Respiratory Tract Infection Pharmacotherapy Revised
Respiratory Tract Infection Pharmacotherapy Revised
Respiratory Tract Infection Pharmacotherapy Revised
Pharmacotherapy
Anatomy of the Respiratory Tract
Sinuses
Ear (otitic)
Pharynx
Lungs
▪ Bronchus
▪ Alveolus
Mucocillary
clearance,
Secretory
IgA, Cough,
Mechanical
Barrier
Upper Respiratory Tract
Sinusitis
Otitis Externa & Media
Pharyngitis
Lower Respiratory Tract
Bronchitis
Pneumonia
▪ Community Acquired
▪ Nosocomial (HAP)
▪ Aspiration…
A 43-year-old man has a two-week history of
nasal congestion, postnasal drip, and fatigue. He
has used an over the- counter nasal decongestant
and acetaminophen, without relief
During the past few days, facial pain and
pressure have developed and have not
responded to decongestants
In addition, his nasal discharge has turned from
clear to yellow
How should he be treated?
Inflammation and/or infection of the paranasal sinuses,
or membrane-lined air spaces, around the nose
Nasal congestion, purulent nasal discharge, maxillary tooth
discomfort, hyposmia or anosmia, cough
Facial pain or pressure that is made worse by bending
forward, headache, fever, and malaise
Viral: Usually improves in 5-7 days
Bacterial: Symptoms > 10 days or worsens after 5-7 d
50-60 % of cases: S. pneumoniae & H. influenzae
Amoxicillin* 500 mg three times daily for 10
days
Continued use of nasal saline and
decongestant therapy
* Doxycycline or trimethoprim–sulfamethoxazole
also reasonable
If patient’s symptoms did not improve after 72
hours
Switch to azithromycin, levofloxacin, or high-dose
amoxicillin–clavulanate
Oral Dosing Guidelines for Acute Bacterial Sinusitis
An otherwise healthy 17-month-old boy had a cold
accompanied by two days of rhinorrhea, cough, and
fever (temperature of up to 38.8°C [102°F]).
On day 5 he became fussy and woke up crying multiple
times during the night.
The following day he was afebrile, and a physical
examination was normal except for findings of slight
redness of the left tympanic membrane with no middle-
ear fluid and a bulging right tympanic membrane with
white fluid behind it obscuring the umbo.
How should this child be treated?
Otitis media: is an inflammation of the middle ear
Three subtypes of otitis media:
acute otitis media, otitis media with effusion, and
chronic otitis media
are differentiated by onset, signs and symptoms of
infection, and the presence of fluid in the middle ear
Acute otitis media is the subtype with the greatest role
for antibiotics
Diffuse = Swimmers Ear
Topical cleaning including hypertonic saline or alcohol
with acetic acid; topical antibiotics +/-
glucocorticoids
Invasive malignant or necrotic
Usually due to P. aeruginosa
Early / mild with close follow up
▪ Oral and topical ciprofloxacin
Everyone else
▪ Systemic antipseudomals (piperacillin/tazobactam) &
surgery
Onset within 48 hours 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 the tympanic
membrane or slight bulging accompanied by
either otalgia or marked erythema of the
membrane
Seven discrete items: tugging of ears, crying,
irritability, difficulty sleeping, diminished
activity, diminished appetite, and fever.
Parents rate comparison w/ child’s usual state
―none,‖ ―a little,‖ or ―a lot,‖
0, 1, and 2 points
Goal: Pain management, prudent antibiotic use, and
secondary disease prevention
Consider: primary prevention of acute otitis media through the use
of bacterial and viral vaccines
Differentiate acute otitis media from otitis media with effusion or
chronic otitis media
Recognize that amoxicillin is the mainstay of therapy and that
penicillin resistance can be overcome, in many cases, with high-
dose amoxicillin therapy
Acetaminophen or NSAID, such as ibuprofen, should be offered
early to relieve pain in acute otitis media
One strategy to reduce antibiotic use in this setting is "delayed
therapy …. 48 to 72 hours
Initial Antibiotics
Amoxicillin 80-90 mg/kg/day divided Q12h
Alternatives for non IgE allergy
▪ Cefdinir, Cefuroxime, Cefpodoxime, Cefprozil
Alternative for IgE (anaphylactic) allergy
▪ Azithromycin, Clarithromycin
Severe or fails initial therapy
Amoxicillin / Clavulanate
Ceftriaxone 50 mg/kg/day IM/IV for 3 days
▪ Clindamycin if penicillin allergy
6 months to 2 years
Amox / Clav (not placebo) should be given for 10
days if diagnostic criteria met
▪ N Engl J Med 2011;364:105-15
Giving Amox / Clav will
▪ N Engl J Med 2011;364:116-26
reduce treatment failures 62%
Cause ADE’s almost twice as often vs placebo
▪ 47.8% diarrhea vs 26.6% in placebo (P<0.001
Duration of treatment
10 days standard [ < 2 years of age , Ethiopia]
