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Shahideh Amini
Clinical Pharmacist
Upper Respiratory Tract Infection
Acute respiratory tract infections are the commonest acute
conditions managed in primary care, and the control of
symptoms is a central concern of patients and parents of
young patients.
Patients’ expectations and practitioners’ perceptions of those
expectations have helped fuel prescribing, and antibiotic use in
primary care is rising progressively again after a reduction that
followed a peak in the late 1990s)
This is a key driver for antibiotic resistance, potentially
leading to major infections becoming untreatable
BMJ 2014; 348 doi: (Published 06 March 2014) Cite this as: BMJ
Upper Respiratory Tract Infection
Delayed prescription is recommended in international
guidance, and the National Institute for Health and Care
Excellence currently recommends using a strategy of either no
antibiotic prescriptions or a delayed antibiotic prescription for
dealing with uncomplicated acute sore throats and other
respiratory infections.
Systematic reviews of delayed prescription—where the
patient is advised to wait for at least the expected natural
history of the illness before using the prescription—have
concluded that the strategy is an effective way of reducing
antibiotic use
Upper Respiratory Tract Infection
Upper Respiratory Tract Infection
 The common cold
 Influenza
 Pertussis
 Pharyngitis
 Sinusitis
 acute otitis media
Upper Respiratory Tract Infection
Three basic principles for the effective use of antibiotics
to treat are as follows:
Accurate diagnosis of a bacterial infection
Consideration of the risks vs benefits of antibiotic treatment;
Implementation of judicious prescribing strategies, including
selection of the most effective antibiotic, prescription of an
appropriate dose, and treating for the shortest possible
Delayed antibiotic prescribing strategies for respiratory
tract infections in primary care: pragmatic, factorial,
randomised controlled trial
Little et al evaluated the effectiveness of delayed antibiotic
prescribing strategies for respiratory tract infections in
889 United Kingdom primary care patients (age ≥3 y)
assessed as not requiring immediate antibiotics.
They reported that using strategies of either no or
delayed prescription resulted in fewer than 40% of the
patients across 25 practices using antibiotics.
Delayed prescribing strategies consisted of recontact for
a prescription, postdated prescription, collection of the
prescription, and giving the prescription (patient led).
Sinusitis and rhinosinusitis refer to inflammation in the nasal cavity and
paranasal sinuses.
Acute rhinosinusitis (ARS) lasts less than four weeks.
The most common etiology of ARS is a viral infection associated with the
common cold.
Distinguishing acute viral rhinosinusitis related to colds and influenza-like
illnesses from bacterial infection is a frequent challenge to the primary care
Symptoms of the common cold and ARS often overlap. However, patients
with the common cold generally do not have facial pain. They typically
primarily have symptoms of rhinitis (sneezing and anterior or posterior
rhinorrhea), often with a sore throat or cough
The most common viruses that cause AVRS are
rhinovirus, influenza virus, and parainfluenza virus
Acute bacterial infection occurs in only 0.5 to 2.0 percent
of episodes of ARS
Acute bacterial infection most commonly occurs as a
complication of viral infection, but can be also associated
with rhinitis or conditions that obstruct the nose or
impair local or systemic immune function
Symptoms of acute rhinosinusitis (ARS) include:
 nasal congestion and obstruction, purulent nasal discharge,
maxillary tooth discomfort, and facial pain or pressure that is
worse or localized to the sinuses when bending forward
 Other signs and symptoms include fever, fatigue, cough,
hyposmia or anosmia, ear pressure or fullness, headache, and
 Patients may also have signs and symptoms of eustachian tube
dysfunction (eg, ear pain, fullness or pressure, hearing loss, or
The symptoms of acute viral rhinosinusitis (AVRS) and acute
bacterial rhinosinusitis (ABRS) overlap. There are no clinical
criteria that have been validated to distinguish between them.
AVRS and ABRS have different clinical courses.
acute viral rhinosinusitis has a similar clinical course to other viral URIs
with patients having partial or complete resolution of symptoms within 7
to 10 days.
Although symptoms may persist for more than 10 days, there is typically
some improvement by day 10.
In most cases of viral URI, symptoms peak in severity between day three to
six, after which symptoms improve.
Patients typically do not have fever. If fever is present, it is generally present
early in the illness, and disappears within the first 24 to 48 hours with
respiratory symptoms becoming more prominent after the fever has
Patients with viral infection may have purulent nasal discharge during the
course of their illness; discolored nasal discharge is a sign of inflammation.
