Upper respiratory tract infections responsible for the majority
of antibiotics prescribed in ambulatory practice
Slide 4
Acute Otitis Media (AOM)
Slide 5
Otitis media inflammation of the middle ear most common in
infants and children
Slide 6
Slide 7
Slide 8
Risk factors Winter season/outbreaks of respiratory syncytial
or influenza virus Attendance at day care centers Lack of
breast-feeding in infants Early age of first diagnosis Genetic
predisposition Siblings in the home
Slide 9
Risk factors Cleft palate Lower socioeconomic status Exposure
to tobacco smoke Use of a pacifier Bottle feeding Male gender
Immunodeficiency Allergy
Slide 10
Pathophysiology usually follows a viral upper respiratory tract
infection eustachian tube dysfunction and mucosal swelling in the
middle ear Entry of colonized bacteria to the middle ear Impairment
of clearance by the mucociliary system Proliferation of
bacteria
Slide 11
Pathogens Streptococcus pneumoniae (20% to 35%) Haemophilus
influenzae (20% to 30%) Moraxella catarrhalis (20%)
Slide 12
Clinical presentation The acute onset of signs and symptoms of
middle ear infection following cold symptoms of runny nose, nasal
congestion, or cough
Slide 13
Clinical presentation Symptoms Pain that can be severe (more
than 75% of patients) Fever (less than 25% of patients) Children:
irritable, difficult sleeping Signs Discolored (gray), thickened,
bulging eardrum Pneumatic otoscopy demonstrates an immobile eardrum
Draining middle ear fluid (less than 3% of patients)
Slide 14
Slide 15
Slide 16
Laboratory tests Gram stain Culture
Slide 17
Diagnosis
Slide 18
Treatment Acetaminophen or NSAIDs to relieve pain and malaise
Surgical insertion of tympanostomy tubes (T tubes) For children who
have at least three episodes in 6 months
Slide 19
First LinePenicillin AllergyTreatment Failure Amoxicillin high
dose 8090 mg/kg/day divided twice daily If severe symptoms (severe
otalgia and T > 39C ) Amoxicillin-clavulanate Ceftriaxone (1-3
days) Cefuroxime 30 mg/kg/day divided twice daily Cefixime 8
mg/kg/day Azithromycin 10 mg /kg /day 1, then 5 mg /kg /day for
days 25 Clarithromycin 15 mg /kg /day divided twice daily
Co-trimoxazole 8 mg/kg/day TMP divided twice daily
Amoxicillin-clavulanate Ceftriaxone 50 mg /kg/day IM/IV for 3 days
Alternatives: Clindamycin 3040 mg/kg /day in 3 divided doses
Tympanocentesis
Slide 20
Antibiotic Prophylaxis of Recurrent Infections at least three
episodes in 6 months or at least four episodes in 12 months risk of
hearing loss and language and learning disabilities in children
younger than 3 years of age
Slide 21
Vaccination Influenza vaccine Pneumococcal vaccine Children
ages 2 to 23 months Patients with recurrent otitis media
Slide 22
Sinusitis
Slide 23
inflammation and/or infection of the paranasal sinus mucosa
Rhinosinusitis Majority of cases are viral.
Slide 24
Slide 25
Slide 26
Slide 27
Slide 28
Sinusitis Viral: resolve by 7 to 10 days Bacterial: persistence
of symptoms beyond this time or worsening of symptoms likely
indicates this type.
Slide 29
Bacterial sinusitis Acute: lasts less than 30 days Chronic:
lasts more than 3 months
Slide 30
Pathophysiology usually follows a viral respiratory tract
infection mucosal inflammation obstruction of the sinus ostia
Mucosal secretions become trapped local defenses are impaired
Proliferation of bacteria from adjacent surfaces
Slide 31
Pathogens Viruses (most cases) S. pneumoniae H. influenzae M.
