Community Respiratory Tract Infections: Upper and Lower Thomas M - PowerPoint PPT Presentation

Community Respiratory Tract Infections: Upper and Lower Thomas M File, Jr MD MSc MACP FIDSA FCCP Chair, Infectious Disease Division Summa Health System Akron, Ohio; Professor of Internal Medicine,Chair ID Section Northeast Ohio Medical University Rootstown, Ohio

Acute Respiratory Tract Infections  Most common reason for antimicrobials  Many infections Unspecified URI Otitis Common Cold Acute Bronchitis Sinusitis Chronic Bronchitis Pharyngitis Pneumonia  Challenge  What infections warrant antimicrobial therapy?  What etiology (viral vs bacterial)?

Which of the following options is the most appropriate therapy for a 45 year old, non- smoking male with 5 days of non-productive cough, malaise, and nasal obstruction who is afebrile with normal vital signs and whose lungs findings are clear to auscultation? A. Macrolide antimicrobial b. Fluoroquinolone antimicrobial c. Doxycyline antimicrobial d. Telithromycin e. non of the above

Appropriate Use of Antibiotics: Indications for RTI  Consider most likely pathogens  Stratify patients according to risks for resistant strains and predictors of outcome  Recent Antibiotic use  Severity of illness

Risk Factors for Drug-Resistant S. pneumoniae  Underlying disease  Recent  HIV antimicrobials  Immunodeficiency  Recently hospitalized  Institutionalized patients  Extremes of age patients (especially < 6 yrs)  Day care center Campbell GD Jr, Silberman R. Clin Infect Dis. 1998;26:1188.

You are asked to evaluate a 20 y/o college student who presents with a sore throat of 2 days duration. Afebrile. Pharynx-moderate erythema. Which of the following options is your choice of management ? A. Pen VK 500 mg bid x 10 days b. Oral cephalosporin Qd x 5 days c. Z-pac d. Rapid antigen test for S. pyogenes e. Throat culture

Pharyngitis  Most pharyngitis is viral  S. pyogenes (GAS) — only common etiology of pharyngitis for which antimicrobials are indicated • accounts for up to 25% in children, much less in adults  Concern for severe post-streptococcal complications • Acute rheumatic fever (risk is low in developed countries) • Acute glomerulonephritis (no evidence ATB prevents) • Local suppurative (low risk)  Other causes: GC, Mono, Mycoplasma, Grp C/G Strep, Arcanobacterium hemolyticus ( unresponsive to PCN), Fusobacterium necrophorum (Lemierres syndrome) Inf Dis Soc Am Guidelines, Clin Inf Dis . 2012: available www.idsociety .org

Rash associated with Arcanbacterium hemolyticus

Pharyngitis  Indications for antimicrobial therapy  Base on rapid antigen test or throat culture • Newer antigen tests have sensitivity approx 90% • No need to do culture for adults if antigen neg.  vs syndromic approach (adenopathy, exudate, fever, lack of cough….) • Low predictability • Consider if high risk; ie, history of recurrent GAS-pharyngitis or ARF; epidemic) Inf Dis Soc Am Guidelines, Clin Inf Dis . 2012: available www.idsociety .org .

Grp A Strep vs Viral Pharyngitis Grp A Strep Viral Inf Dis Soc Am Guidelines, Clin Inf Dis . 2012: available www.idsociety .org .

IDSA Guideline: Grp A Strep therapy b. Avoid if immediate PCN hypersensitivity; c. Resistance variable Inf Dis Soc Am Guidelines, Clin Inf Dis . 2012: available www.idsociety .org

• F necrophorum casues pharyngitis in adolescents/young adults as common as Grp A Strep • Use a penicillin or cephalosporin or clindamycin (not macrolide) if a consideration in Strept-negative pharyngitis • Pharyngitis normally resolves in 3-5 days • 2 major flags are worsening sore throat and neck swelling • Often bacteremic and toxic; may require surgical intevention Centor R. Annals Intern Med. 2009; 151: 812-815 (Dec 1)

Which of the following is most appropriate concerning management of sinusitis? A. The most common cause of acute rhinosinusitis is pneumococcus b. An imaging study (X-ray or CT) is recommended to identify acute maxillary sinusitis c. Clinical manifestations of illness reliably predict the etiology d. An antimicrobial can be warranted if symptoms of sinusitis are persisting for > 10 days e. The drug of choice of mild bacterial sinustis is a macrolide

Management of Sinusitis  Acute sinusitis is generally viral  0.5%-2% develop secondary bacterial sinusitis  Predictors of bacterial sinusitis (acute maxillary)  Symptoms >7 days; severe  Facial pain/tenderness, fever, dental pain, abnormal transillumination, intranasal pus, unresponsive to decongestants  Imaging studies not suggested for initial Rx  Most common bacterial pathogens: S. pneumoniae, H. influenzae Sinus and Allergy Health Partnership. Otolaryngol Head Neck Surg . 2004;130(Suppl 1):1-45.

