Jimmy's Got Cooties!

Common Childhood Infections and How Best to Treat Them

Objectives:

!   Recognize and manage several infections commonly seen in Pediatric practice

!   Discuss best practices and current clinical guidelines for these common childhood infections

!   Discuss emerging evidence-based treatments and new data for each infection

Upper Respiratory Infection

!   Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Infections (published November 2013)

!   Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis (published July 2013)

!   The Diagnosis and Management of Acute Otitis Media (published February 2013)

!   Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis (published September 2012)

Bacterial URI?

!   "Most upper respiratory tract infections are caused by viruses and require no antibiotics."

!   3 recognized bacterial infections: acute bacterial sinusitis, acute otitis media, and streptococcal pharyngitis

!   Everything else, including non-strep pharyngitis, the common cold, acute cough illness, and bronchitis show NO benefit to antibiotic therapy

Principles of Judicious Antibiotic Use: 3 Core

Principles

!   Apply rigorous and stringent diagnostic criteria

!   Weigh the ratio of benefit to harm

!   Select the most appropriate narrow-spectrum drug at the appropriate dose and for the shortest effective duration

Scope of the Problem: Antibiotic Overuse

!   50 million antibiotic prescriptions annually

!   10-12 million per year are "directed toward respiratory conditions for which they are unlikely to provide benefit"

!   Broad-spectrum, "shotgun" antibiotic use is on the rise, contributing to increasing antibiotic resistance and increased rates of drug-related events

Antibiotic Resistance

Antibiotic Resistance

Acute Bacterial Sinusitis Diagnostic Criteria

!   Persistent illness: URI symptoms lasting >10 days without improvement

!   Worsening illness (double sickening): worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement

!   Severe illness: concurrent fever and purulent nasal discharge for >3 consecutive days

!   No role for imaging to distinguish viral vs. bacterial etiology

Acute Bacterial Sinusitis

Acute Bacterial Sinusitis

!   Initiate treatment for "worsening" and "severe" infections

!   Consider a 3 day observation period prior to initiating antibiotics for "persistent" infections

!   Use high dose Amoxicillin (80 to 90 mg/kg per day divided bid) with or without clavulanate if antibiotics are indicated

!   If no improvement in 72 hours, upgrade to either high-dose amoxicillin-clavulanate or clindamycin PLUS cefixime or levofloxacin

!   Duration of therapy is not well-defined, but a good option is to treat for 7 days past the patient becoming symptom-free

Judicious Prescribing Strategies

Acute Bacterial Sinusitis

!   Intranasal steroids: while data in adults show significant reduction in symptoms, nearly all of the studies had "methodological flaws" including the 2 studies done in children.

!   OTC cold medications: insufficient data to recommend use, but these meds are generally contraindicated in children

!   Saline irrigation: few well-designed studies, with mixed results; minimal negative effects

Adjunctive Therapies

Acute Bacterial Sinusitis

!   Do "watch and wait" prescriptions work? A study by Little et al in the UK (March 2014) says they do.

!   Zinc supplementation for the common cold (2011) showed reduction in duration and severity of symptoms as well as frequency of infections but firm recommendations could not be made

The Latest

Acute Otitis Media

!   Moderate to severe bulging of TM or new-onset otorrhea

!   Mild bulging of TM along WITH <48 hours of ear pain

!   Both require presence of middle ear effusion

Diagnostic Criteria

Acute Otitis Media

Acute Otitis Media

Acute Otitis Media Judicious Prescribing Strategies

!   Assessment and treatment of pain is REQUIRED regardless of further treatment path chosen

!   Prescribe antibiotics for those with severe signs or symptoms: fever >102.2, moderate or severe otalgia, or pain >48 hours

!   Prescribe antibiotics for those with otorrhea

!   For children 6 months to 2 years, prescribe antibiotics for bilateral infections, even without severe symptoms

