“DO Not Be Snotty: Treatment of Pediatric Upper Respiratory Infections”

1. “DO Not Be Snotty: Treatment of Pediatric Upper Respiratory Infections” Stanley E. Grogg, DO, FACOP Professor of Pediatrics OSU-CHS

2. A Common Airway

3. Thus, URIs may include • “Colds” • Tonsillitis/pharyngitis/laryngitis • Otitis media • Conjunctivitis • Rhinosinusitis

4. What is the most common bacterial infection diagnosed in children? • Tonsillitis/pharyngitis • Conjunctivitis • Pneumonia • Rhinosinusitis • Acute otitis media

5. Which of the following bacterial organism is NOT a common URI pathogen? • Streptococcus pneumonia • Haemophilus influenzae, nontypable • Moraxella catarrhalis • Group A Beta Hemolytic Streptococcus (GABHS) • Klebsiella

6. Should be seen by PCP if? • Symptoms last longer than 10 days. • Severe sore throat, earache, or headache not relieved by Tylenol or ibuprofen. • History of tuberculosis, rheumatic fever, kidney disease, or heart disease. • Severe chest pain or shortness of breath. • You are coughing up thick, green or bloody sputum. • You have swollen glands on the sides or back of your neck

7. What is the best way to decrease spread of URIs? • 1. See the PCP at the first indication of infection • 2. Treat the elevated temperature with antipyretics • 3. Use of antibiotics immediately • 4. Start OTC antihistamines/decongestants and/or Vitamin C/Echinacea early in the disorder • 5. Good hand washing

8. Handwashing and Health • Children under 5 years of age in house holds that received plain soap and hand washing promotion had 50% lower incidence of pneumonia • Incidence of disease did NOT differ significantly between households given plain soap compared with those given antibacterial soap • Luby, SP et al, Lancer 366:225-233, July 16, 2005

9. How long will cold & flu symptoms last? • Fever and sore throat generally improve within 4 days • Cough and nasal discharge may last 2 weeks or more • Both are caused by viruses, NOT bacteria. • Antibiotics DO NOT work

10. Antibiotic and “The Common Cold” • Do families of health professional parents prescribe their children with nasopharyngitis antibiotic prescriptions more often than non-health professional parents? • Huang, N, et. al, Pediatrics Vol. 116, Oct. 2005

11. http://www.cdc.gov/ncidod/op/antibiotics.htm • Viruses cause • All colds and flu • Most coughs • Most sore throats

12. http://www.cdc.gov/ncidod/op/antibiotics.htm • Bacteria cause: • Most ear infections • Some sinus infections • Strep throat • Urinary tract infections • Antibiotics do kill specific bacteria

13. CAM for Immune Support • Echinacea • Astragalus (Chinese herb) • High-dose Vitamin C • Zinc • Mind-body strategies • Nutrition • Exercise • Prayer • http://nydailynews.healthology.com/nydailynews/14958.htm

14. Manipulative therapy of URI infections in children • Case study of over 4,600 incidents of upper respiratory tract infections • Only 5% of cases treated with spinal manipulative therapy developed secondary complications. • results are superior to those obtained by antimicrobial therapy or symptomatic therapy alone. • It would seem unnecessary to use any therapy other than manipulative therapy. • Purse FM.; JAOA, 1966 (MAY)

15. Consider Safety-Net Antibiotic Prescription (SNAP) • Disadvantages of antibiotics • Adverse effects • Higher treatment costs • Increased bacterial drug resistance • Marchetti, F. et al, Arch. Pediatr. Adolesc. Med., July 2005

16. Criteria for ABX or observation for AOM(AAP/AAFP Guidelines Posted March 9, 2004)

17. ABX for AOM/rhinosinusitis(2004 AAP/AAFP Guidelines) • First-line • High-dose amoxicillin (90mg/kg for 5-10 days) • Non-type 1 penicillin allergy • Cefdinir (Omnicef), cefuroxime (Ceftin) or cefpodoxime (Vantin) • Type 1 penicillin allergy • Macrolide or sulfonamide • Ceftriaxone (1-3 days) if toxic

