Continuing Education

Going Viral: An Overview of Community-

Acquired Respiratory Tract Infections

Authors:

Christopher Whitman, Pharm.D. Harrison School of Pharmacy, Auburn University

Joshua Staples, Pharm.D.

Harrison School of Pharmacy, Auburn University

Samantha Rodriguez, Pharm.D. Harrison School of Pharmacy, Auburn University

Corresponding Author:

Wesley T. Lindsey, Pharm.D. Associate Clinical Professor

Drug Information and Learning Resource Center Harrison School of Pharmacy, Auburn University

Universal Activity #: 0178-0000-19-106-H04-P | 1.75 contact hours (.175 CEUs)

Initial Release Date: December 10, 2019 | Expires: October 1, 2021

Alabama Pharmacy Association | 334.271.4222 | www.aparx.org | apa@aparx.org

4

Objectives After completing this activity, participants

should:

● Describe at least three strategies that can

be used by community pharmacists to

ensure appropriate antibiotic use in

community-acquired respiratory

infections.

● Recognize the consequences of poor

antimicrobial stewardship in the

community setting.

● Given a clinical case, identify the most

common pathogen(s) responsible for the

infection.

● Given a clinical case, identify guideline

recommended treatment strategies

including selection of the most

appropriate antibiotic, dose, and duration.

● Identify patients that qualify for

preventative vaccines.

Introduction Respiratory tract symptoms such as

congestion, sore throat, runny nose, and

cough are the most common reasons that

patients seek out physician care.1,2 Patients

may often perceive that these symptoms are

caused by infectious pathogens requiring

treatment with antibiotics. However, the vast

majority of respiratory infections are caused

by viruses which are innately resistant to

antibiotics (Table 1).3 Even knowing this,

clinicians may be influenced to prescribe

antibiotics due to the patients’ perceptions.4

Table 1

Etiology Prevalence in Common

Respiratory Conditions5-8

Infection Most Common

Etiology

Acute

Rhinosinusitis Viral: 98% to 99.5%

Acute

Pharyngitis Viral: 85% to 95%

Influenza Viral: 100%

Acute

Bronchitis Viral: 85% to 95%

Despite the mild nature of these

symptoms, acute respiratory conditions are

the most common indication for antibiotic

prescriptions written in the United States.

Based on a study from the CDC, it is

estimated that respiratory conditions

accounted for 40% of all antibiotic

prescriptions.3 Of these prescriptions it was

estimated that 30% were unnecessary,

accounting for 57 million unneeded

prescriptions annually. Furthermore, half of

the antibiotic prescriptions were deemed

inappropriate based on incorrect drug, dose,

or duration of therapy. The CDC collected

data comparing the number of oral antibiotic

prescriptions dispensed through U.S.

community pharmacies from 2011 to 2015.9

Alabama ranks among the worst in the

nation (45 of 50) in total antibiotics

dispensed with 1,149 antibiotics dispensed

per 1,000 people. The inappropriate

management of these infections may result

in consequences including the increase in

antimicrobial resistance, increase in the rate

of community acquired infections, and an

increase in adverse effects of medications.

The primary objective of this article is to

provide a broad overview of routinely

encountered respiratory tract infections.

Increasing pharmacist awareness of this

problem is a key step in outpatient

antimicrobial stewardship.

Acute Pharyngitis Acute pharyngitis (a sore throat) is a

common illness that is routinely encountered

in outpatient medical practice and is

characterized by mucous membrane

inflammation in the pharynx, erythema,

fever, and sore throat.11 The most recent

ambulatory medical care utilization

estimates published by the CDC in 2011

reported that acute pharyngitis is responsible

for about 12 million ambulatory care visits

in the United States every year.11 Viruses are

4

the primary causes of a sore throat and are

responsible for up to 95% of cases. Group A

Streptococcus (GAS pharyngitis or “Strep

Throat”) is only responsible for 5% to 15%

of adults presenting with a sore throat.6 The

incidence of GAS pharyngitis is higher in

children (20% to 30%) and is more common

during winter and spring.

Diagnosis

The causes of pharyngitis can be

characterized as either infectious (bacterial

or viral) or noninfectious.12 Physicians have

the difficult responsibility of determining

the underlying etiology of pharyngitis as it is

not possible to differentiate between

bacterial vs viral pharyngitis by simply

examining the back of the throat. The signs

and symptoms overlap between the two

etiologies, but certain clinical findings have

been identified to help distinguish bacterial

from viral pharyngitis. Table 2 lists common

clinical features and characteristics of viral

and GAS pharyngitis that may be useful in

determining the causative pathogen.

Table 2

Clinical Features and Diagnostic Characteristics of Viral and Streptococcal Pharyngitis12

Viral Pharyngitis GAS Pharyngitis

● Conjunctivitis

● Cough

● Malaise

● Hoarseness

● Nasal congestion

● Rhinorrhea

● Oral ulcerative lesions

● Viral rash

● Diarrhea

● ± Fever

● Sudden onset of sore throat

● Age 5-15 years old

● Fever

● Headache

● Nausea & vomiting

● Recent exposure to strep pharyngitis

● Patchy pharyngeal exudates

● Scarlet fever

● Anterior cervical lymphadenopathy

The Infectious Disease Society of America

(IDSA) clinical practice guidelines for the

diagnosis and management of GAS suggest

that if a patient presents with signs and

symptoms that are strongly suggestive of a

viral etiology then GAS pharyngitis can be

ruled out.12 For patients who do not have the

features typically associated with viral

pharyngitis the guidelines further

recommend that a rapid antigen detection

test (RADT) be performed. RADTs are

highly specific with a low incidence of false

positives. It is not possible to diagnosis strep

throat without a positive bacteriologic test.

