agents for treatment of mild to moderate otalgia

- acetaminophen

- ibuprofen

dose of acetaminophen for mild to moderate otalgia

10-15 mg/kg/dose q4-6h PRN pain (MAX 5 doses in 24h)

dose of ibuprofen for mild to moderate otalgia (only for >6 month)

10 mg/kg/dose q6-8h PRN pain

agents for treatment of moderate to severe otalgia

narcotic analgesic with codeine or analogs

other options for pain

- topical (benzocaine, lidocaine, procaine, naturopathic)

- home remedies (external heat/cold, oil drops, distraction techniques)

- homeopathic agents

prevention of recurrent otitis media

vaccination (4 dose pneumococcal series by 15 months, annual influenza)

prophylaxis of recurrent otitis media

no options due to resistance concerns

treatment for recurrent otitis media

tympanostomy tube

indications for tympanostomy tube

- frequent AOM (>3 episodes in 6 months or >4 episodes in 1 year)

- documented hearing loss

- persistent otitis media with effusion >3 months

monitoring during treatment of AOM

- efficacy: resolution of signs and symptoms, back to regular sleep

- toxicity: GI upset, diarrhea

rhinosinusitis

inflammation of the mucosal lining of the nasal passage and paranasal sinuses

duration of symptoms of acute rhinosinusitis

up to 4 weeks

duration of symptoms of chronic rhinosinusitis

>3 months

duration of symptoms of subacute rhinosinusitis

4 weeks to 3 months

risk factors for ABRS

- smoking or smoke exposure

- asthma

- allergic rhinitis

- nasal obstruction

- ciliary apparatus dysfunction

- viral upper respiratory infections

major symptoms of ABRS

- purulent anterior nasal discharge

- purulent or discolored posterior nasal drainage

- nasal congestion/obstruction

- facial congestion or fullness

- facial pain, pressure

- hyposmia or anosmia

- fever

minor symptoms of ABRS

- headache

- ear pain, pressure, or fullness

- halitosis

- dental pain

- cough

- fever

- fatigue

definitive diagnosis for ABRS

sinus aspiration and culture (gold standard)

step 1: evidence of sinusitis based on compatible symptoms

>2 major symptoms or 1 major symptoms and >2 minor symptoms with radiographic findings

viral rhinosinusitis

- congestion and obstruction

- daytime cough

- sore throat

- fever, headache, myalgia resolution within 24-48 hours

- peak respiratory symptoms in 2-3 days and wane thereafter; lasts 7-10 days

bacterial rhinosinusitis diagnosis

- persistent symptoms without improvement that lasts 10 days

- worsening symptoms (initially improved but worsened after 5 days)

- severe symptoms from start (fever >39C, purulent nasal discharge, or facial pain >3 days)

common pathogens of ABRS

- Gram-positive: Strep. pneumoniae, Strep. pyogenes, Staph. aureus

- Gram-negative: H. influenzae, Moraxella catarrhalis

risks for pneumococcal resistance

- age

- antibiotics within the last month

- hospitalization within the last 5 days

- comorbidities (smoking, diabetes, chronic cardiac/hepatic/renal disease)

- immunocompromised

agents for treatment of ABRS in adults

standard and high-dose amoxicillin-clavulanate

standard dose of amoxicillin-clavulanate for ABRS in adults

500/125mg PO TID or 875/125mg PO BID

high-dose of amoxicillin-clavulanate for ABRS in adults

2000/125mg PO BID

When to use high-dose amoxicillin-clavulanate for treatment of ABRS in adults?

- severe presentation

- high risk for multi-drug resistant pathogens

- high endemic rates of PCN non-susceptible Strep. pneumoniae

alternative agents for treatment of ABRS in adults with penicillin allergy

- doxycycline (1st line)

- levofloxacin (2nd line)

- moxifloxacin (2nd line)

