Upper respiratory tract infections

1. Infectious diseases Pharmacotherapy
Lesson 2
Upper respiratory tract infections[URTIs]
By: Tsegaye Melaku [MSc]
tsegayemlk@yahoo.com or tsegaye.melaku@ju.edu.etJuly, 2018 +251913765609+251913765609
Upper respiratory tract infections[URTIs]

2.  Session hits:Session hits:
Antimicrobial initiation concern
Common bacterial cause for URTIs
Pathophysiology and risk factors for URTIsPathophysiology and risk factors for URTIs
Clinical pictures associated with specific URTIs
Treatment plan for patient(specific) with URTIs
Monitoring plan for URTIs
2

3. 3

4. URTIs: comprehensive term for upper airway infections
[otitis media, sinusitis, pharyngitis, laryngitis, common cold
& other].
3 most common: of bacteria cause3 most common: of bacteria cause
Otitis media.
Pharyngitis.
Sinusitis.
Less common: laryngitis, rhinitis, and epiglottitis.
4

5. Most caused by viruses,
Have non-specific symptoms,
Resolve spontaneously
Antibiotics for URTIs serve as catalysts for abx resistance.Antibiotics for URTIs serve as catalysts for abx resistance.
Prudent antibiotic use…… critically important.
5

6. Otitis Media
6

7.  A 13-month-old boy presents to the pediatric clinic with 2 days of
fever (max To 39.3°C), rhinorrhea, and fussiness. His mother reports
that he was rubbing his left ear throughout the day yesterday. She
states that he is irritable and he was crying intermittently throughout
the night last night. He has not eaten much today. He attends day carethe night last night. He has not eaten much today. He attends day care
3 days a week and has a 5-year-old sister who recently had a cold.
1. What information is suggestive of acute otitis media (AOM)?
2. What risk factors does this child have for AOM?
3. Additional information you need before recommending a treatment plan?
4. Which drug of choice and supportive care you recommend?
7

8.  Otitis media: an inflammation of the middle ear.
 Most common childhood illness
 Usually results from a nasopharyngeala nasopharyngeal viralviral infection
8

9. 9

10. Otitis Media (OM)
Acute OM OM with effusion Chronic OM
Not an acute illnessRapid, Persistent discharge
– Differentiated by onset, signs and symptoms, and the presence of fluid
in the middle ear
– Acute otitis media: greatest role for abx
10
Not an acute illness
X-zed by middle ear effusion.
Effusions resolve slowly(3 months)
No pain & bulging ear drum
Rapid,
Symptomatic
infection with
effusion, or fluid.
Persistent discharge
from the middle
ear/perforation

11.  Most common reason for an ER/physician office visit.
 Occurs in all ages (common b/n 6 months -2 yrs of age).
 >15 million emergency room and clinic visits annually.
 ~~ 65~~ 65%% recurrencerecurrence ~~ 65~~ 65%% recurrencerecurrence
 >80>80%% of patients seen for AOM receive a prescription.
 Direct and indirect costs almost $3 billion$3 billion annually
11

12. 12
Figure 1 Estimates of the percentage of deaths in children aged under five years from ARIs in the year 2000. (Source:
The Open University, Pathogens and People (S320 Book 1), Figure 1.13, p.32, based on data from Williams, B.G. et al.
(2002), The Lancet Infectious Diseases, 2)

13.  ~~ 40% to 75% of AOM causes: viral.
 Common pathogens:
 S. pneumoniae (50%),
 H. influenzae (non-typeable) (30%), H. influenzae (non-typeable) (30%),
 M. catarrhalis (20%).
 S. pneumoniae (alteration PBPs)
 H. influenzae, and M. catarrhalis (ß-lactamases)
 Can all possess resistance to ß-lactams.
13PBPs: penicillin-binding proteins

14.  The risk factors for resistance:
Attendance at child care centers.
Antibiotic treatment hx (within the past 30 days).
Age younger than 2 years.Age younger than 2 years.
14