A negative RADT for GAS can significantly

diminish the number of antibiotics that are

overprescribed for acute pharyngitis.

Noninfectious causes of pharyngitis may

include allergies, irritants, postnasal drip,

dry air, gastroesophageal reflux disease

(GERD), and muscle strain.13

Treatment Recommendations: Antibiotic

Considerations

It is estimated that 70% of patients who

present to an outpatient clinic with a sore

throat receives a prescription for an

antibiotic.12 However, several studies have

reported that physicians are strongly

influenced by the doctor-patient

relationship. Though they were aware of the

evidence and limited efficacy of antibiotics,

physicians were 10 times more likely to

prescribe an antibiotic when they perceived

that a patient expects antibiotics.4 Physicians

describe this as the most uncomfortable

decision about prescribing that they have to

make in their practice.14

5

The IDSA and the American Heart

Association provide similar

recommendations regarding the treatment of

confirmed GAS pharyngitis. 12,15 Table 3

provides an overview of the recommended

antimicrobial therapy. Due to its narrow

spectrum, no documented GAS resistance,

and efficacy, oral penicillin (penicillin VK)

is the drug of choice for the treatment for

GAS. Although a clinical response is usually

seen within 24 to 48 hours after initiation of

antibiotic therapy the typical recommended

duration of therapy is 10 days. It is

important to counsel patients that even

though they may see symptom improvement

they should complete the full course of the

antibiotic to avoid further complications

including acute rheumatic fever. The

guidelines do not recommend continuous

antimicrobial prophylaxis to prevent strep

throat unless the patient has a history of

rheumatic fever.

As drug experts, it is essential for

pharmacists to also be aware of antibiotics

that are not recommended. Tetracyclines

(doxycycline),

trimethoprim/sulfamethoxazole

(TMP/SMX), and fluoroquinolones

(ciprofloxacin, levofloxacin, and

moxifloxacin) should not be prescribed for

the treatment of acute pharyngitis.12

Table 3

Recommended Antibiotic Therapy for Confirmed GAS Pharyngitis12,15

Antibiotic Dosing Comments

No penicillin allergy

Penicillin V

Potassium

Children: 250 mg BID or TID

Adults: 250 mg QID or BID

● Drug of choice

● No resistance has ever been reported

● Limited availability

Amoxicillin 50 mg/kg once daily or 25mg/kg BID

(max: 1 g/day)

● Available in a once daily formulation

● The suspension formulation may be

preferred for children

Penicillin G

Benzathine

1-time intramuscular dose:

< 27 kg: 600000 units

≥ 27 kg: 1200000 units

● Bicillin L-A: 600000 units/mL

● Once daily regimen may be beneficial

for patients with adherence concerns

● Limited availability & higher cost

Penicillin allergy

Cephalexin 20 mg/kg BID (max: 1 g/day) ● For use in patients with a non-type I

hypersensitivity penicillin allergy

only. Cefadroxil 30 mg/kg once daily (max: 1 g/day)

Clindamycin 7 mg/kg TID (max: 900 mg/day) ● Resistance is ~1% in the US

Azithromycin †

12 mg/kg once daily (max: 500 mg/day) ● Macrolide resistance to GAS is

increasing and local antibiograms

should be considered.

● Azithromycin has a long half-life and

may be given once daily for 5 days.

Clarithromyc

in 7.5 mg/kg BID (max: 500/day)

† All oral regimens are recommended for 10 days except azithromycin (5 days)

The doses provided are dosed based on weight since most of confirmed GAS pharyngitis cases are in

children and adolescents.

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Treatment Recommendations: Supportive

therapy

Antibiotics will not help throat pain

caused by a virus. Adjunctive symptomatic

therapy should be the primary focus for

most patients who present with a sore throat.

Table 4 summarizes several symptomatic

relief approaches that may be considered in

patients with acute pharyngitis.

Table 4

Symptomatic Relief for Acute Pharyngitis 6,12,15

Treatment Considerations Symptom Control

Fever & Pain Relief

Oral Analgesics:

● NSAIDs

● Acetaminophen

● Aspirin (should not be used in children)

Local Pain Relief

Local Analgesics:

● Sore throat sprays (~1.5% phenol)

● Sore throat lozenges (Benzocaine/Menthol)

Non-Pharm

● Rest

● Drink plenty of fluids

● Eat soft foods

● Clean humidifier or cool mist vaporizer

● Avoid irritants (allergies, smoke, etc…)

● Gargle with salt water

Rhinosinusitis Acute rhinosinusitis (ARS), also referred

to as a sinus infection, is a common

condition that is characterized by

inflammation in the nasal cavity and

paranasal sinuses that last less than 4

weeks.16 When these areas get infected they

swell and make the extra mucus that is

responsible for the symptoms. The CDC

reported that more than 30 million adults

were diagnosed with rhinosinusitis (1 out of

8 adults).6 A viral infection accounts for

approximately 98% of all cases. Given this

fact it is important to be able to distinguish

acute viral rhinosinusitis (AVRS) from acute

bacterial rhinosinusitis (ABRS).

