Common Cold, Sinusitis, Influenza: The Diseases, Prevention, Treatment

8/12/2019 Common Cold, Sinusitis, Influenza: The Diseases, Prevention, Treatment

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Mona T. Thompson, R.Ph., PharmD

continuing educat ion for pharmacists

Common Cold, Sinusit is , In fluenza:

The Diseases, Prevention, Treatment

Volume XXX, No. 11

Dr. Mona T. Thompson has no relevant

nancial relationships to disclose.

Goal. The goal of this lesson is toprovide disease state reviews of the

common cold, sinusitis, and inu-enza. This lesson will also high-

light key differences between each

disease state, and review current

treatment recommendations and

prevention when applicable.

Objectives. At the completion ofthis activity, the participant will be

able to:

1. demonstrate an understand-

ing of the basic pathophysiology

of the common cold, sinusitis, and

inuenza;

2. compare the symptoms of

these three disease states;

3. list the antibiotics used in

the treatment of sinusitis;

4. recognize the appropriate

use of antiviral agents in the pre-

vention and/or treatment of inu-

enza; and

5. list the recommendations for

the appropriate use of the inuenza

vaccine.

The Common ColdThe term common coldrefers to

a collection of upper respiratory

symptoms that are caused by an

array of viral pathogens. Symp-

toms include nasal congestion,

rhinorrhea, sneezing, sore throat,

cough, low-grade fever, headache,

and malaise. The average incidence

of the common cold is six to eight

episodes per year in preschool chil-

dren, and two or three per year in

adults. Adults who live with young

children experience more colds

than those who dont. In infants

and young children, symptoms usu-ally peak on day two or day three of

the illness and persist for 10 to 14

days. In some children, the cough

may last up to three or four weeks.

The duration of illness for adoles-

cents and adults is usually seven to

10 days.

While generally considered

mild and self-limiting, the common

cold is associated with a tremen-

dous economic burden due to lost

productivity and the cost of treat-

ment. It is estimated that viralrespiratory tract infections account

for 21 million days of school ab-

sence and 20 million days of work

absence per year in the U.S. alone.

Annually, approximately three bil-

lion dollars are spent on over-the-

counter cough and cold medications

for symptomatic treatment.

The pathogens most commonly

associated with common cold symp-

toms are the rhinoviruses. There

are over 100 different types that

account for 40 to 50 percent of the

cases. Other responsible pathogens

include coronaviruses and respira-

tory syncytial virus (RSV). While

inuenza, parainuenza, and ad-

enoviruses may be associated with

cold symptoms, they often cause

lower respiratory and systemic

symptoms, in addition to the upper

respiratory symptoms character-

istic of the common cold. These

infections also present differently

in younger children, versus older

children and adults. For instance,

RSV in older chidren and adults

often presents the same as other

colds, but in infants and toddlers,it can result in bronchiolitis and

involve the lower respiratory tract.

Similarly, parainuenza may pres-

ent as croup in younger children

and as a typical cold in an older

child.

The cold season begins in late

August/September and remains

constant until the spring due to

the number of viruses. Rhinovirus

begins to increase in the early fall.

Alternatively, parainuenza peaks

in the late fall and late spring,while RSV and inuenza viruses

are highest between December

and April. Common cold symptoms

are associated with each of these

outbreaks.

An effective vaccine for the

common cold is unlikely for two

reasons. First, some of these

viruses do not cause lasting im-

munity such as RSV, parainuenza

viruses, and coronavirus which

can result in recurrent infections.

Second, even though other virusesdo produce lasting immunity, there

are so many serotypes that a

vaccine would not produce a real

impact on reducing the frequency

of common cold infections.

Transmission and Preven-

tion.Colds may be spread through

three mechanisms: (1) small-parti-

cle aerosols produced from cough-

ing and inhaled by another person;


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(2) large particle droplets produced

from saliva that is expelled during

a sneeze and lands on the conjunc-

tivae or nasal mucosa of another

person; or (3) self-inoculation from

touching ones own nasal mucosa

after touching a person or object

contaminated with a cold virus.

Hence, poor hygiene and cu-

riosity may be factors that lead tochildrens increased susceptibility

to colds. Hand-washing removes

the cold virus from the hands.

Virucidal tissues have been shown

to reduce secondary transmis-

sion. However, alcohol-based hand

sanitizers have not been shown to

reduce secondary transmission of

colds, most likely because rhinovi-

rus is not affected by these prod-

ucts.

