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

Stanley E. Grogg, DO, FACOP

Professor of Pediatrics

OSU-CHS

A Common Airway

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

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