“do not be snotty: treatment of pediatric upper respiratory infections” stanley e. grogg, do,...
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“DO Not Be Snotty: Treatment of Pediatric Upper Respiratory Infections”
Stanley E. Grogg, DO, FACOP
Professor of Pediatrics
OSU-CHS
Thus, URIs may include “Colds” Tonsillitis/pharyngitis/laryngitis Otitis media Conjunctivitis Rhinosinusitis
What is the most common bacterial infection diagnosed in children? Tonsillitis/pharyngitis Conjunctivitis Pneumonia Rhinosinusitis Acute otitis media
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
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
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
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
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
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
http://www.cdc.gov/ncidod/op/antibiotics.htm
• Viruses cause• All colds and
flu • Most coughs • Most sore
throats
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
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
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)
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
Criteria for ABX or observation for AOM(AAP/AAFP Guidelines Posted March 9, 2004)
Age Certain DX Uncertain DX
< 6 mo ABX ABX
6 mo- 2 yr ABX ABX if severe, observe if non-severe (SNAP?)
> 2 yr ABX if severe illness, observe otherwise?
ABX for AOM/rhinosinusitis(2004 AAP/AAFP Guidelines)
First-lineHigh-dose amoxicillin (90mg/kg for 5-10 days)Non-type 1 penicillin allergy
Cefdinir (Omnicef), cefuroxime (Ceftin) or cefpodoxime (Vantin)
Type 1 penicillin allergyMacrolide or sulfonamide
Ceftriaxone (1-3 days) if toxic
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
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
Prevention of AOM DO
Breast feeding Vaccines
Avoid Daycare Smoke Allergens Pacifiers Prophylactic antibiotics
What organism is MOST likely to cause AOM with conjunctivitis?
1. Adenovirus 2. Haemophilus
influenzae 3. Klebsiella
pneumoniae 4. Moraxella
catarrhalis 5. Streptococcus
pneumoniae2. Haemophilus
influenzae
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
What organism is the MOST likely etiology of pharyngitis-conjunctivitis?
1. Adenovirus 2. Haemophilus
influenzae 3. Klebsiella
pneumoniae 4. Moraxella
catarrhalis 5. Streptococcus
pneumoniae1. Adenovirus
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
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
Match the type of tonsillopharyngitis with the organism Exudative Erythematous Ulcerative Membranous URI symptoms
1. Adenovirus 2. GABHS 3. Coxsachie
virus 4. EB Virus 5. Rhinovirus
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
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
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
“Pink Eye” Bacterial
conjunctivitis True or False
Most children will get better regardless of antimicrobial therapy
AAP Grand Rounds, Sept. 2005
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
What is the best screening test in children for rhinosinusitis?
History Physical Facial x-ray MRI CT Scan (limited)
“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