Acute respiratory infections (ARI) are one of the major causes of morbidity and mortality in developing countries. Children under five years may suffer from 5-8 attacks of ARI annually. In Indonesia, children with ARI constitute about one-third of the out-patient attendance for any doctor working in the community. One-fourth to one-third of under-five mortality in developing countries has been shown to be attributable to ARI as an underlying or a contributing cause. Most of these deaths are due to pneumonia and arc preventable with adequate antibiotic treatment. While many children with ARI lack the benefit of essential antibiotic treatment, others are victims of indiscriminate and inappropriate use of antibiotics. Research studies in Indonesia and other developing countries have shown that training of health personnel in the rational and effective management of ARI episodes can help to reduce mortality due to ARI in the community.

1. Aditya Wicaksana

2. Definition and Scope

5.  Rarely fatal
 A source of significant morbidity and carry a considerable economic
burden
 Prompting frequent use of over the counter and prescription
medications and alternative remedies
 Clinical presentation does not accurately predict viral or bacterial
Acute Upper Respiratory Infection
British Medical Bulletin 2002; 61: 215-30
Am Fam Physician 2007;75:515-20

6.  Traditional term used for self-limited acute minor corryza illness.
 Results in significant school absence and complications such as secondary
bacterial infections
 Play a significant part in exacerbations of asthma
 Children experience 3-8 cold per year and 10-15% have at least 12 per year,
associated with attendance of day care centres or nurseries
The Common Cold

7.  Sore throat, malaise, low grade fever at onset  resolve within a few days
 Followed by nasal congestion, rhinorrhea and cough within 24-48 hours after
onset of the first symptoms  see a physician
 Symptoms usually peak around day 3 or 4 and begin to resolve by day 7
 Nasal discharge, appearing at the peak of illness, can become thick and
purulent and may be diagnosed as a bacterial infection
Clinical Presentation of A Common
Cold

8.  There were no effective antivirals to cure the common cold
 The treatment is symptoms relief
 The most commonly used treatment : over the counter antihistamines,
decongestant, cough supressants and expectorant (alone or in combination),
antipyretic
 Antibiotics often are inappropriately prescribed to patient
Pharmacologic Therapy of
the Common Cold

9.  Decongestants and antihistamines (and analgesics) either alone or in
combination are widely used in children with common cold symptoms
 Current evidence suggests that antihistamine-analgesic-decongestant
combinations have some general benefit in adults and older children.
These benefits must be weighed against the risk of adverse effects.
There is no evidence of effectiveness in young children
 The combination of antihistamine-decongestant had more adverse
effects than the control intervention but the difference was not
significant
Decongestant and Antihistamine
Preparations for the Common Cold
Cochrane Database Syst Rev 2012 (2)

10.  Antihistamine + decongestant combinations :
 have a limited effect on subjective severity of nasal obstruction, but it is not
clear whether this is clinically significant.
 although a small effect on rhinorrhoea on some days of a treatment, a
clinically relevant effect is unlikely.
 has some effect on sneezing, but the effect is small and probably not
clinically relevant.
 although the total number of adverse effects is not significantly, dry mouth
and insomnia are more frequent
 Combinations of antihistamine-decongestant have no effect on common cold
symptoms in young children (6 mos-5 yo), except may be increased sleepiness
Decongestant and Antihistamine
Preparations for the Common Cold
Cochrane Database Syst Rev 2012 (2)

11. Decongestant and Antihistamine...
• Pseudoephedrine Use Among US Children 1999-2006:
• Over half a million US chiildren who are younger than 2 have been
exposed to pseudoephedrine weekly in the past several years
despite the absence of evidence of efficacy and safe dosing
recommendation. Pediatric use seems to be declining, probably as
result of the Combat Methamphethamine Epidemic Act of 2005
Efficacy and safety of Oral Phenylephrine: systematic review and meta-
analisis:
• There is insufficient evidence that oral phenylephrine is effective
for use as a decongestant
Pediatrics 2008; 122(6): 1299-1304
Pharmacother 2007: 41; 381-90

12. There is growing interest in the use of complementary and alternative
medicines for URTIs
Herbal remedies have been studied and conflicting results found  the
lack of standardisation.
 Echinacea
 Vitamin C
 Zinc
 Probiotics
 Essential Oils
 Honey
Complementary and Alternative
Therapies for the Common Cold

13.  Honey is superior to both dextromethorphan and no treatment for
night time coughing associated with URTIs
 Hypothesis :
 The effect could be due its anti oxidant or antimicrobial effect
 A sweet taste might induce endogenous opioids
 Should not be given to infant under 12 months of age
Honey
Arch Pediatr Adolesc Med 2007;161(12):1140–6.
J Clin Pharm Ther 2006;31(4):309–19