Treatment.While treatment

options differ in adults and chil-dren, symptomatic and supportive

treatment remains the mainstay

for the common cold. The following

treatment options do not reduce

disease duration. Antibiotics are

not indicated unless symptoms

strongly suggest a secondary bacte-

rial infection. Antiviral therapy is

not available for viruses that cause

the common cold.

Treatment in Adults. Ipra-

tropium bromide (Atrovent Nasal

Spray), an anticholinergic medica-tion which is administered intra-

nasally, may be helpful in improv-

ing symptoms of rhinorrhea and

sneezing. Via application to the

nasal mucosa, it inhibits mucous

gland secretions. However, it does

not improve nasal congestion. It is

usually dosed as two sprays in each

nostril, three to four times a day.

Adverse effects include nosebleeds,

nasal dryness, and dry mouth.

First-generation antihista-

mines such as diphenhydramine

may improve rhinorrhea and

sneezing, but their use is limited

due to bothersome side effects

including sedation and drying

of the eyes, nose, and mouth. A

systematic review of available data

concluded that rst-generation

antihistamines had a small clinical

benet for relief of rhinorrhea and

sneezing, but that this was out-

weighed by the frequency of side ef-

fects. Non-sedating antihistamines,

such as loratadine and cetirizine,

were not effective. Therefore, anti-

histamines have minimal benet in

treating the common cold.

Cough associated with the com-

mon cold is often due to post-nasal

drip or nasal obstruction. The

American College of Chest Physi-cians guidelines do not recommend

cough suppressants or antitussives,

such as codeine or dextromethor-

phan, for relief of cough associated

with upper respiratory infections.

Several clinical trials, however,

have concluded that dextromethor-

phan is superior to placebo for

cough suppression. Trials exam-

ining patients with acute cough

due to the common cold found

no consistent benet when co-

deine was compared with placebo,even though it may be helpful for

chronic cough.

Topical and oral adrenergic

agents such as phenylephrine and

pseudoephedrine may temporar-

ily alleviate nasal congestion.

Phenylephrine is less effective

than pseudoephedrine for treating

rhinitis symptoms, yet it is a com-

mon ingredient in many OTC cold

preparations. Since pseudoephed-

rine is currently being used in the

illegal manufacturing of meth-amphetamine, FDA has limited

purchases and the availability to

behind-the-counter in pharmacies.

Topical decongestants should not

be used for longer than two to three

days, as they can result in rebound

rhinitis. Adverse effects associated

with these agents include increased

blood pressure in those with pre-

existing hypertension, nosebleeds

(topical), agitation, and insomnia.

Expectorants are intended to

increase mucous production. The

most common commercial agent is

guaifenesin. Studies show it may

have a marginal effect in improv-

ing the thickness and quantity of

sputum in adults.

Sore throat may be treated

with aspirin or acetaminophen,

while non-steroidal anti-inam-

matories (NSAIDs) may be used

for headache, ear pain, muscle and

joint pains, malaise, and sneezing

associated with the common cold.

While their effectiveness is

questioned, saline nasal sprays or

irrigations and inhaling warm va-

porized air may ease some of these

symptoms.

Treatment in Children.

Over the past few years, the use of

OTC cough and cold medicationsfor children and infants has been

under investigation. Over the past

20 years, 123 deaths involving

children younger than six years of

age have resulted from the use of

OTC cough and cold medications.

The adverse events associated with

their use, as well as accidental

ingestion, are a common cause for

emergency department visits. Poor

labeling, use of multi-ingredient

products, and multiple caregivers

administering medications are fac-tors that lead to inadvertent over-

dosing. In October 2007, the U.S.

Food and Drug Administration

(FDA) Advisory Committee voted

to recommend against the use of

OTC cough and cold medications in

children younger than two years.

Drug manufacturers voluntarily

discontinued the marketing of

these agents for children less than

two years of age. Subsequently, the

number of emergency department

visits for adverse events involv-ing these medications was cut in

half for children in this age group.

In 2011, the FDA advisory group

voted again to further ban the use

of these agents in children less

than six years of age. The Ameri-

can Academy of Pediatrics (AAP)

recommends against the use of

OTC cough and cold medications

in children younger than six years,

due to safety concerns and the lack

of efcacy data surrounding their

use.

