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Upper Respiratory
Infections
Khaled Saad Zaghloul
MD Pediatrics
 The most common cause ofThe most common cause of cough inin
children is represented by airwayschildren is represented by...
Cough associated with a single
infective episode may last from days
to weeks, with an average of 1–3
weeks , and it has be...
The infections may occurThe infections may occur ‘‘back to back’’
and give the impression of a chronicand give the impress...
UPPER RESPIRATORY TRACT
IFECTIONS
 Common cold
 Pharyngitis
 Sinusitis
 Ear infections
The common cold
 Short, mild and usually self-limiting illness.
 Children may have up to12 colds per year.
 200 types o...
Clinical features of common cold:
 Rhinorrhea, sore throat,cough,fever and
malaise lasting up to 7 days and often
lingeri...
Treatment of common cold
Echinacea, humidified air, nasal decongestants,
vitamin C and zinc have reported some
positive re...
Acute sore throat
Pharyngitis
 Bacterial infectionBacterial infection
 Viral infection
 Streptococcus pyogenes – most serious type
 Scar...
Streptococcus pyogenesStreptococcus pyogenes
Group A is virulent
Streptolysins - toxin (hemolysins)
Erythrogenic – toxi...
ƄƄ Bacterial infection:Bacterial infection:
Group A beta-hemolytic Streptococcus
• Most common and important
• Commonly pr...
The surface antigens of group A streptococcus serve as
virulence factors.
Fig. 21.5 Cutaway view of group A streptococcus.
Streptococcus infection causing inflammation of the throat
and tonsils.
Treatment of acute phryngitis
 Penicillin V 250 mg/dose for children and
500mg/dose for adolescents and adults.
 Amoxici...
Azithromycin offers convenience of once-
daily administration and shorter length of
therapy.
Cephalosporins appear to be...
Candida
Coxsackie virus:
•Herpangina
ulcerative vesicles over the tonsils, posterior
pharynx, and palate
• Commonly occurs in chil...
EBVEBV
 DiagnosisDiagnosis
By Clinical presentation
CBC with differential (atypical lymphocytes –T
lymphocytes)
Detect...
EBV petechiae
Herpes Simplex Virus-1Herpes Simplex Virus-1
Herpes labialis
• Recurrent infection
• HSV-1
• vesicle at lip or
mucocutaneous junction
Acute herpes gingivostomatitis
Colour Atlas of
Infectious Disease,
Inflamed pharynx and tonsils marked by a grayish
pseudomembrane formed by the bacteria are characteristic
signs of diphthe...
Sinuses
 Sinuses are moist air spaces within the bones of
the face around the nose
 Human have 4 pairs of sinuses
 The ...
Sinuses
Sinusitis
Microbial etiologyMicrobial etiology
 Viruses are the most frequent cause ofViruses are the most frequent cause of
rhinos...
Microbial etiology
Bacterial causes of sinusitis
OrganismOrganism %%
S. pneumoniaeS. pneumoniae 30%30%
H. Influenzae (nontypableH. Influenzae...
Sign and symptoms
 In pediatric patients, most URIs last 5-7 days.
By 10 days, the URI almost always improves.
Most rhi...
The clinical diagnosis of Bacterial sinusitis is
based solely on history.
Persistent of symptoms of URI , including
nasal ...
Chronic sinusitisChronic sinusitis
 CoughCough
Nasal discharge or nasal congestion lasting
more than 90 days
Physical examination
- Facial tenderness to palpation is present
- Nasal mucosa is inflammation, redness and
swelling
- Pu...
Antibiotics for siuusitisAntibiotics for siuusitis
 Risk factors:
1. antibiotics treatment in the preceding1-3 mo,
2. day...
 Frontal sinusitis can rapidly progress toFrontal sinusitis can rapidly progress to
intracranial complication -parenteral...
POST-NASAL DRIP SYNDROMEPOST-NASAL DRIP SYNDROME
The leading cause of PND, is allergic rhinitis or,The leading cause of PN...
The pathogenesis of PND induced cough isThe pathogenesis of PND induced cough is
probably due to the inflammatory nature o...
Acute Otitis MediaAcute Otitis Media
. Otitis media is one of the most common
diagnosis made by pediatricians
 30-60% of children have had at least one
putat...
Approximately 80-90% will have had
at least one episode of either AOM or
asymptomatic middle ear effusion in
the first yea...
Eustachian Tube
Connects middle ear and nasopharynx
Lumen shaped like two cones with apex
directed toward middle
Mucosa...
Eustachian tube
 Adults
 ant 2/3- cartilaginousant 2/3- cartilaginous
post 1/3- bonypost 1/3- bony
 45 degree angle45 d...
Eustachian tube
Usually closed
Opens during swallowing, yawning, and
sneezing
Opening involves cartilaginous portion
T...
Eustachian tube function
Protection from nasopharyngeal sound and
secretions
clearance of middle ear secretions
ventila...
Bacteria can migrate along the eustachian tube from
the upper respiratory tract, and a buildup of mucus
and fluids can cau...
Risk factors for AOM
Age
 Male genderMale gender
Exposure to group day care
Exposure to environmental smoke or other
r...
