بنام خداوند جان وخرد

1. بنام خداوند جان وخرد

2. Empiric Antibiotic Therapy of Upper and Lower Respiratory Tract Infections Dr. Alireza Emami Naeini Associate Prof. Department of Infectious Diseases Isfahan University of Medical Sciences(IUMS)

3. Pharyngitis • Bacterial (group A Streptococci)(C, G) • Membranous, Arcanobacterium ( C. hemolyiticum). C. diphtheria. • Viral ( EBV, CMV, HHV- 6) • Other ( M. pneumonia, C. pneumonia)

4. Streptococcal Pharyngitis • Streptococcal Pharyngitis, Streptococcal Tonsillitis, or Streptococcal sore throat (known as Strep. throat) is a type of Pharyngitis caused by a group A streptococcal infection. It affects the pharynx including the tonsils. Common symptoms include: Acute sore throat with fever and bilateral anterior cervical adenopathy.It is the cause of 37% of sore throats among children.

5. A case • A 10-year-old girl presents with a sore throat and fever that has lasted for 1 day. She appears flushed and moderately ill. Physical examination reveals a temperature of 39°C, tender bilateral anterior cervical lymph nodes that are 1 to 2 cm in the greatest dimension, and erythema and whitish-yellow exudate over enlarged tonsils and the posterior pharynx. A rapid antigen-detection test from a throat-swab specimen is positive for group A streptococcus. How should the patient be evaluated and treated?

11. Clinical Scoring System (likelihood of positive throat culture) Criteria Points Fever(38) 1 Absence of cough 1 Swollen, tender anterior cervical nodes 1 Tonsillar swelling or exudate 1 Age 3 to <15 1 15 to< 45 0 = > 45 -1

12. A score of 0 or a negative score is associated with risk of 1 to 2.5%. • 1 point is associated with a risk of 5 to 10%. • 2 points is associated with a risk of 11 to 17%. • 3 points is associated with a risk of 28 to 35%. • 4 or more points is associated with a risk of 51 to 53%

13. Antimicrobial Therapy for GAS Pharyngitis • Penicillin V(10 days) Children: 250 mg bid or tid Adolescence and adults: 250 tid or qid or 500 mg bid.

14. Antimicrobial Therapy for GAS Pharyngitis • For penicillin allergic patients: - Erythromycin ethylsuccinate ( 20 – 40 mg / kg divided into 2 to 4 doses) ( maximum 1 g/ day) - First generation cephalosporin's: Cephalexin 250 mg PO qid.

15. Antimicrobial Therapy for GAS Pharyngitis • IM Regimens: - Benzathine penicillin G, 600000 U for patients < 27 kg 1200000 U for patients > 27 kg - Mixtures of penicillin's.

16. PO Therapy • Amoxicillin q8h x10 days. • Clindamycin q8h x10 days. • Clarithromycin XL q 24. 10 days • Azithromycin 500x1 dose then , then 250 mg q24 x 4 days. - Threat within 10 days to prevent ARF.

18. Bacterial sinusitis • Acute Bacterial Sinusitis • Chronic Bacterial Sinusitis

19. Acute Bacterial Sinusitis • Clinical presentation: Nasal discharge and cough frequently with headache, facial pain, and low grade fever lasting > 10-14 days. Can also present acutely with high fever and purulent nasal discharge ± intense headache lasting for => 3 days. • Other manifestations depend on the affected sinus.

20. Diagnostic considerations • Diagnosis by sinus x- rays or CT or MRI showing complete sinus opacification. Air – fluid levels, mucosal thickening. Consider sinus aspiration in immunocompromized hosts or treatment failure. • In children , acute sinusitis is a clinical diagnosis, imaging studies are not common.

25. Oral Antimicrobial agents for Acute Bacterial Sinusitis(Ambulatory) • Amoxicillin • Pediatric dosage: 40 – 80 mg/ kg/day divided q12. • Adult dosage: 500 - 875 mg q12h

26. Oral Antimicrobial agents for Acute Bacterial Sinusitis • Amoxicillin / clavulanate x 10 days • Doxycicline 200 mg qid x 3 days then 100 q12

27. Therapeutic considerations • Macrolides and TMP-SMX may predispose to drug – resistant S. pneumonia (DRSP), and => 30% of S. pneumonia are naturally resistance to macrolides.