Supportive therapy for chil-

dren, as well as adults, includes

increasing uid intake to thin

secretions; ingesting warm uids

such as tea which may soothe the

respiratory mucosa, increase the

ow of nasal mucus, and loosen

mucus; the use of topical saline

and nasal suction to remove nasal

secretions; and the use of a humidi-


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er which helps loosen nasal secre-tions. While these interventions

are not proven to be effective, they

are safe and inexpensive.

Symptomatic treatment is sug-

gested only when symptoms are in-

terfering with sleep or causing dis-

comfort. Single ingredient products

are recommended to avoid overdos-

ing from multiple medications that

contain the same ingredient. Fever

and general discomfort from the

common cold may be treated with

acetaminophen for children older

than three months or ibuprofen for

children older than six months. The

use of aspirin is not recommended

in children due to the association

with Reyes Syndrome.

Regarding the treatment of na-

sal congestion and rhinorrhea, ip-

ratropium 0.06 percent nasal spray

(AtroventNasal Spray) is indicat-

ed for the relief of rhinorrhea due

to the common cold for ages ve to

11 years. There is no evidence sup-porting the effectiveness of either

oral or topical decongestants in

children. Antihistamines or com-

bination antihistamine/deconges-

tants are also not recommended for

nasal symptoms.

Antitussives are not recom-

mended in children for several

reasons. Coughing is a protective

action that clears the airway; sup-

pressing it may be harmful to chil-

dren, especially those with asthma.In addition, studies have failed to

indicate improvement when dex-

tromethorphan was used. Lastly,

accidental overdose of antitussives

can cause respiratory depression.

One recent study suggested

that the bedtime application of

vapor rub containing menthol,

camphor, and eucalyptus oils to

the chest and neck of children aged

two to 11 years resulted in relief

of night-time cough, congestion,

and difculty in sleep compared

to petrolatum or no treatment. It

should not be applied to the nasal

passages, as it may cause chemical

irritation there. Gastrointestinal

and central nervous system effects

may result from accidental inges-

tion.

Complications of the Com-

mon Cold. Wheezing or secondary

bacterial infections such as otitis

media, sinusitis, or pneumonia

may complicate the common cold.Approximately 30 percent of colds

in preschool-aged children may be

complicated by otitis media, with

the risk being highest in children

six to 11 months of age. Sinusitis

may occur in 5 to 10 percent of

children with colds, and is con-

sidered when symptoms do not

improve after 10 days. Infants

and children with reactive airway

disease or asthma are at a higher

risk for complications, and may

have increased severity and dura-

tion of respiratory symptoms. Fifty

percent of asthma exacerbations

are associated with viral infections

particularly rhinovirus. RSV is also

associated with wheezing exacerba

tions.

Table 1 includes comparison of

symptoms, prevention and treat-ment for the common cold and

inuenza.

SinusitisAcute rhinosinusitis (ARS) is

dened as symptomatic inam-

mation of the nasal cavity and

paranasal sinuses lasting fewer

than four weeks. The term rhinosi-

nusitisis used since inammation

of the sinuses is almost always

accompanied by inammation

of the nasal cavity, and is morecommonly referred to as sinusitis.

Viral etiology associated with an

upper respiratory infection (URI)

or the common cold is the most

frequent cause of sinusitis. Howev-

er, sinusitis can also be caused by

allergens, environmental irritants,

and bacterial or fungal infections.

Acute viral rhinosinusitis (AVRS)

is extremely common, while sec-

ondary bacterial infections of the

paranasal sinuses following a viral

URI are estimated to occur in 0.5 to2 percent of adults and 5 percent of

children. Even though viral infec-

tions account for 92 to 98 percent

of the cases, acute rhinosinusitis

is the fth leading indication for

antibiotic prescribing by healthcare

professionals. Contrary to common

belief, the presence of colored or

green nasal discharge alone does

not indicate that the infection has

been complicated by bacteria. In an

uncomplicated case of viral URI,

the nasal discharge begins as clear

and watery, and becomes thicker

and more mucoid throughout

the course of the disease. It may

become thick, colored, and opaque

for several days before reversing to

mucoid and clear again or drying.

Because differentiating between

AVRS and bacterial infection is dif-

cult, it is challenging to determine

when antibiotics are indicated.