Risk factors for AOM
 URIURI
 Winter season
 Siblings in household
Immunodeficiency
 AllergiesAllergies
 Craniofacial...
NEVER bottle-feed an infant on it’s back
like this!
Large tonsils can obstruct the
Eustachian tubes
How we are challengedHow we are challenged….….
**Clinical History is a poor predictorClinical History is a poor predictor…...
 Otalgia usually is associated withusually is associated with
inflammation of the external orinflammation of the external...
In young infantsIn young infants,,
-- pulling or rubbing the ear along withpulling or rubbing the ear along with
-- genera...
Three important keys to improving diagnostic
accuracy for AOM centre around the
following:
 diligent cleaning of ear ceru...
Normal EarNormal Ear
Acute Otitis MediaAcute Otitis Media
Acute Otitis MediaAcute Otitis Media
Middle ear effusion
(MEE)
YesYes YesYes
Diagnostic Criteria: OME andDiagnostic Criteria: OME and
AOMAOMAt least two of:
1....
S. pneumoniae*
50%
M. catarrhalis
15%
Other
5%
H. influenzae*
30%
Predominant AOM Pathogens
Barnett ED, et al. Pediatr Cli...
Clinical GuidelinesClinical Guidelines
AMERICAN ACADEMY OF PEDIATRICS
AMERICAN ACADEMY OF FAMILY
PHYSICIANS
Subcommittee o...
AOM OutcomeAOM Outcome InitialInitial
AntibacteriaAntibacteria
l Therapyl Therapy
InitialInitial
ObservatioObservatio
nn
P...
AOM OutcomeAOM Outcome InitialInitial
AntibacteriaAntibacteria
l Therapyl Therapy
InitialInitial
ObservatioObservatio
nn
P...
AOM spontaneous resolution rateAOM spontaneous resolution rate
varies by pathogenvaries by pathogen
OrganismOrganism Spont...
2004AAP/AAFP Clinical Practice
Guideline on AOM
 Released March 2004
 Evidence-based clinical practice guideline:
 3461...
2004AAP/AAFP Clinical Practice
Guideline on AOM: Conclusions II
1. To diagnose acute otitis media the clinician should con...
2004AAP/AAFP Clinical Practice Guideline on
AOM: Conclusions II
4. If the patient fails to respond to the initial manageme...
Criteria for initial antibacterial therapy vs. observation:
2004 AAP/AAFP AOM Guidelines
AgeAge Certain DiagnosisCertain D...
Amoxicillin: first line therapy for AOM
 Recommended as the first line drug of choice by:Recommended as the first line dr...
 AOM is commonly over diagnosed. Thus, if
clinicians are going to continue to overuse
antibiotics—because of parental pre...
Antibiotic therapy: at time of diagnosis
2004 AAP/AAFP AOM Guidelines
Temperature <39Temperature <39oo
CC
and/or Severe Ot...
Antibiotic therapy: clinical failures, 48-72 hr
2004 AAP/AAFP AOM Guidelines
Temperature <39Temperature <39oo
CC
and/or Se...
Drugs chosen for second-line treatment should be
effective against B lactamase- producing strains of H.
influenzae and M. ...
Cefdinir was not available when the above
recommendations were made. However, clinical
Practice and efficacy with cefdinir...
Conjunctivitis–otitis syndrome:
ß lactamase- producing H influenzae
tends to be the predominant organism, causing
both con...
Ambulatory pneumonia (‘‘walking
pneumonia’’ AND O M
As atypical pathogens (Chlamydia
pneumoni , Mycoplasma pneumoniae) are...
ImpetigoImpetigo
Impetigo or skin infection and AOM:
Typically, impetigo and skin infections are caused by
Staphylococcus aureus and only r...
Impetigo or skin infection and AOM:
Patients whose skin infection does
not respond in 24–28 h would then
additionally rece...
Aspirin
Non-narcotic, anti-inflammatory; antiplatelet
Antipyretic, nonsteroidal agent.
Used in the treatment of pain, infl...
Aspirin
Cautions: contraindicated in children below 16yr
with chickenpox or flu-like symptom due to
risk of Reye syndrome....
Acetaminophen
Mechanism of action
Inhibits the synthesis of prostaglandins in the centralInhibits the synthesis of prostag...
Acetaminophen, 10-15mg/kg orally every4hr,
is not associated with significant adverse
effects; however, prolonged use may ...
Ibuprofen
Nonsteroidal anti-inflammatory agent thatNonsteroidal anti-inflammatory agent that
inhibits prostaglandin synthe...
Ibuprofen
Adverse eventsAdverse events::
Abdominal pain, heartburn, nausea, GITAbdominal pain, heartburn, nausea, GIT
blee...
Nimesulid
Nimesulide has a disadvantage of long duration of action andNimesulide has a disadvantage of long duration of ac...
Diclofenac Sodium
Diclofenac, a nonselective nonsteroidal anti-
inflammatory drug, exerts analgesic action
both in the per...
What Can Be DoneWhat Can Be Done??
 Options for reducing
rates of severe otitis
media:
 Additional hygiene
practices
 I...