ARS is more common in patients that have

asthma, smoke, have seasonal allergies, and

the elderly.17 The most common bacteria

associated with ABRS are Streptococcus

pneumoniae, Haemophilus influenzae, and

Moraxella catarrhalis.

Diagnosis

The diagnosis of ARS is multi-step and is

based on the duration and severity of

symptoms.18-20 The duration of symptoms is

beneficial to 1) distinguish between acute,

subacute, and chronic sinusitis and 2) help

identify the cause of the infection.

It is difficult to distinguish between

bacterial and viral ARS as the signs and

symptoms overlap (Table 5).18-20 Fever and

purulent nasal discharge may be present in

both viral and bacterial sinusitis. There are

no defined clinical criteria or tests to

distinguish between AVRS and ABRS.

Studies have shown that the duration of the

signs and symptoms may be beneficial in

distinguishing between the two etiologies.

Viral sinus infections general peak in

severity in 3 to 6 days and last 7 to 10 days.

In contrast bacterial sinus infections usually

last longer than 10 days.

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Table 5

Diagnosis of Acute Rhinosinusitis

Based on Symptoms19

Major Symptoms Minor Symptoms

A diagnosis of ARS may be considered if at

least 2 of the major symptoms or 1 of the

major symptoms and ≥ 2 of the minor

symptoms are present.

● Purulent nasal

discharge

● Facial pain

● Nasal congestion

● Facial congestion

or fullness

● Facial pressure

● Reduction or loss

of sense of smell

● Fever

● Headache

● Ear pain

● Dental pain

● Cough

● Fatigue

● Halitosis

● Loss of sense

of smell

With most cases being viral, AVRS should

be suspected when patients present with

signs and symptoms of ARS of 10 days or

less and the symptoms are not worsening.

The IDSA and the American College of

Physicians (ACP) consider a diagnosis of

ABRS if any one of the following 3 clinical

indications are present:18,19

1. Persistent signs and symptoms of ARS

that last ≥ 10 days without evidence of

improvement

2. Onset of severe signs and symptoms

including high fever (102°F) and

purulent nasal discharge or facial pain

for at least 3 to 4 consecutive days at the

beginning of the infection

3. “Double-sickening” or “double-

worsening”: When a patient who had

symptoms typical of sinusitis began to

see an initial improvement but was then

followed by new onset or worsening

symptoms.

Treatment Recommendations: Antibiotic

Considerations

Over the past 4 decades there have been

many randomized, placebo-controlled

clinical trials in patients with acute sinusitis.

Studies have repeatedly shown that most

cases of ARS are self-limited and resolve

within 10 days without the use of antibiotics.

However, antibiotics are still prescribed in

over 80% of patients with acute

rhinosinsusitis.18 Antibiotic use in the

majority of patients with ARS result in more

adverse effects than benefits.19

Antibiotic therapy should only be

considered in the small number of patients

that have met the diagnostic criteria of

ABRS. The IDSA and the American

Academy of Otolaryngology-Head and Neck

Surgery (AAO-HNS) have conflicting

guideline recommendations on when it is

most appropriate to initiate therapy.18,20 The

IDSA recommends that antibiotic therapy be

initiated immediately after diagnosis of

ABRS while the AAO-HNS recommends an

initial shared decision-making approach.

The shared decision-making approach

recommended by the AAO-HNS gives

clinicians the option to discuss two different

treatment strategies with the patient:

1) “Watchful Waiting” is deferring

antibiotic treatment for patients with

ABRS for up to 7 days after the

diagnosis. If a patient’s condition does

not improve or worsens in 7 days, then

antibiotics are started.

2) Prescribing initial antibiotics

A summary comparing the IDSA

recommendations and the AAO-HNS

recommendations regarding the practice of

“watchful waiting” and the initial treatment

of ABRS is summarized in Table 6.

Table 6

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Initial Management of Acute Bacterial Rhinosinusitis Comparison18,20

IDSA AAO-HNS

After a clinical diagnosis of ABRS is recognized, what is the initial management

approach?

Empiric antibiotic therapy should be initiated “Watchful waiting” or begin empiric antibiotic

therapy

Stance on “watchful waiting” “Watchful waiting” is not recommended for

ABRS. Watchful waiting may be considered for a

max of 3 days for patients with mild persistent

symptoms when one is uncertain about the

diagnosis of ABRS

“Watchful waiting” should only be offered when

there is assurance of follow-up, and that antibiotic

therapy is started if the patient does not improve

or worsens after 7 days of the initial diagnosis

Reasoning supporting their stance on “watchful waiting” Prompt antimicrobial therapy for patients likely to

have ABRS will shorten the duration of illness,

provide earlier symptom relief, improve quality of

life, and prevent recurrent infections. The patient

selection criteria for the diagnosis of ABRS is

stringent and will limit antibiotic therapy and

potential ADRs to the patients who will likely

benefit from antibiotic therapy.

A more selective initial use of antibiotics will

reduce adverse events and the risk of bacterial

resistance. Clinical trials have shown that the

majority of ABRS resolves spontaneously on its

own.