Table 1Comparison of the common cold and flu

Symptoms Cold Flu

Fever Rare Characteristic, high, lasting 3-4 days

Headache Rare Prominent

General Aches, Pains Rare Prominent

Fatigue, Weakness Mild May last 2-3 weeks

Extreme Exhaustion Never Early and prominent

Stuffy Nose Common Sometimes

Sneezing Usual Sometimes

Sore Throat Usual Sometimes

Chest Discomfort, Cough Mild to Common; can become severe

moderate

hacking cough

Prevention Good hygiene Inuenza vaccine

Treatment Temporary Antiviral drugs (Relenza

symptom or Tamiu) within 24-48 hours

relief


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Studies indicate that some patients

with acute bacterial rhinosinusitis(ABRS) may clear the infection

spontaneously without antibiotic

treatment. Sinusitis rarely leads to

severe complications.

Several practice guidelines

have been published by various

professional organizations to aid

practitioners in appropriate anti-

microbial prescribing. The treat-

ment recommendations discussed

in this lesson are based on the

Clinical Practice Guideline for

Acute Bacterial Rhinosinusitis inChildren and Adultspublished

by the Infectious Disease Society

of America (IDSA) in 2012. Since

sinus aspirate cultures are not

readily available, it is not possible

to distinguish between AVRS and

ABRS in the rst 10 days of illness

based on history and examina-

tion. Therefore, ABRS should be

considered when any of the fol-

lowing are present: (1) persistent

signs and symptoms of ARS lasting

10 or more days with no clinicalimprovement; (2) severe symptoms

or signs of high fever (>102F) and

purulent nasal discharge, or facial

pain lasting for at least three to

four consecutive days at the begin-

ning of the illness; or (3) worsening

signs or symptoms characterized by

the new onset of fever, headache,

or increase in nasal discharge, fol-

lowing a typical upper respiratory

infection that lasted ve to six days

and were initially improving. Thelast symptoms are referred to as

double-sickening.

Treatment of Sinusitis. The

following treatment recommenda-

tions are for patients with suspect-

ed ABRS. For the relief of pain as-

sociated with ARS, analgesics such

as NSAIDs and acetaminophen

may be used. Intranasal saline ir-

rigation, with either normal saline

or hypertonic saline, may be used

in adults and children to relieve

nasal symptoms. Although salineirrigation is safe and may make the

patient more comfortable, it is as-

sociated with nasal burning, irrita-

tion, and nausea. Saline irrigation

is less well tolerated in babies and

young children. Intranasal cortico-

steroids may be used as an adjunct

to antibiotics in patients with a

history of allergic rhinitis. Neither

decongestants (topical or oral) nor

antihistamines is recommended for

adjunct treatment in patients with

ABRS.Empiric antimicrobial therapy

should be initiated in patients with

signs and symptoms suggestive

of ABRS as soon as the clinical

diagnosis is made. Based on IDSAs

clinical criteria previously outlined,

patients with bacterial infection

are more likely to be appropriately

identied. The recommendation

for watchful waiting is gener-

ally no longer necessary. However,

watchful waiting with follow-up

still may be employed in patients

where the diagnosis of a bacterial

infection is uncertain and milder

symptoms are present.

Treatment in Adults. Amoxi-

cillin was formerly recommended

as a rst-line agent due to its

narrow spectrum of coverage andlow cost. However, the pathogens

for ABRS have changed since the

introduction of routine conjugated

pneumococcal vaccination in chil-

dren. For both adults and children,

the percentage of ABRS due to S.

pneumoniaehas decreased while

the percentage due to H. inuenzae

has increased. Antimicrobial resis-

tance to both respiratory pathogens

continues to rise. Therefore, the

IDSA guidelines now recommend

amoxicillin-clavulanate (Augmen-tin) over amoxicillin as a rst-line

agent for non-penicillin allergic

adults. The dose for most adults is

500mg/125mg orally three times a

day, or 875mg/125mg orally twice

daily.

High dose amoxillin-clavulan-

ate of 2 grams orally twice daily

is recommended for geographic

regions with high endemic rates

(>10 percent) of penicillin-nonsus-

ceptible (PNS) S. pneumoniae,and

for patients who are 65 years andolder, recently hospitalized, treated

with an antibiotic in the previous

month, or immunocompromised.

For patients who are allergic to

penicillin, doxycycline may be used

rst line, or a respiratory uoro-

quinolone such as levooxacin or

moxioxacin.