Upper respiratory infections in children
Upper respiratory infections in children
Upper respiratory infections in children
Upper respiratory infections in children
Upper respiratory infections in children
Upper respiratory infections in children
Upper respiratory infections in children
Upper respiratory infections in children
Upper respiratory infections in children
Upper respiratory infections in children
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Upper respiratory infections in children
Common cold
Pharyngitis
Sinusitis
Ear infections

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Upper respiratory infections in children

  1. 1. Upper Respiratory Infections Khaled Saad Zaghloul MD Pediatrics
  2. 2.  The most common cause ofThe most common cause of cough inin children is represented by airwayschildren is represented by airways respiratory infection,respiratory infection, mostly concerning the upper airway and of viral origin (URTI).  A healthy child is expected to present with 3.8–8 infective episodes per year, vs. the average of two episodes for an adult . Monto AS. Epidemiol Rev 1994: 16: 351–73Monto AS. Epidemiol Rev 1994: 16: 351–73.. Leder et al. Aust N Z J Public Health 2003: 27:399–404Leder et al. Aust N Z J Public Health 2003: 27:399–404..
  3. 3. Cough associated with a single infective episode may last from days to weeks, with an average of 1–3 weeks , and it has been demonstrated that 10% of children will be expected to be still coughing after 4 weeks from the beginning of the infection. Hay & Wilson . Br J Gen Pract 2002: 52: 401–9. Hay et al. Fam Pract 2003:20: 696–705.
  4. 4. The infections may occurThe infections may occur ‘‘back to back’’ and give the impression of a chronicand give the impression of a chronic persistent cough. However, these childrenpersistent cough. However, these children should experience short breaks in theirshould experience short breaks in their symptoms in between infections.symptoms in between infections.
  5. 5. UPPER RESPIRATORY TRACT IFECTIONS  Common cold  Pharyngitis  Sinusitis  Ear infections
  6. 6. The common cold  Short, mild and usually self-limiting illness.  Children may have up to12 colds per year.  200 types of viruses, the most common is rhinovirus ( 40% ).
  7. 7. Clinical features of common cold:  Rhinorrhea, sore throat,cough,fever and malaise lasting up to 7 days and often lingering mucopurlant nasal discharge.  In infants cold may manifest as irritability, snuffles and difficulty with feeding.  Infants under 3 months of a age are susceptible to LRTI.
  8. 8. Treatment of common cold Echinacea, humidified air, nasal decongestants, vitamin C and zinc have reported some positive results but there insufficient data to recommend any of these for treatment. Hems and Henderson, Respiratory disorders. Forfar and Arneil' Textbook of Pediatrcs, 715,2008
  9. 9. Acute sore throat
  10. 10. Pharyngitis  Bacterial infectionBacterial infection  Viral infection  Streptococcus pyogenes – most serious type  Scarlet fever  Rheumatic fever  Glomerulonephritis
  11. 11. Streptococcus pyogenesStreptococcus pyogenes Group A is virulent Streptolysins - toxin (hemolysins) Erythrogenic – toxin Toxins can act as superantigens Over stimulate T cells Tumor necrosis factor
  12. 12. ƄƄ Bacterial infection:Bacterial infection: Group A beta-hemolytic Streptococcus • Most common and important • Commonly presents in children aged 5–6 • Fever, dry sore throat, cervical adenopathy, dysphagia, and odynophagia • The tonsils and pharyngeal mucosa are erythematous and may be covered with purulent exudate • The tongue may also become red ("strawberry tongue") • Sequelae: acute rheumatic fever and poststreptococcal glomerulonephritis
  13. 13. The surface antigens of group A streptococcus serve as virulence factors. Fig. 21.5 Cutaway view of group A streptococcus.
  14. 14. Streptococcus infection causing inflammation of the throat and tonsils.
  15. 15. Treatment of acute phryngitis  Penicillin V 250 mg/dose for children and 500mg/dose for adolescents and adults.  Amoxicillin; 750 mg once daily for10 days or 50 mg/kg/day for 6 days divided bid.  A single IM injection of benzathine penicillin (600,000U for children < 27 kg; 1,2 million U for larger children and adults.  Erythromycin 40 mg/kg in divided doses for 10 days.
  16. 16. Azithromycin offers convenience of once- daily administration and shorter length of therapy. Cephalosporins appear to be as, good as or better than penicillin, perhaps because these drugs are more effective in eradicating streptococcal carriage. Evidence is not sufficient to recommend shorter courses of cephalosporins for routine therapy at this time Pappas and Henley: Nelson textbook of pediatrics, 2007Pappas and Henley: Nelson textbook of pediatrics, 2007
  17. 17. Candida
  18. 18. Coxsackie virus: •Herpangina ulcerative vesicles over the tonsils, posterior pharynx, and palate • Commonly occurs in children under the age of 16 • Generalized symptoms of headache, high fever, anorexia, and odynophagia
  19. 19. EBVEBV  DiagnosisDiagnosis By Clinical presentation CBC with differential (atypical lymphocytes –T lymphocytes) Detection of heterophil antibodies (Monospot test) IgM titers
  20. 20. EBV petechiae
  21. 21. Herpes Simplex Virus-1Herpes Simplex Virus-1
  22. 22. Herpes labialis • Recurrent infection • HSV-1 • vesicle at lip or mucocutaneous junction
  23. 23. Acute herpes gingivostomatitis Colour Atlas of Infectious Disease,
  24. 24. Inflamed pharynx and tonsils marked by a grayish pseudomembrane formed by the bacteria are characteristic signs of diphtheria.
