Pediatric Respiratory Infections: When are antibiotics indicated?

1. Renee Fife, MSN, CPN, CPNP Associate Clinical Professor Purdue University Northwest Pediatric Respiratory Infections: When are antibiotics indicated?

2. Antibiotic Resistance is Rising:Regional Trends

3. Antibiotic Prescribing Rates

4. Think Before Ordering Antibiotics • Indiana’s antibiotic statistics are concerning • Some of the highest resistance to antibiotics in the nation • In the category of the 2nd highest Antibiotic Prescribing rates in the community (cdc.gov2014) • Are you, as a prescriber, aware of the local resistance patterns in Northwest Indiana? • Local antibiogram • How should it affect your prescribing for pediatric respiratory infections?

5. Local Antibiogram

6. Guideline Based Care for Pediatric Respiratory Illnesses • No antibiotics for • Asthma/allergy • Bronchitis • Bronchiolitis • Influenza • URI/nasopharyngitis • Judicious use of antibiotics for • Acute Otitis Media • Sinusitis • GABS Pharyngitis • Upper Respiratory Pathogens • Streptococcus pneumoniae • NontypeableHaemophilusinfluenzae • Moraxella catarrhalis

7. Acute Otitis Media (AOM) • Description • Acute infection of the middle ear • Requires 3 components • Recent abrupt onset of signs & symptoms • MEE confirmed with pneumatic otoscopy • Middle ear inflammation visualized or otalgia that is interfering with activities, including sleep • History • Sudden, occurring with other signs of illness • High fever to 104 F • Complaints of feeling ill • Pain in the ear (pulling at ear) • Sudden hearing loss in the verbal child • Vomiting/diarrhea • Otorrhea

8. Often occurs in conjunction with eustachian tube dysfunction • Negative pressure draws fluid into the middle ear from ET when child cries/sucks • Pain results from the fluid pressure and can result in effusion (glue ear) • If effusion persists, conductive hearing loss can occur

9. Acute Otitis Media (AOM) • Physical exam • Bulging membrane • Does not move with insufflation • If drainage is present, tympanic membrane (TM) has been perforated • Obscured or absent landmarks • Red, yellow or purple color • Diagnostics • Pneumatic otoscopy by NP • Otoscopy usually not done til 4+ months • Tympanocentesis in infants less than 2 months to identify the organism • Should be done by otolaryngologist

10. Acute Otitis Media (AOM) • Differential Diagnoses • OME, mastoiditis, dental abscess, sinusitis, ET dysfunction, TMJ dysfunction, peritonsillar abscess • NOTE: infants less than 2 month should be worked up for Fever Without Focus and not just treated for AOM • Management depends on age and severity • Pain management for all • Acetaminophen or ibuprofen (over 6 months) • External use of heat or cold • Observation if it is an option to reduce overuse of antibiotics • May be viral, especially with URI symptoms

11. Watchful Waiting for AOM • Watchful waiting for 48-72 hours with analgesia and a follow upplan that includes • Parent to call if no improvement • Scheduled follow-up appointment • Routine follow-up phone call to parent • Antibiotic script to fill if no improvement • If no improvement in 48-72 hours, confirm diagnosis and initiate antibiotics

12. Acute Otitis Media (AOM) Use of Antimicrobials Note there is no mention of Azithromycin: meta-analysis of 10 trials indicated greater likelihood of clinical failure with macrolide (Courter at al, 2010)

13. Penicillin Allergy and Cephalosporins • There is often concern about ordering a cephalosporin if the patient claims to have an allergy to Penicillin • Terico and Gallagher (2014) • Reviewed literature from 1950 to 2013 • Cross reactivity was less than 5% • Campagna et al (2012) • Review • Overall cross reactivity rate was about 1%

14. Allergies and Antibiotics • True Allergy, Type 1, IgE-mediated, to Penicillin products is over-reported • About 10% of patients report an allergy • Only about 1% will have a true allergy • These may lose sensitivity after 10 years • It is recommended that allergies be confirmed by an allergist • This can decrease the use of broad spectrum antibiotics • Only 1-5% of children with a true Penicillin allergy will also be allergic to cephalosporins • www.cdc.gov/getsmart