According to the IDSA, the

duration of treatment in adults

should be ve to seven days.

Second-line treatment options

include amoxicillin-clavulanate

2000mg/125mg orally twice daily;

levooxacin 500mg orally once

daily; or moxioxacin 400mg orally

once daily. (Table 2)

Treatment in Children.

Again, amoxicillin-clavulanate,

rather than amoxicillin alone, is

recommended as empiric rst-

line therapy in children. The

addition of clavulanate improves

Table 2Outpatient antimicrobial regimens for

acute bacterial rhinosinusitis in adults*

Indication First-line Second-line

Initial empiric therapy Amoxicillin-clavulanate Amoxicillin-clavulanate

(500mg/125mg PO tid (2000mg/125mg PO bid)

or 875mg/125mg PO bid) Doxycycline (100mg PO bid or

200mg qd)

Beta-lactam allergy Doxycycline (100mg PO bid or

200mg qd)

Levooxacin (500mg PO qd)

Moxioxacin (400mg PO qd)

Risk for antibiotic resistance or Amoxicillin-clavulanate

failed initial therapy (2000mg/125mg PO bid)

Levooxacin (500mg PO qd)

Moxioxacin (400mg PO qd)

*Adapted from IDSA Guidelines for ABRS 2012


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coverage for ampicillin-resistant

H.inuenzaeand M. catarrhalisin

ABRS. However, it also increases

the likelihood of diarrhea. If oral

antibiotics cannot be given initially

due to vomiting, a single dose of

ceftriaxone, dosed at 50mg/kg/day,

may be administered intramuscu-

larly or intravenously, followed by

oral antibiotics 24 hours later (once

vomiting has been resolved).

High dose amoxicillin-clavulan-

ate, 90mg/kg/day orally twice daily,

is recommended for children in

geographic areas with PNS

S. pneumoniae, as well as those

with severe infection, attending

daycare, less than 2 years of age,

recently hospitalized, having used

antibiotics within the past month,

or those who are immunocompro-

mised.

Combination therapy with athird-generation oral cephalosporin

(i.e., cexime or cefpodoxime)

plus clindamycin may be used as

second-line therapy for children

with non-type I penicillin allergy in

regions with high rates of PNS

S. pneumoniae. Children with a

type I penicillin allergy may be

treated with levooxacin. (Table 3)

In children, the recommended

duration of antimicrobial therapy

for ABRS is 10 to 14 days. This

longer duration, in comparison

to adults, is indicated based on

the lack of randomized studies in

children concluding efcacy in the

shorter duration.

Macrolides, such as clarithro-

mycin and azithromycin,

trimethoprim-sulfamethoxazole

(TMP-SMX), and second- or third-

generation cephalosporins, are not

recommended for empiric therapy

due to high rates of resistance with

S. pneumoniae. TMP-SMX also

has high rates of resistance with

H. inuenzae.

Response to empiric therapy

should be seen after three to ve

days. Altering therapy is suggested

for patients who do not show an

improvement in that time frame, or

when symptoms worsen after two

to three days of therapy.

InfluenzaInuenza virus infection is an-

other common viral disease that is

highly contagious among children

and adults. The annual inuenza

cycle or season begins as early as

October, with a peak in January

or February, and ends as late as

May. It causes an acute febrile

illness and varying other systemic

and upper respiratory symptoms

which result in loss of workdays,

school absences, as well as mor-

bidity and mortality. Over the

past three decades, the estimated

annual inuenza-related deaths

have ranged from 3,000 to 49,000,

with approximately 226,000 annua

hospitalizations in the U.S. alone.

Pediatric mortality from inuenzais typically highest in the rst year

of life.

The signs and symptoms of

inuenza overlap with other viral

URIs and include: fever, myalgia,

headache, malaise, non-productive

cough, sore throat, and rhinitis.

Additionally, otitis media, nau-

sea, and vomiting are common in

children. A typical uncomplicated

course of illness begins after an

incubation period of one to two

days (up to four), and resolves inthree to seven days for most per-

sons, although cough and malaise

can persist for greater than two

weeks. Fever is the most important

clinical nding. It rises rapidly to a

peak of 100F to 104F (occasional-

ly 106F), and subsides after three

days along with other systemic

symptoms. However, the fever may

last four to eight days. Complica-

tions can occur and lead to primary

inuenza viral pneumonia; exacer-

bate underlying medical conditions(i.e,. pulmonary or cardiac disease)

lead to secondary bacterial pneu-

monia, otitis media, or sinusitis;

and contribute to co-infections with

other viral or bacterial pathogens.

