Upper Respiratory Tract Infections & Bronchitis PDF

Upper Respiratory Tract Infections & Bronchitis Emily Drwiega, PharmD, BCIDP, BCPS, AAHIVP Clinical Assistant Professor of Pharmacy Practice Retzky College of Pharmacy, University of Illinois at Chicago [email protected] UNIVERSITY OF ILLINOI...

Upper Respiratory Tract Infections & Bronchitis Emily Drwiega, PharmD, BCIDP, BCPS, AAHIVP Clinical Assistant Professor of Pharmacy Practice Retzky College of Pharmacy, University of Illinois at Chicago [email protected] UNIVERSITY OF ILLINOIS CHICAGO 1 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. UNIVERSITY OF ILLINOIS CHICAGO 2 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 UNIVERSITY OF ILLINOIS CHICAGO URTI: upper respiratory tract infection 3 Outline Acute bacteria Pharyng Bronchit l itis is sinusitis UNIVERSITY OF ILLINOIS CHICAGO 4 Acute Rhinosinusitis UNIVERSITY OF ILLINOIS CHICAGO 5 What is Acute Rhinosinusitis? Inflammation of the mucosal lining of the nasal passage and paranasal sinuses Acute: < 4 weeks duration UNIVERSITY OF ILLINOIS CHICAGO https://www.cdc.gov/antibiotic-use/sinus- infection.html. 6 Chow AW. Clin Infect Dis. 2012;54(8):e72-112. Epidemiology 1 in 7 adults in the US affected by sinusitis annually. 5 th most common diagnosis responsible for antibiotic therapy. UNIVERSITY OF ILLINOIS CHICAGO 7 Rosenfeld, et al. Otolaryngol Head Neck Surg. 2015;152(2):S1-S39. Clinical Presentation Nasal Facial M Purulent congestio congestio Facial pain nasal n or or AJ discharge obstructio n or pressure fullness O n R Hyposmia Ear pain, MI or Fever Headache pressure N anosmia or fullness O R Dental Halitosis Cough Fatigue pain UNIVERSITY OF ILLINOIS CHICAGO 8 Chow AW. Clin Infect Dis. 2012;54(8):e72-11 Diagnosis Sinus aspiration and culture Imaging studies A Compatible signs and symptoms B R Bacterial vs. viral S UNIVERSITY OF ILLINOIS CHICAGO ABRS: acute bacterial rhinosinusitis 9 Chow AW. Clin Infect Dis. 2012;54(8):e72-11 Bacterial vs. Viral 2-10% Viral Rhinoviruses Coronaviruse s 90-98% Influenza viruses Adenoviruses UNIVERSITY OF ILLINOIS CHICAGO Chow AW. Clin Infect Dis. 2012;54(8):e72-112. 10 Rosenfeld, et al. Otolaryngol Head Neck Surg. Differentiating Bacterial vs. Viral Persiste Onset with persistent symptoms or signs, lasting ≥ 10 days without nt improvement Onset of severe symptoms or high fever Severe (≥ 39°) and purulent nasal discharge or facial pain lasting ≥ 3-4 days Worseni Onset of worsening symptoms including new onset fever, headache, increased discharge following typical viral URTI ng that lasted 5-6 days and were improving UNIVERSITY OF ILLINOIS CHICAGO ABRS: acute bacterial rhinosinusitis 11 Chow AW. Clin Infect Dis. 2012;54(8):e72-11 Acute Bacterial Sinusitis Streptococcu s pneumoniae Haemophilus influenzae Moraxella catarrhalis UNIVERSITY OF ILLINOIS CHICAGO 12 Chow AW. Clin Infect Dis. 2012;54(8):e72-11 Treatment – Key Concepts High rate of spontaneous recovery Viral vs. bacterial Lack of microbiologic info Initiate antibiotics once ABRS is established Increasing antimicrobial resistance UNIVERSITY OF ILLINOIS CHICAGO ABRS: acute bacterial rhinosinusitis 13 ABRS Outpatient Treatment Amoxicillin-clavulanate Adults: When to use HIGH DOSE: High rates of penicillin 500/125 mg po TID or 875/125 non-susceptible S. mg po BID pneumo (≥ 10%) High dose: 2000/125 mg po BID Severe infection (≥ 39° C) Pediatrics: Age < 2 or > 65 years Recent hospitalization 45 mg/kg/day po divided BID Antibiotics within the High dose: 45 mg/kg po BID past month Attends daycare Immunocompromised UNIVERSITY OF ILLINOIS CHICAGO BID: twice daily; TID: three times daily 14 Chow AW. Clin Infect Dis. 2012;54(8):e72-11 Alternative Therapies 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 UNIVERSITY OF ILLINOIS CHICAGO BID: twice daily 15 Chow