Upper Respiratory Tract Infections (PDF)

Upper & Lower Respiratory Tract Infections Objectives Describe the following for each infection:  Etiology  Pathophysiology  Signs & Symptoms  Treatment List the following for each medication:  MOA  Adverse effects  Drug-drug interactions...

Upper & Lower Respiratory Tract Infections Objectives Describe the following for each infection:  Etiology  Pathophysiology  Signs & Symptoms  Treatment List the following for each medication:  MOA  Adverse effects  Drug-drug interactions  Contraindications  Expectations of therapy (e.g., formulation, dosing, renal dosing, duration and others) Otitis Media Guidelines: American Academy of Pediatrics Otitis Media Acute otitis media  Etiology  Streptococcus pneumoniae  Resistance via penicillin-binding proteins  Haemophilus influenzae (non-typeable) & Moraxella catarrhalis  Resistance via β-lactamases Otitis media with effusion Chronic otitis media Otitis Media Acute otitis media  Pathophysiology  Children more susceptible due to shorter / more horizontal eustachian tube  Middle ear is blocked with fluid  Proliferation of bacteria from nasopharynx  Results in bulging and erythematous tympanic membrane  Diagnosis – American Academy of Pediatrics (AAP)  Middle ear effusion with either  Moderate-to-severe bulging of the tympanic membrane or new onset otorrhea not due to acute otitis externa  Mild bulging of the tympanic membrane and onset of ear pain within the last 48 hours or intense erythema of the tympanic membrane Otitis Media Acute otitis media Otitis Media Acute otitis media  Treatment  APAP or ibuprofen  Antibiotics  6 months – 12 years old + moderate to severe pain + 102.2°F  6 – 23 months old + nonsevere bilateral acute otitis media  Observation or antibiotics  6 – 23 months old + nonsevere unilateral acute otitis media  24 months to 12 years old + nonsevere acute otitis media  Otitis Media Acute otitis media b. If a patient has received amoxicillin in the last 30 days, has concurrent purulent conjunctivitis, or has a history of recurrent infection unresponsive to amoxicillin Otitis Media Acute otitis media  Therapy duration  10 days  May treat for 5 – 7 days  > 6 years old  Mild-to-moderate acute otitis media  By day 7, AOM will become otitis media with effusion and does not require additional antibiotics  Addition of dexamethasone to a topical antibiotic ciprofloxacin (CiproDex) may decrease the length of time necessary for middle ear drainage when compared with a topical antibiotic alone  Recurrent AOM  3 episodes in six months  4 episodes in one year  Consider tympanostomy tubes (T tubes) to prevent AOM  Reduces risk of hearing loss and language / learning disabilities  Prevention  Influenza, Haemophilus influenzea & pneumococcal vaccines Side Note What is a formulary?  List of drugs for use by prescriber, insurance, pharmacy or hospital  Prescriber (You)  PAs will collaborate with supervising physician to create a list of prescription drugs  Insurance  List of drugs covered by insurance  Pharmacy benefits managers (PBMs) and prior authorization departments  Pharmacy  List of drugs stocked in pharmacy  Hospital  List of drugs approved for use  Pharmacy & Therapeutics Committees AOM  Diagnosis o Ear effusion w/ mod/severe bulging tympanic membrane or otorrhea o Ear effusion w/ mild bulging tympanic membrane & ear pain ( w/in 48 hours) or tympanic erythema  Antibiotics o 6 months – 12 years old + moderate to severe pain (pain for 48 hours) + 102.2°F o 6 – 23 months old + nonsevere bilateral acute otitis media  Observation or antibiotics o 6 – 23 months old + nonsevere unilateral acute otitis media o 24 months to 12 years old + nonsevere acute otitis media  1 line – Amoxil 80-90 mg/kg/day BID st o Amox/clav. 90 mg/kg/day BID  If a patient has received amoxicillin in the last 30 days, has concurrent purulent conjunctivitis, or has a history of recurrent infection unresponsive to amoxicillin o Cefdinir 14 mg/kg/day  Type II PCN allergy (may consider clindamycin monotherapy for Type I PCN allergy)  Therapy failure at 48 to 72 hours o Amox/clav. 90 mg/kg/day BID o Clindamycin 30-40 mg/kg/day tid +/- Cefdinir 14mg/kg/day  Age > 6 years old treat for 5 to 7 days if mild to moderate; treat for 