Supporting Evidence The IDSA recognizes that the randomized clinical

trials (RCTs) cited by AAO-HHNS find that about

70% of patients in placebo arms of ABRS trials

spontaneously improve in 7 to 12 days. However,

the RCTs cited did not have stringent inclusion

criteria and were not similar to the current

recommendations for ABRS and included patients

who most likely had viral rather than bacterial

ARS.

A more recent 2009 double-blind placebo-

controlled trial with stringent inclusion criteria for

ABRS reported a spontaneous improvement rate

of only 32% at 14 days vs an improvement rate of

64% in patients treated with Amoxicillin-

Clavulanate (NNT of 3).

Systematic reviews and meta-analysis have found

that approximately 86% of patients have cure or

improvement between 7 to 15 days when not

treated with antibiotics.

Number needed to treat (NNT): 10 to 15 patients

need to be treated with antibiotics to get 1 patient

better after 7 to 15 days.

However, the studies have limitations and the rate

of recovery in patients without antibiotics may be

falsely elevated and lower than reported in these

analyses due to a less stringent inclusion criteria

of the clinical trials. (many of the patients may

have had AVRS).

Regardless of the approach taken, when a

decision is made to initiate empiric

antibiotics the selection of first line

antibiotic therapy is based on the most

common bacteria associated with ABRS

(Streptococcus pneumoniae, Haemophilus

influenza, and Moraxella catarrhalis).16,18

The IDSA recommends Amoxicillin-

Clavulanate as a first line therapy while the

AAO-HNS recommends Amoxicillin with

or without clavulanate. The IDSA

acknowledges that previous studies showed

that Amoxicillin-Clavulanate did not have

any additive benefit over Amoxicillin in the

treatment of ABRS, but these studies were

performed when the prevalence of beta-

lactamase producing H. influenza was lower.

H. influenza is now estimated to be

responsible for 40% to 45% of all ABRS

cases with about 50% of those isolates

9

producing beta lactamases. Amoxicillin

alone would not be effective compared to a

beta-lactamase producing H. influenza. The

benefit of adding clavulanate provides

greater coverage and efficacy but carries the

risk of increased ADRs.

A decision on the most appropriate dose of

Amoxicillin-Clavulanate must be considered

based on the potential for additional

mechanisms of resistance. Beta-lactamase

resistance is likely the most common

recognized resistance that is accounted for

when selecting the appropriate antimicrobial

regimen but some isolates of Streptococcus

pneumoniae (penicillin-resistant

Streptococcus pneumoniae, PNSP) have a

modified penicillin binding protein (PBP)

that is often overlooked.16-18 To overcome

the decreased binding affinity of amoxicillin

to its target binding site (PBP) in PNSP a

higher dose of amoxicillin (2g BID or 90

mg/kg/day in divided doses) is

recommended in patients who are at

increased risk for resistance (Table 7). The

IDSA guidelines reported an approximate

25% frequency of PNSP in the southeast.

This is further supported by the 2017

Alabama statewide antibiogram which

reported that only 64% of community

acquired isolates of S. pneumoniae were

susceptible to penicillin.21 Therefore,

patients in Alabama who meet antibiotic

criteria for ABRS and do not have any

contraindications to amoxicillin-clavulanate

should receive high-dose amoxicillin-

clavulanate.

The recommended duration of antibiotic

therapy is 5 to 7 days in adults and 10 to 14

days in children.18 A complete list of the

recommended antibiotics including second-

line agents for patients with documented

penicillin allergy is included in Table 8.

Although often a popular treatment option,

macrolides such as azithromycin are not

recommended and are not effective for the

treatment of ABRS due to the emergence of

antimicrobial resistance.

When antibiotic therapy is indicated, and

the appropriate antibiotic is prescribed,

patients should respond within 48 to 72

hours.

Table 7

Risk factors for penicillin resistant S. pneumoniae (PNSP) in ABRS18

High-dose amoxicillin is recommended if the any of the following PRSP risk factors for penicillin

resistant S. pneumoniae are present:

● Regions with ≥ 10% rate of PRSP†

● Antibiotic use within the last 30 days or recent hospitalization

● Severe infection (systemic toxicity with a fever of > 102°F, and threat of suppurative

complications)

● < 2 or > 65 years old

● Immunocompromised or severely ill patients who are likely to have a poor outcome as a result of

treatment failure

● Attendance at daycare †The 2017 statewide antibiogram for Alabama reported a 64% susceptibility of penicillin G to S.

pneumonia.

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Table 8

Recommended Antibiotic Therapy for ABRS18,19

Antibiotic Dosing Adult Comments

First Line

Amoxicillin-

Clavulanate

2000/125 mg PO BID

(total of 4G of

Amoxicillin daily)

High dose is preferred due to the increasing prevalence

of PNSP and beta-lactamase producing H. influenza

Second Line or Penicillin Allergy

Doxycycline 100 mg PO BID or

200 mg PO once daily

Best alternative to amoxicillin-clavulanate. Little

resistance to respiratory pathogens. Should not be used

in children.

Levofloxacin 500 mg PO once daily Fluoroquinolones should be reserved for patients with no

alternative treatment options due to increasing resistance.

Not superior to amox-clav in head to head trials. Moxifloxacin 400 mg PO once daily

Clindamycin +

Cefpodoxime

Clindamycin 150 or 300

mg Q6H + Cefpodoxime

200mg BID

For patients with a non-type I allergy to penicillin only.

These agents should never be used alone for ABRS.