AW. Clin Infect Dis. 2012;54(8):e72-11 Treatment Duration Adults Pediatrics 5-7 days 10-14 days UNIVERSITY OF ILLINOIS CHICAGO 16 Chow AW. Clin Infect Dis. 2012;54(8):e72-11 Adjunctive Therapy Intranasal saline irrigation Intranasal corticosteroids in allergic rhinitis Decongestants and antihistamines not recommended UNIVERSITY OF ILLINOIS CHICAGO 17 Chow AW. Clin Infect Dis. 2012;54(8):e72-11 Nonresponsive Patients When to consider: Symptoms worsen after 48-72 hours Fail to improve after 3-5 days empiric antibiotics Recommend to switch to alternate antibiotic Considerations: resistant pathogens, noninfectious etiology, structural abnormality, other causes for treatment failure Culture recommended UNIVERSITY OF ILLINOIS CHICAGO 18 Chow AW. Clin Infect Dis. 2012;54(8):e72-11 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 UNIVERSITY OF ILLINOIS CHICAGO 19 Which of the following scenarios MOST LIKELY represents a bacterial cause of sinusitis? A. 5 days of clear mucus drainage B. 5 days of purulent, colored mucus drainage C. 5 days of purulent, colored mucus drainage with 39.1 degree Celcius fever D. 10 days of headache Which of the following is a recommended treatment regimen for an adult with acute bacterial sinusitis? A. Amoxicillin-clavulanate 875/125 mg po BID x 7 days B. Amoxicillin-clavulanate 500/125 mg po TID x 10 days C. Levofloxacin 500 mg po BID x 7 days D. Doxycycline 100 mg po BID x 14 days Pharyngitis UNIVERSITY OF ILLINOIS CHICAGO 22 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 UNIVERSITY OF ILLINOIS CHICAGO 23 RSV: respiratory syncytial virus; HSV: herpes simplex virus https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html Epidemiology 15 million pediatrician/primary care visits per year in the US 1 Most common in children ages 5 5 UNIVERSITY OF ILLINOIS CHICAGO 24 https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html 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 UNIVERSITY OF ILLINOIS CHICAGO GAS: group A Streptococcus 25 Shulman ST. Clin Infect Dis. 2012;55(10):e86-102. Clinical Presentation Other GAS Clinical Findings symptoms: Sore Tonsillopharyn Headache throat geal erythema Abdominal +/- exudates pain GAS Tender, Nausea/ pharyngi enlarged vomiting tis lymph nodes Viral symptoms: Odynopha Red, swollen Cough Fever gia uvula Rhinorrhea Petechiae on Hoarseness the palate Oral ulcers Scarlatiniform Conjunctiviti UNIVERSITY OF ILLINOIS CHICAGO rash GAS: group A Streptococcus 26 https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html GAS Pharyngitis Testing Throat swab and rapid antigen detection testing RADT (RADT) and/or culture Testing not recommended if Negativ Positive viral features or children < 3 e years old Follow- up culture UNIVERSITY OF ILLINOIS CHICAGO Shulman ST. Clin Infect Dis. 2012;55(10):e86-102. RADT: rapid antigen detection testing 27 https://www.cdc.gov/groupastrep/diseases-public/strep-throat.html Transmission Respiratory Droplets Direct contact Incubation: 2-5 days UNIVERSITY OF ILLINOIS CHICAGO 28 https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html Treatment – GAS only Drug/ Durati Dose route on Penicillin V, Children: 250 mg po oral 2-3x/day 10 Adults: 250 mg 4x/day or days 500 mg BID Amoxicillin, 25 mg/kg (max 500 mg) 10 oral BID or 50 mg/kg/day (max days 1000 mg) Benzathine < 27 kg: 600,000 U penicillin G, ≥ 27 kg: 1,200,000 29 U UNIVERSITY OF ILLINOIS CHICAGO IM: intramuscular; BID: twice daily 1 dose Shulman ST. Clin Infect Dis. 2012;55(10):e86-102. https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html Treatment – Penicillin Allergy Drug, all Durati Dose oral on Cephalexin 20 mg/kg BID (max 500 10 mg/dose) days Cefadroxil 30 mg/kg/day (max 1g) 10 days Clindamyci 7 mg/kg TID (max 300 10 n mg/dose) days Azithromyc 12 mg/kg/day (max 500 5 days in mg) UNIVERSITY