Acute Otitis Media Judicious Prescribing Strategies

!   For bilateral infections in kids over 2 with non-severe symptoms, consider a WASP

!   For unilateral infections with non-severe symptoms in all ages, consider a WASP

Acute Otitis Media Judicious Prescribing Strategies

!   First line antibiotic choice is amoxicillin at high dose (80-90 mg/kg/day) as long as child is not penicillin-allergic, has not been treated with amoxicillin in past 30 days, and does not have concurrent conjunctivitis

!   If the child has recently been on amoxicillin, has conjunctivitis, or has a history of unresponsiveness use high dose amoxicillin-clavulanate

!   Alternate medications include cefdinir, cefuroxime, cefpodoxime, IM ceftriaxone

Acute Otitis Media Judicious Prescribing Strategies

!   Use a 10 day course for children <2 and for those with severe symptoms

!   Use a 5-7 day course in those >2 with mild to moderate symptoms

!   Do NOT use long-term prophylactic antibiotics

Acute Otitis Media Adjunctive Therapies

!   Xylitol shows benefit for prevention of recurrence of AOM, when used as a lozenge or chewing gum

!   NO good studies evaluating the effectiveness of complementary/alternative treatments, such as saltwater gargles, chiropractic manipulation, essential oils, etc

!   Consider referral to ENT for tympanostomy tubes in cases of recurrent OM, defined as 3 episodes in 6 months or 4 episodes in one year

!   Recommend PCV and Influenza vaccination

Acute Otitis Media The Latest

!   Probiotics for prevention of AOM? Maybe...(2013)

!   Vitamin D supplementation may reduce the risk of recurrence Of AOM (2013)

!   Novel live-attenuated pneumococcal vaccine provides serotype-independent coverage for AOM, sinusitis, pneumonia and invasive disease in mice (2014)

!   Diagnosis should NOT be based solely on clinical signs/symptoms, though there are some that point toward or away from strep

Strep Pharyngitis Diagnostic Criteria

Toward Away

Acute Pharyngitis Bacterial vs. Viral

Acute Pharyngitis Bacterial vs. Viral

Acute Pharyngitis Bacterial vs. Viral

Strep Pharyngitis Diagnostic Criteria

!   Throat swabs, either rapid in-office tests or cultures, SHOULD be performed for patients WITHOUT features suggestive of viral infections

!   Swabs are NOT indicated for children <3

!   Back up throat cultures SHOULD be sent for children and adolescents, but may not be necessary for adults

Strep Pharyngitis Judicious Prescribing Strategies

!   Rationale for treatment is prevention of complications and to reduce the spread of infection, not to shorten the duration of illness.

!   GAS infections are self-limited; symptoms typically resolve within a few days of onset

!   Routine testing and treatment of asymptomatic household contacts and chronic carriers is NOT recommended

Strep Pharyngitis Judicious Prescribing Strategies

!   Penicillin, amoxicillin or IM benzathine penicillin G are the drugs of choice in non-allergic patients

!   Amoxicillin can be used once daily at 50 mg/kg and tastes better than penicillin

!   In penicillin-allergic patients, use a first generation cephalosporin, such as cephalexin or cefadroxil; azithromycin or clarithromycin; or clindamycin

!   All should be given for 10 days, except azithromycin which is given for 5 days

Strep Pharyngitis

!   Analgesics/antipyretics, such as acetaminophen or NSAIDs are helpful

!   Do not use aspirin in children <18

!   Oral corticosteroids are NOT recommended

!   Topical agents may give symptomatic relief

!   Tonsillectomy is NOT recommended to reduce frequency of pharyngeal infection

Adjunctive Therapies

Strep Pharyngitis The Latest

!   Is a strep throat vaccine not only possible, but in the works? Several studies show work is ongoing (2013 and 2014)

!   Why do "treatment failures" exist when there is no resistance to penicillin? (2014)

!   Are the recommended medications really the best choices? (2014)

Thanks for your attention!

