Upper Respiratory Infections · Use non-antibiotic measures to manage upper respiratory infection (URI) symptoms. * “Management of the common cold, non-specific URI, acute cough

Collaborative Advancement of

C A EPrescription Excellence

Rhinosinusitis

Bronchitis

PharyngitisOtitis media

Common cold

Inf luenza

Upper Respiratory InfectionsImproving Symptom Management and Antibiotic Use

Spring 2018

Use non-antibiotic measures to manage upper respiratory infection (URI) symptoms.*

“Management of the common cold, non-specific URI, acute cough illness, and acute bronchitis should focus on symptomatic relief. Antibiotics should not be prescribed for these conditions.”

- American Academy of Pediatrics

• Almost 80 percent of these ADEs were allergic reactions.• Most allergic reactions can only be prevented by avoiding

exposure to a drug.

Avoiding unnecessary antibiotics (abx) reduces adverse drug events (ADEs).

Nearly 20% of all

emergency visits are

due to abx-ADEs

• The rate of frequency for abx-associated emergency department (ED) visits is highest for patients age < 1.

• More than 6 percent of abx-associated ADEs lead to hospitalization.• Reducing antibiotic prescribing by 10 percent may reduce community-

associated C. difficile infection by 17 percent.

Recommending symptom management and ruling out antibiotics improves parent satisfaction and reduces abx prescribing.

• Parents feel frustrated when no specific symptom management treatments are recommended.• Parents are most satisfied when:

» they receive tools to manage their child’s symptoms AND » they have an explanation of the inappropriateness of abx treatment for their child

Parents are 16% more likely to give provider the highest rating

85% decrease in abx prescribing

Symptom management and ruling out antibiotics:

References: 1 - 5*Upper respiratory infections: sinusitis, pharyngitis, tonsillitis, epiglottitis, tracheitis, bronchitis, laryngitis, acute otitis media, rhinitis, influenza

2 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

3

Increase vaccination rates to reduce the need for antibiotics.

Increased rates of flu vaccinations lead to decreased antibiotic prescribing.

Less than 46 percent of eligible U.S. patients receive the annual flu vaccine.

Each year, only 41 percent of Oklahomans are vaccinated for flu.

64%decreasein

abxprescribing

> 54%are not

vaccinated for flu

When universal flu vaccinations are implemented, flu-associated abx prescribing decreases by 64 percent.

Annual flu vaccination is recommended for everyone 6 months and older, including women who are pregnant, and those with egg allergy.

“Vaccination is the single most important step people can take to protect themselves from influenza.”

- Tom Frieden, M.D., M.P.H., infectious disease expert, former director of the Centers for Disease Control and Prevention (CDC)

Increased rates of pneumococcal vaccinations (PCVs) lead to decreased antibiotic prescribing.

PCV-13 administration reduces incidence of AOM by up to 67%.

For children age < 2 years, antibiotic prescription rates decrease by 11 percent, when 90 percent PCV-13 coverage is achieved.

• AOM is the leading cause of antibiotic prescribing among children from 6 months to 12 years of age. • PCV-13 vaccination results in up to 87 percent decrease in resistant pneumococcal disease.

References: 6 - 19

Nearly 20 percent of flu patients receive initial abx without:• underlying secondary infection• contributing comorbidity

Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

Use shared decision making to improve treatment of upper respiratory infections.

Benefits of using shared decision making (SDM) for URI prescribing may be seen for many years.

54%

27%39%

26%

0%

10%

20%

30%

40%

50%

60%

usual careUR

I pat

ient

s re

ceiv

ing

abx

pres

crip

tion Lasting Effects of SDM

initial 30 days 3.5 yrs later

SDMUR

I pat

ient

s re

ceiv

ing

abx

pres

crip

tion

References: 20 - 23

Treatment-associated-risk knowledge increases 30%

Only 2.6 minutes more provider time

SDM aids require minimal provider time, improve patient knowledge, and increase patient satisfaction when compared to usual care for URIs.

Disease knowledge increases 13%

Patients are 3% more satisfied

30%

13%

3%

2.6


5

A) There are multiple treatment options

Supportive care Watchful waiting Rest Adequate fluid intakeHumidified air Analgesics Antipyretics DecongestantsAntitussives Antivirals AntibioticsB) Patients have misconceptions

They believe they have only two options:1. “If I don’t take an antibiotic I will stay sick.”2. “If I take an antibiotic, I might stay sick, but I

might get better.”“If I take antibiotics, mostly nothing bad will happen.”“Antibiotics are worth the risk of side effects.” (> 75% believe antibiotics are worth the risk.)

SDM is especially helpful for upper respiratory infection (URI) treatment decisions because:

Use SDM to clarify patient expectations and prescriber perceptions.• 90 percent of URI patients expect to receive information and/or reassurance.• When patients actually expect an antibiotic, prescribers are four times more likely to prescribe

one.• When providers think their patients expect an antibiotic, they are ten times more likely to

prescribe one.• Clarifying expectations and providing information and/or reassurance through SDM can result in

a 40 percent or greater decrease in antibiotic prescribing for URIs.

SDM is endorsed by multiple organizations and is recommended to be implemented whenever possible.

• American Academy of Family Physicians• American Academy of Orthopaedic Surgeons• American Academy of Pediatrics• American College of Physicians• American College of Critical Care• American Osteopathic Association

• American Thoracic Society• Centers for Medicare and Medicaid Services• Health and Medicine Division of the National

Academies of Science (formerly Institute of Medicine)

• U.S. Department of Health & Human ServicesReferences: 24 - 37


When antibiotics are necessary, choose the most narrow spectrum possible.

Use narrow spectrum abx to avoid adverse drug reactions (ADRs)Pediatric ADRs compared: diarrhea, rash, upset stomach, vomiting

Amoxicillin-clavulanate, azithromycin, cefdinir, cefprozil, cefuroxime, cephalexin, ceftriaxone, cefadroxil

35.6 percent had ADRs

Penicillin, amoxicillin 25.1 precent had ADRsAdverse drug reactions (ADRs) are more likely with even moderately broad-spectrum antibiotics.

References: 1, 38 - 41

Narrow-spectrum antibiotics are underutilized for URI treatment.

Otitis Media Sinusitis

100

75

50

25

0

Used and adapted with permission: Adam L. Hersh, M.D., Ph.D.

Per

cent

age

When a bacterial URI is reasonably suspected:• First-line agents are used only 52 percent of the time. • First-line agents should be used 80 percent of the time.

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Pharyngitis

Pediatric Patients

Sinusitis Pharyngitis

Adult Patients

First-line:Amoxicillin, penicillinAmoxicillin-clavulanate

Non-first-line:MacrolideBroad cephalosporinFluoroquinoloneOthers


7

Outcomes were equivalent for:Speed of symptom resolution Duration of fever Hospital admissionChild sleep quality Need for additional child care SepsisNeed for supplemental oxygen Need for second antibiotic Need for intensive careEmergency department admissionMissed work days (parent) or school days (child)

Broad-spectrum antibiotics have not been shown to produce better clinical outcomes when compared to narrow-spectrum antibiotics.

How drug resistance happens:

Use narrow-spectrum antibiotics to reduce drug-resistance.

Narrow-spectrum killing X: Broad-spectrum killing

Lots of bacteria.A few are

drug resistant.

Antibiotics killbacteria causing the

illness, as well as good bacteria.

Drug-resistantbacteria are allowed to

grow and take over.

XX

X

XX

Drug-resistantbacteria give their

resistance to other bacteria, causing more resistance.

Permission granted 8/7/17

Chronology of viral and bacterial sinusitis

Per

cent

of p

atie

nts

ViralAerobes

Anaerobes

3 Months8-10 Days

100

80

60

40

20

0

Used and adapted with permission: Itzhak Brook, M.D.

URIs follow a pattern that supports

choosing narrow-spectrum antibiotics

before broad-spectrum antibiotics.