Cefpodoxime may be substituted with cefixime 400mg

once daily.

Not Recommended Macrolides Azithromycin and macrolides have high (> 30% resistance) to S. pneumoniae

TMP/SMX High rates of resistance to S. pneumoniae and H. influenza

Treatment: Symptom Management

Acute sinusitis usually resolves naturally

without antibiotic or supportive therapy

within 10 days. However, most patients

present with facial pain, dental pain,

headache, or sinus tenderness, so the

management of ARS is primarily aimed at

symptomatic relief. Supportive care is

recommended for all patients diagnosed

with ARS regardless of the etiology of the

infection. Table 9 details the recommended

and non-recommended symptomatic relief

therapies for ARS. These therapies may help

symptom relief, but they do not shorten the

clinical course.

Table 9

Symptomatic Therapies for Acute Rhinosinusitis18-20

Therapy Comment

Recommended

NSAIDs and Acetaminophen Recommended for fever and pain relief

Intranasal saline irrigation May provide symptomatic relief with minor rate of adverse effects.

Irrigants should be prepared from bottled or sterile water

Intranasal corticosteroids

May provide symptomatic relief. 5 clinical trials reported a modest

symptomatic improvement. Studies have shown that they are most

beneficial in patients with underlying allergic rhinitis.

Not Recommended

Decongestants

There has been no reported evidence that either oral or intranasal

decongestants are efficacious in reducing the symptoms or duration

of ARS. They may induce rebound congestion and inflammation.

Antihistamines

Antihistamines are not recommended due to their adverse effects.

They may dry the mucous membrane and decrease the clearance of

secretions.

11

Figure 1 provides an algorithm for the initial treatment of ARS with a focus on when antibiotics

are indicated.

Figure 1 Acute Rhinosinusitis Treatment Decision Summary18,19

12

Community Acquired Pneumonia Overview of Disease State

Pneumonia is an infection of the lung

parenchyma.22 It is one of the most common

causes of severe sepsis and death in the

United States with a mortality rate of 30 to

40%.8 Community acquired pneumonia

(CAP) can be caused by bacterial, viral, or

fungal pathogens. The most common causes

of CAP include the bacteria S. pneumoniae,

the influenza virus, and the respiratory

syncytial virus (RSV).8,23 Other bacteria that

can cause CAP include Haemophilus

influenzae, Mycoplasma pneumoniae, and

Chlamydophila pneumoniae.8 S. pneumoniae

makes up 36% of adult CAP cases. Viral

infections like the flu and RSV can lead to

secondary bacterial pneumonia which is

usually caused by S. pneumoniae.24

Pneumococcal pneumonia leads to

approximately 400,000 hospitalizations in

the United States each year.

Pneumonia is caused by pathogen entry

into the lower respiratory tract.8,22 This can

occur through several mechanisms like

inhalation of aerosolized particles, transport

of pathogens through the bloodstream from

an extrapulmonary site, or aspiration of

oropharyngeal contents. Aspiration is the

most common cause of pneumonia and it

occurs regularly in healthy and sick patients

during sleep. Typically, the lungs protective

mechanisms prevent infection, but these

mechanisms can be impaired or overcome.

For example, in aspiration, if the patient has

factors that promote aspiration like

decreased level of consciousness, the

amount of oropharyngeal contents delivered

to the lungs increases and can overcome the

protective mechanisms. Other risk factors

for development of CAP include age over 65

years old, diabetes mellitus, smoking,

alcohol abuse, asplenia, and chronic

cardiovascular, pulmonary, renal, or liver

disease.8

Clinical presentation of pneumonia usually

involves abrupt onset fever, chills, dyspnea,

tachycardia, tachypnea, and productive

cough.8,22 Typically, the cough produces

rust-colored sputum or hemoptysis. It can

also present with chest pain due to

inflammation of the lining of the lungs.

Diagnosis of pneumonia requires at least one

respiratory symptom as well as a chest

radiograph showing a new infiltrate.

Diagnosis of CAP also requires that patients

have had no contact with a healthcare

facility.8 CAP can affect patients of all ages

and without regard to time of year.

However, it can be more severe in very

young, elderly, or chronically ill patients.

Severity is typically measured using scales

like the CRB65, CURB-65, or PSI.

Treatment Recommendations Overview

Disclaimer: The guidelines for treatment

of community acquired pneumonia

published by the Infectious Diseases Society

of America and the American Thoracic

Society were due to be updated during 2018

but had not been updated at the time of this

writing.

The 2007 Infectious Diseases Society of

America/American Thoracic Society

Consensus Guidelines on the Management

of Community-Acquired Pneumonia in

Adults separates treatment choices by

likelihood of drug resistant pathogens.25 This

overview will focus on outpatient treatment

options for bacterial and viral CAP

infections.

The goal of therapy for CAP is to

eradicate the infecting pathogen which will

result in improved clinical symptoms.25

There is a lack of rapid testing to identify

causative pathogens, so initial treatment will

typically be an empiric antimicrobial

regimen. For outpatient treatment, the risk

for drug resistant pathogens is identified by

presence of risk factors as described in

Table 10).