14. Two RCTs of high risk of bias involving 265 children. The studies
compared the effect of honey with dextromethorphan,
diphenhydramine and ’no treatment’ on symptomatic relief of cough
using the 7-point Likert scale.
 Honey was better than ’no treatment’ in reducing frequency of cough
(mean difference (MD) -1.07; 95% CI -1.53 to -0.60)
 Moderate quality evidence suggests honey did not differ significantly
from dextromethorphan in reducing cough frequency (MD -0.07; 95%
CI -1.07 to 0.94).
 Low quality evidence suggests honey may be slightly better than
dyphenhydramine in reducing cough frequency (MD -0.57; 95% CI -
0.90 to -0.24)
Cochrane Database of Systematic Reviews 2012, Issue 3

15. Honey
 antioxidants
 possess antibacterial
 anti-inflammatory properties
 broad-spectrum antimicrobial actions, various gram-negative and
gram-positive bacteria and is active against common bacteria found in
the upper respiratory tract
Authors’ conclusions
 Honey may be better than ’no treatment’ and diphenhydramine in the
symptomatic relief of cough but not better than dextromethorphan.
 There is no strong evidence for or against the use of honey.
Honey...
Cochrane Database of Systematic Reviews 2012, Issue 3

16.  Remains contentious since more than 90% of the infections are of
viral aetiology
 The reasons cited for prescribing antibiotics:
 Diagnostic uncertainty
 Sociocultural
 Economic pressures
 Concern mallpractice litigation
 Parental expectations of an antibiotics
 Antibiotics are overprescribed for URTIs and promote antibiotic
resistance
Antibiotics

17.  Respiratory infectious diseases are mainly caused by viruses or
bacteria that often interact with one another.
 Although their presence is a prerequisite for subsequent infections,
viruses and bacteria may be present in the nasopharynx without
causing any respiratory symptoms.
 The upper respiratory tract hosts a vast range of commensals and
potential pathogenic bacteria, which form a complex microbial
community.
 Disturbances in the equilibrium, for instance due to the acquisition
of new bacteria or viruses, may lead to overgrowth and invasion
www.plospathogens.orgJanuary 2013 | Volume 9 | Issue 1

18. What is the indication?
 High and prolonged fever?
 Purulent nasal discharge?
 Prolonged nasal discharge?
So, if it is common cold, when to start
antibiotics?

19. Fever
 High and prolonged fever?
 No - Unable to differentiate viral and bacterial infection
(Putto A, Am J of Dis Child 1986;140(11):1159-63)
When to start antibiotics…..

20.  Indicate bacterial rhinosinusitis ?
 Purulent nasal discharge?
Purulent discharge
 Refer to thick, opaque, colored discharge
 Natural course of viral rhinitis
 Initial discharge is clear after 1-3 days, mucopurulent resolves by 7 days
 Or prolonged nasal discharge?
When to start antibiotics…

21.  It has long been believed that antibiotics have no role in the
treatment of common colds yet they are often prescribed in the
belief that they may prevent secondary bacterial infections
 There is evidence of high usage of antibiotics for the common cold
(viral URTI) in spite of doubts about the efficacy of such therapy
 The presence of purulent nasal discharge (or a runny nose with
coloured discharge) has repeatedly been shown to be an important
determinant of antibiotic prescribing for respiratory tract
infections for both adults and children
Cochrane Database of Systematic Reviews 2013, Issue 6

22. Systemic review concludes:
 Antibiotics offer no benefit in the initial treatment of the common
cold (acute upper respiratory tract infections (URTIs)).
 Antibiotics should not be given in the first instance as they will not
improve the symptoms and adult participants will be affected by
their adverse effects.
 Antibiotics offer no benefit for acute purulent rhinitis while there is
an increase in adverse effects.
 There is no evidence of benefit from antibiotics for the common cold
or for persisting acute purulent rhinitis in children or adults.
 Routine use of antibiotics for these conditions is not recommended.
Antibiotics for common cold and
acute purulent rhinitis...
Cochrane Database of Systematic Reviews 2013, Issue 6

23.  Inflammation of any structure of the pharynx
 Pharyngitis /tonsillitis/pharyngotonsillitis
Pharyngitis

24. Classical GAS
pharyngitis
Viral pharyngitis
Season Late winter /early spring All seasons
Age Pk: 5-11y All ages
Sympt om Sudden onset Onset varies
Sore throat, may be
severe
Sore throat, often mild
Fever Fever varies
Abd
pain,nausea,vomiting
Abd pain in
Influneza/EBV
Headache Myalgia, arthalgia
Signs Pharyngeal erythema &
exudate
Usually no exudates
Palatal petechiae enanthem
Tender, enlarge ant LN Minor, non-tender LN
Scarlet fever rash Characteristic exanthem
Tonsillar hypertrophy Varies with agent
Absence of cough, coryza Often with cough, coryza

