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Family Medicine Department Dr. Eman Ahmad Marei Husam Salhab URTI & Antibiotics

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بسم الله الرحمن الرحيم <ul><li>Definition </li></ul><ul><li>Epidemiology </li></ul><ul><li>Types and causative agents </li></ul><ul><li>Management principles </li></ul><ul><li>Effects of Rx </li></ul><ul><li>Antibiotic in specific URTI </li></ul><ul><li>Factors affect prescription </li></ul>Objectives

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Definition <ul><li>URTI inflammation of respiratory mucosa from the nose to the lower respiratory tree not including the alveoli. </li></ul>

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Symptoms <ul><li>Sore throat </li></ul><ul><li>Rhinorrhea </li></ul><ul><li>Facial fullness and Pain </li></ul><ul><li>Headache </li></ul><ul><li>Cough </li></ul><ul><li>Fever </li></ul><ul><li>Tender lymph nodes </li></ul><ul><li>Ear Pain </li></ul>

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Epidemiology <ul><li>In average Children will have 5 URTI/Year, & adults 2-3/Year </li></ul><ul><li>Acute rhinitis is by far the most common cause of doctors visit. </li></ul><ul><li>Otitis media is the most common cause for a child under age 15 to visit a physician. </li></ul><ul><li>Acute Otitis Media, the most common condition for antibiotics (50%). </li></ul><ul><li>Group A beta-hemolytic streptococcus is only found in 15% to 36% of children with sore throat. </li></ul>

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Types and causative agents

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Management Principles <ul><li>Viral infections need only symptomatic treatment: </li></ul><ul><li>-Analgesics ( Paracetamol, Aspirin, Ibuprofen ) </li></ul><ul><li>-Anti-histamines </li></ul><ul><li>-Cough suppressants </li></ul><ul><li>-Nasal decongestants </li></ul><ul><li>- Vitamin C </li></ul><ul><li>-Increase fluid intake </li></ul><ul><li>Bacterial Infections need antibiotics in addition of symptomatic treatment </li></ul>

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Management Principles Viral (Don’t Use Antibiotics) Why? -Promotes antibiotic resistance -Adverse reactions such as allergy and anaphylaxis -Costly -Patients do not need antibiotics to feel satisfied Bacterial (Use antibiotics) Why? - To prevent rheumatic fever - To prevent suppurative complications (e.g., peritonsillar abscess) - To speed up recovery - To reduce spread to others

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Management Principles <ul><li>Viral (Don’t Use Antibiotics) </li></ul><ul><li>-Influenza, Common Cold </li></ul><ul><li>-Viral Pharyngitis </li></ul><ul><li>-Mild Acute Sinusitis </li></ul><ul><li>-Mild Acute Otitis Media </li></ul>Bacterial (Use antibiotics) -GABHS Pharyngitis -Moderately to severe Acute Sinusitis -Moderately to severe Acute Otitis Media -Special Cases (Pertussis, Croup)

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<ul><li>But how can we differentiate between Viral and Bacterial Pharyngitis, Sinusitis & Otitis Media? </li></ul>

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Acute Pharyngitis (Sore Throat) <ul><li>Viral </li></ul><ul><li>Erythema </li></ul>

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Acute Pharyngitis <ul><li>-No Evidence that bacterial sore throat are more severe than viral ones or that the duration of the illness is significantly different in either cases. </li></ul><ul><li>-Based on symptoms , bacterial and viral sore throat are limited to be distinguished. Clinical examination should not be relied upon to differentiate between viral and bacterial sore throat. </li></ul><ul><li>-Sensitivity and Specificity suggest that reliance on clinical diagnoses will miss 25-50% of GABHS Pharyngitis cases. </li></ul>

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Acute Pharyngitis <ul><li>To determine bacterial Pharyngitis </li></ul><ul><li>Strep. Score </li></ul><ul><li>McIsaac Criteria </li></ul>

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Acute Pharyngitis <ul><li>Rapid Antigen Test (RAT) </li></ul><ul><li>Sensitivity of RAT against culture varies between 61-95%. </li></ul><ul><li>Specificity of RAT 88-100% </li></ul><ul><li>Takes 10 min to be performed </li></ul><ul><li>-ve results should be confirmed by culture. </li></ul><ul><li>Not found in Jordan </li></ul>

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Acute Pharyngitis <ul><li>Throat Culture </li></ul><ul><li>20-40% of those with negative throat culture will be labeled as having GABHS. </li></ul><ul><li>+ve culture makes the Dx of GABHS likely , but –Ve culture does not rule out. </li></ul>

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Acute Pharyngitis (Drug Of choice) <ul><li>-Oral penicillin or erythromycin (in penicillin-allergic individuals), given for 10 days. </li></ul><ul><li>-Fortunately, no resistance to penicillin has been reported, so far, among GABHS-related Pharyngitis patients. </li></ul>

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Complication <ul><li>Rheumatic Fever </li></ul><ul><li>- Major Criteria: </li></ul><ul><li>- polyarithritis </li></ul><ul><li>- carditis </li></ul><ul><li>- sydenham chorea </li></ul><ul><li>- subcutaneous nodules </li></ul><ul><li>- erythema marginatum </li></ul><ul><li>- Minor Criteria: </li></ul><ul><li>- fever </li></ul><ul><li>- leukocytosis </li></ul><ul><li>- elevated ESR,CRP </li></ul><ul><li>- arthralgia </li></ul><ul><li>with evidence of recent group A strep infection </li></ul>