References: 39, 42-44


Resources



Symptomatic treatment of URIs Pg. 9

Decision support tools: Acute rhinosinusitis Pg. 10 - 13

Decision support tools: Acute bronchitis Pg. 14 - 17

Decision support tools: Acute pharyngitis Pg. 18 - 21

Decision support tools: Acute otitis media Pg. 22 - 25

Decision support tools: Common cold Pg. 26 - 27

Decision support tools: Influenza Pg. 28

Medication record Pg. 29

Bacterial URI pathogens Pg. 30

Ambulatory treatment of bacterial URI Pg. 31 - 36

Ambulatory treatment of cough Pg. 37

Ambulatory treatment of influenza Pg. 38 - 39

Inhaled corticosteroids, probiotics Pg. 40

National quality measures Pg. 41

Child care letter Pg. 42

ACIP immunization schedules Pg. 43 - 50

References Pg. 51 - 56

Additional resources Pg. 57 - 58


9

Symptomatic treatment and supportive care are recommended for treatment of acute, uncomplicated URIs.


adult

Evidence-based symptomatic management Supportive care is recommended for all URI diagnoses • Rest• Hydration• Clean cool mist vaporizer• Avoiding smoke and other

pollutants

Rhino-sinusitis

Bronchitis, tracheitis

Pharyngitis, epiglottitis, laryngitis, tonsillitis

Acute otitis media (AOM)

Common cold

Influenza

> 98% viral, allergic, or

irritant> 90% viral

Adults: > 85% viral

Children: > 70% viral

Up to 96% bacterial

100% viral 100% viral

NSAIDS

Acetaminophen

Warm, moist compress

Topical anesthetics adult

In 4 of 5 patients with bacterial AOM, symptoms resolve:

• within 24 hours

• without antibiotic drug therapy

1st-generation antihistamines age ≥ 6 adults: only as combo therapy

age ≥ 6

Systemic decongestants age ≥ 6 age ≥ 6

Cough suppressants age ≥ 6 age ≥ 6

Beta-2 agonistsif wheezing

present

Honey children: age ≥ 1 age ≥ 1 children: age ≥ 1

Inhaled corticosteroidschildren: high

dose, if wheezingchildren: high

dose, if wheezing

Intranasal corticosteroidsage varies with

agent

Breathe in steam adult

Mast stabilizers

Nasal inhalants children: age ≥ 2

Mucolytics adult

CAM*

Lozenges/hard candy age ≥ 5

Warm liquids

Oral rinses if able to gargle

Ice chips

Topical decongestants

Saline irrigation

Antiviral treatmentwithin 48 hours of symptom onset

*CAM: Complementary alternative medicine (zinc, echinacea, pelargonium, see pg. 13 - 28)

Demonstrated efficacy in absence of antibiotic treatment, may also have role as adjuvant therapy if antibiotics are initiated.

Mixed evidence for efficacy.


Acute rhinosinusitis: Antibiotics or not?

How long have you had sinus symptoms?Children: 0 - 9 days

Adults: 0 - 6 days

Children: 10 - 14 days

Adults: 7 - 10 days

Have you had any of the following:

Double sickening (getting better, then getting worse) 1 1

Colored nasal discharge 1 1

Facial or sinus pain 1 1

Pain near top molars 1 1

Decongestants not working 1 1

Additional signs from examination:

Purulent discharge in nasal cavity (middle meatus) and/or throat 1 1

Sinus pain on one side 1 1

Abnormal translumination on one side 1 1

Total:

Probability of acute BACTERIAL rhinosinusitis

4 or more 30 % 95 %

3 15 % 75 %

2 5 % 50 %

1 2 % 25 %

0 1 % 5 %

Alerts:

Persistent high fever

Severely ill

Swelling/redness near or around eye(s)

Double vision, bulging eye(s), or neurological signs

References: 61 - 62 Used and adapted with permission: France Légaré, M.D., Ph.D10 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

11References: 61 - 62Used and adapted with permission: France Légaré, M.D., Ph.D

Rating benefits and risks:On a scale of 1 - 5:

How important are these benefits? How important are these risks?

Antibiotic

Having symptoms for a little less time (6 days instead of 7)

Taking medicine for many days

Having additional problems (side effects)

No antibiotic

Feel better/cured without adding drugs Having symptoms for a little more time (7 days instead of 6)

Not having additional problems (side effects)

Any other benefits or risks?

Acute rhinosinusitis: Benefits

If we look at 100 patients with symptoms like yours, here is what we see after 1 week.

AntibioticsNo AntibioticsOnly 10 patients

actually benefit from an antibiotic. They feel

better 1 day sooner.

Acute rhinosinusitis: Risks

If we look at 100 patients with symptoms like yours, here are the additional problems we see from antibiotics.

If you decide to take an antibiotic, there is no way to know for certain if you will be one who benefits, or if you will be one who has additional problems from the antibiotic.

70 feel better/cured.

30 still have symptoms.

85 will not have any additional problems.

15 will have diarrhea, stomach ache, or skin

rash.

An additional 5 patients will have diarrhea, stomach ache, or skin rash from an antibiotic.

AntibioticsNo Antibiotics


Micromedex

Adults and children age 12 years and older: Acute rhinosinusitis* These medications are not covered through most pharmacy benefits.

Your diagnosis today is acute rhinosinusitis. This means you have a sinus infection, most likely caused by a virus. You will probably feel much better in 7 - 10 days. These activities and medications will help you feel better while your body heals from the infection:

• Warm, moist compress applied to nose and/or forehead to relieve sinus pressure. May be used as often as desired.

• Breathe in steam from bowl of hot water or shower. May be used as often as desired.

• “Normal” saline (salt water) spray or nasal rinse (ex. Neti-pot, etc.). May be used 1 - 3 times in 24 hours.

Drug: Dose: May use every:

In 24 hours,Do NOT take more than:

Feve

r and

/or p

ain

Aspirin (age ≥ 20 yr) 325 - 650 mg 4 - 6 HR 4000 mg

Ibuprofen 200 - 400 mg 4 - 6 HR 1200 mg, also < 10 days

Naproxen 500 mg as 1st dose, 250 mg later 6 - 8 HR 1250 mg

Acetaminophen RS 650 mg 4 - 6 HR 3250 mg

Acetaminophen ES 1000 mg 6 HR 3000 mg

Acetaminophen ER 1300 mg 8 HR 3900 mg

Acetaminophen SUPP 650 mg 4 - 6 HR 6 SUPP

Stuf

fy n

ose

Pseudoephedrine 60 mg 4 - 6 HR 240 mg

Pseudoephedrine SR 120 mg 12 HR 240 mg


Phenylephrine 10 - 20 mg (oral) 4 HR 120 mg

Oxymetazoline 2 - 3 sprays in each nostril 12 HR 12 sprays, also < 3 days

Phenylephrine 2 - 3 sprays in each nostril 4 HR

Run

ny n

ose

Chlorpheniramine 4 mg 4 - 6 HR 24 mg

Chlorpheniramine SR 8 - 12 mg 8 - 12 HR 24 mg

Brompheniramine 4 mg 4 - 6 HR 40 mg

Diphenhydramine 25 - 50 mg 4 - 6 HR 300 mg

Cromolyn 1 spray in each nostril 4 - 8 HR 12 sprays

Additional steroid nasal sprays are available by prescription. Over-the-counter and prescription sprays are equally effective. Benefits will usually not be seen until after 2 weeks of use.

Fluticasone 2 sprays in each nostril 24 HR 4 sprays

Fluticasone 1 sprays in each nostril 12 HR

Triamcinolone 2 sprays in each nostril 24 HR 4 sprays*HR: hour RS: Regular Strength ES: Extra Strength ER: Extended Release SUPP: Suppository SR: Sustained release

References: 19, 21, 45 - 46, 50 - 51, 55 - 57, 61 - 88

Today we have decided that you:

do NOT want to be prescribed an antibiotic. do NOT want a prescription steroid spray.

want to be prescribed an antibiotic. want a prescription steroid spray.

are taking the prescription(s) with you today. asked that I send the prescription(s) to your preferred pharmacy.


13

https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.html

Micromedexfacts & comparisons

Children age 11 years and younger: Acute rhinosinusitis* These medications are not covered through most pharmacy benefits.

Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.Your child’s diagnosis today is acute rhinosinusitis. This means they have a sinus infection, most likely caused by a virus. They will probably feel much better in 7 - 10 days. These activities and medications will help them feel better while their body heals from the infection:

• Warm, moist compress applied to nose and/or forehead to relieve sinus pressure. May be used as often as desired.

• Breathe in steam from bowl of hot water or shower. May be used as often as desired.

• “Normal” saline (salt water) spray or nasal rinse (ex. Neti-potTM, etc.). May be used 1 - 3 times in 24 hours.

