Antibiotic Use in URTI

1. Antibiotic Use in URTI Gary Kroukamp ENT Specialist Kingsbury Hospital

2. Frequency of URTI’s • Antibiotics? • Self limiting? • Side Effects? • Natural History of Disease? • Viral vs Bacterial

3. When parents ask for antibiotics to treat viral infections: • Explain that unnecessary antibiotics can be harmful. • Tell parents that based on the latest evidence, unnecessary antibiotics CAN be harmful, by promoting resistant organisms in their child and the community. • Share the facts • Explain that bacterial infections can be cured by antibiotics, but viral infections never are. • Explain that treating viral infections with antibiotics to prevent bacterial infections does not work. • Build cooperation and trust. • Convey a sense of partnership and don’t dismiss the illness as only a viral infection

4. Encourage active management of the illness. • Explicitly plan treatment of symptoms with parents. Describe the expected normal time course of the illness and tell parents to come back if the symptoms persist or worsen. • Be confident with the recommendation to use alternative treatments. • Prescribe analgesics and decongestants, if appropriate. • Emphasize the importance of adequate nutrition and hydration. • Consider providing “care packages” with non-antibiotic therapies

5. Natural History/Resolution Sinusitis • Most cases of acute rhinosinusitis due to uncomplicated viral, upper respiratory tract infections. • Bacterial and viral rhinosinusitis difficult to differentiate clinically. • Bacterial? > 7 days or unilateral maxillary facial/tooth pain or tenderness and purulent nasal secretions. • Patients who have rhinosinusitis symptoms for less than 7 days are unlikely to have a bacterial infection. • Sinus Xray not recommended for routine diagnosis • Acute bacterial rhinosinusitis resolves without antibiotic treatment in the majority. • Symptomatic treatment and reassurance is the preferred, initial management strategy for patients with mild symptoms. • Initial treatment - antibiotics active against likely pathogens Strep pneumoniae and Haemophilus influenzae

6. Antibiotic Strategy • Patients or parents concerns and expectations should be addressed when agreeing on one of the three antibiotic prescribing strategies • no prescribing • delayed prescribing • immediate prescribing.

7. A no antibiotic or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions: • acute otitis media • acute sore throat/acute pharyngitis/acute tonsillitis • common cold • acute rhinosinusitis

8. Patients in the following subgroups can be considered for an immediate antibiotic prescribing strategy • bilateral acute otitis media in children younger than 2 years • acute otitis media in children with otorrhoea • acute sore throat/acute pharyngitis/acute tonsillitis with three or more Centor criteria

9. Centor Criteria The patients are judged on four criteria, with one point added for each positive criterion • History of fever • Tonsillar exudates • Tender anterior cervical adenopathy • Absence of cough

10. Natural History Average duration of the disease • acute otitis media: 4 days • acute sore throat/acute pharyngitis/acute tonsillitis : 1week • common cold : 1½ weeks • acute rhinosinusitis: 2½weeks

11. Immediate Antibiotics • patient systemically very unwell • symptoms and signs of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications) • high risk of serious complications pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis • premature babies • if the patient is older than 65 years with acute cough one or more of the following criteria: • hospitalisation in previous year • type 1 or type 2 diabetes • history of congestive heart failure • on steroids

12. Resistance – Strep Pneumonia

13. Resistance - Haemophilus Influenza

14. Antibiotic Choice • Tonsillopharyngitis – amoxycillin/penicillin (90mg/kg/day) • AOM – co-amoxyclav • Rhinosinusitis – co-amoxyclav • 2nd line – 3rd gen cephalosporin, fluoroquinolone or telithromycin • Chronic sinusitis – co-amoxyclav + macrolides (anti-inflammatory/immune modulating)