Upper Respiratory Tract Infections & Bronchitis Lecture PDF

Here's the conversion of the image to a structured markdown format: # Upper Respiratory Tract Infections & Bronchitis Emily Drwiega, PharmD, BCIDP, BCPS, AAHIVP Visiting Clinical Assistant Professor of Pharmacy Practice College of Pharmacy University of Illinois at Chicago [email protected] ## Read...

Here's the conversion of the image to a structured markdown format: # Upper Respiratory Tract Infections & Bronchitis Emily Drwiega, PharmD, BCIDP, BCPS, AAHIVP Visiting Clinical Assistant Professor of Pharmacy Practice College of Pharmacy University of Illinois at Chicago [email protected] ## Readings * Chow AW, Benninger MS, Brook I, et al. IDSA Clinical Practice Guidelines for Acute Bacterial Rhinosinusitis in Children and Adults. *Clin Infect Dis*. 2012;54(8):e72-112. * Rosenfeld RM, Piccirillo JF, Corrigan MD, et al. Clinical Practice Guideline (Update): Adult Sinusitis. *Otolaryngol Head Neck Surg*. 2015;152(2):S1-S39. * Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. 2012;55(10):e86-102. * Kinkade S, Long NA. Acute Bronchitis. *Am Fam Physician*. 2016;94(7):560-565. ## Objectives * Differentiate between bacterial and viral etiologies of URTIs * Describe the microbiology, epidemiology, clinical manifestations, diagnosis, and treatment of sinusitis, pharyngitis, and acute bronchitis * Discuss the overprescribing of antibiotics for URTIs and strategies to reduce inappropriate use ## Outline The image shows a flowchart that goes from left to right 1) Acute bacterial sinusitis 2) Pharyngitis 3) Bronchitis ## Acute Rhinosinusitis ### What is Acute Rhinosinusitis? * Inflammation of the mucosal lining of the nasal passage and paranasal sinuses * Acute: < 4 weeks duration The image shows an illustration that compares **Healthy Sinuses** to and **Inflamed Sinuses**. In the **Inflamed Sinuses** illustration, you can see the *Frontal sinuses*, *Ethmoid sinuses*, *Nasal cavity*, and *Maxillary sinus*. Fluid is indicated with an **Obstructed sinus opening**. ### Epidemiology The image shows 7 human figures, one is colored red; the rest are black. It states: *1 in 7 adults in the US affected by sinusitis annually.* **5**th most common diagnosis responsible for antibiotic therapy. ### Clinical Presentation | Major | | Minor | | | -------------------------- | ---- | --------------------------- | ---- | | Purulent nasal discharge | | Ear pain, pressure or fullness | | | Nasal congestion or obstruction | | Fever | | |Facial congestion or fullness| | Headaches | | | Facial pain or pressure | | Fatigue | | | Hyposmia or anosmia | | Dental pain | | | Halitosis | | Cough | | ### Diagnosis * Sinus aspiration and culture * Imaging studies * Compatible signs and symptoms * Bacterial vs. viral ### Bacterial vs. Viral The image shows a pie chart which indicates the following information: *Despite the fact that the vast majority of these infections are viral, antibiotics are prescribed (inappropriately) in many sinusitis cases.* * Bacterial *2-10%* * Viral *90-98%* ### Differentiation of ABRS | Category | Definition | | :----------- | :------------------------------------------------------------------------------------------------------------------------------------------------- | | Persistent | Onset with *persistent* symptoms or signs, lasting ≥ 10 days without improvement | | Severe | Onset of *severe* symptoms or high fever (≥ 39°) and purulent nasal discharge or facial pain lasting ≥ 3-4 days | | Worsening | Onset of *worsening* symptoms including new onset fever, headache, increased discharge following typical viral URTI that lasted 5-6 days and improving | ### Treatment – Key Concepts * High rate of spontaneous recovery * Viral vs. bacterial * Lack of microbiologic info * Increasing antimicrobial resistance * Initiate antibiotics once ABRS is established ### Acute Bacterial Sinusitis The image shows a visual representation that indicates common bacteria strains that cause sinusitis * *Streptococcus pneumoniae* * *Haemophilus influenzae* * *Moraxella catarrhalis* ### ABRS Outpatient Treatment **Amoxicillin-clavulanate** | Category | Dose | When to use HIGH DOSE: | | :------- | :------------------------------------------- | :---------------------------------------------------------------------------------------- | | Adults | 500/125 mg po TID or 875/125 mg po BID High dose: 2000/125 mg po BID | High rates of penicillin non-susceptible *S. pneumo* (≥ 10%) Severe infection (≥ 39°) Age < 2 or > 65 years Recent hospitalization Antibiotics within the past month Attends daycare Immunocompromised | | Pediatrics | 45 mg/kg/day po BID High dose: 90 mg/kg/day po BID | | ### Alternative Therapies | Category | Treatment | | ---------------: | :---------------------------------------------------------------------------------------------------- | | Adults | Doxycycline 100 mg po BID Levofloxacin 500 mg po daily Moxifloxacin 400 mg po daily | | Pediatrics | Levofloxacin 10-20 mg/kg/day po every 12-24 hours Clindamycin 30-40 mg/kg/day po TID + cefixime 8 mg/kg/day po BID OR cefpodoxime 10 mg/kg/day po BID | | Severe disease | May require IV antibiotics | ### Treatment Duration | Adults | Pediatrics | | :-------- | :----------- | | 5-7 days | 10-14 days | | | **Duration of treatment is twice as long for pediatric patients.