Age/weight: Drug: Dose: May use every:


Feve

r and

/or p

ain 6 MO to 12 YR Ibuprofen 5 - 10 mg/kg 6 - 8 HR 4 doses, also < 10 days

Your child’s ibuprofen dose is:

< 60 kg (132 lb) Acetaminophen 10 - 15 mg/kg 4 - 6 HR Age 1 or younger: 75 mg/kgAge ≥ 1 yr: 100 mg/kg, OR 1625 mgYour child’s acetaminophen dose is:

> 60 kg (132 lb) Acetaminophen RS 650 mg 4 - 6 HR 3250 mg

Stuf

fy n

ose

4 to 5 YR Pseudoephedrine 15 mg 4 - 6 HR 60 mg


4 to 6 YR Phenylephrine (oral) 5 mg 4 HR 30 mg


6 to 12 YR Oxymetazoline 2 - 3 sprays in each nostril 12 HR 12 sprays, also < 3 days

4 to 6 YR Phenylephrine 0.125 % 2 - 3 sprays in each nostril 4 HR 36 sprays, also < 3 days

6 to 12 YR Phenylephrine 0.25 %

Run

ny n

ose

6 to 11 YR Chlorpheniramine 2 mg 4 - 6 HR 12 mg4 to 6 YR Brompheniramine 1 mg 4 - 6 HR 6 mg6 to 12 YR Brompheniramine 2 mg 4 - 6 HR 12 mg4 to 6 YR Diphenhydramine 6.25 - 12.5 mg 4 - 6 HR 75 mg6 to 12 YR Diphenhydramine 12.5 - 25 mg 4 - 6 HR 150 mg≥ 2 YR Cromolyn 1 spray in each nostril 4 - 8 HR 12 spraysAdditional steroid nasal sprays are available by prescription. Over-the-counter and prescription sprays are equally effective. Benefits will usually not be seen until after 2 weeks of use.

≥ 4 YR Fluticasone 1 spray in each nostril 24 HR 4 sprays

2 to 5 YR Triamcinolone 1 spray in each nostril 24 HR 2 sprays

6 to 12 YR Triamcinolone 1 spray in each nostril 24 HR 4 sprays*MO: months YR: year HR: hour RS: regular strength


do NOT want to be prescribed an antibiotic for your child.

do NOT want a prescription steroid spray for your child.

want to be prescribed an antibiotic for your child. want a prescription steroid spray for your child.


References: 21, 45, 56 - 57, 60 - 62, 64, 66 - 67, 69, 70 - 79, 86 - 89


Acute bronchitis: Antibiotics or not?

Acute bronchitis is considered for a cough lasting less than 3 weeks.

Note: Presence or absence of phlegm/mucus (clear or colored) with cough does not indicate presence or absence of acute bronchitis.

Do you have, or have you recently experienced any of the following?

Pneumonia(Pneumonia is excluded [< 1% probability] only if vital signs and lung exam are both normal)

yes no

COPD with infection yes no

Acute respiratory infection/sinus infection yes no

Whooping cough yes no

Influenza (flu) yes no

Bronchiolitis (children only) yes no

Asthma yes no

Other respiratory condition: ___________ yes no

If all above answers were all “no,” then acute bronchitis is the most probable diagnosis.

Probability of acute BACTERIAL bronchitis 10% or less


15References: 61 - 62

Acute bronchitis: Benefits

If we look at 100 patients with a cough like yours, here is what we see after 2 weeks.


actually benefit from an antibiotic. They

feel better 1/2 to 1 day sooner.

Acute bronchitis: Risks

If we look at 100 patients with a cough like yours, here are the additional problems we see from antibiotics.


70 are not coughing.

30 are still coughing.



rash.





AntibioticHaving a cough for a little less time (1/2 to 1 day less, over 2 - 3 weeks total)



No antibioticFeel better/cured without adding drugs Having a cough for a little more time

(1/2 to 1 day more, over 2 - 3 weeks total)Not having additional problems (side

effects)Any other benefits or risks?

Used and adapted with permission: France Légaré, M.D., Ph.D


Today we have decided that you:want to be prescribed an antibiotic. do NOT want to be prescribed an antibiotic.

want to be prescribed a cough suppressant, to be used when needed.

want to be prescribed a rescue medication, to be used when needed.


Micromedexfacts and comparisons

Adults and children age 12 years and older: Acute bronchitis* Over-the-counter (OTC) medications are not covered through most pharmacy benefits.

Your diagnosis today is acute bronchitis, also known as a “chest cold.” This means you have an infection, most likely caused by a virus. You will probably feel much better in 2 - 3 weeks. These activities and medications will help you feel better while your body heals from the infection:

• Breathe in steam from bowl of hot water or shower or use a clean humidifier/cool mist vaporizer. May be used as often as desired.



Cou

gh -

OTC

Diphenhydramine 25 - 50 mg 4 - 6 HR 300 mgPhenylephrine (spray) 2 - 3 sprays in each nostril 4 HR 12 sprays, also < 3 daysPhenylephrine (oral) 10 - 20 mg 4 HR 120 mgDextromethorphan HBr 30 mg 6 - 8 HR 120 mgDextromethorphan Polistirex 10 mL 12 HR 20 mLGuaifenesin IR 200 - 400 mg 4 HR 2400 mgGuaifenesin ER 600 - 1200 mg 12 HR*Additional evidence has shown pelargonium and echinacea to help some patients. FDA does not regulate strength or purity of these products. Pelargonium (11% extract) 30 drops 8 HR 90 dropsEchinacea (dried root) 0.5 - 1 G 8 HR 3 G

Cou

gh -

Rx

• These prescription medications may reduce your cough. • Complete instructions are provided with prescriptions.

* Some medications may not be covered through most pharmacy benefits or may require prior authorization.

Benzonatate (+ guaifenisen) These are cough suppressants/mucolytics. You may use them, if needed, when you are coughing. Codeine (age ≥ 18 YR only)

Albuterol (inhaler or nebulizer)

This is a rescue medication, to be used if you are coughing AND wheezing.

*HR: hour IR: immediate release ER: extended release YR: year

References: 50 - 51, 55, 61 - 62, 67, 73, 77, 80 - 82, 84, 86, 90 - 9516 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

17


Children age 11 years and younger: Acute bronchitis* Over-the-counter (OTC) medications are not covered through most pharmacy benefits.

Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.Your child’s diagnosis today is acute bronchitis, also known as a “chest cold.” This means they have an infection, most likely caused by a virus. They will probably feel much better in 2 - 3 weeks. These activities and medications will help them feel better while their body heals from the infection:

• Breathe in steam from bowl of hot water or shower or use a clean humidifier/cool mist vaporizer. May be used as often as desired.



Cou

gh -

OTC

4 to 6 YR Diphenhydramine 6.25 - 12.5 mg 4 - 6 HR 75 mg

6 to 12 YR Diphenhydramine 12.5 - 25 mg 4 - 6 HR 150 mg



4 to 6 YR Phenylephrine 0.125 % 2 - 3 sprays in each nostril

4 HR 36 sprays, also < 3 days

6 to 12 YR Phenylephrine 0.25 %

4 to 5 YR Dextromethorphan HBr

5 mg 4 HR 30 mg

6 to 12 YR 10 mg 4 HR 60 mg

4 to 5 YR Dextromethorphan Polistirex

15 mg 12 HR 30 mg

6 to 12 YR 30 mg 12 HR 60 mg

4 to 5 YR Guaifenesin IR 100 mg 4 HR 600 mg6 to 12 YR Guaifenesin IR 100 - 200 mg 4 HR 1200 mg≥ age 1 Dark honey 2 tsp (10 mL) May be used as often as desired.

*Additional evidence has shown pelargonium to help some patients. FDA does not regulate strength or purity of these products.

6 to 12 YR Pelargonium (11% extract)

10 drops 8 HR 30 drops

Cou

gh -

Rx

• These prescription medications may reduce their cough. • Complete instructions are provided with prescriptions.

* Some medications may not be covered through most pharmacy benefits or may require prior authorization.

≥ age 10 Benzonatate (+ guaifenisen)

These are cough suppressants/mucolytics. You may give them, if needed, when they are coughing.

0 - 12 YR Albuterol (inhaler or nebulizer)

This is a rescue medication, to be used if they are coughing AND wheezing.

0 - 12 YR Inhaled corticosteroid This is an anti-inflammatory to be used daily until the cough is gone.

*YR: year HR: hour IR: immediate release

References: 50 - 51, 55, 55, 60 - 62, 67, 73, 77, 80 - 82, 84, 86, 90 - 94

For your child, today we have decided that you:want to be prescribed an antibiotic. do NOT want to be prescribed an antibiotic.

want to be prescribed a cough suppressant, to be used when needed.

want to be prescribed a rescue medication, to be used when needed.

want to be prescribed a corticosteroid, to be used every day.



Acute pharyngitis: Antibiotics or not?

For patients with a sore throat:

No cough + 1

Temperature > 100.4 °F + 1

Age 3 - 15 years + 1

Age ≥ 44 years - 1

Additional signs from examination:

Swollen, tender lymph nodes + 1

Tonsillar swelling or exudates + 1

Total:

Probability of acute BACTERIAL pharyngitis

(Group A streptococci)

Close contact with Group A strep-infected person within the past 2 weeks,

OR current local Group A strep epidemicno yes

4 or more 50 % 65 %

3 30 % 45 %

2 15 % 45 %

1 8 % 15 %

0 1 % 2 %

Alerts:Stiff neck in childrenLateral shift of the uvulaStridor and dyspneaSkin rash

Additional note:

Rapid antigen detection test (RADT) should be used only when patients do NOT have viral symptoms (rhinorrhea, cough, oral ulcers, and/or hoarseness). Back-up cultures are recommended for a negative strep test in children and adolescents.