15.  AOM is caused by an interplay of numerous factors.
 Usually follows a viral URTIs
 Viral URTIs impair eustachian tube function  
Mucosal inflammation,Mucosal inflammation,
Impairing mucociliary clearance
– Bacteria that colonize the nasopharynx enter the
middle ear and are not cleared properly.
Promoting bacterial proliferation and infection.
15

16.  Tympanic membrane becomes blocked with fluid  bulging &
erythematous ear drum
– So, it is less functional for middle ear drainage and
protection
 Children Versus Adult??
 Children are more susceptible
Shorter eustachian tube
More horizontal (facilitating bacterial entry).
16

17. 17

18.  Acute onset of ear pain.
 Irritability & tugging on the ear  clue for Dx in young children.
 Otitis media with effusion
– Fluid in the middle ear with no S & Sxsno S & Sxs of acute ear
infection [pain & bulging eardrum].
18

19.  3 criteria to Dx AOM:
 Acute onset of signs and symptoms,
 Middle ear effusion,
 Middle ear inflammation. Middle ear inflammation.
19

20.  Middle ear effusion …indicated by:
Bulged tympanic membrane,
Limited or absent mobility of tympanic membrane,
Air-fluid level behind the tympanic membrane, or
Otorrhea.
 Signs and symptoms of middle ear inflammation:
Distinct erythema of the tympanic membrane or
Distinct ear otalgia (or ear pain).
20

21. Impaired mobility
 Triad of bulged tympanic membrane (TM)
Redness
Opacification of TM
21

22.  General
Acute onset: runny nose, nasal congestion, or cough
 Signs and Symptoms
Ear pain [severe] (>75% of patients)
22
Irritable, tug on the involved ear,& have difficulty sleeping
Fever (<25% of patients), more often in younger children

23. Discolored (gray), thickened, bulging eardrum
On pneumatic otoscopy/tympanometry [immobile
eardrum]; ~~50% cases…bilateral
Draining middle ear fluid occurs [<3%]Draining middle ear fluid occurs [<3%]
 Laboratory tests
Gm stain, culture, and sensitivities
Adapted from Hendley JO. Clinical practice: Otitis media. N Engl J Med
2002;347(15):1169–1174.
23

24. 24

25. 25

26.  Complications of otitis media are infrequent but include
Mastoiditis, bacteremia, meningitis,
Cholesteatoma
Auditory sequelae with potential for speech and languageAuditory sequelae with potential for speech and language
impairment.
26
Why speech and language impairment?

27.  What effect do you think pus in the middle ear will have on
normal hearing, and why?
Thick, sticky pus stops the ossicles from vibrating properly,
so sounds are not transmitted to the brain in the normal way.
27
 Can you recall which vaccine-preventable disease is transmitted by
airborne droplets and may lead to acute otitis media (AOM) as one of its
complications?
 Measles is associated with several complications in young children,
including AOM and pneumonia.

28.  Onset within 48 hrs of symptoms that parents rated > 3 on Acute
Otitis Media Severity of Symptoms (AOM-SOS) scale
 0 to 14 – higher scores indicating greater severity
 Middle-ear effusion
 Moderate or marked bulging of TM or slight bulging accompanied by Moderate or marked bulging of TM or slight bulging accompanied by
either otalgia or marked erythema of the membrane
28
A, Normal TM. B, TM with mild bulging. C, TM with moderate bulging. D, TM with severe bulging.

29.  Seven discrete items:
Items 0 1 2
Tugging of ears,
Crying
Irritability
Difficulty sleeping
 Parents rate comparison with child’s usual state
‘’none,” “a little,” or “a lot,”
0, 1, and 2 points, respectively
29
Difficulty sleeping
Diminished activity,
Diminished appetite
Fever

30.  Goal of therapy:
– Alleviate ear pain and fever,
– Prudent antibiotic use/avoid unnecessary antibiotic use.
– 2˚ disease prevention/eradicate infection– 2˚ disease prevention/eradicate infection
– Prevent complications;
 Consider: 1˚ prevention: Vaccines.
– Hib/pneumococcal vaccine
– Influenza vaccine
30