  25. 25. Sinuses  Sinuses are moist air spaces within the bones of the face around the nose  Human have 4 pairs of sinuses  The ethmoid and the maxillary sinuses form in the third to fourth gestational month  The sphenoid sinuses are generally pneumatized by 5 years of age  the frontal sinuses appear at age 7 to 8 years but are not completely developed until late adolescence.
  26. 26. Sinuses
  27. 27. Sinusitis
  28. 28. Microbial etiologyMicrobial etiology  Viruses are the most frequent cause ofViruses are the most frequent cause of rhinosinusitisrhinosinusitis  viruses are known to predispose toviruses are known to predispose to subsequent bacterial infection via suchsubsequent bacterial infection via such mechanisms as viral-induced impairmentmechanisms as viral-induced impairment of the mucociliary apparatus.of the mucociliary apparatus.
  29. 29. Microbial etiology
  30. 30. Bacterial causes of sinusitis OrganismOrganism %% S. pneumoniaeS. pneumoniae 30%30% H. Influenzae (nontypableH. Influenzae (nontypable(( 20%20% M. catarrhalisM. catarrhalis 2%2% 50% of H. Influenzae and 100% M. catarrhalis are B- lactamase positive
  31. 31. Sign and symptoms  In pediatric patients, most URIs last 5-7 days. By 10 days, the URI almost always improves. Most rhinoviral infections improve within 7-10 days so the complaint of persistent or worsening symptoms may indicate a developing bacterial sinusitis. Pediatric patients may complain of a daytime cough and persistent nasal discharge. Complaints of facial pain and headache are rare in children.
  32. 32. The clinical diagnosis of Bacterial sinusitis is based solely on history. Persistent of symptoms of URI , including nasal discharge and cough, for >10-14 days, or temp 39 C and purulent discharge for 3-4 days
  33. 33. Chronic sinusitisChronic sinusitis  CoughCough Nasal discharge or nasal congestion lasting more than 90 days
  34. 34. Physical examination - Facial tenderness to palpation is present - Nasal mucosa is inflammation, redness and swelling - Purulent secretions in the middle meatus (highly predictive of maxillary sinusitis) - Complete opacification of sinus on transillumination is present..
  35. 35. Antibiotics for siuusitisAntibiotics for siuusitis  Risk factors: 1. antibiotics treatment in the preceding1-3 mo, 2. day care attendance, age ≤2 yr ) 3. resistant bacterial species 4. failure to respond to initial amoxicillin within 72 hr
  36. 36.  Frontal sinusitis can rapidly progress toFrontal sinusitis can rapidly progress to intracranial complication -parenteralintracranial complication -parenteral ceftriaxone until improvement then oraluntil improvement then oral antibiotic therapy.antibiotic therapy. The use of decongestants, antihistamines, mucolytics and intranasal steroids have not adequately studied in children
  37. 37. POST-NASAL DRIP SYNDROMEPOST-NASAL DRIP SYNDROME The leading cause of PND, is allergic rhinitis or,The leading cause of PND, is allergic rhinitis or, more appropriately, chronic rhinosinusitis. Inmore appropriately, chronic rhinosinusitis. In Hong Kong, the prevalence of allergic rhinitisHong Kong, the prevalence of allergic rhinitis in children between 6 and 7 years old is 33%,in children between 6 and 7 years old is 33%, and this figure increases to 52% in childrenand this figure increases to 52% in children between 13 and 14 years oldbetween 13 and 14 years old.. Bousquet et al. J Allergy Clin Immunol 2001; 108:S147-334Bousquet et al. J Allergy Clin Immunol 2001; 108:S147-334.. Lau & Karlberg . J Paediatr Child Health 1998; 34:47-52Lau & Karlberg . J Paediatr Child Health 1998; 34:47-52.. Leung et al.Eur Resp J 1997; 10:354-60Leung et al.Eur Resp J 1997; 10:354-60..
  38. 38. The pathogenesis of PND induced cough isThe pathogenesis of PND induced cough is probably due to the inflammatory nature of theprobably due to the inflammatory nature of the nasal secretion and/or direct mechanicalnasal secretion and/or direct mechanical stimulation of the cough receptors bystimulation of the cough receptors by secretions dripping from the nostrils down intosecretions dripping from the nostrils down into the hypopharynx. Microaspiration of thethe hypopharynx. Microaspiration of the secretions and nasobronchial reflex have alsosecretions and nasobronchial reflex have also been suggestedbeen suggested.. Bush A. Paediatric problems of cough. Pulm Pharmacol Ther 2002;15:309-15Bush A. Paediatric problems of cough. Pulm Pharmacol Ther 2002;15:309-15.. Lack G. Pediatric allergic rhinitis and comorbid disorders. J Allergy Clin Immunol 2001; 108:S9-15Lack G. Pediatric allergic rhinitis and comorbid disorders. J Allergy Clin Immunol 2001; 108:S9-15..