References: 47, 61 - 62 Used and adapted with permission: France Légaré, M.D., Ph.D18 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

19

Acute pharyngitis: Benefits

If we look at 100 patients with symptoms like yours, here is what we see after 4 - 5 days.


Only 10 patients actually benefit from

an antibiotic. They feel better 1 day sooner.

Acute pharyngitis: Risks



70 do not have throat pain.

30 still have throat pain.



rash.



Used and adapted with permission: France Légaré, M.D., Ph.D



Antibiotic Having throat pain for a little less time (3 - 4 days instead of 4 - 5 days)



No antibioticFeel better/cured without adding drugs

Having throat pain for a little more time (4 - 5 days instead of 3 - 4 days)Not having additional problems (side


References: 61 - 62Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018


do NOT want to be prescribed an antibiotic.

want to be prescribed an antibiotic.

are taking the antibiotic prescription with you today.

asked that I send the prescription to your preferred pharmacy.

Facts & Comaprisons:

Adults and children age 12 years and older: Acute pharyngitis* Over-the-counter (OTC) medications are not covered through most pharmacy benefits.

Your diagnosis today is acute pharyngitis, also known as a “sore throat.” This means you have an infection, most likely caused by a virus. You will probably feel much better in 4 - 5 days. The medications will help you feel better while your body heals from the infection.These non-medicated items will help you feel better and may be used as often as desired:• Ice chips and frozen treats such as popsicles.• Hard candies (may be as effective as medicated lozenges).• Warm salt water rinse/gargle: 1/4 to 1/2 teaspoon of salt + 8 ounces (1 cup) warm water. Do not swallow.• Warm liquids such as tea with or without lemon and/or honey. Limit teas containing caffeine.• Use a clean humidifier or cool mist vaporizer.



Feve

r and

/or p

ain



Naproxen 500 mg as 1st dose, 250 mg later

6 - 8 HR 1250 mg





Pain

Medicated throat lozenge 1 lozenge 2 HR 12 lozenges

Medicated throat spray 2 - 3 sprays 6 HR 12 sprays

*HR: hour RS: Regular Strength ES: Extra Strength ER: Extended Release SUPP: Suppository

References: 12, 47 - 48, 55, 60 - 62, 65, 67 - 71, 86, 96 - 9920 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

21



want to be prescribed an antibiotic for your child.

are taking the antibiotic prescription with you today. asked that I send the prescription to your preferred pharmacy.


Adults and children age 11 years and younger: Acute pharyngitis* Over-the-counter (OTC) medications are not covered through most pharmacy benefits.

Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.

Your child’s diagnosis today is acute pharyngitis, also known as a “sore throat.” This means they have an infection, most likely caused by a virus. They will probably feel much better in 4 - 5 days. The medications will help them feel better while their body heals from the infection.These non-medicated items will help them feel better and may be used as often as desired:• Ice chips and frozen treats such as popsicles and ice cream.• Hard candies (may be as effective as medicated lozenges). Age ≥ 5 YR.• Warm salt water rinse/gargle (age ≥ 6 YR and able to gargle): 1/4 to 1/2 teaspoon of salt + 8 ounces (1 cup)

warm water. Do not swallow.• Warm liquids such as tea with or without lemon and/or honey (honey: age ≥1 YR). Limit teas containing caffeine.• Use a clean humidifier or cool mist vaporizer.



Feve

r and

/or p

ain

6 MO to 12 YR Ibuprofen 5 - 10 mg/kg 6 - 8 HR 4 doses, also < 10 days


< 60 kg (132 lb) Acetaminophen 10 - 15 mg/kg 4 - 6 HR Age 1 or younger: 75 mg/kg

Age ≥ 1 yr: 100 mg/kg, also 1625 mg

Your child’s acetaminophen dose is:


Pain

≥ age 5 Medicated throat lozenge

1 lozenge 2 HR 12 lozenges

≥ age 1 Honey 2 tsp (10 mL) May be used as often as desired.

*MO: month YR: year HR: hour RS: regular strength

References: 12, 47, 60 - 62, 67, 69, 71, 86, 96, 98 - 102


Acute otitis media: Antibiotics or not?

For patients with suspected AOM, or suspicion of AOM by parent(s):

Signs from examination:

Inflammation:

Erythema of ear drum no yes

Fluid in the middle ear

Bulging of ear drum no yes

Limitied mobility/loss of mobility of ear drum no yes

Air-fluid level behind ear drum no yes

Ear discharge no yes

Probability of AOM

Do you have distinct and sudden ear pain that interferes with normal activities or sleep?

no yes

Inflammation AND fluid 99 % 99 %

Fluid only 40 % 85 %

Inflammation only 20 % 60 %

No inflammation, no fluid < 1 % 3 %

Alerts:

Persistent high fever

Severely ill


23References: 61 - 62

Acute otitis media: Benefits

If we look at 100 patients with symptoms like yours, here is what we see after 2 - 3 days.


actually benefit from an antibiotic. They

feel better a few hours sooner.

Acute otitis media: Risks



70 do not have ear pain.

30 still have ear pain.



rash.





Antibiotic Having ear pain for a little less time (a few hours less, over 2 - 3 days total)



No antibioticFeel better/cured without adding drugs

Having ear pain for a little more time (a few hours more, over 2 - 3 days total)Not having additional problems (side


Used and adapted with persmission: France Légaré, M.D., Ph.D



do NOT want to be prescribed an antibiotic.

want to be prescribed an antibiotic.

are taking the antibiotic prescription with you today.

asked that I send the prescription to your preferred pharmacy.


Adults and children age 12 years and older: Acute otitis media* These medications are not covered through most pharmacy benefits.

Your diagnosis today is acute otitis media. This means you have an ear infection, which may be caused by bacteria or a virus.

Even if the infection is from bacteria, 4 out of 5 people feel better in 24 hours, without adding an antibiotic.

You will probably feel much better in 2 - 3 days. These activities and medications will help you feel better while your body heals from the infection:

• Warm, moist compress applied to the ear. May be used as often as desired.



Feve

r and

/or p

ain








*HR: hour RS: Regular Strength ES: Extra Strength ER: Extended Release SUPP: Suppository

References: 21, 55 - 56, 60 - 62, 65, 67 - 71, 86, 10324 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

25



want to be prescribed an antibiotic for your child.

are taking the antibiotic prescription with you today. asked that I send the prescription to your preferred pharmacy.


Children age 11 years and younger: Acute otitis media* These medications are not covered through most pharmacy benefits.

Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.Your child’s diagnosis today is acute otitis media. This means your child has an ear infection, which may be caused by bacteria or a virus.

Even if the infection is from bacteria, 4 out of 5 children feel better in 24 hours, without adding an antibiotic.

Your child will probably feel much better in 2 - 3 days. These activities and medications will help them feel better while their body heals from the infection:

• Warm, moist compress applied to the ear. May be used as often as desired.



Feve

r and

/or p

ain




Age ≥ 1 yr: 100 mg/kg, also 1625 mg



*MO: months YR: year HR: hour RS: regular strength

References: 4, 13, 21, 65, 60 - 62, 67, 69, 71, 103 - 106


Zinc, Cold Eeze facts & comparisons

Adults and children age 12 years and older: Common cold* These medications are not covered through most pharmacy benefits.

Your diagnosis today is the common cold. This means you an infection, caused by a virus. You will probably feel much better in 10 days. These activities and medications will help you feel better while your body heals from the infection:• “Normal” saline (salt water) spray or nasal rinse (ex. Neti-pot, etc.).

May be used 1 - 3 times in 24 hours.• Breathe in steam from bowl of hot water or shower.

May be used as often as desired.• Zinc lozenges (acetate or gluconate), started within the first 24 - 48 hours of symptoms.

May be used up to six times per day (age > 18); up to four times per day (age 12 - 17 YR).Drug: Dose: May use

every:In 24 hours,Do NOT take more than:

Feve

r and

/or p

ain








Stuf

fy n

ose Pseudoephedrine 60 mg 4 - 6 HR 240 mg



Phenylephrine 10 - 20 mg (oral) 4 HR 120 mg

Run

ny n

ose Chlorpheniramine 4 mg 4 - 6 HR 24 mg

Chlorpheniramine SR 8 - 12 mg 8 - 12 HR 24 mg

Brompheniramine 4 mg 4 - 6 HR 40 mg

Diphenhydramine 25 - 50 mg 4 - 6 HR 300 mg

Cou

gh -

OTC

Dextromethorphan HBr 30 mg 6 - 8 HR 120 mg

Dextromethorphan Polistirex

10 mL 12 HR 20 mL

*Additional evidence has shown echinacea to help some patients. FDA does not regulate strength or purity of these products.Echinacea (dried root) 0.5 - 1 G 8 HR 3 G

Cou

gh -

Rx

• These prescription medications may reduce your cough. • Complete instructions are provided with prescriptions.• Some medications may not be covered through most pharmacy benefits or may require prior

authorization.Benzonatate (+ guaifenisen) These are cough suppressants/mucolytics.