- cefixime or cefpodoxime + clindamycin

dose of doxycycline for ABRS in adults

100mg PO BID or 200mg PO once daily

dose of levofloxacin for ABRS in adults

500mg PO once daily

dose of moxifloxacin for ABRS in adults

400mg PO once daily

dose of cefixime for ABRS in adults

400mg PO once daily

dose of cefpodoxime for ABRS in adults

200mg PO BID

dose of clindamycin for ABRS in adults

300mg PO q6h

duration of treatment for ABRS in adults

5-7 days

doxycycline considerations for treatment of ABRS

- retains high activity against primary pathogens

- first line alternative for penicillin allergy because of lower side effect profile

fluoroquinolone considerations for treatment of ABRS

- no superiority demonstrated against beta-lactams

- no significant different in outcomes, but adverse effects occurred more frequently

- 2016 boxed warning: reserve use in ABRS for patients with no alternative because of risk of disabling and potentially serious adverse reactions

- 2nd line alternative for PCN allergy

cephalosporin considerations for treatment of ABRS

- all are inferior in efficacy

- recommend 3rd gen cephalosporin

- cefpodozime: best in class for ABRS treatment

TMP-SMX considerations for treatment of ABRS

not recommended due to high risk of resistance with H. influenzae and lack of adequate activity against S. pneumoniae

macrolide considerations for treatment of ABRS

not recommended due to lack of reliable coverage against S. pneumoniae

treatment failure of ABRS in adults

symptoms that do not abate after 3-5 days of therapy or worsening after 48-72 hours of therapy

steps in the case of treatment failure of ABRS in adults

- broaden coverage or switch antibiotic classes

- switch amoxicillin-clavulanate to doxycycline or respiratory fluoroquinolones

- complete 7-10 days of therapy

- cultures (reserved for patients who fail 1st and 2nd line therapy)

monitoring during treatment of ABRS

- efficacy: resolution of signs and symptoms

- toxicities: diarrhea, GI upset, photosensitivity, esophageal ulceration, QT prolongation, tendon rupture

adjunctive therapy for ABRS

- intranasal corticosteroids (INCSs) (benefits with hx of allergic rhinitis

- nasal irrigation with saline

when to refer for ABRS

- severe infection, orbital edema, severe headache, visual disturbances

- immunosuppression, fungal sinusitis

- anatomic defects requiring surgical intervention

- unresponsive to antibiotic therapy and all other causes are ruled out

- presence of multiple/complicated comorbidities

considerations on chronic sinusitis

- avoid antibiotic therapy

- short course antibiotics targeting typical ABRS pathogens for acute exacerbations

strep throat (GAS pharyngitis)

infection of the oropharynx caused by S. pyogenes

adults at increased risk of strep throat

- parents of school aged children

- adults who are often in contact with children

clinical presentation of strep throat

- sore throat

- pain or swelling

- fever

- enlarged tonsils

- cervical lymphadenopathy

- white-gray exudate

- petechiae on soft palate

- scarlatiniform rash (scarlet fever)

- abdominal pain, nausea, vomiting, headache

strep throat diagnosis

- culture (gold standard): requires 24-48 hours for results

- rapid antigen detection test (RADT): practical, quicker, less expensive

agents for treatment of GAS pharyngitis

- penicillin V, oral

- amoxicillin, oral

- benzathine penicillin G, IM

dose and duration of penicillin V for treatment of GAS pharyngitis (children)

250mg PO BID or TID for 10 days

dose and duration of penicillin V for treatment of GAS pharyngitis (adult)

250mg PO QID or 500mg PO BID

dose and duration of amoxicillin for treatment of GAS pharyngitis

50 mg/kg PO once daily (MAX 1000mg) or 25 mg/kg PO BID (MAX 500mg) for 10 days

dose and duration of benzathine penicillin G for treatment of GAS pharyngitis

agents for treatment of GAS pharyngitis in patients with penicillin allergy

- cephalexin, oral

- clindamycin, oral

- azithromycin, oral

- clarithromycin, oral

dose and duration of cephalexin for treatment of GAS pharyngitis

20 mg/kg/dose PO BID (MAX 500mg/dose) for 10 days

dose and duration of clindamycin for treatment of GAS pharyngitis

7 mg/kg/dose PO TID (MAX 300mg/dose) for 10 days

dose and duration of azithromycin for treatment of GAS pharyngitis

12 mg/kg PO once (MAX 500mg), then 6 mg/kg PO once daily (MAX 250mg) for 4 days

dose and duration of clarithromycin for treatment of GAS pharyngitis

7.5 mg/kg/dose PO BID (MAX 250mg/dose) for 10 days