18. AOM/rhinosinusitis Treatment Failures(2004 AAP/AAFP Guidelines) • High dose amoxicillin/clavulanate (Augmentin ES) at 90/mg/kg in bid doses • Cefdinir (Omnicef) • Cefuroxime (Ceftin) • Cefpodoxime (Vantin) • Ceftriaxone (50 mg/kg IM qd 1-3 days) • Comment: All oral cephalosporins offer comparable efficacy. TX based on other factors such as palatability

19. URIs and Complications • In an era of increasing bacterial resistance, it is crucial for PCP’s • Make an accurate diagnosis • Use antimicrobial agents judiciously • Treat the pain

20. Prevention of AOM • DO • Breast feeding • Vaccines • Avoid • Daycare • Smoke • Allergens • Pacifiers • Prophylactic antibiotics

21. What organism is MOST likely to cause AOM with conjunctivitis? • 1. Adenovirus • 2. Haemophilus influenzae • 3. Klebsiella pneumoniae • 4. Moraxella catarrhalis • 5. Streptococcus pneumoniae • 2. Haemophilus influenzae

22. The MOST likely cause of exudative tonsillopharyngitis? • 1. Adenovirus • 2. Group A beta-hemolytic streptococcus (GABHS) • 3. Coxsachie virus • 4. EB Virus • 5. Rhinovirus • 1. Adenovirus

23. What organism is the MOST likely etiology of pharyngitis-conjunctivitis? • 1. Adenovirus • 2. Haemophilus influenzae • 3. Klebsiella pneumoniae • 4. Moraxella catarrhalis • 5. Streptococcus pneumoniae • 1. Adenovirus

24. Group A Beta Hemolytic Streptococcal (GABHS) Tonsillitis • Which of the following symptoms is NOT likely due to GABHS • Nausea/vomiting • Sore throat • Adenopathy • Headache • Cough/runny nose

25. The MOST important reason to treat GABHS is the following • 1. Shorten the coarse of the illness • 2. Decrease the carrier state • 3. Prevent rheumatic fever • 4. Decrease the extension of infection • 5. None of the above

26. Exudative Erythematous Ulcerative Membranous URI symptoms 1. Adenovirus 2. GABHS 3. Coxsachie virus 4. EB Virus 5. Rhinovirus Match the type of tonsillopharyngitis with the organism

27. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) • Children with multiple streptococcal infections had a markedly increased risk of Tourette’s syndrome (TS) and obsessive-compulsive disorder (OCD) • Post-infectious autoimmune phenomenon? • Mell et al, Pediatrics, July 2005

28. T or F: Adenoidectomy and/or Insertion of Tympanostomy Tubes • Reduce the incidence of acute otitis media • Procedures of adenoidectomy and/or tube insertions have taken on many features of “ritual surgery” • Hammaren-Malmi et al, Pediatrics, July, 2005

29. You are seeing a 6-year-old girl with bilateral conjunctivitis and moderate discharge. • Which of the following pathogens is the MOST likely etiologic agent? • Adenovirus • Haemophilus influenzae • Klebsiella pneumoniae • Moraxella catarrhalis • Streptococcus pneumoniae

30. “Pink Eye” • Bacterial conjunctivitis • True or False • Most children will get better regardless of antimicrobial therapy • AAP Grand Rounds, Sept. 2005

31. 3 year old with persistent runny nose and fever of 101 • When would you suspect rhinosinusitis • URI changes to a “thick yellow” color after 5-7 days • Usually good sign

32. What is the best screening test in children for rhinosinusitis? • History • Physical • Facial x-ray • MRI • CT Scan (limited)

33. “A pill for every ill” • Unfortunately, it takes less time and less talk to write a prescription than it does to extol the virtues of observation, patience and analgesia

34. In conclusion • MOST upper respiratory infections are viral • Amoxil is NOT a good “cough” medicine • Fever is GOOD: helps the body stimulate an immune response • Treat discomfort with analgesics • Rapid Strept tests or throat cultures may be indicated