  39. 39. Acute Otitis MediaAcute Otitis Media
  40. 40. . Otitis media is one of the most common diagnosis made by pediatricians  30-60% of children have had at least one putative episode of AOM by age one.  10-20% have had three or more.  80% have had at least one episode by age 3 years.
  41. 41. Approximately 80-90% will have had at least one episode of either AOM or asymptomatic middle ear effusion in the first year of life.
  42. 42. Eustachian Tube Connects middle ear and nasopharynx Lumen shaped like two cones with apex directed toward middle Mucosa has mucous producing cells and ciliated cellscells
  43. 43. Eustachian tube  Adults  ant 2/3- cartilaginousant 2/3- cartilaginous post 1/3- bonypost 1/3- bony  45 degree angle45 degree angle  isthmus 1-2 mmisthmus 1-2 mm  nasopharyngeal orificenasopharyngeal orifice 8-9 mm8-9 mm  Children  longer bony portion  10 degree angle  isthmus larger  nasopharyngeal orifice 4-5 mm in infants
  44. 44. Eustachian tube Usually closed Opens during swallowing, yawning, and sneezing Opening involves cartilaginous portion Tensor veli palatini responsible for active tubal opening No constrictor function
  45. 45. Eustachian tube function Protection from nasopharyngeal sound and secretions clearance of middle ear secretions ventilation (pressure regulation) of middle ear
  46. 46. Bacteria can migrate along the eustachian tube from the upper respiratory tract, and a buildup of mucus and fluids can cause inflammation and effusion. Fig. 21.2 An infected middle ear.
  47. 47. Risk factors for AOM Age  Male genderMale gender Exposure to group day care Exposure to environmental smoke or other respiratory irritants and allergens that interfere with Eustachian tube function. Lack of breast feeding. Supine feeding position.
  48. 48. Risk factors for AOM  URIURI  Winter season  Siblings in household Immunodeficiency  AllergiesAllergies  Craniofacial abnormalitiesCraniofacial abnormalities  Down syndromeDown syndrome  PacifierPacifier
  49. 49. NEVER bottle-feed an infant on it’s back like this!
  50. 50. Large tonsils can obstruct the Eustachian tubes
  51. 51. How we are challengedHow we are challenged….…. **Clinical History is a poor predictorClinical History is a poor predictor…… **A clear view isn’t always easyA clear view isn’t always easy…… **Examining a crying child can be toughExamining a crying child can be tough!!
  52. 52.  Otalgia usually is associated withusually is associated with inflammation of the external orinflammation of the external or middle ear, but it may represent painmiddle ear, but it may represent pain referred from involvement of thereferred from involvement of the teeth, temporomandibular joint, orteeth, temporomandibular joint, or pharynx.pharynx.
  53. 53. In young infantsIn young infants,, -- pulling or rubbing the ear along withpulling or rubbing the ear along with -- general irritability or poor sleep, especiallygeneral irritability or poor sleep, especially --when associated withwhen associated with fever, may be the only, may be the only signs of ear pain.signs of ear pain. Ear pulling alone is not diagnostic of ear pathology.
  54. 54. Three important keys to improving diagnostic accuracy for AOM centre around the following:  diligent cleaning of ear cerumen for better visualisation of the tympanic membrane.  use of nickel–cadmium or lithium rechargeable batteries.  and the use of original equipment full-length speculums.
  55. 55. Normal EarNormal Ear
  56. 56. Acute Otitis MediaAcute Otitis Media
  57. 57. Acute Otitis MediaAcute Otitis Media
  58. 58. Middle ear effusion (MEE) YesYes YesYes Diagnostic Criteria: OME andDiagnostic Criteria: OME and AOMAOMAt least two of: 1. Abnormal color of tympanic membrane (TM): white, yellow, amber, blue 2. Opacification not due to scarring 3. Decreased or absent motility Bubbles or air- fluid interfaces Adapted from Hoberman A, et al. Pediatr Ann. 2000;29:609-620. Otitis media with effusion (OME) No acuteNo acute inflammationinflammation AcuteAcute inflammationinflammation At least one of: 1. Distinct fullness or bulging of the TM 2. Marked redness of the TM 3. New onset of ear pain Acute otitis media (AOM) YesYes Acute purulent otorrhea not due to otitis externa YesYes OrOr
  59. 59. S. pneumoniae* 50% M. catarrhalis 15% Other 5% H. influenzae* 30% Predominant AOM Pathogens Barnett ED, et al. Pediatr Clin North Am 1995;42:509–517. Jacobs MR. Pediatr Infect Dis J 1996;15:940–943.