15. Acute Otitis Media (AOM) • Treatment duration is age dependent • < 2 years: 10 days • 2-5 years: 7 days • > or = 6 years: 5-7 days • Follow up exam 3-4 weeks after • Refer to otolaryngology if antimicrobial failure occurs • Persistent AOM occurs when infection is still present after full course of antibiotics • Retreat with broader spectrum antibiotic • Recurrent AOM is defined as more than 3 bouts of AOM in 6 mos or 4 in 12 mos • May have PETs placed

16. Acute Otitis Media (AOM) • Prevention of AOM • Prevnar 13 immunization (pneumococcal AOM) • Attend day care with smaller enrollment • Annual Flu vaccine if >6 month old (2 shot series for first ) • Xylitol chewing gum, 5-6 sticks per day • Bacteriostatic effects against S. pneumoniae • Exclusive Breastfeeding for the first 6 months (Ig’s) • Avoid feeding the infant while lying down • Avoid passive smoke

17. Otitis Media with Effusion • Description • Evidence of fluid without signs of acute infection • Decreased mobility of TM which interferes with sound conduction • Common after AOM (clears in 3 months) • History • If verbal, reports • Popping in the ear/talking in a barrel • Hearing loss • Dizziness or poor balance • If preverbal • Poor language development

18. Otitis Media with Effusion • Physical exam • Asymptomatic and afebrile • Exam is normal except for decreased TM mobility • Dull opaque TM with no visible landmarks • Retracted TM with landmarks • TM with bulging , air bubbles • Management • Watchful waiting for low risk since most resolve spontaneously • Monitor verbal skills and any learning difficulties • Those at risk should be referred for further evaluation of hearing, speech and language • If skills are negatively effected, refer to otolaryngology

19. Three organisms cause inflamed tonsils requiring antibiotics • GABHS • Neisseria gonorrhoeae • Corynebacteriumdiphtheriae What helps distinguish between the three?

20. Acute Pharyngitis/Tonsillitis • VIRAL • Most common: Adenovirus • Classic features • Hoarseness, mild cough • CORYZA • Conjunctivitis • Diarrhea • Rashes • Gradual onset • Low grade fever • Diagnostic tests • Only to r/o other conditions • Management: supportive • BACTERIAL • Most common: GABHS • Classic features GABHS • Uncommon under 2 yr • Abrupt onset • NO nasal symptoms/NO CORYZA • Moderate to high fever • Sore throat/dysphagia • N/V, headache, abdominal pain • Petechiae on soft palate • Enlarged tonsils with exudate • +cervical lymphs • Scarlatiniformrash (Sandpaper)

21. GABHS Tonsillitis • Diagnostic tests • Rapid strepculture: 90-95% accurate • Do not culture every child that presents with a sore throat • They might be a carrier • When to culture? • Use the McIsaac criteria to help decide • Temp > 38 C (100.4F) • Tender anterior cervical nodes • Sore throat • Absence of cough • Tonsillar swelling • Age < 15 years and >2 years

22. GABHS Tonsillitis • Interpreting rapid strep results • If result is negative but has + symptoms, plate it • If positive, treat • but remember they could be a carrier • Other possible lab • Antistreptolysin O titer (ASO) • Confirms past GABHS infection • Confirmed diagnosis is important for treatment • Prevent complications (RF or PSGN) • Prevent horizontal transmission

23. GABHS Tonsillitis • Antibiotics are needed to prevent • Rheumatic fever • Spread of infection • 24 hour rule for school • Suppurative complications

24. GABHS Treatment • Penicillin • PO: 250mg BID if <27kg or 500mg BID if >27kg • IM: single dose 600,000units <27kg or 1.2 million >27kg • Amoxicillin, 50mg/kg/day for 10 days • Single daily dose • Maximum 1,000mg • Cephalexin (Keflex) 40-50mg/kg/day, split BID • Maximum 500mg BID • Cefadroxil (Duricef) 30mg/kg/day • Maximum 1 gram