13

Table 10

2007 Guideline Empiric Antimicrobial Therapy Recommendations for Outpatient CAP 25

Patient Population Medication Choices Previously healthy and no use of

antimicrobials in the past 3

months

No risk factors for Drug Resistant

S. Pneumoniae (DRSP)†

One of the following options:

● Macrolide (azithromycin, clarithromycin, or erythromycin)

● Doxycycline

Presence of comorbidities††, use of

antimicrobials in the past 3

months, or other risk factors for

DRSP†

One of the following regimens:

● Respiratory fluoroquinolone (moxifloxacin, Gemifloxacin, or

levofloxacin 750mg)

● Beta-lactam plus a macrolide or doxycycline (beta-lactam

options include: high dose amoxicillin 1g TID or amoxicillin-

clavulanate 2g BID preferred, Alternative: ceftriaxone,

cefpodoxime, or cefuroxime)

Located in regions with high rate

(> 25%) of infection with high-

level (MIC > 16 μg/mL)

macrolide-resistant S.

pneumoniae†††

One of the following regimens:

● Respiratory fluoroquinolone

● Beta-lactam plus doxycycline (see beta-lactam options above)

If influenza viral (H5N1) infection

is suspected

Patients should be treated with both of the following:

● Oseltamivir

● Antibacterial agents that target S. pneumonia and S. aureus

(primary causes of secondary bacterial pneumonia) †Risk Factors for DRSP: Age < 2 y/o or > 65 y/o, Antibiotic therapy within the previous 3 months,

alcoholism, medical comorbidities, immunosuppressive illness or drugs, and exposure to a child in a

daycare center ††Comorbidities = Chronic heart, lung, liver, or renal disease, Diabetes mellitus, Alcoholism,

Malignancies, Asplenia, Immunosuppressive conditions or drugs †††In Alabama, the macrolide-resistant S. pneumoniae rate is 65% as of 2017 21

When to start therapy is well defined for

patients admitted to the hospital with CAP,

but for outpatients it is a little less clear.25

The recommendation for patients admitted

to the hospital is to administer the first dose

of antibiotic in the emergency department

(ED). There is not enough evidence to say

that earlier administration of antibiotics

improves outcomes, but later antibiotic

therapy does have consequences in critically

ill patients. Due to the potential for risk, the

guidelines recommend that patients receive

antibiotics while in the ED. Admission to

the hospital is determined based on severity

scores (CRB65, CURB-65, and PSI) with

more severe scores leading to

hospitalization.

CAP therapy should be discontinued after

a minimum of 5 days have passed, but only

if the patient has been afebrile for 48 to 72

hours and has no more than one CAP-

associated sign of clinical instability.25

Clinical stability is defined as having a

temperature < 100.04°F, heart rate < 100

beats per minute, respiratory rate < 24

breaths per minute, systolic blood pressure >

90 mmHg, arterial oxygen saturation > 90%

or pO2 > 60 mmHg on room air, ability to

maintain oral intake, and normal mental

status. Most patients achieve this clinical

16

stability after 3 to 7 days of antibiotic

therapy, so longer durations are not typically

necessary. If patients have persistent

symptoms, they should be directed to return

to their primary care physician or the

physician who diagnosed their pneumonia.

Current Prescribing Patterns The current guidelines have very specific

recommendations for outpatient CAP based

on additional patient risk factors. Despite

this, it is not uncommon to see alternative

antibiotics or antibiotics at different doses,

durations, frequencies, and routes of

administration prescribed. There have been

several studies done to address this in

response to the Centers for Medicare and

Medicaid Services (CMS) updated

readmission and reimbursement policy.26

One such study addressed several

prescribing criteria to determine whether

appropriate antibiotic therapy was selected

for patients with CAP. 26 This study was a

retrospective chart review at an outpatient

academic primary care practice. They

assessed appropriateness of antibiotic

therapy based on patient risk factors, drug,

duration, route, dose, and frequency. This

study identified 101 episodes of CAP. Of

those episodes, 49% were treated with an

antibiotic. Twenty-four of those treated

patients were low-risk and only 7 of those

24 patients (29%) were treated appropriately

based on all of the factors reviewed by this

study. For high risk patients the percent was

slightly better, but still of 25 patients only

13 were treated with the appropriate

antibiotic. Two patients were excluded for

lower dose than recommended and one

patient was excluded for shorter duration

than recommended. So, overall, only 40% of

patients in the high-risk group received

appropriate antibiotic therapy. For all 49

patients who received antibiotic therapy,

only 17 (35%) were treated with guideline

directed therapy. This study emphasizes the

importance of addressing all components of

prescribing for antimicrobial stewardship.

Inappropriate duration of antibiotic

therapy has been addressed in several

studies as well. Two studies looked at the

impact of an antimicrobial stewardship

program on duration of antibiotic therapy for

CAP.27,28 Both studies recognized that there

have been improvements in CAP

identification, time to start of antibiotic

therapy, cultures, and assessment of

vaccination needs, but note a lack of

regulation for duration of therapy.