  60. 60. Clinical GuidelinesClinical Guidelines AMERICAN ACADEMY OF PEDIATRICS AMERICAN ACADEMY OF FAMILY PHYSICIANS Subcommittee on Management of Acute Otitis Media CLINICAL PRACTICE GUIDELINE Diagnosis and Management of Acute Otitis Media
  61. 61. AOM OutcomeAOM Outcome InitialInitial AntibacteriaAntibacteria l Therapyl Therapy InitialInitial ObservatioObservatio nn PP Incidence of mastoiditis orIncidence of mastoiditis or suppurative complicationssuppurative complications 0.59%0.59% 0.17%0.17% NSNS Persistent MEE at 4–6 weeksPersistent MEE at 4–6 weeks 45%45% 48%48% NSNS Persistent MEE at 3 monthsPersistent MEE at 3 months 21%21% 26%26% NSNS Antibacterial agent–inducedAntibacterial agent–induced diarrhea or vomitingdiarrhea or vomiting 16%16% —— —— Antibacterial agent–inducedAntibacterial agent–induced skin rashskin rash 2%2% —— —— Is antibiotic therapy of AOM necessary? Source: AAP/AAFP Clinical Practice Guideline on AOM, March 2004
  62. 62. AOM OutcomeAOM Outcome InitialInitial AntibacteriaAntibacteria l Therapyl Therapy InitialInitial ObservatioObservatio nn PP Symptomatic relief at 24Symptomatic relief at 24 hourshours 60%60% 59%59% NSNS Symptomatic relief at 2–3Symptomatic relief at 2–3 daysdays 91%91% 87%87% NSNS Symptomatic relief at 4–7Symptomatic relief at 4–7 daysdays 79%79% 71%71% NSNS Clinical resolution at 7–14Clinical resolution at 7–14 daysdays 82%82% 72%72% NSNS Pain duration, mean daysPain duration, mean days 2.82.8 3.33.3 NSNS Crying duration, mean daysCrying duration, mean days 0.50.5 1.41.4 .>.>0000 11 Analgesic use, mean dosesAnalgesic use, mean doses 2.32.3 4.14.1 ..004004 Fever duration, medianFever duration, median daysdays 2.02.0 3.03.0 ..004004 Is antibiotic therapy of AOM necessary?
  63. 63. AOM spontaneous resolution rateAOM spontaneous resolution rate varies by pathogenvaries by pathogen OrganismOrganism SpontaneousSpontaneous bacteriologicbacteriologic clearance rateclearance rate S. pneumoniaeS. pneumoniae 19%19% H. influenzaeH. influenzae 48%48% M. catarrhalisM. catarrhalis 75%75% Howie VM. Clin Infect Dis 1992;14:S209-10; Klein JO. PIDJ 1993;12:973-5
  64. 64. 2004AAP/AAFP Clinical Practice Guideline on AOM  Released March 2004  Evidence-based clinical practice guideline:  3461 articles initially identified; 760 reviewed  Extensively peer-reviewed  Scope: diagnosis and management of uncomplicated AOM in children aged 2 m to 12 y  Excludes children with:  underlying conditions that predispose to AOM  children with recurrence of AOM within 30 days of AOM or underlying chronic OME
  65. 65. 2004AAP/AAFP Clinical Practice Guideline on AOM: Conclusions II 1. To diagnose acute otitis media the clinician should confirm a history of acute onset, identify signs of middle–ear effusion, and evaluate for the presence of signs and symptoms of middle-ear inflammation (Recommendation). 2. The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain (Strong Recommendation). 3A. Observation without use of antibacterial agents in a child with uncomplicated AOM is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up (Option). 3B. If a decision is made to treat with an antibacterial agent, the clinician should prescribe amoxicillin for most children. (Recommendation). When amoxicillin is used, the dose should be 80–90 mg/kg/day (Option).
  66. 66. 2004AAP/AAFP Clinical Practice Guideline on AOM: Conclusions II 4. If the patient fails to respond to the initial management option within 48–72 hours, the clinician must reassess the patient to confirm AOM and exclude other causes of illness. If AOM is confirmed in the patient initially managed with observation, the clinician should begin antibacterial therapy. If the patient was initially managed with an antibacterial agent(s), the clinician should change the antibacterial agent(s) (Recommendation). 5. Clinicians should encourage the prevention of AOM through reduction of risk factors (Recommendation). 6. There is insufficient evidence to make a recommendation regarding the use of Complementary and Alternative Medicine (CAM) for AOM (No Recommendation). The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
  67. 67. Criteria for initial antibacterial therapy vs. observation: 2004 AAP/AAFP AOM Guidelines AgeAge Certain DiagnosisCertain Diagnosis Uncertain DiagnosisUncertain Diagnosis >>66momo Antibacterial therapyAntibacterial therapy Antibacterial therapyAntibacterial therapy 66mo–2 ymo–2 y Antibacterial therapyAntibacterial therapy Antibacterial therapy ifAntibacterial therapy if severe illness; observationsevere illness; observation option* if non-severe illnessoption* if non-severe illness <=<=22yy Antibacterial therapy ifAntibacterial therapy if severe illness;severe illness; observation option* ifobservation option* if non-severe illnessnon-severe illness Observation optionObservation option** *Observation is an appropriate option only when follow-up can be ensured and antibacterial agents started if symptoms persist or worsen. Non-severe illness is mild otalgia and fever >39o C in the past 24 hours. A certain diagnosis of acute otitis media meets all 3 criteria: 1) rapid onset, 2) signs of middle-ear effusion, and 3) signs and symptoms of middle-ear inflammation.