You may use them, if needed, when you are coughing.Codeine (age ≥ 18 YR)

Ipratropium*HR: Hour RS: Regular Strength ES: Extra Strength ER: Extended Release SUPP: Suppository SR: Sustained release YR: Year

References: 21, 47, 52 - 53, 60 - 62, 65, 67 - 73, 75 - 77, 91, 93 - 95, 107 - 10826 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

27

Children age 11 years and younger: Common cold* These medications are not covered through most pharmacy benefits.

Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.Your child’s diagnosis today is the common cold. This means they have an infection, caused by a virus. They will probably feel much better in 10 days. These activities and medications will help them feel better while their body heals from the infection:

• “Normal” saline (salt water) spray or nasal rinse (ex. Neti-pot, etc.). May be used 1 - 3 times in 24 hours.

• Zinc sulfate syrup, 15 mg/5 mL, age 1 to 10 YR, started within the first 24 - 48 hours of symptoms. May give once daily, up to 30 mL per day.



Feve

r and

/or p

ain 6 MO to 12 YR Ibuprofen 5 - 10 mg/kg 6 - 8 HR 4 doses, also < 10 days



Age ≥ 1 yr: 100 mg/kg, OR 1625 mg


> 60 kg (132 b) Acetaminophen RS 650 mg 4 - 6 HR 3250 mg

Stuf

fy n

ose 4 to 5 YR Pseudoephedrine 15 mg 4 - 6 HR 60 mg




Run

ny n

ose

6 to 11 YR Chlorpheniramine 2 mg 4 - 6 HR 12 mg

4 to 6 YR Brompheniramine 1 mg 4 - 6 HR 6 mg

6 to 12 YR Brompheniramine 2 mg 4 - 6 HR 12 mg

4 to 6 YR Diphenhydramine 6.25 - 12.5 mg 4 - 6 HR 75 mg

6 to 12 YR Diphenhydramine 12.5 - 25 mg 4 - 6 HR 150 mg

Cou

gh -

OTC

4 to 5 YR Dextromethorphan HBr 5 mg 4 HR 30 mg

6 to 12 YR 10 mg 4 HR 60 mg

4 to 5 YR Dextromethorphan Polistirex 15 mg 12 HR 30 mg

6 to 12 YR 30 mg 12 HR 60 mg

2 to 12 YR Vapor Rub thin film 6 - 8 HR 4 times

*Additional evidence has shown pelargonium to help some patients. FDA does not regulate strength or purity of these products.

6 to 12 YR Pelargonium (11% extract) 10 drops 8 HR 30 drops

≥ age 1 Dark honey 2 tsp (10 mL) May be used as often as desired.

Cou

gh -

Rx • Complete instructions are provided with prescriptions.

Some medications may not be covered through most pharmacy benefits or may require prior authorization.

≥ age 10 Benzonatate (+ guaifenisen) To be given as needed when coughing.

0 - 12 YR Inhaled corticosteroid To be used daily until the cough is gone.

2 - 11 YR Inhaled acetylcysteine

*MO: months YR: year HR: hour RS: regular strength

References: 4, 21, 52 - 53, 60 - 62, 67, 69, 71 - 73, 75 - 77, 91, 93 - 94, 105, 108 - 111


Adults and children age 12 years and older: Influenza A or B* These medications are not covered through most pharmacy benefits.

Your diagnosis today is influenza (flu). This means you have an infection, caused by a virus. You will probably feel much better in 3 - 4 days. You should get plenty of rest and fluids. These medications and activities will help you feel better while your body heals from the infection:• Use a clean humidifier or cool mist vaporizer.

May be used as often as desired.



Feve

r and

/or p

ain








Rx Oseltamivir Complete instructions are provided with prescriptions.

Zanamivir*HR: hour RS: Regular Strength ES: Extra Strength ER: Extended Release SUPP: Suppository

Children age 11 years and younger: Influenza A or B* These medications are not covered through most pharmacy benefits.

Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.Your child’s diagnosis today is influenza (flu). This means they have an infection, caused by a virus. They will probably feel much better in 3 - 4 days. They should get plenty of rest and fluids. These medications and activities will help them feel better while their body heals from the infection:• Use a clean humidifier or cool mist vaporizer.

May be used as often as desired.



Feve

r and

/or p

ain




Age ≥ 1 yr: 100 mg/kg, OR 1625 mg



Rx Oseltamivir Complete instructions are provided with prescriptions.

Zanamivir*MO: months YR: year HR: hour RS: regular strength

References: 61 - 62, 65, 67 - 71, 112 - 12028 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

29

Med

icat

ion

Rec

ord:

Med

icat

ion

nam

e:D

ose:

Tim

e:D

ose:

Tim

e:D

ose:

Tim

e:D

ose:

Tim

e:D

ose:

Tim

e:D

ose:

Tim

e:

Not

es:


Recommended empiric antibiotic treatment: Bacterial URI pathogens

Pen

icill

in G

Pen

icill

in V

K

Am

pici

llin

Am

oxic

illin

Am

ox-c

lav

Cef

dini

r (3r

d)

Cef

dito

ren

(3rd

)

Cef

adro

xil (

1st)

Cep

hale

xin

(1st

)

Cef

aclo

r (2n

d)

Cef

proz

il (2

nd)

Cef

urox

ime

(2nd

)

Cefi

xim

e (3

rd)

Cef

tibut

en (3

rd)

Cef

podo

xim

e (3

rd)

Cef

triax

one

(3rd

)

TMP

-SM

X

Dox

ycyc

line

Ery

thro

myc

in

Azi

thro

myc

in

Cla

rithr

omyc

in

Clin

dam

ycin

Levo

floxa

cin

Mox

iflox

acin

Gem

iflox

acin

Cip

roflo

xaci

n

Line

zolid

Aerobic bacteria: 0-10 days of URI symptomsStrep. pneumoniae w w w w w w w fw fw fw w

H. influenza w w w w w w w fw fw fw fw

Staph. aureus w w w w w w w fw fw fw fw

M. catarrhalis w w w w w w w fw fw fw fw

Strep. groups w w w w w w w w w w w

Enterobacter sp. w w w w w w w fw fw fw fw

P. aeruginosa w w w w w w w fw fw fw fw

Anaerobic bacteria: more than 10 days of URI symptomsPeptostrep. sp. w w w w w w w fw fw fw fw

P. acnes w w w w w w w w w fw fw

P. melaningenica w w w w w w w w fw fw fw

F. necrophorum w w w w w w w fw fw fw fw

Rare URI pathogensC. trachomatis w w w w w w w fw fw fw fw

B. pertussis w w w w w w w fw fw fw fw

Chlamydophila sp. w w w w w w w fw fw fw fw

M. pneumoniae w w w w w w w fw fw fw fw

S. aureus (CA-MRSA) w w w w w w w fw fw fw fw

C.diptheriae w w w w w w w fw fw fw fw

N. gonorrhoeae w w w w w w w fw fw fw fw

T. pallidum w w w w w w w fw fw fw fw

F. tularensis w w w w w w w fw fw fw fw

Arcanobacter sp. w w w w w w w fw fw fw fw

Y. enterocolitica w w w w w w w fw fw fw fw

Y. pestis w w w w w w w fw fw fw fw

Recommended: Agent is a first-line therapy: reliably active in vitro, clinically effective, guideline recommended, recommended as a first-line agent or acceptable alternative agent in the Sanford Guide to Antimicrobial Therapy or Infectious Diseases Society of America clinical guidelines

Active: Agent is a potential alternative agent (active in vitro, possesses class activity comparable to known effective agents or a therapeutically interchangeable agents and hence likely to be clinically effective, but second-line due to overly broad spectrum, toxicity, limited clinical experience, or paucity of direct evidence of effectiveness)

Variable: Variable activity such that the agent, although clinically effective in some settings or types of infections, is not reliably effective in others, or should be used in combination with another agent, and/or its efficacy is limited by resistance which has been associated with treatment failure

Not Recommended: Agent is a poor alternative to other agents because resistance is likely to be present or occur, due to poor drug penetration to site of infection or an unfavorable toxicity profile, or limited or anecdotal clinical data to support effectiveness