10 days if severe  Age 2 – 6 years old treat for 7 days if mild to moderate; treat for 10 days if severe  Age < 2 years old treat for 10 days Acute Bacterial Rhinosinusitis Acute Bacterial Rhinosinusitis Etiology  2 – 10% of all upper respiratory infections are bacterial  Streptococcus pneumoniae & Haemophilus influenzae (50 – 70% of cases)  Moraxella catarrhalis (8 – 16% of cases) Pathophysiology  Preceded by a viral respiratory tract infection that causes mucosal inflammation  Mucosal secretions become trapped, local defenses are impaired, and bacteria from adjacent surfaces begin to proliferate Acute Bacterial Rhinosinusitis Acute Bacterial Rhinosinusitis Treatment  Nasal decongestants and antihistamines not recommended  Saline spray for nasal irrigation  Intranasal corticosteroids are recommended only for patients with a history of allergic rhinitis  Duration of therapy  Adults for 5 – 7 days  Children for 10 – 14 days High-dose amoxicillin-clavulanate is preferred in the following situations: (a) geographic regions with high endemic rates (10% or greater) of invasive penicillin-nonsusceptible S. pneumoniae, (b) severe infection, (c) attendance at daycare, (d) age less than 2 or greater than 65 years, (e) recent hospitalization, (f) antibiotic use within the last month, and (g) immunocompromised persons ABR  Diagnosis o S/Sx not improving after >= 10 days o Severe S/Sx (fever > = 102.2 F) for >= 3 days at start of infection o Worsening of S/Sx for >= 3 days starting at day 6-8 of initial infection  Antibiotics o 1st line – Amox/clav. 45 mg/kg/day BID or amox/clav. 875mg BID  Amox/clav. 90mg/kg/day BID or amox/clav. 2000mg BID  (a) geographic regions with high endemic rates (10% or greater) of invasive penicillin-nonsusceptible S. pneumoniae, (b) severe infection, (c) attendance at daycare, (d) age less than 2 or greater than 65 years, (e) recent hospitalization within 5 days, (f) antibiotic use within the last month, and (g) immunocompromised persons  Doxycycline 100mg BID  Adult Type I or Type II PCN allergy  Levofloxacin 10-20mg/kg/day  Pediatric Type I PCN allergy  Clindamycin 30-40 mg/kg/day tid + cefixime 8mg/kg/day BID  Pediatric Type II PCN allergy o 2 line – Amox/clav. 90mg/kg/day BID or amox/clav. 2000mg BID nd  Levofloxacin 500mg Qday  Adult abx failure  Clindamycin 30-40 mg/kg/day tid + cefixime 8mg/kg/day BID  Pediatric abx failure  Duration of therapy (variable) o Adults = 7 days o Pediatrics = 10 days Acute Pharyngitis Acute Pharyngitis Etiology  Viruses cause majority of cases (39%)  β-hemolytic Streptococcus pyogenes Pathophysiology  Mechanism is not well defined Acute Pharyngitis Acute Pharyngitis Treatment  Prevent transmission to close contacts; contagious period reduced to 1 day when antibiotics are started  Prevent acute rheumatic fever and suppurative complications, such as peritonsillar abscess, cervical lymphadenitis, and mastoiditis  Antipyretics, analgesics, and nonprescription lozenges and sprays containing menthol and topical anesthetics for temporary relief of pain  Note: Chronic Carries -Clindamycin dose is similar -Add rifampin to PCN -Amoxil  Augmentin Acute Pharyngitis Secondary prophylaxis  Documented histories of rheumatic fever  Evidence of rheumatic heart disease  Intramuscular benzathine penicillin G every 4 weeks  Penicillin allergy?  Sulfadiazine Copyrights apply AP  Diagnosis o Throat swab / rapid antigen-detection test  Antibiotics o Amoxil  Pediatrics – 50 mg / kg / day; max 1,000 mg / day; can divide dose; preferred over PCN due to palatability  Adults – 1,000 mg Qday; can divide dose o Cephalexin – Type II PCN allergy  Pediatrics – 20mg/kg/dose BID  Adults – 500mg BID o Azithromycin – Type I PCN allergy  Pediatrics – 12mg/kg day x 5 days  Adults – 500mg qday x 5 days o Clindamycin – Type I PCN allergy or macrolide resistance  Pediatrics – 7mg/kg/dose TID  Adults – 300mg TID  Duration of therapy o 10 days; five days if it is azithromycin Reference Frei CR, Frei BL. Upper Respiratory Tract Infections. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD, Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw Hill; 2020. Accessed January 23, 2023. https://accesspharmacy.mhmedical.com/content.aspx?b ookid=2577&sectionid=224360273