  68. 68. Amoxicillin: first line therapy for AOM  Recommended as the first line drug of choice by:Recommended as the first line drug of choice by:  CDC DRSP Working GroupCDC DRSP Working Group Pediatr Infect Dis JPediatr Infect Dis J 1999;18:1-91999;18:1-9  AAP/AAFP Subcommittee on AOM, March 2004AAP/AAFP Subcommittee on AOM, March 2004  Active againstActive against S. pneumoniaeS. pneumoniae::  Recommended dose now isRecommended dose now is 90 mg/kg/day90 mg/kg/day divided BID:divided BID: achieves adequate MEF levels to kill pen-I and many pen-Rachieves adequate MEF levels to kill pen-I and many pen-R pneumococcipneumococci  At this dose, superior to all other oral antibiotics against pen-At this dose, superior to all other oral antibiotics against pen- NS pneumococci in vitroNS pneumococci in vitro  NotNot effective against β-lactamase producingeffective against β-lactamase producing H.H. influenzaeinfluenzae oror M. catarrhalisM. catarrhalis (but these are more(but these are more likely to resolve spontaneously)likely to resolve spontaneously)  Decades of experience: safe, effective, inexpensive,Decades of experience: safe, effective, inexpensive, narrow-spectrum; tastes goodnarrow-spectrum; tastes good
  69. 69.  AOM is commonly over diagnosed. Thus, if clinicians are going to continue to overuse antibiotics—because of parental pressure or the lack of diagnostic accuracy—it is better to limit the mistake to less expensive drugs with a narrower spectrum.
  70. 70. Antibiotic therapy: at time of diagnosis 2004 AAP/AAFP AOM Guidelines Temperature <39Temperature <39oo CC and/or Severe Otalgiaand/or Severe Otalgia At Diagnosis for Patients Being TreatedAt Diagnosis for Patients Being Treated Initially With Antibacterial AgentsInitially With Antibacterial Agents RecommendedRecommended Alternative forAlternative for Penicillin AllergyPenicillin Allergy NoNo Amoxicillin 80–90Amoxicillin 80–90 mg/kg/daymg/kg/day Non-Type I: cefdinir,Non-Type I: cefdinir, cefuroxime,cefuroxime, cefpodoximecefpodoxime Type I: azithromycin,Type I: azithromycin, clarithromycinclarithromycin YesYes Amoxicillin-Amoxicillin- clavulanate (90clavulanate (90 mg/kg/day ofmg/kg/day of amoxicillin withamoxicillin with 6.4 mg/kg/day of6.4 mg/kg/day of clavulanateclavulanate Ceftriaxone—1 or 3Ceftriaxone—1 or 3 daysdays
  71. 71. Antibiotic therapy: clinical failures, 48-72 hr 2004 AAP/AAFP AOM Guidelines Temperature <39Temperature <39oo CC and/or Severe Otalgiaand/or Severe Otalgia Clinically Defined Treatment Failure at 48–Clinically Defined Treatment Failure at 48– 72 Hours After Initial Management With72 Hours After Initial Management With Antibacterial AgentsAntibacterial Agents RecommendedRecommended Alternative forAlternative for Penicillin AllergyPenicillin Allergy NoNo AmoxicillinAmoxicillin -clavulanate (90-clavulanate (90 mg/kg/day ofmg/kg/day of amoxicillin, withamoxicillin, with 6.4 mg/kg/day of6.4 mg/kg/day of clavulanateclavulanate)) Non-Type I:Non-Type I: ceftriaxone—3 daysceftriaxone—3 days Type I: clindamycinType I: clindamycin YesYes Ceftriaxone— 3Ceftriaxone— 3 daysdays Tympanocentesis;Tympanocentesis; clindamycinclindamycin
  72. 72. Drugs chosen for second-line treatment should be effective against B lactamase- producing strains of H. influenzae and M. catarrhalis and against susceptible and most nonsusceptible strains of S. pneumoniae. Only 3 drugs have been shown clearly to meet that requirement: amoxicillin- clavulanate, cefuroxime axetil, and intramuscular ceftriaxone. Kersshner J E,Otitis Media In:Nelson Textbook of Pediatrics, 2641, 2007
  73. 73. Cefdinir was not available when the above recommendations were made. However, clinical Practice and efficacy with cefdinir suggest that it deserves consideration as a second line agent as well, with antibacterial spectrums similar to those of cefuroxime axetil, and good rates of compliance' as the medicationis quite palatable. Kersshner J E,Otitis Media In:Nelson Textbook of Pediatrics, 2641,Kersshner J E,Otitis Media In:Nelson Textbook of Pediatrics, 2641, 20072007
  74. 74. Conjunctivitis–otitis syndrome: ß lactamase- producing H influenzae tends to be the predominant organism, causing both conjunctivitis and AOM. High-dose amoxicillin–clavulanate (90 mg/kg/day), cefdinir or cefpodoxime would be preferred choices. Block S L. Arch Dis Child 2006;91:959–961.