Complications from inappropriate antibiotic

duration include superinfection, readmission

to the hospital with pneumonia, and

antimicrobial resistance. In one study, a

group of 56 patients treated in 2008 before

the stewardship program was implemented

was compared to a group of 63 patients

treated in 2010 after the program was

implemented. 27 In this study, 92% of the

2008 patients and 91% of the 2010 patients

were treated with an appropriate antibiotic,

but median duration of therapy was 3 days

longer in the 2008 group (7 days vs. 10

days; p < 0.001). This study found that after

the program was implemented, there were

148 fewer days of antibiotic therapy. No

significant difference was found between C.

difficile infection, but fewer patients in the

2010 group (1 patient) were infected than

the 2008 group (3 patients). In another

study, 307 control patients treated from

November 2014 to April 2015 before a

stewardship intervention were compared to

293 intervention patients treated from

November 2015 to April 2016 after a

stewardship intervention.28 There was a

significant difference between the median

days of therapy with the intervention group

receiving 6 (5 to 7) days of therapy

compared to 9 (7 to 10) days of therapy in

the control group (p<0.001). Overall, the

control group had a median excess of 3 days

of antibiotic treatment and the intervention

16

group had a median of 1 day of excess

treatment. This intervention prevented 586

days of unnecessary treatment compared

with the control group. This reduction in

excess antibiotic use has the potential to

prevent superinfections and antimicrobial

resistance. However, when evaluated, there

was no significant difference between

readmission to hospital with pneumonia or

mortality, but numeric differences were

found with fewer patients having

complications in the intervention group. No

patients in this study tested positive for C.

difficile.

In conclusion, inappropriate antibiotic use

is very common in the treatment of CAP but

has been improved with the implementation

of antimicrobial stewardship programs.

Pharmacists can play a pivotal role in

preventing inappropriate therapy in the

outpatient setting. Being aware of

prescribing patterns and guideline

recommendations allows pharmacists to

recommend appropriate therapy and prevent

antibiotic side effects and potentially

antimicrobial resistance.

Influenza The influenza virus causes more deaths

each year than any other vaccine-

preventable illness.29 Seasonal epidemics

result in approximately 200,000

hospitalizations and 30,000 deaths each year

in the United States. The groups with the

highest rates of hospitalization, severe

illness and death include: those older than

65 years of age, young children, and those

with underlying medical conditions such as

pregnancy and cardiopulmonary disorders

that may increase the risk of complications.

The complications of influenza most likely

to result in death are secondary bacterial

pneumonia, primary viral pneumonia and

exacerbation of underlying comorbidities.

Influenza virus has the highest rates of

infection during the winter months;

however, infection can occur at any time of

year.29 The flu is contagious and can be

spread from person to person through

inhalation of respiratory droplets when the

infected person coughs or sneezes. Touching

contaminated objects is another route of

possible transmission. Some of the common

signs and symptoms include rapid onset of

fever, myalgia, nonproductive cough and

sore throat. These usually resolve in 3-7

days without intervention but may persist for

several more days. Patients who develop

primary viral pneumonia most often present

with a productive cough with bloody sputum

that will progress to dyspnea and

hypoxemia. Patients who develop secondary

bacterial pneumonia most often present with

a fever, productive cough and radiologic

evidence of consolidation.

Pathogens:

Influenza virus is composed of types A, B

and C which cause disease in many different

species including humans, pigs, horses and

birds; however, humans are only susceptible

to types A and B.29 The annual influenza

outbreaks are associated with the type A

virus; conversely, the sporadic outbreaks are

typically due to type B. The type A virus is

further broken down into subtypes, H1-H16

and N1-N9, with the most common subtypes

affecting humans being H3N2 and H1N1.

The subtypes come from changes in the

surface antigens, hemagglutinin and

neuraminidase. Certain changes, such as

point mutations, produce antigenic variants

that result in a differing immunity profile.

This process is referred to as antigenic drift

and is the reason for the changing annual

influenza vaccine combination.

Treatment Recommendations

There are three antivirals (neuraminidase

inhibitors) currently approved by the FDA

for the prevention and treatment of

influenza: oral oseltamivir, inhaled

16

zanamivir and intravenous peramivir. (Table

11).7 Since 2009, 99% of influenza virus

isolates tested in the US have been

susceptible to neuraminidase inhibitors.30

Table 11

Antiviral Agents for Treatment of Influenza 7

Oseltamivir

(Tamiflu)

Zanamivir

(Relenza)

Peramivir

(Peramivir)

Dosage Form(s) Oral Capsule

Oral Suspension

Inhalation Intravenous Solution

Treatment Dose Age > 12†: 75 mg

BID for 5 days

Pediatric: weight-

based dosing*

Age > 7: 10mg (two

5mg inhalations) BID

for 5 days

Age >: One 600 mg

IV infusion

Prophylaxis Dose Age > 12†: 75mg

once daily for 7 days

Age > 5: 10mg (two

5mg inhalations) once

daily for 7 days

n/a

Common ADRs Nausea/

Vomiting

Headache

Sinusitis

Ear/Nose/Throat

infections

Throat pain

Bronchospasms

Diarrhea

Other CrCl ≤ 60 ml/min:

dose adjustment is

required

Not recommended for

use in patients with

underlying respiratory

disease

(asthma/COPD)

Only FDA approved

for adults > 18 years

old

CrCl ≤ 50 ml/min:

dose adjustment is

required

†Pediatric patients (age 2 to 12 years): Dose is based on body weight

Most of the clinical trials of antivirals

were limited to patients who started antiviral

therapy within 48 hours of onset of

symptoms. It is therefore recommended that

treatment begin as early as possible, but

treatment may still have some benefit after

48 hours.7 Neuraminidase inhibitors

decrease the duration of influenza symptoms

by about 1 to 3 days7,29. Early treatment with

antivirals may also reduce the severity and

risk of complications from influenza.