25. If Penicillin Allergic • Cephalexin (Keflex) 40-50mg/kg/day, split BID • Maximum 500mg BID • If immediate Type 1 hypersensitivity • Clindamycin 20mg/kg/day, split TID • Maximum 600mg/dose (1.8gm/day) • Consider a macrolide, but may be up to 20% resistance (Redbook, 2015) • Azithromycin 12mg/kg/day for 5 days • Maximum 500mg

26. GABHS Tonsillitis • What if the child doesn’t improve on the antibiotic? • Treatment failure versus new infection • Look at the time frame • Viral infection • Look at the time frame • Carrier status • Culture between episodes to determine if still positive when asymptomatic • Eradication needed if transferring to others • Clindamycin 20-30mg/kg/day, split TID X 10 days • Maximum 300mg/dose

27. Acute Purulent Rhinitis • Often, result of a superinfection from common cold • Classic features • URI with purulent yellow-green discharge for 3 + days • If viral origin, usually worse in morning • Diagnostic tests • To r/o other causes (Foreign Body) • Management • Watchful waiting approach if from URI • Clear nasal passages as needed (saline, bulb,..) • Return if not cleared in 10-14 days and then consider antibiotic • Likely cause is sinusitis

28. Sinusitis • Inflammation and secondary infection of para-nasal sinuses • URI symptoms that last > 10 days • Ethmoidal sinus: present at birth and pneumatized • Can occur as early as 6 months • Frontal sinus: develop around 7 years • Usually occurs around age 10 yearss

29. Acute Sinusitis: diagnosis Timeframe of >10 days but <30 days AND Two Major or One Major with two Minor • Major Criteria • Facial congestion and/or fullness • Fever • Purulent rhinorrhea or post nasal drip • Facial pain or pressure • Nasal obstruction • Hyposmia or anosmia • Minor Criteria • Headache • Halitosis • Fatigue • Dental pain • Cough • Otalgia and or aural/fullness

30. Acute Sinusitis • Diagnostic Tests: New 2013 AAP Guidelines • Should NOT use imaging to determine acute bacterial sinusitis from viral sinusitis • Includes Xray, CT, MRI, and ultrasound • Inflammation is seen with viral along with bacterial • Should be a Clinical Diagnosis • Presumptive Acute Bacterial Sinusitis occurs if any of the 3 occur: • Persistent illness • 10-30 days w/o improvement, cough • Worsening course • Improvement followed by sudden worsening • Severe onset • 39C (102.2F), purulent nasal discharge, looks ill

31. Acute Sinusitis • Management (AAP 2013 guidelines) • 60-80% resolve without antibiotics in 4 weeks (viral) • Is the patient high or low risk? • Antibiotics for bacterial sinusitis • First line: Amoxicillin • If > 2yrs, no day care, no antibiotics in past 4 wks: 45 mg/kg/day, split BID • If high risk of resistance, use high dose of 80-90mg/kg/day, split BID • If < 2yrs, in day care or recent antibiotics: use amoxicillin-clavulnate 80-90mg/kg/day, split BID • If penicillin allergic • Cefdinir(Omnicef), cefuroxime(Ceftin), cefpodoxime (Vantin) • Consider otolaryngology if persistent or fail treatment

32. How Long to Treat for Sinusitis? • 10, 14, 21, 28 days? • “Optimal duration has nt received systematic study” (Wald 2013) • AAP, 2013 • 10 days or 7 days after improvement • Majority improve in 3 days • Infectious Disease Society, 2012 • 5 to 7 days

33. Additional Sinusitis Care • Remember to include • Saline nasal spray or drops • Liquifies secretions • Decreases crusting near the sinus ostia • Topical decongestants • Decreases tissue edema and nasal resistance • Enhances drainage of secretions from sinus ostia • Corticosteroids • Helpful in chronic sinusitis or concurrent allergic rhinitis • No evidence for acute sinusitis

34. Antibiotic Stewardship in Outpatient Prescribing • Know the organism • Know the resistance in your area • Display a Commitment in the office • Track prescribing in the practice • Educate the patient/parent about the harms of antibiotic treatment