catarrhalis
Slide 32
Clinical presentation: acute Nasal congestion Nasal discharge
Maxillary tooth pain Facial or sinus pain that may radiate
(unilateral in particular) Facial pressure Fever Fatigue Cough
Hyposmia or anosmia Ear pressure or fullness Headache
Halitosis
Slide 33
Indications for referral Abnormal vision (diplopia, blindness)
Change in mental status Periorbital edema
Slide 34
Clinical presentation: chronic Symptoms are similar to acute
sinusitis but more nonspecific Chronic unproductive cough and
headache may occur Rhinorrhea is associated with acute
exacerbations Hyposmia o Chronic/recurrent infections occur three
to four times a year
Slide 35
Complications Osteomylitis Cellulitis of the orbit Abscess
Meningitis
Slide 36
Orbital abscess
Slide 37
Diagnosis Purulent rhinorrhea Nasal congestion Facial
pain/pressure Radiologic tests For differential diagnosis when
sinusitis is not clearly suspected In complicated sinusitis In
recurrent or treatment-resistant sinusitis
Slide 38
Symptoms suggestive of bacterial cause 1.onset with persistent
symptoms or signs, lasting at least 10 days without evidence of
clinical improvement 2.onset with severe symptoms or signs of high
fever (39 C) and purulent nasal discharge lasting for 3 to 4
consecutive days 3.onset with worsening symptoms or signs
Antibiotic therapy Uncomplicated Sinusitis Uncomplicated
sinusitis, penicillin- allergic patient Treatment failure, prior
antibiotic therapy in past 4 to 6 weeks, 10% nonsusceptible
pneumococci, attendance at day care, age younger than 2 years or
older than 65 years, recent hospitalization Amoxicillin Doxycycline
Respiratory fluoroquinolone High-dose amoxicillin High-dose
amoxicillin/clavulanate Cephalosporin Respiratory
fluoroquinolone
Slide 41
Antibiotic therapy Failure of high-dose
amoxicillin/clavulanate: Respiratory FQ Cefixime + clindamycin or
linezolid Neither azithromycin nor clarithromycin have adequate
coverage for H. influenzae and S. pneumoniae
Slide 42
Slide 43
Duration of therapy 10 to 14 days or at least 7 days after
symptoms are under control
Slide 44
Treatment failure: Persistence or worsening of symptoms 72
hours after initiating antimicrobial therapy
Slide 45
Treatment of chronic rhinosinusitis Antibiotics (aerobes and
anaerobes) Nasal corticosteroids Nasal irrigation
Slide 46
Monotherapy Amoxicillin-clavulanate children: 45 mg/kg/day
divided every 12 hours adults: 500 mg three times daily Clindamycin
children: 20 to 40 mg/kg/day orally divided every 6 to 8 hours
adults: 300 mg four times daily or 450 mg three times daily
Moxifloxacin 400 mg once daily generally in adults only
Slide 47
Two-drug regimens Metronidazole, PLUS one of the following:
Cefuroxime Levofloxacin Azithromycin Clarithromycin
Trimethoprim-sulfamethoxazole
Slide 48
Duration At least 3 weeks (up to 10 weeks in refractory
cases)
Slide 49
Follow-up Culture: preferably directly from the sinus cavity in
patients who fail to have significant improvement or who
demonstrate signs of deterioration despite therapy
Slide 50
Pharyngitis
Slide 51
an acute infection of the oropharynx or nasopharynx the reason
for 1% to 2% of all outpatient visits
Slide 52
Slide 53
Slide 54
Pathogens Viruses (the most common) group A Streptococcus or S.
pyogenes (10% to 30%)
Slide 55
Signs and Symptoms Sore throat Pain on swallowing Fever
Headache, nausea, vomiting, and abdominal pain (especially
children) Erythema/inflammation of the tonsils and pharynx with or
without patchy exudates Enlarged, tender lymph nodes Red swollen
uvula, petechiae on the soft palate
Slide 56
Slide 57
Slide 58
Slide 59
Several symptoms that are not suggestive of group A
Streptococcus: Cough Conjunctivitis Coryza Diarrhea
Slide 60
Slide 61
Slide 62
Slide 63
Diagnosis Testing for presence of bacteria: Culture Rapid
antigen-detection test (RADT)
Slide 64
Slide 65
Slide 66
Treatment (adult) DrugAdult dosageDuration Penicillin VK250 mg
three or four times daily or 500 mg twice daily 10 days Penicillin
benzathine1.2 million units intramuscularlyOne dose Amoxicillin500
mg three times daily10 days Erythromycin40 mg/kg/day divided two to
four times daily (max: 1 g/day) 10 days Cephalexin250500 mg orally
four times daily10 days