Adults shed the virus from the day

before symptoms occur, through

ve to 10 days after illness onset,

while the infectivity decreases

rapidly by three to ve days. Young

children may shed the virus severa

days before illness onset, and can

be infectious for 10 or more days

after. While limited antivirals are

available to treat inuenza, vaccine

prevention is the most effective

strategy.

Inuenza viruses are encapsu-

lated, single-stranded RNA viruses

of the family Orthomyxoviridae.

The core nucleotides are used to

distinguish between types A, B,

and C. In humans, inuenza A is

Table 3Outpatient antimicrobial regimens for

acute bacterial rhinosinusitis in children*

Indication First-line Second-line

Initial empiric therapy Amoxicillin-clavulanate Amoxicillin-clavulanate (90mg/

(45mg/kg/day PO bid) kg/day PO bid)

Beta-lactam allergy

Type I hypersensitivity Levooxacin (10-20mg/kg/dayPO every 12-24 hours)

Non-type I hypersensitivity Clindamycin (30-40mg/kg/day

PO tid) plus cexime (8mg/kg/

day PO bid) or cefpodoxime

(10mg/kg/day PO bid)

Risk for antibiotic resistance or failed Amoxicillin-clavulanate (90mg/

initial therapy kg/day PO bid)

Clindamycin (30-40mg/kg/day

PO tid) plus cexime (8mg/kg/

day PO bid) or cefpodoxime

(10mg/kg/day PO bid)

Levooxacin (10-20mg/kg/day

PO every 12-24 hours)

*Adapted from IDSA Guidelines for ABRS 2012


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generally more pathogenic than

inuenza B. These viruses infect

humans and a variety of animals;

some of these strains may spread

from animal species to humans as

well.

The inuenza viruses are ever

changing via antigenic drift and

shift.Antigenic driftis a process by

which the virus produces ongoinggene mutations resulting in new

subtypes and altered virulence.

Antigenic shift is less common, but

creates virulent strains that are

transmissible to a greater popu-

lation of susceptible individuals

which can cause a pandemic. The

gene segments between two strains

are re-assorted, presumably during

a co-infection in a single host. The

Spanish u of 1918 was a result

of an antigenic shift. This pandem-

ic alone affected 20 to 50 millionpeople globally and was responsible

for 549,000 deaths in the U.S. The

2009 H1N1 inuenza (also referred

to as Swine Flu) pandemic was a

recombinant inuenza consisting

of a mix of swine (pig), avian (bird),

and human gene segments.

Infuenza Diagnosis.Respi-

ratory illnesses caused by inu-

enza virus infection are difcult to

differentiate from other illnesses

caused by respiratory pathogens

based on signs and symptomsalone. Once the presence of inu-

enza virus is conrmed in a region

or community, healthy adults with

acute inuenza-like symptoms

most likely have the infection. The

accuracy of diagnosis in an inu-

enza outbreak can be as high as 80

to 90 percent. Rapid diagnosis can

also be made by testing respira-

tory secretions from nasopharyn-

geal samples and/or throat swabs.

There are a variety of rapid tests

with results available as quickly

as 30 minutes. While some are

useful in differentiating inuenza

A and inuenza B, none of the cur-

rent tests can distinguish between

inuenza A (H1N1) and inuenza

A (H3N2). The optimal use of rapid

diagnostic tests in patient manage-

ment is not yet dened.

Transmission.Inuenza

viruses are spread primarily

through large-particle respiratory

droplet transmission via coughing

or sneezing. Transmission requires

close contact with a susceptible

individual, since the large droplets

do not remain suspended in the air

and only travel a short distance.

Transmission may also occur via

contact with surfaces contami-

nated with respiratory droplets orthrough small particles suspended

in the air.

Infuenza Vaccine.Each

year in the U.S., a vaccine contain-

ing the antigens from the strains

most likely to cause infection

during the season is produced.