Insufficient Data: Insufficient data to recommend use

f: United States Food and Drug Administration (FDA) advises that risks of significant, potentially permanent side effects outweigh the benefit of use unless no treatment alternatives are available.

w: This antibiotic has been placed in the “WATCH” group by the World Health Organization (WHO) due to higher resistance potential. WHO recommends to use as first or second choice only for a specific, limited number of indications.References: 21, 45 - 46, 60, 67, 97, 121 - 134


31

Ambulatory treatment of acute BACTERIAL rhinosinusitis: Adults Antibiotic Dose Administration

Initi

al e

mpi

ric th

erap

y

First-lineTx: 5 - 7 days

Amox-clav 500/125 mg PO, TID

Amox-clav 875/125 mg PO, BID

Second-lineTx: 7 - 10 days


Doxycycline 100 mg PO, BID200 mg Daily

Indications for second-line:• age > 65 • immunocompromised • recent hospitalization

• antibiotic use within the last month

• fever ≥ 102 °F + threat of suppurative complications

Peni

cilli

n al

lerg

y

Type I OR Non-type ITx: 5 - 7 days

Doxycycline 100 mg PO, BID200 mg Daily

Levofloxacinfw 500 mg PO, Daily

Moxifloxacinfw 400 mg PO, Daily

Type I hypersensitivity (reactions within minutes of administration):• angioedema • bronchospasm • pruritus

• diarrhea • anaphylaxis • urticaria

• vomiting

Non-type I hypersensitivity: may use full dose 3rd-generation cephalosporins, test-dose PCN (1/10 to 1/4 of full dose)• neutropenia • thrombocytopenia • serum sickness

• rash • arthralgias • lymphadenopathy

• glomerulonephritis • urticaria (after 1 - 3 weeks) • vasculitis

• hemolytic anemia • fever

• allergic contact dermatitis or macropapular drug rash (2 to 7 days after cutaneous drug exposure)

Faile

d in

itial

th

erap

y

Worsening or no improvement (after 3 - 5 days)

Tx: 5 - 7 days


Levofloxacinfw 500 mg PO, Daily

Moxifloxacinfw 400 mg PO, Daily





w: This antibiotic has been placed in the “WATCH” group by the World Health Organization (WHO) due to higher resistance potential. WHO recommends to use as first or second choice only for a specific, limited number of indications.

References: 21, 45, 67, 122 - 128, 131 - 132, 134 - 142


https://www.fda.gov/Drugs/DrugSafety/ucm5530.htm

Ambulatory treatment of acute BACTERIAL rhinosinusitis: Children Antibiotic Total daily dose Administration

Initi

al e

mpi

ric th

erap

y First-lineTx: 5 - 7 days

Amox-clav 45 mg/kg (amox dose) PO, BID

Second-lineTx: 7 - 10 days


Indications for second-line:

• attendance at day care • immunocompromised • age < 2

• recent hospitalization • antibiotic use within the last month

• fever ≥ 102 °F + threat of suppurative complications

Peni

cilli

n al

lerg

y

Type I Levofloxacinfw 10 - 20 mg/kg PO, every 12 - 24 HR

Non-type ITx: 5 - 7 days

Dual therapy Clindamycin 30 - 40 mg/kg PO, TID

Cefiximew 8 mg/kg PO, BID

Cefpodoximew 10 mg/kg PO, BID

Type I hypersensitivity (reactions within minutes of administration):• angioedema • bronchospasm • pruritus

• diarrhea • anaphylaxis • urticaria

• vomiting

Non-type I hypersensitivity: may use full dose 3rd-generation cephalosporins, test-dose PCN (1/10 to 1/4 of full dose)• neutropenia • thrombocytopenia • serum sickness

• rash • arthralgias • lymphadenopathy

• glomerulonephritis • urticaria (after 1 - 3 weeks) • vasculitis

• hemolytic anemia • fever

• allergic contact dermatitis or macropapular drug rash (2 to 7 days after cutaneous drug exposure)

Faile

d in

itial

ther

apy

Worsening or no improvement (after 3 - 5 days)

Tx: 5 - 7 days


Dual therapy Clindamycin 30 - 40 mg/kg PO, TID

Cefiximew 8 mg/kg PO, BID

Cefpodoximew 10 mg/kg PO, BID

Levofloxacinfw 10 - 20 mg/kg PO, every 12 - 24 HR




w: This antibiotic has been placed in the “WATCH” group by the World Health Organization (WHO) due to higher resistance potential. WHO recommends to use as first or second choice only for a specific, limited number of indications.References: 21, 45, 67, 122 - 128, 131 - 132, 134, 136, 138, 140 - 14532 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

33

Ambulatory treatment of acute rhinosinusitis: All Ages, all etiologies

Initi

al e

mpi

ric th

erap

yTreatment: 15 - 21 days

Age/weight Drug Dose (IEN) May use every: In 24 hours,Do NOT take more than:

4 to 11 YR Beclomethasone (QnaslTM)

1 spray 24 HR 2 sprays

≥ 12 YR 2 sprays 24 HR 4 sprays

6 to 12 YR Beclomethasone (Beconase AQTM)


≥ 12 YR 1 or 2 sprays 12 HR 8 sprays

6 to 12 YR Budesonide (RhinocortTM)


≥ 12 YR 1 spray 24 HR 4 sprays

≥ 6 YR Ciclesonide (OmnarisTM)

2 sprays 24 HR 4 sprays

≥ 12 YR Ciclesonide (ZetonnaTM)


2 to 12 YR Fluticasone furoate (VeramystTM)



2 to 12 YR Mometasone (NasonexTM)



*YR: year IEN: in each nostril HR: hour



Ambulatory treatment of acute bronchitis: All agesAll major guidelines on bronchitis, including those from the American College of Chest Physicians, National Committee for Quality Assurance, and the American Academy of Pediatrics, recommend against using antibiotics for acute bronchitis.

Recommend treatment:• Supportive care• Symptom management

Ambulatory treatment of acute BACTERIAL pharyngitis: All ages

Initi

al e

mpi

ric th

erap

y

Treatment: 10 days unless otherwise notedAge Antibiotic Dose Administration

Children Penicillin V (oral) 250 mg PO, BID - TIDAdolescents and adults 250 mg PO, 4 times daily

500 mg PO, BIDAll Amoxicillin 50 mg/kg (NTE 1000 mg) PO, daily

25 mg/kg (NTE 500 mg) PO, BIDPenicillin G (IM) < 27 kg: 600,000 units IM, 1 dose

≥ 27 kg: 1,200,000 units

Peni

cilli

n al

lerg

y Non-type I:• May use full dose

3rd-generation cephalosporins.

• May use test-dose PCN (1/10 to 1/4 of full dose)

Cephalexinb 20 mg/kg (NTE 500 mg/dose)

PO, BID

Cefadroxilb 30 mg/kg (NTE 1 G) PO, dailyClindamycin 7 mg/kg

(NTE 300 mg)PO, TID

Azithromycinw 12 mg/kg (NTE 500 mg) PO, daily for 5 daysClarithromycinw 7.5 mg/kg (NTE 250 mg) PO, BID






NTE: Not to exceed IM: Intramuscular

b: Avoid initial full dose in patients with Type I hypersensitivity to penicillin, may consider test dose.

References: 21, 47 - 48, 55, 67, 80, 97, 102, 128, 131, 133 - 134, 140 - 142, 150 - 15534 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

35

JAMA 2017 Clarifying a PCN allergy

Ambulatory treatment of BACTERIAL acute otitis media: Adults Antibiotic Total daily dose Administration

Watchful waiting:Unilateral OR bilateral, mild symptoms, < 102.2° F

Treatment duration, unless otherwise noted: 5 - 7 days: mild - moderate illness10 days: severe illness

Initi

al e

mpi

ric th

erap

y(im

med

iate

or d

elay

ed)

First-line Amoxicillin (mild - moderate)

500 mg PO, BID250 mg PO, TID

Amoxicillin (severe)

875 mg PO, BID500 mg PO, TID

Amox-clava 500 mg (amox dose) PO, BID250 mg (amox dose) PO, TID875 mg PO, BID500 mg PO, TID

Second-linec

non type I hypersensitivity to penicillin • May use full

dose 3rd- or 4th-generation cephalosporins.