  75. 75. Ambulatory pneumonia (‘‘walking pneumonia’’ AND O M As atypical pathogens (Chlamydia pneumoni , Mycoplasma pneumoniae) are such a common cause of milder pneumonias in children ≥ 2 years of age, macrolides such as azithromycin or clarithromycin are preferred. Block S L. Arch Dis Child 2006;91:959–961.
  76. 76. ImpetigoImpetigo
  77. 77. Impetigo or skin infection and AOM: Typically, impetigo and skin infections are caused by Staphylococcus aureus and only rarely by Streptococcus pyogenes. Staphylococcus aureus in the produces b lactamase, rendering amoxicillin useless. Clinicians would be wiser to initiate treatment with a b lactamase-stable antibiotic, such as amoxicillin-clavulanate, cefdinir or even cefuroxime, which possess activity against both methicillin-susceptible Staphylococcus aureus and typical otopathogens. Block S L. Arch Dis Child 2006;91:959–961.
  78. 78. Impetigo or skin infection and AOM: Patients whose skin infection does not respond in 24–28 h would then additionally receive either clindamycin or trimethoprim-sulfamethoxale for presumptive methicillin-resistant Staphylococcus aureus. Block S L. Arch Dis Child 2006;91:959–961.
  79. 79. Aspirin Non-narcotic, anti-inflammatory; antiplatelet Antipyretic, nonsteroidal agent. Used in the treatment of pain, inflammation and fever by inhibition of prostaglandin synthesis. Dose:- 10-15 mg/kg/dose q 4-6 hr
  80. 80. Aspirin Cautions: contraindicated in children below 16yr with chickenpox or flu-like symptom due to risk of Reye syndrome. Distintinue if hearing loss or tinnitus occurs. Adverse events: Bleeding from gums or GIT, gastric ulcers, bronchospasm in asthmatics, hearing loss or tinnitus.
  81. 81. Acetaminophen Mechanism of action Inhibits the synthesis of prostaglandins in the centralInhibits the synthesis of prostaglandins in the central nervous system and peripherally blocks pain impulsenervous system and peripherally blocks pain impulse generation.generation. Acetaminophen produces antipyresis from inhibition ofAcetaminophen produces antipyresis from inhibition of the hypothalamic heat regulating centre.the hypothalamic heat regulating centre. Dosage:Dosage: 10-15 mg/kg every 4 to 6 hours P.O.10-15 mg/kg every 4 to 6 hours P.O.
  82. 82. Acetaminophen, 10-15mg/kg orally every4hr, is not associated with significant adverse effects; however, prolonged use may produce renal injury, and massive overdose may produce hepatic failure
  83. 83. Ibuprofen Nonsteroidal anti-inflammatory agent thatNonsteroidal anti-inflammatory agent that inhibits prostaglandin synthesis and used toinhibits prostaglandin synthesis and used to treat pain fever and rheumatoid arthritistreat pain fever and rheumatoid arthritis.. DoseDose: -: - Children: 5 -10 mg/kg/dose q6-8hrChildren: 5 -10 mg/kg/dose q6-8hr Juvenile rheumatoid arthritisJuvenile rheumatoid arthritis:: 30-50mg/kg/24 hr in 4 divided doses30-50mg/kg/24 hr in 4 divided doses
  84. 84. Ibuprofen Adverse eventsAdverse events:: Abdominal pain, heartburn, nausea, GITAbdominal pain, heartburn, nausea, GIT bleeding and perforation, fluid retention,bleeding and perforation, fluid retention, edema, hypertension, tachycardia, acute renaledema, hypertension, tachycardia, acute renal failurefailure..
  85. 85. Nimesulid Nimesulide has a disadvantage of long duration of action andNimesulide has a disadvantage of long duration of action and hence ideally should be repeated 12 hourly. Its therapeutichence ideally should be repeated 12 hourly. Its therapeutic dose is small (5 mg/kg/day) as compared to paracetamol (60dose is small (5 mg/kg/day) as compared to paracetamol (60 mg/kg/day) and has small therapeutic window. These factsmg/kg/day) and has small therapeutic window. These facts result in easy overdosing by negligence or ignorance, leadingresult in easy overdosing by negligence or ignorance, leading to adverse effectsto adverse effects.. nimesulide may cause lowering of body temperature to evennimesulide may cause lowering of body temperature to even subnormal levels that can be harmfulsubnormal levels that can be harmful.. It has been found to have serious side effects, Maternal ingestionIt has been found to have serious side effects, Maternal ingestion of nimesulide has been shown to result in end-stage renalof nimesulide has been shown to result in end-stage renal failure in a neonate(9failure in a neonate(9))
  86. 86. Diclofenac Sodium Diclofenac, a nonselective nonsteroidal anti- inflammatory drug, exerts analgesic action both in the peripheral tissues and in the central nervous system by inhibiting cyclooxygenase enzymes COX-1/2 . Diclofenac inhibits prostaglandin synthesis
  87. 87. What Can Be DoneWhat Can Be Done??  Options for reducing rates of severe otitis media:  Additional hygiene practices  Immunisation  Antibiotics
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Upper respiratory infections in children Common cold Pharyngitis Sinusitis Ear infections

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