31.  1st Differentiate AOM from OME or COM the latter 2 do not
benefit from abx.
– Tympanostomy tube placement with or without
adenoidectomy
 2nd  address pain [oral analgesics].
 3rd  Consider if a brief observation period is warranted.
– Majority of uncomplicated cases resolve spontaneously.
31

32. 32

33.  Watchful waiting and “safety-net” antibiotic prescriptions!!
 APAP or
 NSAID (ibuprofen): early to relieve pain.
– Avoided in children <6 months [increased toxicity– Avoided in children <6 months [increased toxicity
concerns]
 Ear-drops with a local anesthetic
 Don’t use decongestants or antihistamines routinely
– Minimal benefit and increased side effects.
33

34.  One strategy before Rx: "delayed therapy“
For 48 to 72 hrs…see if the symptoms resolve on their
own.
 ‘’Delayed therapy’’: Candidates
a) Age 6 months - 2 yrs + No severe sxs + uncertain dx.
b) Age ≥2 yrs + without severe sxs.
c) Age ≥2 yrs + uncertain dx.
34

35.  Bulging tympanic membrane with visible pus
Immediate antibiotic therapy
 AOM without bulging eardrums
Likely to clear spontaneouslyLikely to clear spontaneously
Consider delayed therapy (while giving APAP).
35

36.  Amoxicillin: mainstay of therapy:
Proven effectiveness,
High middle ear concentrations,
Excellent safety profile,
Low cost, good-tasting suspension,
Relatively narrow spectrum
36

37.  High-dose amoxicillin: overcome resistance
[80 to 90 mg/kg/day] vs [40–45 mg/kg/day]
» Results in higher middle ear fluid concentrations
 Change Rx: if complications symptoms unresolved within 3
days.
37

38.  High dose amoxicillin-clavulanate:
(Amox. 90 mg/kg/day/Clav. 6.4 mg/kg/day) into 2
doses
Considered for
– Who received amoxicillin within 30 days,– Who received amoxicillin within 30 days,
– Concurrent purulent conjunctivitis,
– Hx of recurrent AOM unresponsive to amoxicillin
– Suspected ß-lactamase producing organisms.
– Moderate to severe illness ( T˚>39°C [102°F] and/or
severe otalgia),
38

39.  2nd line agents:
 2nd-gen. cephalosporins
 Cefuroxime, cefdinir, cefpodoxime,
 Ceftriaxone.
 [ß-lactamase stable, expensive, increased incidence of side [ß-lactamase stable, expensive, increased incidence of side
effects].
 Trimethoprim-sulfamethoxazole and macrolides
 Have limited efficacy against S. pneumoniae and H.
influenzae
 Not DOC
39DRSP: drug-resistant S. pneumoniae

40.  Ceftriaxone :
 Achieve MIC for >40% of the dosing interval at middle ear
 50 mg/kg/day IM/IV stat have been used.
– But, daily doses for 3 days are recommended to optimize
clinical outcomes.clinical outcomes.
 Reserved for:
– Severe and unresponsive infections or
– Unable to take PO (V, D, or non-adherence].
40

41.  Penicillin allergic patients
Non-type I [non- IgE] hypersensitivity
– Cefdinir, cefpodoxime, or cefuroxime
Type I (anaphylactic) [IgE]Type I (anaphylactic) [IgE]
– Macrolide (azithromycin or clarithromycin)
Clindamycin:
– If penicillin allergy + documented S. pneumoniae
– To cover PRSP.
41

42.  Tympanocentesis
For treatment failure or persistent acute otitis media.
Can relieve pain and pressure.
Used to collect fluid to identify the causative agent.Used to collect fluid to identify the causative agent.
42

