1. Stanley E. Grogg, DO, FACOP Professor of Pediatrics OSU-CHS
“DO Not Be Snotty: Treatment of Pediatric Upper Respiratory Infections”
Stanley E. Grogg, DO, FACOP
Professor of Pediatrics
OSU-CHS

2. A Common Airway

3. Thus, URIs may include “Colds” Tonsillitis/pharyngitis/laryngitis
Otitis media
Conjunctivitis
Rhinosinusitis

4. What is the most common bacterial infection diagnosed in children?
Tonsillitis/pharyngitis
Conjunctivitis
Pneumonia
Rhinosinusitis
Acute otitis media

5. 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

6. 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

7. 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

8. 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: , July 16, 2005

9. 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

10. 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

11.
Viruses cause
All colds and flu
Most coughs
Most sore throats

12. 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

13. CAM for Immune Support Echinacea Astragalus (Chinese herb)
High-dose Vitamin C
Zinc
Mind-body strategies
Nutrition
Exercise
Prayer

14. 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)

15. 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

16. Criteria for ABX or observation for AOM (AAP/AAFP Guidelines Posted March 9, 2004)
Age
Certain DX
Uncertain DX
< 6 mo
ABX
6 mo- 2 yr
ABX if severe, observe if non-severe (SNAP?)
> 2 yr
ABX if severe illness, observe otherwise?

17. ABX for AOM/rhinosinusitis (2004 AAP/AAFP Guidelines)
First-line
High-dose amoxicillin (90mg/kg for 5-10 days)
Non-type 1 penicillin allergy
Cefdinir (Omnicef), cefuroxime (Ceftin) or cefpodoxime (Vantin)
Type 1 penicillin allergy
Macrolide or sulfonamide
Ceftriaxone (1-3 days) if toxic

18. 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

19. 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

20. Prevention of AOM DO Breast feeding Vaccines Avoid Daycare Smoke
Allergens
Pacifiers
Prophylactic antibiotics

21. What organism is MOST likely to cause AOM with conjunctivitis?
1. Adenovirus
2. Haemophilus influenzae
3. Klebsiella pneumoniae
4. Moraxella catarrhalis
5. Streptococcus pneumoniae

22. The MOST likely cause of exudative tonsillopharyngitis?
1. Adenovirus
2. Group A beta-hemolytic streptococcus (GABHS)
3. Coxsachie virus
4. EB Virus
5. Rhinovirus

23. What organism is the MOST likely etiology of pharyngitis-conjunctivitis?
1. Adenovirus
2. Haemophilus influenzae
3. Klebsiella pneumoniae
4. Moraxella catarrhalis
5. Streptococcus pneumoniae

24. 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

25. 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

26. 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

27. Post-infectious autoimmune phenomenon?
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

28. 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

29. 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

30. “Pink Eye” Bacterial conjunctivitis True or False
Most children will get better regardless of antimicrobial therapy
AAP Grand Rounds, Sept. 2005

31. 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

32. What is the best screening test in children for rhinosinusitis?
History
Physical
Facial x-ray
MRI
CT Scan (limited)

33. “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

34. 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