Most often, the discharge starts clear, becomes purulent, and then becomes
clear again
Patients with Acute bacterial infection tend to have
symptoms that last longer (>10 days) or are more severe .
Purulent discharge early in the disease course suggests
bacterial infection.
Purulent nasal discharge, nasal obstruction, and facial
pain/pressure/fullness have relatively high sensitivity and
specificity for ABRS, particularly when they occur
concurrently and when symptoms persist for more than
10 days.
Acute bacterial rhinosinusitis — We use the following criteria to
diagnose ABRS, which are supported by the guidelines from the Infectious
Diseases Society of America and the American Academy of OtolaryngologyHead and Neck surgery :
Persistent symptoms or signs of ARS lasting 10 or more days without
evidence of clinical improvement or
Onset of severe symptoms or signs of high fever (>39°C or 102°F) and
purulent nasal discharge or facial pain for at least three to four consecutive
days at the beginning of illness or
Symptoms of a typical viral upper respiratory infection that are slowly
improving but then worsen again ("double-worsening") with more severe
symptoms and signs (new-onset fever, headache, nasal discharge) after five
to six days.
The 2012 Infectious Disease Society of America (IDSA)
guidelines on sinusitis recommend considering treatment if
symptoms persist without improvement for 10 days or longer
or if symptoms are severe or worsen during a period of 3-4
days or longer.
In light of increasing microbial resistance to antibiotics, we
suggest initial empiric treatment with amoxicillin-clavulanate.
We treat patients with risk factors for resistance with highdose amoxicillin-clavulanate
Amoxicillin-clavulanate (500 mg/125 mg orally three times
daily or 875 mg/125 mg orally twice daily) is appropriate initial
therapy for patients with ABRS who do not have risk factors
for resistance
High-dose amoxicillin-clavulanate (2 g orally twice daily) is
appropriate initial therapy for patients who are at higher risk
for resistance
Patients with penicillin allergy – Doxycycline (100 mg
orally twice daily or 200 mg orally daily) is a reasonable
alternative for first-line therapy and can be used in patients
with penicillin allergy.
A respiratory fluoroquinolone (levofloxacin 500 mg orally or
moxifloxacin 400 mg orally once daily) is another option for
penicillin-allergic patients.
For penicillin-allergic patients who can tolerate cephalosporins,
clindamycin 150 mg or 300 mg every six hours plus a thirdgeneration oral cephalosporin (cefixime 400 mg daily or
cefpodoxime 200 mg twice daily) is an option for treatment.
Macrolides (clarithromycin or azithromycin), trimethoprimsulfamethoxazole, and second- or third-generation
cephalosporins are not recommended for empiric therapy
because of high rates of resistance of S. pneumoniae (and of H.
influenzae for trimethoprim-sulfamethoxazole)
Patients who are improving on initial therapy should be
treated for a course of five to seven days .
Shorter courses (five to seven days) are reasonable as the
available evidence suggests that response rates are similar
to longer courses of antibiotics, and longer courses are
associated with more adverse events
Symptomatic therapies
 Analgesics and antipyretics
 Saline irrigation
 Intranasal glucocorticoids
 Oral decongestants
 Antihistamines
 Mucolytics
Acute pharyngitis is one of the most common conditions
encountered in office practice, accounting for 12 million ambulatory
visits in the United States annually.
While group A streptococcus is an important treatable infection, it
accounts for a minority (approximately 5 to 15 percent) of adults
presenting with pharyngitis
Despite this, a majority of patients with pharyngitis receive
presumptive antibiotic therapy. One report estimates that 60
percent of adults seen in a United States clinic in 2010 for a
complaint of sore throat received an antibiotic prescription, with a
trend toward prescribing broader spectrum antibiotics
(azithromycin) rather than narrow spectrum antibiotics (eg,
Overtreatment of acute pharyngitis is a major cause of
inappropriate antibiotic use, which can be avoided by a systematic
approach to evaluation and treatment
The three most commonly reported reasons for a
physician visit, all ranked as very/rather important reasons
for the visit by >80 percent of patients, were:
●To establish the cause of the symptoms
●To obtain pain relief
●To receive information regarding the expected course of
Adults with pharyngitis typically complain of sore throat,
particularly when swallowing. Fever is often present with
bacterial pharyngitis and may occur in association with
headache or malaise. Patients may note “swollen glands”
or anterior neck pain related to lymphadenopathy.