** | ### Adjunctive Therapy * Intranasal saline irrigation * Intranasal corticosteroids in allergic rhinitis * Decongestants and antihistamines not recommended ### Clinical Practice Guidelines * Infectious Diseases Society of America (IDSA) – 2012 * American Academy of Otolaryngology – Head and Neck Surgery – 2015 (adult only) * Amoxicillin with/without clavulanate for 5-10 days ## Pharyngitis ### What is pharyngitis? * Infection of the oropharynx * Predominately caused by viral pathogens * Adenovirus, influenza, parainfluenza, rhinovirus, RSV, Epstein-Barr virus, coxsackievirus, HSV * "Strep throat" – acute pharyngitis caused by *Streptococcus pyogenes* ### Epidemiology * 15 million pediatrician/primary care visits per year in the US * Most common in children ages 5-15 ### Group A strep pharyngitis * Caused by *Streptococcus pyogenes* (Group A strep - GAS) * Most common bacterial cause of acute pharyngitis * Children: 3/10 sore throats are GAS strep throat * Adults: 1/10 sore throats are GAS strep throat * Most commonly occurs in winter and early spring ### Clinical Presentation The diagram has three nodes * Sore throat * GAS pharyngitis * Clinical Findings * Tonsillopharyngeal erythema +/- exudates * Tender, enlarged lymph nodes * Red, swollen uvula * Petechiae on the palate * Scarlatiniform rash * Fever Other symptoms * Headache * Abdominal pain * Nausea/Vomiting Viral Symptoms * Cough *Rhinorhea * Hoarseness * Oral ulcers * Conjunctivits ### GAS Pharyngitis Testing * Throat swab and rapid antigen detect testing (RADT) and/or culture * Testing not recommended if viral features or children < 3 years old | | | | | :---- | :-------------- | :-------------- | | | **RADT positive** | **RADT Negative** | | | | Follow-up culture | ### Transmission * Respiratory Droplets * Direct contact * Incubation: 2-5 days ### Treatment | Drug/route | Dose | Duration | | :------------------- | :----------------------- | :------- | | Penicillin V, oral | Children: 250 mg po 2-3x/day Adults: 250 mg 4x/day or 500 mg BID | 10 days | | Amoxicillin, oral | 25 mg/kg (max 500 mg) BID or 50 mg/kg/day (max 1000 mg) | 10 days | | Benzathine penicillin G, IM | < 27 kg: 600,000 U ≥ 27 kg: 1,200,000 U | 1 dose | ### Treatment – Penicillin Allergy | Drug, all oral | Dose | Duration | | :------------- | :--------------------------- | :------- | | Cephalexin | 20 mg/kg BID (max 500 mg/dose) | 10 days | | Cefadroxil | 30 mg/kg/day (max 1g) | 10 days | | Clindamycin | 7 mg/kg TID (max 300 mg/dose) | 10 days | | Azithromycin | 12 mg/kg/day (max 500 mg) | 5 days | | Clarithromycin | 7.5 mg/kg BID (max 250 mg/dose) | 10 days | ### Adjunctive Therapy * Acetaminophen or NSAIDs may be appropriate * Avoid aspiring in children * Corticosteroids not recommended ### Rheumatic Fever *Delayed sequala of some GAS infections* *Immune response NOT infection* *Leading cause of pediatric acquired heart disease in some countries* *Can occur 1-5 weeks after initial infection* *Symptoms: fever, arthritis, chest pain, SOB, tachycardia, fatigue, chorea, nodules, rash, heart murmur, enlarged heart, fluid around the heart* *Most Common ages 5-15 years old* *Treatments: underlying GAS, symptom management* ## Bronchitis ### What is acute bronchitis? * Inflammation and mucus in the airways in the lungs * Can last up to 3 weeks * Characterized by persistent cough * “Chest cold” ### Epidemiology * Acute bronchitis reported in 5% of the population annually * Accounts for > 10 million office visits annually ### Bacterial vs. Viral *Most commonly cause by a virus* *Bacterial cause in 1-10% of cases* The image shows the following bacterial or viral strains: Influenza, Coronoavirus, hMPV, RSV, Rhinovirus, Enterovirus, Parainfluenza ### Symptoms | Cough (+/- mucus) | Nasal congestion | Chest soreness | Fatigue | | :-------------- | :--------------- | :------------- | :--------- | | Headache | Body aches | Sore throat | Fever | ### Diagnosis * Laboratory testing not indicated * Infrequent leukocytosis * Specific pathogen testing if highly suspicious and treatment would be impacted ### Treatment * Supportive care and symptom management * Recommend against the use of antibiotics * Exception: pertussis (macrolide) * Symptomatic management: * Fluids, rest, humidifier/cool mist vaporizer, nasal saline, breathe in steam, lozenges, honey * OTC medications (APAP, ibuprofen, antihistamines, decongestants) * Minimal benefit * Avoid antihistamines and antitussives in young children ### Antibiotic Overprescribing * Antibiotics prescribed in 71% of visits for acute bronchitis * Increased adverse effects * Antibiotics decreased cough by 0.46 days, no difference in clinical improvement at follow-up ### Strategies to Reduce Inappropriate Antibiotic Use * Delayed prescription strategies * Address patient concerns in a compassionate manner * Expected course of illness and cough duration * Explain that antibiotics do not significantly shorten illness duration and are associated with adverse effects and antibiotic resistance * Discuss the use of nonantibiotic medications to control symptoms * Describe the infection as a viral illness or chest cold