5-7 days (short course)
▪ Children > 6 years old with mild to moderate disease
Observation without antibiotics for 48-72 hours:
6 months to 2 years, otherwise healthy with non-severe
illness at presentation and an uncertain diagnosis
2 years of age and older without severe symptoms at
presentation or with an uncertain diagnosis
Bulging tympanic membrane with visible pus
Immediate antibiotic therapy with high-dose
amoxicillin
Acute otitis without bulging eardrums
likely to clear spontaneously
Consider delayed antibiotic-prescribing strategy
(waiting 48 to 72 hours to prescribe antibiotics
while giving the patient acetaminophen)
Case – Pharyngitis
Aspiration
Community Mouth anaerobes Penicillin or clindamycin
Hospital Mouth anaerobes, S. aureus, Clindamycin, ticarcillin–clavulanate,
gram-negative enterics piperacillin–tazobactam, plus
aminoglycoside
Nosocomial Gram-negative bacilli (e.g., K. Piperacillin-tazobactam,
pneumonia pneumoniae, Enterobacter carbapenem, e or extended spectrum
species, Pseudomonas cephalosporing plus aminoglycoside;
f
Empirical Antimicrobial Therapy for Pneumonia in
Pediatric Patients
AGE USUAL PATHOGEN(S) PRESUMPTIVE THERAPY
1 month Group B streptococcus, Haemophilus Ampicillin–sulbactam, cephalosporinb
influenzae (nontypeable), Escherichia carbapenemc
coli, Staphylococcus aureus, Listeria,
CMV, RSV, adenovirus Ribavirin for RSV
1–3 Chlamydia, possibly Ureaplasma, CMV, Macrolide/azalide,d trimethoprim-
months Pneumocystis carinii (afebrile pneumonia sulfamethoxazole
syndrome)
RSV Ribavirin
Pneumococcus, S. aureus Semisynthetic penicilline or cephalosporinf
3 months– Pneumococcus, H. influenzae, RSV, Amoxicillin or cephalosporinf
6 years adenovirus, parainfluenza Ampicillin–sulbactam, amoxicillin–
clavulanate
Ribavirin for RSV
>6 years Pneumococcus, Mycoplasma pneumoniae, Macrolide/azalided cephalosporin,f
Evidence-Based Guidelines for Management of Community-
Acquired Pneumonia in Immunocompetent Adults
Preferred parenteral agents for treatment of pneumococcal pneumonia for strains with
reduced susceptibility to penicillin are cefotaxime or ceftriaxone.
For susceptible strains, amoxicillin is the preferred antibiotic for pneumococcal
pneumonia.
Recommended initial therapy for a hospitalized patient consists of a beta-lactam plus
macrolide combination or a fluoroquinolone alone.
For an intensive care patient and in the absence of a Pseudomonas infection, a
combination of a beta -lactam plus either a macrolide or a respiratory fluoroquinolone
should be prescribed.
For an intensive care patient and in the presence of a penicillin-resistant isolate,
cefotaxime, ceftriaxone, or a respiratory fluoroquinolone
For hospitalized patients, for Legionnaires' disease is azithromycin or a fluoroquinolone.
For nonhospitalized patients, erythromycin, doxycycline, azithromycin, clarithromycin, or a
fluoroquinolone.
Amantadine, rimantadine, oseltamivir, or zanamivir is effective for early (within 48 hrs)
Dose adequately, switch to PO when able
Use combinations if MDR likely
Avoid inadequate therapy
Monotherapy once C&S back
Limit aminoglycosides to 5-7 days if able
Treat for 14-21 days
? 7 days if not P. aeruginosa or S. aureus & good
clinical response with resolution.
P. aeruginosa combination therapy recommended.
Development of resistance on monotherapy
Combination therapy may not prevent resistance, may
avoid Inappropriate and ineffective treatment
Acinetobacter
carbapenems, sulbactam, colistin, and polymyxin most
active; no data supporting combination regimen
Enterobacteriaceae
Use carbapenem
Avoid monotherapy with 3rd gen cephalosporin
Considered adjunctive therapy with an inhaled
aminoglycoside or polymyxin for MDR gram-
negative
Linezolid is alternative to vancomycin for MRSA
VAP
May be preferred on the basis of a subset analysis of
two prospective randomized trials
Antibiotic restriction can limit epidemics of specific
resistant pathogens.
Antibiotic cycling etc. may help but data not conclusive
/ not recommended
• Go through Ethiopian standard treatment guidelines for
specific conditions:
• Treatment recommendations for CAP in patients treated in
the outpatient setting
• Treatment recommendations for CAP in patients requiring
hospitalization
• Treatment recommendation for HAP ,VAP,HCAP
• Pneumonia in special populations, such as aspiration
pneumonia and immuno-compromised patients
• Reading assignment for submission
• The evidence for efficacy of different antibiotic
medications in the empiric treatment of CAP, HAP, VAP,
HCAP and issues related to drug resistance