References !   Hersh AL, Jackson MA, Hicks LA; Committee on Infectious Diseases.

Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Pediatrics. 2013;132(6):1146–1154

!   Wald ER, Applegate KE, Bordley C, et al; American Academy of Pediatrics. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280

!   Little P, Moore M, et al; Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ 2014;348:g1606

!   Singh M, Das RR. Zinc for the common cold. Cochrane Database Syst Rev. Feb 16 2011;2:CD001364.

! http://sinusirrigationrelief.com/category/sinusitis/

! http://marcofratelli.hubpages.com/hub/snot#slide767502

References !   Lieberthal AS, Carroll AE, Chonmaitree T, et al; The diagnosis and

management of acute otitis media. Pediatrics. 2013;131(3):e964-e998

! http://otitismedia.hawkelibrary.com

! http://www.easynotecards.com/uploads/202/58/_53022d86_13d85ffda7d__8000_00006194.jpg

!   John M; EM, et al; Otitis media among high-risk populations: can probiotics inhibit Streptococcus pneumoniae colonisation and the risk of disease? European journal of clinical microbiology & infectious diseases. 2013; 32(9):1101-10.

!   Marchisio P; Consonni D, et al; Vitamin D supplementation reduces the risk of acute otitis media in otitis-prone children. Pediatric Infectious Disease Journal. 2013; 32(10):1055-1060

!   Rosch JW; Iverson AR, et al; A live-attenuated pneumococcal vaccine elicits CD4+ T-cell dependent class switching and provides serotype independent protection against acute otitis media. EMBO molecular medicine. 2014; 6(1):141-54.

References !   Shulman ST, Bisno AL, Clegg HW, et al; Clinical practice guideline for the

diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86–e102

! http://www.webmd.com/cold-and-flu/ss/slideshow-anatomy-of-a-sore-throat

! http://classconnection.s3.amazonaws.com/1524/flashcards/763163/png/screen-shot-2011-01-23-at-8.14.54-pm.png

! http://4.bp.blogspot.com/-WZStzqPJdYA/Tk-2oxmtQdI/AAAAAAAACyM/Ef2n_00d9BA/s640/Infectious+mononucleosis++petechiae+on+the+palate.png

! http://upload.wikimedia.org/wikipedia/commons/b/ba/Streptococcal_pharyngitis.jpg

!   http://www.mouthmattersbook.com/mrsdalloway/wp-content/gallery/book-images/zp_tonsils.jpg

! http://www.easynotecards.com/print_list/6168

References !   van Sorge NM, Cole JN, et al; The Classical Lancefield Antigen of Group A

Streptococcus Is a Virulence Determinant with Implications for Vaccine Design. Cell Host & Microbe, 2014; 15 (6): 729

!   Song Y, Zhang X, et al; Progress in development of Group A Streptococcus vaccines. Curr Pharm Biotechnol. 2013;14(11):947-50.

!   Scharr V, Uddback I, et al; Group A streptococci are protected from amoxicillin-mediated killing by vesicles containing β-lactamase derived from Haemophilus influenzae. J Antimicrob Chemother. 2014;69(1):117-20.

!   Altamimi S, Khalil A, et al; Short-term late-generation antibiotics versus longer term penicillin for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. 2012 Aug 15;8:CD004872

!   Mijac V, Opavski N, et al; Trends in macrolide resistance of respiratory tract pathogens in the paediatric population in Serbia from 2004 to 2009. Epidemiol Infect. 2014 May 9:1-5.

!   Neely M, Kaplan EL, et al; Serum Penicillin G Concentrations Are Below Inhibitory Concentrations by Two Weeks After Benzathine Penicillin G Injection in the Majority of Young Adults: A Population Pharmacokinetic Modeling Approach. Antimicrob Agents Chemother. 2014 Sep 2. pii: AAC.02744-14.