43. Acute Otitis Media Antibiotic Recommendations
Initial Diagnosis Failure at 48–72 Hours
Non-severe Severea Nonsevere Severea
First line Amoxicillin, high-
dose; 80–90
mg/kg/day
divided twice
daily
Amoxicillin-
clavulanate, high-
doseb 90
mg/kg/day of
amoxicillin plus
Amoxicillin-
clavulanate, high-
doseb 90
mg/kg/day of
amoxicillin plus
Ceftriaxone (1–3
days)
43
daily amoxicillin plus
6.4 mg/kg/day
of clavulnate
divided twice
daily
amoxicillin plus
6.4 mg/kg/day
of clavulanate
divided twice
daily
Non–type 1
allergy
Cefdinir,
cefuroxime,
cefpodoxime
Ceftriaxone (1–3
days)
Ceftriaxone (1–3
days)
Clindamycin
Type 1 allergy Azithromycin,
clarithromycin
Clindamycin Clindamycin
aSevere = temperature 39°C (102°F) and/or severe otalgia. bAmoxicillin-clavulanate
90:6.4 or 14:1 ratio

44.  Defined: at least 3 episodes in ½ yr or at least 4 episodes in 1yr.
 Concern in < 3 yrs children;
 [at high risk for hearing loss and language and learning
disabilities].
 Do not use prophylaxis.Do not use prophylaxis.
 Use of tympanostomy tubes (TUse of tympanostomy tubes (T--tubes): effective its preventiontubes): effective its prevention
 Current insight: Oral fluoroquinolones ???
44

45.  Traditional recommendations: 10 to 14 days
 For all severe infections .
 For children < 2 yrs.
 7 day regimens
 For mild to moderate AOM in children 2 to 5 yrs For mild to moderate AOM in children 2 to 5 yrs
 5- to 7 day regimens
 For mild to moderate AOM in children ≥ 6 yrs.
 Short treatment courses (<10 days) not recommended
 In children < 2 years.
 Perforated eardrums
45

46. 46

47. 47

48. 48

49. 49

50. 50

51. 51

52. Pharyngitis
52

53.  A 7-year-old girl presents to the pediatrician with a sore throat and fever of
39.1°C for the past 12 hours. She has pain while swallowing, she is unable to
eat or drink as much as usual. She has no other symptoms and takes no
medications. She is allergic to amoxicillin (rash). Her mother reports that two
children in her daughter’s class had “strep throat” recently. Physical
examination reveals halitosis, pharyngeal and tonsillar erythema with
exudates, and cervical lymphadenopathy.
 Does this child have streptococcal pharyngitis? Does this child have streptococcal pharyngitis?
 How should the patient be evaluated and treated?
 Any risk factors she had??
 Is antibiotic therapy indicated? If so, what agent should be initiated and
for how long?
 What education should be provided to her mother regarding treatment?
53

54.  Acute infection of the oropharynx or
nasopharynx
 Inflammation of the throat often caused by
infection.
 Associated with rare but severe sequelaerare but severe sequelae if
not treated appropriatelynot treated appropriately
Non suppurative complications
• Acute rheumatic fever, AGN, and reactive
arthritis
Suppurative complications
• Peritonsillar abscess, retropharyngeal
abscess, cervical lymphadenitis, mastoiditis,
otitis media, sinusitis, and necrotizing fasciitis
54

55.  1% to 2% adults visits in and 6% to 8% of pediatric visits
 Ages 5 to 15 yrs are most susceptible
 More common at crowd, institutions areas
 Cost ~$1.2 billion total and up to $539 million for children Cost ~$1.2 billion total and up to $539 million for children
alone.
55

56.  Viral causes: most common.
 Rhinovirus (20%), coronavirus (<5%), adenovirus (5%), RSV(4%),
influenza virus (2%), parainfluenza virus (2%), and EBV(<1%).
 GABHS: 1˚ cause.
 20% to 30% - children & 5% to 15% - adult infections
 Less common bacterial cause
 Groups C and G Streptococcus, Corynebacterium diphtheriae, N.
gonorrhoeae, Mycoplasma/Chlamydia pneumoniae, Yersinia enterocolitica,
56

57.  Mxm not well defined
 If alteration in host immunity (a breach in the pharyngeal mucosa)
 If disruption in mucosal integrity
Asymptomatic pharyngeal carriers or colonization by
GABHS   InfectionInfection
Pathogenic factors associated with the organism [pyrogenic
toxins, hemolysins, streptokinase, and proteinase] itself play
a role.
57