25. Enteroviruses Pharyngeal vesicles or ulcers
Vesicles on palms and soles
Most common in summer
Adenoviruses May have concomitant
conjunctivitis
HSV Anterior oral lesions including
lips
High fever
EBV Exudative pharyngitis
Cervical lymphadenopathy
Hepatosplenomegaly

26.  Most of pharyngitis are self-limiting
 Recognize those patient who suffered from GpA Strep from viral pharyngitis
 Why we need to treat GAS pharyngitis?  Prevent GAS related
complications
 Suppurative complications
 Peritonsillar (Quinsy), retropharyngeal and parapharyngeal abscess
 Non-suppurative complication
 Acute Rheumatic fever (ARF)
 Acute glomerulonephritis (GN)
Cochrane Database of Systematic Reviews 2011

27. Authors’ conclusions
 Antibiotics confer relative benefits in the treatment of sore throat.
However, the absolute benefits are modest.
 Protecting sore throat sufferers against suppurative and non-
suppurative complications in high-income countries requires treating
many with antibiotics for one to benefit. This NNT may be lower in
low-income countries.
 Antibiotics shorten the duration of symptoms by about 16 hours
overall.
Rationale of managing pharyngitis...
Cochrane Database of Systematic Reviews 2011

28.  There has been interest in strategies to reduce antibiotic prescribing for
ARTIs.
 One of these strategies is to advise patients to ’delay’ filling their script
and only to fill it if their symptoms persist or deteriorate.
 Delayed antibiotics are advocated as a means of demonstrating to patients
that antibiotics are not always necessary, without making them feel
under-serviced .
 Two ways of using this strategy have been deployed: giving the patient
the antibiotic (with instructions not to use unless there is deterioration);
and making the prescription available at the clinic reception (to be
picked up in the event of deterioration)
The Cochrane Library 2013, Issue 4

29. Author’s conclusion:
 Most clinical outcomes show no difference between strategies.
Delay slightly reduces patient satisfaction compared to immediate
antibiotics (87% versus 92%) but not compared to none (87%
versus 83%).
 In patients with respiratory infections where clinicians feel it is
safe not to prescribe antibiotics immediately, no antibiotics with
advice to return if symptoms do not resolve is likely to result in
the least antibiotic use, while maintaining similar patient
satisfaction and clinical outcomes to delayed antibiotics.
Delayed antibiotics for respiratory
infections...
The Cochrane Library 2013, Issue 4

30.  A previous Cochrane review comparing the effect of antibiotics to
placebo in participants with or without group A beta-haemolytic
streptococci (GABHS) sore throat pointed to the self limiting nature of
an acute sore throat (even in case of positive GABHS culture).
 Antibiotics provide only modest benefit when prescribed for the
condition ’sore throat’.
 Internationally, guidelines recommend using penicillin as first choice
when choosing to treat acute sore throat (suspected to be caused by
GABHS) with antibiotics.
 However, some argue that cephalosporins are more effective and
should therefore be preferred
The Cochrane Library 2013, Issue 4

31. Author’s Conclusion:
 This is insufficiently convincing evidence to alter current guideline
recommendations for the treatment of patients with GABHS
tonsillopharyngitis.
 No clinically important differences in occurrence of adverse events and data
on the incidence of complications are too scarce to draw conclusions.
 Antibiotics have a limited effect in the treatment of patients with acute sore
throat, even in the presence of GABHS.
 If antibiotics are to be prescribed, based on these results and taking into
consideration the costs and antimicrobial resistance patterns of the different
antibiotics, penicillin can still be considered first choice in both adults and
children.
Different antibiotic treatments for
group A streptococcal pharyngitis...
The Cochrane Library 2013, Issue 4

32. Author’s conclusion
 Three to six days treatment with oral antibiotics has comparable
efficacy to the standard duration 10 days of oral penicillin in treating
children with acute GABHS pharyngitis.
 The shorter duration of antibiotic treatment can be more convenient for
the patient, and will improve compliance.
 If the clinician chooses azithromycin for three days, a dose of 20
mg/kg/day should be used rather than 10 mg/kg/day.
The Cochrane Library 2012, Issue 8

33. Author’s conclusion
 No conclusions can be drawn on the comparison of complication rates of
acute rheumatic fever and acute poststreptococcal glomerulonephritis.
 In areas where the prevalence of rheumatic heart disease is still high, our
results must be interpreted with caution.
Short-term late-generation
antibiotics versus longer term...
The Cochrane Library 2012, Issue 8

34.  Common cold & acute pharyngitis - viruses vs bacteria
 There were no evidence the use of complementary and alternative
therapy for common cold
 Acute pharyngitis: Identify those children likely to have Steptococcus
pyogenes and treat with antibiotic
 Reduce the use of antibiotics and thus reduce the prevalence of
antibiotics resistance bacteria in community
Take Home Messages