Cefdinir 300 mg PO, BID

Cefpodoximew 200 mg PO, BID

Ceftriaxonew 1 to 2 G (NTE 4 G) IM, daily to BID

Afte

r em

piric

failu

re

After 48 hours of failure of first-line

Amoxicillin 875 mg PO, BID

500 mg PO, TID


After 48 hours of failure of second-line


Clindamycin 150 - 300 mg PO, 4 times daily

Clindamycin may be used with OR without a 3rd-generation cephalosporin:

3rd-

gene

ratio

n ce

phal

ospo

rins Cefdinir 300 mg PO, BID

Cefiximew

400 mg PO, daily, for 10 days if due to S. pyogenes

200 mg PO, BID, for 10 days if due to S. pyogenes

Cefpodoximew

200 mg PO, BID

Ceftibutenw

400 mg daily for 10 days




a: May be considered in patients who have received amoxicillin in the previous 30 days, or who have otitis-conjunctivitis syndrome

c: Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to exhibit cross-reactivity with penicillin allergy due to their structure.References: 13, 21, 52, 45, 60, 67, 105, 128, 131, 134, 136, 140 - 145, 151, 156 - 159


Ambulatory treatment of acute BACTERIAL otitis media: Children Antibiotic Total daily dose Administration

Watchful waiting:6 - 23 MO: unilateral, mild symptoms> 2 YR: unilateral OR bilateral, mild symptoms,< 102.2° F

Treatment duration, unless otherwise noted: 5 - 7 days: 6 - 12 YR with mild - moderate illness7 days; 2 - 5 YR with mild - moderate illness10 days: < 2 YR OR severe illness

Initi

al e

mpi

ric th

erap

y(im

med

iate

or d

elay

ed)

First-line Amoxicillin 80 - 90 mg/kg PO, BID

Amox-clava 90 mg/kg (amox dose) PO, BID

Second-linec

non type I hypersensitivity to penicillin: • May use full dose

3rd- or 4th- genera-tion cephalosporins.


Cefdinir 14 mg/kg PO, BID

Cefpodoximew 10 mg/kg BID

Ceftriaxonew 50 mg/kg (NTE 1 g) IM, daily OR for 3 days

Afte

r em

piric

failu

re

After 48 hours of failure of first-line

Amox-clava 90 mg/kg (amox dose) PO, BID

Ceftriaxonew 50 mg/kg (NTE 1 g) IM, for 3 days

After 48 hours of failure of second-line

Ceftriaxonew 50 mg/kg (NTE 1 g) IM, for 3 days

Clindamycin 30 - 40 mg/kg PO, TID

Clindamycin may be used with OR without a 3rd-generation cephalosporin:

Cefdinir 6 MO to 12 YR 14 mg/kg PO, daily to BID

Cefiximew

6 MO to 12 YR 8 mg/kg Daily, for 10 days if due to S. pyogenes

4 mg/kg BID for 10 days if due to S. pyogenes

Cefpodoximew

6 MO to 12 YR 10 mg/kg PO, BID

Ceftibutenw

6 MO to 12 YR 9 mg/kg (NTE 400) PO, daily




a: May be considered in patients who have received amoxicillin in the previous 30 days, or who have otitis-conjunctivitis syndrome

c: Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to exhibit cross-reactivity with penicillin allergy due to their structure.

References: 4, 13, 21, 60, 67, 105, 128, 131, 134, 136, 141 - 145, 151, 156 - 158 36 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

37

Ambulatory treatment of cough: All agesDrug Age/weight Dose Administration, every:

Bet

a-2

agon

ists

Albuterol (MDI) ≥ 4 YR 2 puffs 4 - 6 HR1 puffs 4 HR

Albuterol (0.083%) ≥ 2 YR, ≥ 15 kg 2.5 mg 6 - 8 HRAlbuterol (0.5%) 2 - 12 YR 0.1 - 0.15 mg/kg

(+NS to 3mL total vol-ume)

≥ 12 YR 2.5 mg (+2.5 mL NS)Albuterol (syrup, tablets) 2 - 5 YR 0.1 mg/kg 8 HR

6 - 12 YR 2 mg 6 - 8 HR≥ 12 YR 2 or 4 mg

Albuterol (ER tablets) 6 - 12 YR 4 mg 12 HR≥ 12 YR 8 mg

Levalbuterol (MDI) ≥ 4 YR 2 puffs 4 - 6 HR1 puffs 4 HR

Levalbuterol 0 - 4 YR 0.31 - 1.25 mg 4 - 6 HR5 - 11 YR 0.31 - 0.63 mg 8 HR

0.31 mg/mL

0.63 mg/mL

1.25 mg/mL

1.25 mg/0.5mL

≥ 12 YR 0.63 - 1.25 mg 6 - 8 HR

Cou

gh s

uppr

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Benzonatate ≥ 10 YR 100 or 200 mg 8 HR

Codeine ≥ 18 YR 15 - 60 mg 4 HR, NTE 360 mg/24 HR

• All opioid-containing cough and cold medicines, including codeine and hydrocodone, are only indicated for adult use, age ≥ 18 YR.

• Safety information about risks of misuse, abuse, addiction, overdose, death, and slowed breathing have been added to the existing Boxed Warning

• Codeine and Tramadol are CONTRAINDICATED for treating pain or cough for children younger than 12 YR. They are not FDA-approved or recommended for patients 0 - 18 YR for any indications. Tramadol is not indicated for cough suppression for any age group.

• Breastfeeding is not recommended when taking codeine.

Muc

olyt

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≥ 12 YR 2 - 4 puffs 6 HR

Ipratropium (0.02%) ≥ 12 YR 2 - 4 vials 6 HR

YR: year NS: normal saline ER: extended release NTE: not to exceed

References: 21 - 51, 67, 129 - 130, 160 - 167


Treatment/prophylactic group

Potential benefit/harm

Adults 16.8 HR shortened symptomsAdults No effect on hospital admissionAdults 1% lower risk of patient-reported pneumonia (NNT = 100)Adults 3.66% higher risk of nausea (NNH = 28)Adults 4.56% higher risk of vomiting (NNH = 22)Adults 3.05% lower risk of developing symptoms with prophylaxis dose (NNT = 33)Adults Up to 2.76% higher risk of psychiatric adverse events with prophylaxis (NNH = 94)Adults 3.01% higher risk of headache with prophylaxis (NNT = 32)

Children No effect on: bronchitis, AOM, sinusitis, or any serious complicationChildren 29 HR shortened symptoms in otherwise healthy childrenChildren with asthma No effectChildren 5.34% higher risk of vomiting (NNH = 19)

Based on these results, Cochrane reviewers have called into question the use of oseltamivir and zanamivir for prevention of flu-associated complications. The CDC continues to recommend their use.

Unvaccinated infants Age < 2 YR Cancer Age > 65 YRAmerican Indians/Alaska Natives

Extreme obesity (BMI > 40)

HIV infection or immunosuppression

Women who are pregnant or 2-weeks post-partum

Sickle cell anemia, other hemoglobinopathies

Chronic metabolic disease such as diabetes mellitus

Hemodynamically significant cardiac disease

Chronic cardiovascular, hepatic, or renal dysfunction

Residents of nursing homes or other long-term care institutions

Age < 19 with long-term high-dose aspirin use such as: rheumatoid arthritis, Kawasaki disease

Neuromuscular disorders, seizure disorders, cognitive dysfunction that may compromise handling secretions

Chronic pulmonary diseases such as asthma, cystic fibrosis (in children) or chronic pulmonary obstructive disease (in adults)

References: 168 - 17238 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

39

Oseltamivir antiviral treatment of influenza A and BAge/weight/kidney function

Treatment Dose (5 days)

Prophylaxis Dose (10 days)

Volume suspension per dose (6 mg/mL)

Number of bottles to dispense

Number of capsules to dispense

Age 2 weeks to ≤ 1 YR: weight-based dosing (suspension, refrigerate after reconstitution)2 weeks to < 1 YR 3 mg/kg BID 3 mg/kg daily (> 3 MO

old)0.5 mL/kg 1 NA

Age 1 to 12 YR: weight-based dosing (suspension to be used if patients cannot swallow capsules)≤ 15 kg 30 mg BID 30 daily 5 mL 1 1015.1 to 23 kg 45 mg BID 45 mg daily 7.5 mL 2 1023.1 to 40 kg 60 mg BID 60 mg daily 10 mL 2 20 (30 mg)≥ 40.1 kg 75 mg BID 75 mg daily 12.5 mL 3 10Adults, normal and impaired kidney functionNormal kidney function 75 mg BID 75 mg daily 12.5 mL 3 10> 60 to 90 mL/min 75 mg BID 75 mg daily 12.5 mL 3 10> 30 to 60 mL/min 30 mg BID 30 daily 5 mL 1 10> 10 to 30 mL/min 30 daily 30 mg every other day 5 mL 1 5ESRD (≤ 10 mL/min) 30 mg immediately

after dialysis, then after each dialysis cycle

30 mg immediately after dialysis, then after every other dialysis cycle

5 mL 1 5

ESRD, on continuous ambulatory peritoneal dialysis

30 mg, single dose 30 mg single dose, then once weekly

5 mL 1 5

ESRD, not on dialysis Not recommendedYR: year MO: months NA: not applicable ESRD: end stage renal disease min: minute

Zanamivir antiviral treatment of influenza A and BAge Treatment Dose (5 days) Prophylaxis Dose (10 days

household, 28 days community outbreaks)

Age 7 YR and older (without underlying airway disease)

10 mg BID

(initiate treatment within 36 hours for children)

10 mg daily (may be used age ≥ 5 YR)

YR: year

The WHO recently moved oseltamivir from the essential to the complementary medication list due to disappointing impact on clinical outcomes.