58.  Sudden onset of sore throat, Pain on swallowing
 Fever, Headache, Abdominal pain
 Nausea and vomiting, Tonsillopharyngeal erythema
 Tonsillopharyngeal exudate Tonsillopharyngeal exudate
 Soft-palate petechiae (“doughnut” lesions)
 Beefy red, swollen uvula
 Anterior cervical lymphadenitis
 Scarlatiniform rash
58

59. Cont’d…
Soft-palate petechiae
59
Scarlatiniform rash Beefy red, swollen uvula
Soft-palate petechiae
(“doughnut” lesions)

60.  Symptoms suggestive of other dx like common cold (Rhinovirus,
Coronovirus)
Coryza, Hoarseness, Cough, Diarrhea,
 Laboratory Tests Laboratory Tests
RADT
Throat swab and culture
Always …consider clinical criteria,,,Always …consider clinical criteria,,, +Ve lab…Carrier ~20%+Ve lab…Carrier ~20%
60

61.  Scoring System: Modified Centor Criteria for Clinical Prediction of Group A
ß -Hemolytic Streptococcal Pharyngitis
of streptococcal infection
61

62.  Goals of therapy:
 Eradication of GAS from the pharynx
 Reducing duration and severity of signs and symptoms.
 Reducing incidence of complications
 Reducing transmission
62

63.  Symptomatic treatment (pain)
 APAP (better option than NSAID)
 Rest, fluid, lozenges, salt water gargles
 Antibiotics: if clinical signs & symptoms consistent with GAS and
positive laboratory test (RADT or culture)positive laboratory test (RADT or culture)
 Goals of antibiotic therapy:
 Prevent suppurative complications (abscess etc.)
 Prevent rheumatic fever (up to 3%)
 Decrease infectivity
 Shorten clinical course by 1-2 days (if started early)
63

64.  10 days of:
 Penicillin VK 250 mg 3-4 times daily or 500 mg twice daily
 Amoxicillin 500 mg 3 times daily
– Avoid if patient likely to have mononeucleosis as will cause rash
 Cephalexin 250 – 500 mg PO 4 times daily
 Benzathine Penicillin 1.2 million Units IM once: if unable to take PO
 Macrolides
 Erythromycin 250 mg PO 4 times daily
 Azithromycin 12 mg / kg (max 500 mg) PO daily for 5 days
– 7 – 30 % of strains are now resistant
 Amoxicillin-clavulanate or clindamycin
 For recurrent episodes of pharyngitis
64

65. 65

66. Drug Adult Dosage Pediatric Dosage
Clindamycin 600 mg orally divided in two to
four doses
20 mg/kg/day orally in
three divided doses
(maximum 1.8 g/day)
Amoxicillin-
clavulanate
500 mg orally twice daily 40 mg/kg/day orally in
three divided doses
Penicillin benzathine 1.2 million units IM for one dose 0.6 million units IM for
66
Penicillin benzathine 1.2 million units IM for one dose 0.6 million units IM for
weight <27 kg (50,000
units/kg)
Penicillin benzathine
with rifampin
As above As above
Rifampin 20 mg/kg/day orally
in two divided doses during last
4 days of treatment with
penicillin (maximum daily dose
600 mg)
Rifampin dose same

67. Sinusitis
67

68.  A 43-year-old man has a two-week history of nasal congestion,
postnasal drip, and fatigue. He has used an OTC nasal decongestant
and acetaminophen, without relief. During the past few days, facialfacial
painpain andand pressurepressure have developed and have not responded to
decongestants. In addition, his nasal discharge has turned from clear todecongestants. In addition, his nasal discharge has turned from clear to
yellow.
 Sign and symptoms consistent to sinusitis?
 Could you suspect bacterial cause at this time? Why??
 How should he be treated?
68

69.  Paranasal sinuses (“the sinuses”) are air-filled cavities located within the
bones of the face and around the nasal cavity and eyesbones of the face and around the nasal cavity and eyes.
 Each sinus is named for the bone in which it is located:
 Maxillary sinus
 Ethmoid sinus
 Frontal sinus
 Sphenoid sinus
69