At the time of writing this les-

son, the vaccine contains three

strains, two inuenza A strains

and one inuenza B. The 2012-

2013 vaccine contains the follow-

ing: A/California/7/2009(H1N1)pdm09-like virus, A/Victoria/361/

2011(H3N2)-like virus, and B/

Wisconsin/1/2010-like virus. The

Centers for Disease Control and

Prevention (CDC) recommends

that everyone six months of age

and older get a u vaccine each

year as soon as it is available. It

is especially important for people

who are at high risk of developing

serious complications such as pneu-

monia. This includes individuals

who have asthma, diabetes, chroniclung disease, are pregnant, or are

65 years of age and older. The

vaccine is also important for those

who live with, or care for, persons

at high risk for developing serious

complications. It takes about two

weeks for antibodies to develop

and provide protection against

inuenza. Despite the fact that

immunity declines over time, most

healthy adults and older children

will remain protected throughout

the season.

There are two types of inu-

enza vaccine: inactivated vaccine

given by injection and live, atten-

uated inuenza vaccine (LAIV)

sprayed into the nostrils. The

inactivated vaccine, referred to

as the u shot, may or may not

contain thimerosal. The u shot

can be given to all persons aged six

months and older.

A high-dose inactivated vac-

cine is also available for persons

65 years of age and older. This

product has four times the amount

of antigen in the standard formula-

tion, and has been shown to pro-

vide higher antibody responses in

older adults when compared to the

standard dose.

Side effects are minor andinclude soreness, redness, or swell-

ing at the injection site; hoarse-

ness; sore, red, or itchy eyes; cough

fever, aches, headache, itching, and

fatigue. Life threatening severe

reactions to either vaccine formula-

tion are very rare.

LAIV is recommended for

healthy persons two through 49

years of age who are not pregnant

and do not have chronic health con

ditions (heart disease, lung disease

asthma, kidney or liver disease,diabetes, anemia, or other blood

disorders). The vaccine should

not be given if a severe allergy to

a component of the vaccine exists

or if the patient has an allergy to

eggs. It does not contain thimero-

sal or other preservatives. LAIV

is made from a weakened virus

and does not cause inuenza, but

may cause mild symptoms such

as runny nose, cough, congestion,

fever, headache, muscle aches,

cough, chills, tiredness/weakness,sore throat, wheezing, abdominal

pain, vomiting, or diarrhea.

Specic product labeling and

CDC vaccine information state-

ments (http://www.cdc.gov/vac-

cines/pubs/vis/) should be referred

to for complete prescribing instruc-

tions and recommendations.

Antiviral Treatment/Pro-

phylaxis.Inuenza antiviral

treatment can shorten the duration

of fever, lessen symptoms, reduce

the risk of complications from inu

enza, and shorten hospitalization

stays. It is recommended to begin

antiviral treatment as soon as

possible ideally within 48 hours

of illness onset, for any patient (1)

with conrmed or suspected inu-

enza who is hospitalized; (2) who

has severe, complicated, or progres

sive illness; or (3) at higher risk of

complications. Treatment should


7/8

Program 0129-0000-12-011-H01-PRelease date: 11-15-12

Expiration date: 11-15-15

CE Hours: 1.5 (0.15 CEU)

The author, the Ohio Pharmacists Founda-

tion and the Ohio Pharmacists Association

disclaim any liability to you or your patients

resulting from reliance solely upon the infor-

mation contained herein. Bibliography for

additional reading and inquiry is available

upon request.

This lesson is a knowledge-based CE activity and

is targeted to pharmacists in all practice settings.

The Ohio Pharmacists Foundation Inc. is

accredited by the Accreditation Council

for Pharmacy Education as a provider of

continuing pharmacy education.

not be withheld pending laboratory

conrmation of inuenza. Antiviral

treatment can also be considered

in previously healthy outpatients

without risk of complications on

the basis of clinical judgment,

again, if it is begun within 48

hours.

Antiviral medications for

chemoprophylaxis should not beused indiscriminately as wide-

spread use may lead to resistance.

However, they are recommended to

control outbreaks among high risk

persons in institutional settings. In

order to be effective as chemopro-

phylaxis, the medication must be

taken each day for the duration of

potential exposure to a person with

inuenza, and continued for seven

days after the last known exposure.

For persons taking antiviral medi-

cations following immunization,the duration of therapy is until im-

munity after vaccination develops

(generally two weeks, but may be

longer in children). It is generally

not recommended if more than 48

hours have elapsed since the last

exposure to an infectious person.