Many patients with viral pharyngitis also have signs and
symptoms associated with a viral upper respiratory
infection (nasal congestion, coryza, hoarseness, sinus
discomfort or tenderness, ear pain, or cough).
Findings on physical examination in patients with
pharyngitis will rarely distinguish the etiology
Centor criteria — The Centor criteria are a widely used
and accepted clinical decision tool [38-40]. These criteria
●Tonsillar exudates
●Tender anterior cervical adenopathy
●Fever by history
●Absence of cough
Tonsillopharyngitis due to Streptococcus pyogenes, also
known as group A Streptococcus (GAS), presents with
abrupt onset of sore throat, tonsillar exudate, tender
cervical adenopathy, and fever, followed by spontaneous
resolution within two to five days.
Patients with sore throat lasting longer than one week
usually do not have GAS tonsillopharyngitis
Antibiotic therapy is most beneficial for hastening
resolution of symptoms if instituted within the first two
days of illness
Antibiotic therapy is primarily helpful for reducing the
incidence of acute rheumatic fever as a nonsuppurative
complication of GAS pharyngitis
Antibiotic treatment does have a role for preventing
transmission of GAS
Antimicrobial therapy is warranted for patients with
symptomatic pharyngitis if the presence of group A
streptococci (GAS) in the pharynx is confirmed by culture or
rapid antigen detection testing (RADT)
In general, antimicrobial therapy is of no proven benefit for
treatment of pharyngitis due to bacteria other than
Such therapy unnecessarily exposes patients to the expense
and potential hazards of antimicrobial drugs and contributes to
the emergence of antibiotic-resistant bacteria.
Antibiotic options for treatment of GAS pharyngitis
include penicillin (and other related agents including
ampicillin and amoxicillin), cephalosporins, macrolides, and
Sulfonamides, fluoroquinolones, and tetracyclines should
NOT be used for treatment of GAS pharyngitis because
of high rates of resistance to these agents and their
frequent failure to eradicate even susceptible organisms
from the pharynx
Topical/Local Therapies
 Despite its common occurrence, data examining treatments for
symptomatic management of acute pharyngitis in adults are limited.
 Nonpharmacologic therapies such as salt-water gargles are often
recommended on the basis of anecdotal response, though there are
no studies to confirm that these are effective for sore throat pain
 Several local therapies for sore throat in the form of throat sprays,
gargles, lozenges/drops, and teas have been studied to varying
degrees for relief of pain related to pharyngitis.
 Lozenges and tablets to be sucked achieved higher initial deposition
in the mouth and throat and had slower rates of clearance
compared with throat sprays and gargles, suggesting that lozenges
and tablets could be more effective for symptomatic treatment of
Systemic Analgesics
Guidelines from the Infectious Disease Society of America
(IDSA) recommend against the use of glucocorticoids for
patients with streptococcal pharyngitis . We suggest not
prescribing glucocorticoids on a routine basis for the relief of
pain associated with an acute sore throat. The use of
glucocorticoids should be restricted to the exceptional patient
who presents with severe throat pain and/or inability to
Acute bronchitis
Acute bronchitis is one of the most common conditions
encountered in clinical practice.
It is a self-limited inflammation of the bronchi due to
upper airway infection.
Patients with acute bronchitis present with a cough
lasting more than five days (typically one to three weeks),
which may be associated with sputum production.
Acute bronchitis cannot be distinguished from upper
respiratory infections in the first few days of illness, but
acute bronchitis should be considered when cough
persists for more than five days
Acute bronchitis
The usual causes of acute bronchitis are viral infections of the
upper airways including influenza A and B, parainfluenza,
coronavirus (types 1-3), rhinovirus, respiratory syncytial virus,
and human metapneumovirus.
Other pathogens that can cause acute bronchitis, although less
commonly than viruses, include:
●Mycoplasma pneumoniae
●Chlamydia pneumoniae
●Bordetella pertussis
Acute bronchitis
It is important, however, to distinguish acute bronchitis from
pneumonia, which usually indicates need for antibiotic therapy.
Fever is an unusual sign in patients with acute bronchitis and
suggests the presence of either influenza or pneumonia.
Patients with the combination of cough, fever, sputum
production, and constitutional symptoms are more likely to
have influenza or pneumonia.
Patients with acute bronchitis have few systemic symptoms.
They may have chest wall tenderness related to muscle strain
from coughing.
