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Editorial: Revised guideline for the management of upper respiratory tract infections

Revised guideline for the management of upper respiratory tract infections

In this edition of the Journal, the original guideline for the management of upper respiratory tract infections has been revised and reprinted with permission.1 The aim of this editorial is to highlight issues in the guideline that needed updating, taking cognisance of the following factors: • Introduction of new antibiotics or new formulations of existing antibiotics • Trends in antibiotic pharmacokinetic/pharmacodynamic (PK/PD) parameters that may impact on previous guideline recommendations • The potential impact of the 7-valent pneumococcal conjugate vaccine (PCV) on otitis media • Acute otitis media with otorrhoea in patients with tympanostomy tubes (AOMT) has not previously been considered as a separate clinical entity; in this revised guideline the entity is discussed, including the treatment thereof.

Trends in antibiotic PK/PD parameters
Concerning duration of treatment for ABS, recent studies have shown that bacteriological eradication occurs within 72 hours with moxifloxacin (400 mg once daily) or with high-dose, shortcourse levofloxacin (750 mg once daily for five days).2,3 This higher dose of levofloxacin improves the PK/PD profile of the agent and in a comparative trial of this dose versus levofloxacin 500 mg once daily for 10 days, clinical and microbiological efficacy of the high-dose, short-course treatment was found to be similar.4 These kind of studies might eventually impact on recommendations for duration of treatment of ABS. Based upon PK/PD findings and a clinical trial of otitis media, cefprozil (15 mg/kg twice daily) should not be used empirically in this setting as it is only effective against penicillin-susceptible pneumococci.5,6

Impact of the 7-valent pneumococcal conjugate vaccine (PCV) on otitis media
The most significant development since the original guideline was published has been the introduction of the 7-valent PCV, which has had a significant impact on the prevalence of otitis media. The impact of the PCV on rates of AOM, antibiotic prescriptions for AOM, insertions of pressure-equalising tubes, and overall expenditure, is discussed in this update. In this edition of the Journal, Shabir Madhi reviews the introduction of this vaccine into the South African immunization programme and discusses the “dawn of a new era” in pneumococcal disease (South Afr J Epidem 2008;23 (4):00-00).

Introduction of new antibiotics or new formulations of existing antibiotics
The following new formulations of amoxycillin/clavulanic acid have been registered: • For children, 90 mg/kg amoxicillin/6.4mg/kg clavulanic acid divided in two doses per day • For adults, sustained release tablets of 1 g amoxycillin/62.5 clavulanic acid, two tabs twice daily Both these formulations alleviate the need to use standard doses of amoxycillin/clavulanic acid plus additional amoxycillin to achieve concentrations recommended in the previous guideline. Gatifloxacin has been discontinued and is no longer available. Gemifloxacin (320 mg daily) has been registered as a five-day course for acute bacterial sinusitis (ABS). Ciprofloxacin with dexamethasone as an otic suspension has been registered for the local treatment of AOMT.

Conclusions
While this short editorial summarises most of the issues that have been updated in the Upper Respiratory Tract Infection Guideline, it is envisaged that the Working Group will meet in the future to formally update the document.

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2008;23(4)

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