1. Antibiotic Use in URTI Gary Kroukamp ENT Specialist Kingsbury Hospital

2. Frequency of URTI’s Frequency of URTI’s Antibiotics? Antibiotics? Self limiting? Self limiting? Side Effects? Side Effects? Natural History of Disease? Natural History of Disease? Viral vs Bacterial Viral vs Bacterial

3. When parents ask for antibiotics to treat viral infections: Explain that unnecessary antibiotics can be harmful. Explain that unnecessary antibiotics can be harmful. Tell parents that based on the latest evidence, unnecessary antibiotics CAN be harmful, by promoting resistant organisms in their child and the community.Tell parents that based on the latest evidence, unnecessary antibiotics CAN be harmful, by promoting resistant organisms in their child and the community. Share the facts Share the facts Explain that bacterial infections can be cured by antibiotics, but viral infections never are.Explain that bacterial infections can be cured by antibiotics, but viral infections never are. Explain that treating viral infections with antibiotics to prevent bacterial infections does not work.Explain that treating viral infections with antibiotics to prevent bacterial infections does not work. Build cooperation and trust. Build cooperation and trust. Convey a sense of partnership and don’t dismiss the illness as only a viral infectionConvey a sense of partnership and don’t dismiss the illness as only a viral infection

4. Encourage active management of the illness. Encourage active management of the illness. Explicitly plan treatment of symptoms with parents. Describe the expected normal time course of the illness and tell parents to come back if the symptoms persist or worsen.Explicitly plan treatment of symptoms with parents. Describe the expected normal time course of the illness and tell parents to come back if the symptoms persist or worsen. Be confident with the recommendation to use alternative treatments. Be confident with the recommendation to use alternative treatments. Prescribe analgesics and decongestants, if appropriate.Prescribe analgesics and decongestants, if appropriate. Emphasize the importance of adequate nutrition and hydration.Emphasize the importance of adequate nutrition and hydration. Consider providing “care packages” with non-antibiotic therapiesConsider providing “care packages” with non-antibiotic therapies

5. Natural History/Resolution Sinusitis Most cases of acute rhinosinusitis due to uncomplicated viral, upper respiratory tract infections. Most cases of acute rhinosinusitis due to uncomplicated viral, upper respiratory tract infections. Bacterial and viral rhinosinusitis difficult to differentiate clinically. Bacterial and viral rhinosinusitis difficult to differentiate clinically. Bacterial? > 7 days or unilateral maxillary facial/tooth pain or tenderness and purulent nasal secretions. Bacterial? > 7 days or unilateral maxillary facial/tooth pain or tenderness and purulent nasal secretions. Patients who have rhinosinusitis symptoms for less than 7 days are unlikely to have a bacterial infection. Patients who have rhinosinusitis symptoms for less than 7 days are unlikely to have a bacterial infection. Sinus Xray not recommended for routine diagnosis Sinus Xray not recommended for routine diagnosis Acute bacterial rhinosinusitis resolves without antibiotic treatment in the majority. Acute bacterial rhinosinusitis resolves without antibiotic treatment in the majority. Symptomatic treatment and reassurance is the preferred, initial management strategy for patients with mild symptoms. Symptomatic treatment and reassurance is the preferred, initial management strategy for patients with mild symptoms. Initial treatment - antibiotics active against likely pathogens Strep pneumoniae and Haemophilus influenzae Initial treatment - antibiotics active against likely pathogens Strep pneumoniae and Haemophilus influenzae

6. Antibiotic Strategy Patients or parents concerns and expectations should be addressed when agreeing on one of the three antibiotic prescribing strategies Patients or parents concerns and expectations should be addressed when agreeing on one of the three antibiotic prescribing strategies no prescribingno prescribing delayed prescribingdelayed prescribing immediate prescribing.immediate prescribing.

7. A no antibiotic or a delayed antibiotic prescribing strategy should be agreed for patients with the following conditions: acute otitis media acute otitis media acute sore throat/acute pharyngitis/acute tonsillitis acute sore throat/acute pharyngitis/acute tonsillitis common cold common cold acute rhinosinusitis acute rhinosinusitis

8. Patients in the following subgroups can be considered for an immediate antibiotic prescribing strategy bilateral acute otitis media in children younger than 2 years bilateral acute otitis media in children younger than 2 years acute otitis media in children with otorrhoea acute otitis media in children with otorrhoea acute sore throat/acute pharyngitis/acute tonsillitis with three or more Centor criteria acute sore throat/acute pharyngitis/acute tonsillitis with three or more Centor criteria

9. Centor Criteria The patients are judged on four criteria, with one point added for each positive criterion History of fever History of feverfever Tonsillar exudates Tonsillar exudatesexudates Tender anterior cervical adenopathy Tender anterior cervical adenopathyadenopathy Absence of cough Absence of coughcough

10. Natural History Average duration of the disease acute otitis media: 4 days acute otitis media: 4 days acute sore throat/acute pharyngitis/acute tonsillitis : 1week acute sore throat/acute pharyngitis/acute tonsillitis : 1week common cold : 1½ weeks common cold : 1½ weeks acute rhinosinusitis: 2½weeks acute rhinosinusitis: 2½weeks

11. Immediate Antibiotics patient systemically very unwell patient systemically very unwell symptoms and signs of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications) symptoms and signs of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications) high risk of serious complications pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis high risk of serious complications pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis premature babies premature babies if the patient is older than 65 years with acute cough one or more of the following criteria: if the patient is older than 65 years with acute cough one or more of the following criteria: hospitalisation in previous yearhospitalisation in previous year type 1 or type 2 diabetestype 1 or type 2 diabetes history of congestive heart failurehistory of congestive heart failure on steroidson steroids

12. Resistance – Strep Pneumonia

13. Resistance - Haemophilus Influenza

14. Antibiotic Choice Tonsillopharyngitis – amoxycillin/penicillin (90mg/kg/day) Tonsillopharyngitis – amoxycillin/penicillin (90mg/kg/day) AOM – co-amoxyclav AOM – co-amoxyclav Rhinosinusitis – co-amoxyclav Rhinosinusitis – co-amoxyclav 2 nd line – 3 rd gen cephalosporin, fluoroquinolone or telithromycin 2 nd line – 3 rd gen cephalosporin, fluoroquinolone or telithromycin Chronic sinusitis – co-amoxyclav + macrolides (anti-inflammatory/immune modulating) Chronic sinusitis – co-amoxyclav + macrolides (anti-inflammatory/immune modulating)