While four antiviral drugs are

currently available for the preven-

tion and treatment of inuenza,

only two of them, oseltamivir (Tam-

iu) and zanamivir (Relenza),

which are neuraminidase inhibi-tors, are clinically useful against

inuenza A and B. Amantadine

and rimantadine are part of a class

of medications called adaman-

taneswhich were initially effective

against inuenza A. However, the

current strains of inuenza are re-

sistant to both adamantane agents.

Resistance to the neuraminidase

inhibitors is currently low.

Oseltamivir is approved for

chemoprophylaxis and treatment

in children greater than one year of

age and in adults. Pediatric dos-

ing is weight-based until the child

reaches 40kg or 12 years of age.

Then the child may be adminis-

tered the adult dose of 75mg orally

twice daily for treatment, or 75mg

orally once daily for chemoprophy-

laxis. Oseltamivir is available as

30mg, 45mg, and 75mg capsules

and 6mg/mL powder for suspen-

sion. Directions for emergency

compounding using the capsules

to make a suspension can be found

on the manufacturers website

at: http://www.tamiu.com/hcp/

resources/hcp_resources_pharma-

cists.jsp.

Zanamivir is approved for

chemoprophylaxis in children

greater than ve years of age, andfor treatment in children greater

than seven years as well as adults.

The dose for both populations is

10mg (two inhalations) twice daily

for treatment or 10mg (two inhala-

tions) once daily for chemoprophy-

laxis. Zanamivir is available as a

5mg powder dose for oral inhala-

tion using the Diskhalerinhala-

tion device.

The recommended duration of

therapy for treatment is ve days,

but can be extended for those whoremain severely ill. The recom-

mended duration is seven days for

chemoprophylaxis following expo-

sure. However, CDC recommends

a minimum duration of two weeks

when outbreaks occur in long term

facilities and hospitals.

Practitioners should consult

the Advisory Committee on Immu-

nization Practices (ACIP) recom-

mendations for the appropriate use

of antivirals for inuenza treat-

ment and prophylaxis at: http://www.cdc.gov/mmwr/pdf/rr/rr6001.

pdf.


8/8

continuing education quizCommon Cold, Sinusitis, Influenza:The Diseases, Prevention, Treatment

Program 0129-0000-12-011-H01-P

0.15 CEUPlease print.

Name________________________________________________

Address_____________________________________________

City, State, Zip______________________________________

Email_______________________________________________

NABP e-Prole ID*__________________________________*Obtain NABP e-Prole number at www.MyCPEmonitor.net.

Birthdate____________ (MMDD)Return quiz and payment (check or money order) to

Correspondence Course, OPA,

2674 Federated Blvd, Columbus, OH 43235-4990

Completely ll in the lettered box corresponding to

your answer.1. [a] [b] [c] [d] 6. [a] [b] [c] [d] 11. [a] [b] [c] [d]

2. [a] [b] 7. [a] [b] 12. [a] [b]

3. [a] [b] [c] [d] 8. [a] [b] [c] [d] 13. [a] [b] [c] [d]

4. [a] [b] [c] [d] 9. [a] [b] [c] [d] 14. [a] [b] [c] [d]

5. [a] [b] 10. [a] [b] [c] [d] 15. [a] [b] [c] [d]

I am enclosing $5 for this months quiz made

payable to: Ohio Pharmacists Association.

1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor)

2. Did it meet each of its objectives? yes no

If no, list any unmet_______________________________

3. Was the content balanced and without commercial bias?

yes no

4. Did the program meet your educational/practice needs?

yes no

5. How long did it take you to read this lesson and complete the

quiz? ________________

6. Comments/future topics welcome.

1. The pathogens most commonly associated with symp-

toms of the common cold are: a. adenoviruses. c. respiratory syncytial virus.

b. coronaviruses. d. rhinoviruses.

2. Alcohol-based hand sanitizers have been shown to

reduce secondary transmission of colds.

a. True b. False

3. The mainstay treatment for the common cold is:

a. symptomatic. c. antibacterial agents.

b. antiviral agents. d. vaccine prevention.

4. Which of the following common cold treatments in

adults should not be used longer than two to three days

because they can result in rebound rhinitis? a. First-generation antihistamines

b. Non-sedating antihistamines

c. Topical decongestants

d. Cough suppressants

5. The American Academy of Pediatrics recommends

against the use of OTC cough and cold agents in chil-

dren:

a.

Documents

Common Cold, Sinusitis, Influenza: The Diseases, Prevention, Treatment