70.  The pink membranes lining the sinuses make mucus
Which is cleared out of the sinus cavities  drains into the
nasal passage.
 Both airflow & mucus ends up in a part of throat [nasopharynx] Both airflow & mucus ends up in a part of throat [nasopharynx]
Air is then breathed into the windpipe and lungs, while the
mucus is swallowed
70

71.  Other structures associated with the nasal and sinus tract:
 Tear duct (nasolacrimal duct): drains tears from the inside corner
of the eye into the nasal cavity
 Eustachian tube: responsible for clearing air pressure in the ears; it
opens into the back of the sidewall of the nasopharynx.
 Adenoids: collection of tonsil-like tissue [at top of the nasopharynx]
71

72. 72
F – frontal sinus S - sphenoid sinus ST – superior turbinate, MT - middle turbinate IT – inferior turbinate
E – Eustachian tube opening A – Adenoid
NP –nasopharynx
nasal airflow (arrows)

73. 73

74. 74

75. 75

76.  Inflammation and/or infection of the para-nasal sinuses
 Aka rhinosinusitis [involves contiguous nasal mucosa]
 Occurs in nearly all viral URIsall viral URIs
76
Sinusitis
Acute
Chronic
Symptoms persist for up to 4 wks
Lasts for more than 12 weeks.

77.  > 31million cases annually
 ~ ~9% of all adult and 21% of pediatric antibiotic Rx
 6 to 8x occurrence/year6 to 8x occurrence/year
 5.8$ billion expenditures/year 5.8$ billion expenditures/year
77

78.  Mainly respiratory viruses
 Can be triggered by allergies or environmental irritantsallergies or environmental irritants..
 Complicated rhinosinusitis [2° bacterial infection]: 22 --13%.13%.
 Viral: Usually improves in 5-7 days
 Bacterial: if severe & symptoms > 10 days or worsens after 5-7
daysdays
 Most common
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
 Less Frequent
• Streptococcus pyogenes
• Staphylococcus aureus
• Gram-negative bacilli
• Anaerobes
78

79. Allergic or non-allergic rhinitis
Anatomic defects (eg, septal
deviation)
Mechanical ventilation
Nasogastric tubes
Ciliary dyskinesia
Swimming or divingSwimming or diving
Tobacco smoke exposureTobacco smoke exposure
Viral respiratory tract infectionViral respiratory tract infection
Winter season
79
Nasogastric tubes
Cystic fibrosis
Winter season
Immunodeficiency

80.  Mucosal inflammation and mucociliary dysfunction from viral
infection or allergy  obstruction of sinus ostia
 Trapped mucosal secretions & impaired local defenses 
bacteria from adjacent surfaces begin to proliferate Infectionbacteria from adjacent surfaces begin to proliferate Infection
 Maxillary & ethmoid sinuses: most involved
80

81. 81

82.  General
– A nonspecific URTI that persists beyond 7 to 14 days
 Acute
Adults
– Nasal discharge/congestion, Maxillary tooth pain, facial or sinus pain
that may radiate (unilateral in particular) or that is made worse by
82
that may radiate (unilateral in particular) or that is made worse by
bending forward,
– Purulent nasal discharge, maxillary tooth discomfort, hyposmia or
anosmia, cough, Headache, fever, and malaise
Children
– Morning periorbital edema or facial swelling; Nasal discharge and
cough for longer than 10 to 14 days or severe signs and symptoms such
as temperature above 39°C (102°F) or facial swelling or pain are
indications for antibiotic therapy

83.  Chronic
– Symptoms are similar to acute sinusitis but more non-specific
– Rhinorrhea: in acute exacerbations
– Chronic unproductive cough, laryngitis, and headache
– Chronic/recurrent infections occur 3-4x/yr  unresponsive to
steam and decongestants
 Laboratory Tests
– Gram stain, culture
83

84. 84
At least 2 major or 1 major and >=2 minor criteria

85. 85

86. 86

87. 87

88.  Orbital cellulitis or abscess,
 Periorbital cellulitis,
 Meningitis,
 Cavernous sinus thrombosis, Cavernous sinus thrombosis,
 Ethmoid or frontal sinus erosion,
 Chronic sinusitis, and
 Exacerbation of asthma or bronchitis
88