Pathophysiology of Bacterial Sinusitis – Viral URI most common preceding cause Adapted from Gwaltney: Clin Infect Dis 23:1209-1225, 1996; Reilly: Otoloaryngol Head Neck Surg 103:856-862, 1990.

Radiologic Imaging: CT Photo courtesy J. Hadley, MD.

Antimicrobial Therapy for Acute Bacterial Rhinosinusitis  Mild severity, no recent antibiotic  Amoxicillin, amoxicillin/clavulanate, cefpodoxime, cefuroxime, (Alternative: TMP/SMX, doxycycline, or macrolide)  Mild, recent antibiotic  Amoxicillin/clavulanate (high-dose), amoxicillin (high-dose), cefpodoxime, cefuroxime, respiratory FQ (if  -lactam allergic)  Moderate severity, no recent antibiotic  Amoxicillin, amoxicillin/clavulanate, cefpodoxime, cefuroxime, new FQ (if  -lactam allergic)  Moderate, recent antibiotic  New FQ, amoxicillin/clavulanate (high-dose), combination (amoxicillin or clindamycin + cefixime) Sinus and Allergy Health Partnership. Otolaryngol Head Neck Surg. 2004;130(Suppl1):1-45.

Augmentin XR™  Pharmacokinetic design  Bilayer tablets with immediate release layer of amoxicillin and clavulanate, and extended release layer of amoxicillin  Each tablet contains 1 gm amox and 62.5 gm clavulanate • Increases daily dose of amoxicillin — 2000 mg BID = 4000 mg/day • Maintains daily dose of clavulanate — 125 mg BID = 250 mg/day  Extends coverage to include S. pneumoniae with elevated amoxicillin MICs  Indications  CAP; Acute Bacterial Sinusitis; especially nWhen PRSP is a concern  Tolerability  Similar to Augmentin 875 (clavulanate dose is the same)  Diarrhea approx 10% (most are mild)

New Guideline Recommendations (pending review and approval ) The following clinical criteria (any of three) are recommended for identifying patients with acute bacterial vs. viral rhinosinusitis:  Onset with persistent symptoms (nasal discharge of any quality or daytime cough or both) lasting for >10 days without any evidence of clinical improvement);  Onset with severe symptoms (purulent nasal discharge and fever or facial pain) lasting for at least 3-4 days at the beginning of illness; or  Onset with initial improvement followed by worsening of respiratory symptoms (nasal discharge or cough or new onset fever or headache) lasting for 3-4 days. Clin Infect Dis. April, 2012

New Recommendations (pending approval)  Amoxicillin-clavulanate rather than amoxicillin alone is recommended as empiric antimicrobial therapy for ABRS in both children and adults.  It is recommended that “high - dose” amoxicillin -clavulanate be administered to children and adults from geographic regions with high endemic rates of penicillin-nonsusceptible S. pneumoniae, severe infection, a recent history (within 3 months) of hospitalization or antibiotic use, or those with co- morbidities or are immuno-compromised.  Either doxycycline (not suitable for children) or a respiratory fluoroquinolones (levofloxacin or moxifloxacin) are recommended as alternative agents for empiric initial antimicrobial therapy in patients allergic to penicillin. (macrolides or SXT/TMP NOT listed)  The recommended duration of therapy for uncomplicated ABRS in adults is 5-7 days. (Children 10-14d)

New Recommendations

New Recommendations  Intranasal saline irrigations are recommended as an adjunctive treatment in patients with ABRS. Either physiologic or hypertonic saline is recommended.  Intranasal corticosteroids may be used as an adjunct to antibiotics in the empiric treatment of ABRS, particularly in those with a history of allergic rhinitis. This recommendation places a relatively high value on a small additional relief of symptoms and a relatively low value on avoiding increased resource cost.  Neither topical nor oral decongestants and/or anti-histamines are recommended as adjunctive treatment in patients with ABRS (in placebo trials no significant benefit and causes increase in inflammation)

COPD Airflow limitation/ obstruction present Emphysema Bronchiectasis Chronic bronchitis • Chronic productive cough for 3 months in each of 2 successive years • 85% of COPD AECB • Increased dyspnea • Increased sputum volume • Increased sputum purulence COPD = chronic obstructive pulmonary disease; AECB = acute exacerbations of chronic bronchitis McCrory et al. Chest . 2001 Apr;119(4):1190-209