28. Respiratory quinolone • Gemifloxacin (Factive) Tab 320 mg • Levofloxacin (Tavanex) Tab 500 mg

29. Prognosis • Good if treated for full course. Relapses may occur with suboptimal treatment. For frequent recurrences, consider radiologic studies and ENT consultation.

31. Acute bronchitis Acute bronchitis is an inflammation of the large bronchi (medium-size airways) in the lungs that is usually caused by viruses or bacteria and may last several days or weeks

32. Acute Bronchitis (AB) An acute illness, occurring in a patient without chronic lung disease, with symptoms including cough, which may or may not be productive and associated with other symptoms or clinical signs that suggest LRTIs , and no alternative explanation ( e.g. sinusitis or asthma). Clinical syndrome distinguished by a relatively brief, self – limited inflammatory process of large and midsized airways, not associated with pneumonia on chest radiograph.

33. Etiology of AB Influenza virus Rhinovirus Corona virus adenovirus RSV Human metapneumovirus Para influenza viruses S. pneumonia H. influenza B. pertussis *M. Cataralis

34. Treatment Treatment of patients with AB is generally symptomatic and directed at relief of troublesome upper respiratory symptoms, cough and wheezing. Therapy directed toward bronchospasm may be required. Cough: Narcotic cough suppressants, expectorants, antihistamines, decongestants, β²- agonists(Clobutinol)(Tab 40 mg,drop 60mg/ml)(1-2 tab tid).

35. Treatment In a placebo- controlled double blind trial in experimental rhinovirus infection, the combination of ibuprofen (400mg) plus cholorpheniramine ( 12 mg) administered every 12 hours for 4.5 days, reduced cough significantly. IDSA : Do not recommend the routine use of antibiotics for uncomplicated AB in otherwise normal persons.

36. Antibiotics • Quinolones ( 5 days) • Amoxicillin – clavulanic acid ( 5 days) • Clarythromycin ( 5 days) • Doxycicline( 5 days) • Azithromycin 500 mg / day ( 3 days)

38. Pneumonia Outpatient treatment

39. Pneumonia • To the clinician: Pneumonia is a constellation of symptoms and signs ( fever, chills, cough, pleuritic chest pain, sputum production, hyper or hypothermia, increased Respiratory Rate, dullness to percussion, bronchia breathing, egophony, crackle, wheezes, pleural friction rub) in combination with at least one opacity on chest radiography.

40. Regimen Treatment setting; patient condition Outpatient ; no cardiopulmonary disease, no risk factor DRSP infection Macrolide(e.g., Clarythromycin 500mg bid PO  10 days; or Azithromycin 500 mg PO once then 250 mg/d  4 days ) or Doxycycline 10 bid PO  10 days

41. Regimen Treatment setting; patient condition Outpatient; cardiopulmonary disease and/ or risk factors for DRSP infection or (2) high DRSP prevalence in community Quinolone with enhanced activity against S. pneumonia- e.g., Levofloxacin 500 mg/ d PO( or, with Ccr < 50 mL/min,250 mg/day), Moxifloxacin 400 mg/d PO or -Lactam( cefpodoxime 200 mg bid, Cefuroxime axetil 750 mg tid, or Amoxicillin 1000mg tid, PO; Amoxicillin /clavulanic acid 875/175 mg / tid plus Macrolide or doxycycline or Telithromycin 800 mg q24  10 days

42. Regimen Treatment setting; patient condition Hospital ward Cefuroxime 750 mg q8h IV or ceftriaxone 1 g/day IV or cefotaxime 2g q6h IV or ampicillin / sulbactam 1.5- 3 g q6h IV plus Azithromycin 1 g/d IV followed by 500 mg/d IV quinolone with enhanced activity against S. pneumonia.