OF ILLINOIS CHICAGO BID: twice daily; TID: three times daily 30 Shulman ST. Clin Infect Dis. 2012;55(10):e86-102. Adjunctive Therapy Acetaminophen or NSAIDs may be appropriate Avoid aspirin in children Corticosteroids not recommended UNIVERSITY OF ILLINOIS CHICAGO NSAID: non-steroidal anti-inflammatory drugs 31 Shulman ST. Clin Infect Dis. 2012;55(10):e86-102. Rheumatic Fever Delayed sequela 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 Treatment: underlying GAS, symptom management UNIVERSITY OF ILLINOIS CHICAGO https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html GAS: group A streptococcus; SOB: shortness of breath 32 https://www.cdc.gov/groupastrep/diseases-public/rheumatic- Goals of Therapy Prevent spread of infection to others Infection resolution Minimize treatment adverse effects Prevent rheumatic fever UNIVERSITY OF ILLINOIS CHICAGO 33 Clinical Practice Guidelines Infectious Diseases Society of America (IDSA) – 2012 Management of Group A Streptococcal Pharyngitis UNIVERSITY OF ILLINOIS CHICAGO 34 Which of the following is the triad of symptoms most associated with Group A Strep pharyngitis? A. Cough, rhinorrhea, fever B. Cough, sore throat, headache C. Rhinorrhea, sore throat, fever D. Sore throat, odynophagia, fever Which of the following is NOT an appropriate first-lineantibiotic choice to treat Strep throat? A. Oral penicillin B. Oral amoxicillin C. IM penicillin D. IM ceftriaxone Bronchitis UNIVERSITY OF ILLINOIS CHICAGO 37 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” UNIVERSITY OF ILLINOIS CHICAGO 38 https://www.cdc.gov/antibiotic-use/bronchitis.html Epidemiology Acute bronchitis reported in 5% of the population annually Accounts for > 10 million office visits annually UNIVERSITY OF ILLINOIS CHICAGO 39 Braman SS. Chest. 2006;129:95S-103S. Bacterial vs. Viral Most commonly cause by Rhinovir Enterovir a virus us us Bacterial cause in 1-10% of cases Influenza Coronavi rus Parainflue nza RSV hMPV UNIVERSITY OF ILLINOIS CHICAGO Kinkade S. Am Fam Physician. 2016;94(7):560-565. 40 hMPV: human metapneumovirus; RSV: respiratory syncytial https://www.cdc.gov/antibiotic-use/bronchitis.html Symptoms Cough Nasal Chest (+/- congesti sorenes Fatigue mucus) on s Headach Body Sore Fever e aches throat Symptom duration: 2-3 weeks (18 days) UNIVERSITY OF ILLINOIS CHICAGO Kinkade S. Am Fam Physician. 2016;94(7):560-565. 41 https://www.cdc.gov/antibiotic-use/bronchitis.html Diagnosis Laboratory testing not indicated Infrequent leukocytosis Specific pathogen testing if highly suspicious and treatment would be impacted UNIVERSITY OF ILLINOIS CHICAGO 42 Kinkade S. Am Fam Physician. 2016;94(7):560-565. 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 UNIVERSITY OF ILLINOIS CHICAGO Braman SS. Chest. 2006;129:95S-103S. Kinkade S. Am Fam Physician. OTC: over the counter; APAP: acetaminophen 43 2016;94(7):560-565. Findings Suggestive of Pneumonia Tachypnea Tachycardia Dyspnea Radiologic findings UNIVERSITY OF ILLINOIS CHICAGO 44 Clinical Practice Resource American Academy of Family Physician – Acute Bronchitis (2012) UNIVERSITY OF ILLINOIS CHICAGO 45 Which of the following is the most common cause of bronchitis? A. Streptococcus pyogenes B. Staphylococcus aureus C. Streptococcus pneumoniae D. Haemophilus influenzae E. Viruses Antibiotic Overprescribing UNIVERSITY OF ILLINOIS CHICAGO 47 Risks of Overprescribing Adverse effects Antimicrobial resistance Unnecessary costs UNIVERSITY OF ILLINOIS CHICAGO 48 Sur DKC, Am Fam Physician. 2022;106(6):628-636. UNIVERSITY OF ILLINOIS CHICAGO 49 Havers FP. JAMA Netw Open. 2018;1(2):e180243. UNIVERSITY OF ILLINOIS CHICAGO 50 Havers FP. JAMA Netw Open. 2018;1(2):e180243. 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 UNIVERSITY OF ILLINOIS CHICAGO 51 Kinkade S. Am Fam Physician. 2016;94(7):560-565.