Wheezing may also occur.
Acute bronchitis
Purulence does not signify
bacterial infection, contrary to
commonly held beliefs.
Acute bronchitis
Most patients with acute bronchitis require only
reassurance and symptomatic treatment
Many patients with acute bronchitis have associated
symptoms of the common cold and may benefit from
symptomatic treatment using a nonsteroidal
antiinflammatory drug, acetaminophen, and/or
Acute bronchitis
The major therapeutic issue in most cases of acute
bronchitis is the decision to use or forgo antibacterial
agents. Multiple studies indicate that patients with acute
bronchitis do not experience significant benefit from
antibiotic therapy
United States and United Kingdom guidelines do not
recommend treating uncomplicated acute bronchitis with
antibiotics. Guidelines from the American College of
Physicians and the Centers for Disease Control and
Prevention (CDC) are intended to dissuade clinicians
from prescribing antibiotics for acute bronchitis
Common Cold
The common cold is a benign self-limited syndrome
representing a group of diseases caused by members of
several families of viruses.
It is the most frequent acute illness in the United States
and throughout the industrialized world .
The term "common cold" refers to a mild upper
respiratory viral infection involving, to variable degrees,
nasal congestion and discharge (rhinorrhea), sneezing,
sore throat, cough, low-grade fever, headache, and malaise.
Common Cold
Symptoms of the common cold are largely due to the immune
response to infection, rather than to direct viral damage to the
respiratory tract.
Symptoms may substantially vary from patient to patient;
rhinitis and nasal congestion are most common.
Other common symptoms include sore throat, cough and
Fever is uncommon in adults with a cold, but may be present
in children; conjunctivitis occurs variably in both age groups.
The intensity and type of symptoms of the common cold may
also be related to host factors including age, underlying
illnesses, and prior immunological experience, as well as to the
type of infecting virus
Common Cold
The most common and characteristic initial symptoms are
nasal discharge, nasal obstruction, and a dry or "scratchy
Cough is common and tends to appear after the onset of nasal
discharge and obstruction. When present, cough often persists
past the time that nasal and throat symptoms resolve.
Although cough may be prominent and prolonged in some
patients, rales and signs of lower respiratory tract involvement
typically are not present in adults.
Fever, when present, tends to be low grade.
Many patients also complain of sneezing, malaise, headache, and
pressure or discomfort in their ears and face.
Common Cold
Nasal discharge is usually clear. Purulent nasal discharge
may occur in some patients with the common cold
and/or in patients with secondary viral or bacterial
Many patients and clinicians erroneously place
considerable importance upon the color of nasal
discharge when making decisions about antibiotic use.
colored nasal discharge is a normal self-limited phase of
the uncomplicated common cold. The presence of
purulence alone cannot distinguish between a cold or
sinus infection.
Common Cold
Symptomatic therapy remains the mainstay of common cold
Analgesics may be used to relieve associated symptoms (eg,
headache, ear pain, muscle and joint pains, malaise, and
Symptomatic treatments for nasal symptoms that have
moderate evidence of efficacy include combination product
containing an antihistamine and a decongestant,
intranasal/inhaled cromolyn sodium, or intranasal ipratropium
Cough associated with the common cold may be caused by
nasal obstruction or postnasal drip. We suggest symptomatic
treatment for cough suppression with dextromethorphan
Common Cold
zinc sulfate lozenges and syrup may decrease cold
symptom severity and duration, we suggest not using zinc
preparations because of uncertain benefits and known
toxicities, including irreversible anosmia, for some
preparations. Systematic reviews have found that zinc
intake is associated with a reduction in the duration and
severity of cold symptoms
Common Cold
Ineffective therapies — Evidence does not support the use
of these therapies for treatment of the common cold
 Antibiotic therapy — The common cold is caused by
viruses and there is no indication for antibiotic therapy in
the absence of evidence of secondary bacterial infections.
Treatment with antibiotics for uncomplicated upper
respiratory tract infections causes more harm than
Vitamin C – Vitamin C is often touted as a natural remedy for
the common cold.
A 2013 meta-analysis of 29 trials (n = 11,306) showed a small
but significant 8 percent reduction in the duration of cold
symptoms in adults regularly taking vitamin C supplements (at
least 200 mg/day). This reduction was of uncertain clinical
relevance. The meta-analysis also showed that vitamin C given
therapeutically after symptom onset did not reduce symptom
duration or severity