89.  Goals of therapy
 Relieve symptoms
 Promote sinus drainage/achieve & maintain patency of the ostia
 Use antibiotics when appropriate[minimize resistance] Use antibiotics when appropriate[minimize resistance]
 Prevent development of chronic disease or complications
89

90.  1st: delineate viral and bacterial sinusitis
 Based on disease duration, rather than symptomatology
 Viral sinusitis: improves in 7 to 10 days;
 Acute bacterial sinusitis: Acute bacterial sinusitis:
 Persistent symptoms (10 days) or
 Worsening of symptoms after 5 to 7 days.
 If symptoms do not respond to OTC nasal decongestants & APAP
 Severe symptoms at onset
90

91.  Initiate antibiotics
a) Persistent sxs for >10 days with no improvement;
b) Sudden worsening of sxs within 5 to 10 days of initial
improvement;
c) Severe symptoms for 3 to 4 days at illness onset.
91

92.  Supportive measures
Analgesics/antipyretics
 Humidifiers and saline nasal sprays or drops
– Moisturize the nasal canal, impair crusting of secretions, and
promote ciliary function.promote ciliary function.
 Isotonic/hypertonic saline nasal irrigation
– Specially in patients with recurrent or chronic sinusitis
 Decongestant: phenylephrine, oxymetazoline
– Reduce inflammation by vasoconstriction
 Mucolytics (e.g., guaifenesin)
– Decrease the viscosity of nasal secretions.
92

93.  Antihistamines
 Should not be used for acute bacterial sinusitis
– Have anticholinergic effects
 2nd-generation : have a role in chronic sinusitis,
– Because frequently accompanied by concomitant allergic rhinitis.
 Glucocorticoids [intranasal]
 Decrease inflammation causing headache, nasal congestion, and
facial pain.
 But, limited data to support
93

94.  Antibiotics:
 Amoxicillin: DOC
 High-dose amoxicillin: in high risk of PRSP
– Day care attendance, recent antibiotic use, <2 yo– Day care attendance, recent antibiotic use, <2 yo
 Amoxicillin-clavulanate: alternative
– If no improvement on amoxicillin after 3 days
– If took antibiotics 4- 6 weeks back
– Need of Improved coverage of H. influenzae and M. catarrhalis
94

95. Penicillin allergies
– None-type I: 2nd gen. cephalosporin: cefprozil, cefuroxime,
or cefpodoxime
» β-lactamase-stable cephalosporin» β-lactamase-stable cephalosporin
– Type I: trimethoprim-sulfamethoxazole, doxycycline,
Macrolides, Respiratory fluoroquinolones
Clindamycin:
95

96.  For uncomplicated:
5 to 10 days in adults
10 to 14 days in children
 A 3 or 5-day course of azithromycin 500 mg daily A 3 or 5-day course of azithromycin 500 mg daily
 Generally treat for
10 to 14 days of antibiotic therapy or
At least 7 days after signs and symptoms are under control.
96

97. 97

98. 98
IDSA, 2015

99. 99

100. 100

101. 101

102. 102

103. 1. Which clinical presentations best identify patients with acute bacterial versus
viral rhinosinusitis?
a) Onset with persistent symptoms or signs compatible with acute rhinosinusitis,
lasting for >10 days without any evidence of clinical improvement
b) Onset with severe symptoms or signs of high fever 39ºC and purulent nasal
discharge or facial pain lasting for at least 3–4 consecutive days at the
beginning of illness
c) Onset with worsening symptoms or signs characterized by the new onset of
fever, headache, or increase in nasal discharge following a typical viral URI
that lasted 5–6 days and were initially improving (‘‘double-sickening’’)
103

104. 2. Should a respiratory fluoroquinolone vs a b-lactam agent be used as first-
line agents for the initial empiric antimicrobial therapy of ABRS?
a) May be in our case?? Active against all common respiratory pathogens,
including PRSP and B-lactamase–producing H. influenzae or M. catarrhalis
104

105.  For effectiveness and safety
Clinical signs and symptoms
Laboratory data and diagnostic procedures
105

106. 106