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Case <ul><li>A 25 year old man comes to your office with the complaint of a bad sore throat for 2 days. He has felt chills and fever today but has not measured his temperature. He has some pain on swallowing. He has a slight runny nose and denies cough and other symptoms. He was previously healthy. </li></ul>T= 38.5 ears - TM's normal nose – clear neck - no cervical adenopathy lungs – clear

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How many points does our patient have? 1 1 0 1 0 0 Fever over 38 C Absence of cough Tender ant. cervical adenopathy Tonsillar swelling or exudate Age< 15 y Age> 45 Total = 3

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What are the tests? <ul><li>Rapid strep test -ve </li></ul><ul><li>Throat culture + ve </li></ul><ul><li>Give Penicillin + Symptomatic treatment </li></ul>

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Acute otitis media

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Normal Tympanic Membrane

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Acute otitis media Redness Bulging

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Acute otitis media Bullae Perforation

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Acute otitis media <ul><ul><li>Dutch Guidelines </li></ul></ul><ul><li>-Dutch study found no difference in outcome between antibiotics, myringotomy, antibiotics combined with myringotomy and placebo. </li></ul><ul><li>-Only 1 in 7 children under 2 year old with 1 st episode of A.O.M derived significant benefit from antibiotic treatment. </li></ul><ul><li>-Although it reduce fever faster , it does not reduce duration of pain or crying. </li></ul>

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Acute otitis media <ul><li>Dutch Guidelines </li></ul><ul><li>Diagnostic criteria </li></ul><ul><li>- Recent perforation of the tympanic membrane with discharging pus </li></ul><ul><li>- Inflamed and bulging tympanic membrane </li></ul><ul><li>- One ear drum redder than the other </li></ul><ul><li>- Bullae on tympanic membrane </li></ul>

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TREATMENT GUIDELINES <ul><li>Symptomatic treatment is provided in all cases </li></ul><ul><li>The patient or the parents are instructed to contact the general practitioner if there is an abnormal clinical course, in other words: </li></ul><ul><li>- increasing illness or earache, decreased drinking </li></ul><ul><li>- no improvement within 3 days </li></ul>

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TREATMENT GUIDELINES (cont.) Antibiotics Children < 6 months Children 6 months - 2 years + abnormal clinical course For children >2 years, + recurrent within 12 months or Down's syndrome, cleft palate, compromised immune system

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<ul><li>Treatment : </li></ul><ul><li>- Amoxcillin – Cluv acid </li></ul><ul><li>80-90 mg/kg per day </li></ul><ul><li>- Clarithromycin </li></ul><ul><li>15 mg/kg twice per day </li></ul><ul><li>Complication: </li></ul><ul><li>- meningitis </li></ul><ul><li>- brain abscess </li></ul><ul><li>- mastoiditis </li></ul><ul><li>- cholesteatoma </li></ul>

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Acute sinusitis

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Acute sinusitis Antibiotics Moderate symptoms not improving after 10 days Moderate symptoms that worsen after 5 to 7 days Severe symptoms <ul><ul><li>-Oral amoxicillin, trimethoprim-sulfamethoxazole, or doxycycline, given for 3 to 10 days are the favored antibiotics for treatment. </li></ul></ul>

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Influenza <ul><li>- Antibiotics are ineffective </li></ul><ul><li>- Amantadine and rimantadine (Antiviral) should not be used for the treatment of influenza because of widespread resistance. </li></ul><ul><li>- Rx : Symptomatic treatment only </li></ul>

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Common cold

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Common cold <ul><ul><li>-No significant difference between antibiotics and placebo in cure or general improvement at 6–14 days in people with colds. </li></ul></ul><ul><ul><li>-In a subgroup of people (20%) with nasopharyngeal culture positive Haemophilus influenzae, Moraxella catarrhalis, or Streptococcus pneumoniae, antibiotics increased recovery at 5 days compared with placebo. </li></ul></ul><ul><ul><li>-However, we have no methods currently of easily identifying such people at first consultation. </li></ul></ul><ul><li>-Rx: Symptomatic treatment only </li></ul>

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Pertussis (Whooping Cough)

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Pertussis <ul><li>-Treating acute tracheobronchitis with antibiotics is not recommended, since most cases are viral, and thus resolve spontaneously. </li></ul><ul><li>-In adults who report exposure to a patient with confirmed or suspected pertussis, erythromycin or trimethoprim-sulfamethoxazole should be administered for 14 days. This will decrease contagion from bacterial shedding, but is not expected to improve resolution of symptoms, unless started within 10 days of the onset of illness </li></ul>

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Croup Inflammation of the larynx and upper airway .

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Croup <ul><li>No systematic review, RCTs, or observational studies of sufficient quality on antibiotics in children with moderate to severe croup. </li></ul><ul><li>Antibiotics do not shorten the clinical course of a disease that is predominantly viral in origin. This does not apply if bacterial tracheitis is suspected. </li></ul><ul><li>Rx: - Racemic epinephine </li></ul><ul><li>- Oral dexamethazone </li></ul>

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Factors affect prescription <ul><li>-Patient expectation and satisfaction. </li></ul><ul><li>-Severity. </li></ul><ul><li>-Duration of illness </li></ul><ul><li>-Parents demands. </li></ul><ul><li>-Concerns about secondary bacterial infection. </li></ul><ul><li>-Time. </li></ul>

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<ul><li>Thank You </li></ul><ul><li>تمت بحمد الله </li></ul>