Upper respiratory tract infections

:Include

Otitis media 2- Sinusitis 3- Pharyngitis 4- Laryngitis 5-Common cold -1

Otitis media ( middle ear infection ) -1

-It is the most common childhood illness treated with antibiotics

Occurs mostly between 6 and 18 months of age -

Acute otitis media (AOM) may be viral or bacterial -

- : Historically, bacterial AOM was caused by

Streptococcus pneumoniae (50% of the cases) -1

Haemophilus influenzae (30%) -2

Moraxella catarrhalis (20%) -3

Haemophilus influenzae (60%) ( Due to routine pneumococcal vaccination in( USA >>

Lack of improvement with antibiotics is usually a result of viral infection and subsequent
inflammation rather than antibiotic resistance
‫نحن بندرس من مصادر امريكية او بريطانية فهم بعتمدوا على االحصائيات الي موجودة عندهم بس وجود البكتيريا ونمط مقاومتها للمضادات الحيوية بختلف من منطقة‬
‫االخرى‬

Treatment of AOM

::Empiric treatment > Treatment should be aimed to cover S. pneumonia because

-pneumococcal AOM is unlikely to resolve spontaneously (needs antibiotics)

commonly results in more ear pain and fever (more severe disease)

Antibiotics should be reserved for patients most likely to benefit(confirmed or high suspicion of bacterial
,.infection), which is dependent on proper diagnosis, patient age, and illness severity

Pharmacology therapy

- Analgesics (pain killers) should be used regardless of antibiotic therapy to treat pain

-Paracetamol and ibuprofen are commonly used

Ibuprofen provides longer relief than acetaminophen (Paracetamol) but should be -

.avoided in children younger than 6 months because of increased toxicity concerns
Initial observation and delayed prescriptions are considered in otherwise healthy children to reduce
.antibiotic use

Severe disease

.Otalgia  ear pain-

.Otalgia for more than 48 hours-

.Body temperature more than 39 C-

Bilateral AOM  infection in both ears

Antibiotic therapy

:Amoxicillin is the drug of choice in most patients because

proven effectiveness 2-high middle ear concentrations-1

excellent safety profile 4- Low cost 5- Palatable suspension-3

Relatively narrow spectrum ( to lower the risk of antibiotics resistance in the future) -6

 High dose amoxicillin (80-90 mg/kg/day) is preferred over conventional dose (40-45

mg/kg/day), because higher middle ear fluid concentrations can overcome pneumococcal
.penicillin resistance without substantially increasing adverse effects

:High dose amoxicillin-clavulanate is preferred for children who

received amoxicillin in the previous 30 days-

-conjunctivitis purulent concurrent have)‫(التهاب الملتحمة في العين‬

have a history of recurrent AOM unresponsive to amoxicillin -

 Low cross sensitivity between
penicillin and cephalosporins in
the cases of less severe allergic
reaction (non IgE mediated)

If there is no improvement or worsening with initial therapy during the first 48 to 72

hours  proper diagnosis and antibiotic selection must be reassessed

Note: we try to give the patient the least possible duration recommended to decrease the

.risk of antibiotic resistance

Sinusitis(Also called paranasal sinus inflammation or rhinosinusitis) -2

It is caused mainly by respiratory viruses but can also be triggered by allergies (allergic -
.rhinitis) or environmental irritants

Viral rhinosinusitis is complicated by secondary bacterial infection in 0.2% to 2% of adults -

.and 5% to 7% of children

Bacteria that cause sinusitis are mostly S. pneumonia, H. influenzae and M catarrhalis. -
(same as otitis media)
Treatment of sinusitis
:Initial management should focus on

-Symptom relief )‫(االعراض المزعجة للمريض لدرجة انه ممكن ما يعرف ينام منها‬

identification of patients with acute bacterial rhinosinutis (ABRS) who are most likely to -
.benefit from antibiotics

Antibiotics should be prescribed only when ABRS is most likely and when the benefits

of treatment outweigh the potential harms.(high suspicion to be bacterial infection)

Non-pharmacologic therapy
Humidifiers (dry air makes the mucosa dry ) more susceptible to infections)-1

nasal saline sprays or drops-2

nasal saline irrigation devices (use normal saline to wash the nasal cavity)

All of the above moisturize the nasal canal, impair crusting of secretions promote
.mucociliary clearance

Nasal irrigation with isotonic or hypertonic saline has a low risk of adverse reactions-3

and may reduce medication use and improve symptoms especially in )no side effects(
.patients with allergic rhinitis and recurrent or chronic sinusitis

Medications that target rhinosinusitis symptoms are commonly used despite a lack of -4
.published evidence supporting their efficacy

Analgesics/antipyretics may be used to treat facial pain and fever. ibuprofen/ -5

paracetamol

Oral decongestants (pseudoephedrine) relieve congestion -6

 but should be avoided in children younger than 4 years and patients with ischemic heart
.disease or uncontrolled hypertension

Intranasal decongestants can be used for severe congestion in patients 6 years of age or -7
older.
 but use should be limited to 3 to 5 days to avoid rebound nasal congestion
rebound nasal congestion : nasal congestion comes back more severely after
.discontinued use

Antihistamines should be avoided because they thicken mucus and impair clearance -8
.(not recommended for bacterial rhinosinusitis)
Antibiotic therapy
In adults, some experts recommend the use of watchful waiting for up to 7 days after -
.ABRS is diagnosed

If symptoms worsen or fail to improve by 7 days post diagnosis, reevaluation should occur -
.and antibiotics should be initiated

Other experts recommend prompt antibiotic therapy in all patients when the diagnosis of -
.ABRS is confirmed with use of strict diagnostic criteria
PRSP  Penicillin Resistant
Streptococcus Pneumoniae

If child cannot take oral therapy, a single dose of ceftriaxone 50 mg/kg per day (maximum -
.dose 1 g/day) intravenously (IV) or intramuscularly (IM) can be used