Zanamivir has never met criteria for inclusion in either the essential or complementary list.

References: 14, 118 - 119, 134, 171, 173 - 176


GINA 2017 AsthmaFacts & Comparisons

High-dose, episodic inhaled corticosteroids for pediatric treatment of viral URI with wheezing

Age 11 years and younger: High Dose ICS Daily dose (mcg)

Beclomethasone dipropionate (HFA) > 200

Budesonide (DPI) > 400

Budesonide (nebules) > 1000

Ciclesonide (HFA) > 160

Fluticasone propionate (DPI) > 400

Fluticasone propionate (HFA) > 500

Mometasone furoate (MDI, DPI) ≥ 440

HFA: hydrofluoroalkane propellant DPI: dry powder inhaler

References: 177 - 17940 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

41

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Date: / /

Dear Child Care Profession

I have carefully evaluated and have diagnosed him/her as having:

Cold Middleearfluid(OtitisMediawithEffusion,OME)

Cough Viral sore throat Flu Other:

Thisillnessiscausedbyavirus.Antibiotictreatmentwillnotcureaviralillness(antibioticsonlyareeffectiveintreatingbacterialinfections).Infact,ifantibioticsaregivenwhentheyarenotneeded,theymaybeharmfulbyincreasingthechild’sriskofaresistantinfection.

Thischildmayreturntodaycarewhenhe/shedoesnothaveafever.Atthatpointmostchildrencanparticipateinactivities,anddonotrequiresomuchcarethatthehealthandsafetyofotherchildrenwouldbejeopardized.Excludingchildrenwithviralillnessdoesnotdecreasethespreadofinfectiontootherchildrenbecausevirusesarelikelytobespreadevenbeforesymptomsofillnessoccur.

Sincerelyyours,

P.S.Herearesomeexpertreviewsthatsupporttheserecommendations.

CentersforDiseaseControlandPrevention.TheABC’sofSafeandHealthyChildCare;AHandbookforChild’sProviders.Atlanta,GA:CentersforDiseaseControlandPrevention,DepartmentofHealthandHumanServices,U.S.PublicHealthService,1996.

American Public Health Association and American Academy of Pediatrics. Caring forOurChildren.NationalHealthandSafetyStandards:GuidelinesforOut-of-HomeChild Care Programs.AnnArbor,MI:AmericanPublicHealthAssociationandAmericanAcademyofPediatrics,1992.

www.cdc.gov/antibiotic-useCS281338B

Dear Child Care Professional

References: 18542 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018

43References: 186



45References: 186



47References: 186



49References: 186



51

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6. Misurski DA, Lipson DA, et al. Inappropriate Antibiotic Prescribing in Managed Care Subjects with Influenza. Am J Manag Care. Sep 2011. 17(9):601-608.

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Additional ResourcesFor Clinicians:American Board of Internal Medicine

• www.choosingwisely.orgTopics: Sinusitis, Charting a Fifty Percent Drop in Antibiotic use, Avoiding Antibiotics Overuse, many others

Centers for Disease Control and Prevention (CDC)• www.cdc.gov/vaccines/schedules/syndicate.

html#easy-read Immunization schedules and patient quizzes for embedding in clinic websites, technical assistance

• www.cdc.gov/antibiotic-use/Patient & provider resources, inpatient, outpatient, long-term care, printable in English & Spanish

Sanford Guide to Antimicrobial Therapy• www.sanfordguide.com/

Annually updated print and ecopy, for purchase ($25 - $48)

Nelson’s Pediatric Antimicrobial Therapy• multiple sources (Amazon. Barnes & Noble,

etc.)Annually updated, for purchase ($34 - $36)

Infectious Diseases Society of America• www.idsociety.org/Guidelines_mobile/

Practice guidelines for mobile device, evidence summary, pocketcards, combination free/for purchase ($6.99 - $9.95)

The Pew Charitable Trusts• www.saveantibiotics.org

Monthly alerts, multimedia resources, podcasts

Kognito Patient Simulations• https://www.conversationsforhealth.com/

Practice antibiotic conversations, building patient conversation skills

• www.youtube.com/watch?v=fyRyZ1zKtyA“Rise of the Superbugs” from It’s Okay to be Smart (7.5 minutes)

• www.youtube.com/watch?v=1gfznWXsxcY“Get Smart About Antibiotics” from CDC (4 minutes)

• https://www.youtube.com/watch?v=JiMrcOc3HBM“Get Smart About Antibiotics” from U.S. Food and Drug Administration (2 minutes)

• https://www.youtube.com/watch?v=e5qP891fy9E“Snort. Sniffle. Sneeze. No Antibiotics Please!” from CDC (4 minutes)

• https://www.youtube.com/watch?v=sKlpRjgriGM“Neti Pot Instruction Video” from NeilMed (1.5 minutes)

For Patients and Caregivers:American Academy of Pediatrics

• www.healthychildren.orgParent instructions for managing cough, nasal congestion, sinus pain, symptom checker, antibiotic questions answered

CDC• www.cdc.gov/features/getsmart/

When antibiotics are/are not needed, prevention, symptom checker

Videos for Individual Patient Education Opportunities


CDC: 1.0 or greater AMA PRA category 1, ANCC, ACPE, webcasts also available for non-credit

• https://www.cdc.gov/vaccines/ed/youcalltheshots.htmlYou Call the Shots: 16 disease-specific vaccination courses, exp. 8/2018 - 3/2020,

Stanford University School of Medicine: 1.0 or greater AMA PRA category 1

• https://med.stanford.edu/cme/courses/online/improving-antibiotics-pcs.htmlTo Prescribe or Not to Prescribe? Antibiotics and Outpatient Infections: exp. 10/2018

American Medical Association: 1.0 or greater AMA PRA category 1

• https://cme.ama-assn.org/Activity/5644029/Detail.aspxJournal-based CME: Should Physicians Consider the Environmental Effects of Prescribing Antibiotics: exp. 9/2019

Medscape: 0.25 or greater AMA PRA Category 1, ANCC, ACPE

• www.medscape.org/viewarticle/877581Guidelines and Antibiotic Prescribing: Where are we now: exp. 4/2018

• www.medscape.org/viewarticle/882990Are All Penicillin Allergies in Children Real: exp. 8/2018

• www.medscape.org/viewarticle/885120Which Kids Benefit From Antibiotics for Acute Otitis Media: exp. 9/2018

• www.medscape.org/viewarticle/887253MDROs, Serious Bacterial Infections, and Good Stewardship: exp. 10/2018

• www.medscape.org/viewarticle/886292Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season: exp. 10/2018

• www.medscape.org/viewarticle/865078Patient Requests for Specific Care: exp. 7/2018

Additional ResourcesFree CME Credits Available:


The content appearing in this educational material, prepared by the Oklahoma Health Care Authority (OHCA), University of Oklahoma (OU), College of Pharmacy, and Pharmacy Management Consultants (PMC), is intended to provide helpful clinical information for the health professional community. It is made available with the understanding that individual clinicians will make their own choices with respect to individual patient care. The content should not be considered complete, and does not cover all diseases, ailments, physical conditions or their treatment. It should not be used in place of clinical judgment by individual providers.

Any information about drugs contained within the content is general in nature, and does not cover all possible uses, actions, precautions, side effects, or interactions of the medicines mentioned. The content is not intended as medical advice for individual patients or for making an evaluation as to the risks and benefits of taking a particular drug.

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Upper Respiratory Infections

4) Use shared decision making.• Especially helpful for URI decisions• Minimal time, improved knowledge, and increased satisfaction• Clarifies expectations and perceptions• Endorsed by multiple organizations and recommended whenever possible• Benefits seen for years

3) Choose narrow spectrum.• Frequently underutilized• Less likely to cause ADRs• Reduces development of resistance• Comparable clinical outcomes

1) Manage symptoms.• Reduces ADRs• Improves satisfaction and reduces abx usage• Recommended by clinical guidelines for all patients

2) Increase vaccination rates.• Reduces inappropriate prescribing• Reduces primary and secondary infections• Reduces prevalence of resistant bacteria



Documents

Upper Respiratory Infections · Use non-antibiotic measures to manage upper respiratory infection (URI) symptoms. * “Management of the common cold, non-specific URI, acute cough