Patients should be counseled that when these

antivirals are used to treat influenza they do

not eliminate flu symptoms and may only

reduce the duration and severity of

symptoms. .29

Current Prescribing Patterns

The CDC reports that Alabama has one of

the highest antibiotic prescribing rates in the

3

country annually with about 1,200

antibiotics being prescribed per 1,000

people.9 The rate is higher in the winter

months due to influenza activity and at least

30% of all antibiotics prescribed are not

appropriate treatment. A recent study has

shown that Alabama prescribes more

antibiotics in response for the flu than

anywhere else in the country.31 The study

also found that the excessive antibiotic

overuse was due to a low prescribing quality

among physicians rather than having a

tendency to prescribe more frequently.

Healthcare providers should be aware of the

efforts that need to be made in the future to

prevent rapidly increasing antimicrobial

resistance.

Acute Bronchitis/COPD

Exacerbations Acute bronchitis is a common lower

respiratory tract infection which is

responsible for about 10 million office visits

annually.8 Similar to the influenza virus,

acute bronchitis can occur at any time of

year but occurs most frequently in the winter

months. Some of the risk factors include

exposure to environmental irritants, prior

acute viral infection and smoking.

Pathologically, acute bronchitis causes

inflammation of the epithelium in the large

airways and increases bronchial secretions.

Prescribers as well as patients should be

aware that this is a self-limiting illness and

unlikely to result in permanent damage. The

most common presenting symptom is a

nonproductive cough which will progress

into a persistent, productive cough as the

illness progresses usually lasting about three

weeks.

Patients with COPD can have

exacerbations and it is important to know

how to differentiate an exacerbation from

other disease states sharing similar symptom

profiles such as acute bronchitis.32A COPD

exacerbation is defined as “an acute

worsening of respiratory symptoms that

result in additional therapy.” Symptoms

typically last between 7 and 10 days and are

often caused by respiratory tract infections.

The key symptom to watch out for is

increased dyspnea but can also include

cough, wheeze, increased sputum production

and sputum purulence.

Pathogens

The major pathogens involved in the

development of acute bronchitis are

predominantly respiratory viruses which

account for roughly 85-95% of cases.29

Infection from a bacterial source is a

possibility but the incidence is rare. Patients

presenting with an antibiotic prescription for

acute bronchitis may be the result of a

prescribing error which creates an important

role for the pharmacist to display

antimicrobial stewardship and confirm the

source of infection.

COPD exacerbations mostly stem from

respiratory viral infections but can also

come from bacterial infections and

environmental factors.32 The common cold,

rhinovirus, is the most common causal

factor and results in more severe

exacerbations compared to other causal

factors.

Treatment Recommendations

The most important recommendation for

the management of acute bronchitis is to

avoid prescribing antibiotics and employ

strategies to reduce antibiotic use.33 The

inappropriate use of antibiotics in this

setting has already lead to increased

antimicrobial resistance. The current

treatment recommendations are mostly over-

the-counter medications emphasizing the

importance of pharmacist knowledge in this

area. Treatment will not necessarily reduce

the duration of illness but rather the goal is

aimed at symptom control. Some of the

common medications used to reduce the

3

severity of cough include guaifenesin,

dextromethorphan and an

antihistamine/decongestant combination.

The 2018 Global Initiative for Chronic

Obstructive Lung Disease (GOLD)

guidelines recommend that “antibiotics,

when indicated, can shorten recovery time,

reduce the risk of early relapse, treatment

failure and hospitalization duration.

Duration of therapy should be 5-7 days.”32

There is still some controversy on the use of

antibiotics for exacerbations, but healthcare

providers should be aware of the specific

signs that are necessary to appropriately

prescribe an antibiotic. Acute bacterial

exacerbations of COPD may warrant

antibiotic therapy if the patient presents with

the following three cardinal symptoms: 1)

increase in dyspnea, 2) sputum volume and

3) sputum purulence. Patients can still

receive antibiotics if they only have two of

the cardinal symptoms as long as one of

them is an increase in sputum purulence.

Additional, COPD patients on mechanical

ventilation or with a history of COPD

exacerbations requiring hospitalization

should also receive antibiotics due to their

increased risk for a pseudomonas infection.

Current Prescribing Patterns

While the overwhelming majority of acute

bronchitis cases are viral in nature,

antibiotics are still commonly being

prescribed. Recent studies have shown that

the antibiotic prescribing rate in this setting

is roughly 70% and that number continues to

rise.33 More specifically, smokers who get

acute bronchitis have been found to receive

a round of antibiotics about 90% of the time.

Clinicians most often use the purulent

sputum sign as indication of infection and

subsequently prescribe antibiotics. However,

there has been shown to be no difference in

outcomes between patients who receive

antibiotics and those who don’t. The

population who receives antibiotics are also

at an increased risk for developing adverse

events such as nausea, diarrhea, headache

and skin rash. Healthcare providers should

all be aware that continued antibiotic use in

the treatment of acute bronchitis will lead to

increased healthcare costs and antimicrobial

resistance.

Recent studies have shown that while

prescription antibiotics are given to patients

with COPD exacerbations the majority of

the time, there is much variability in

prescribing patterns from practice to

practice.34,35 The use of antibiotics for

exacerbations has not been extensively

studied resulting in differing prescribing

patterns site by site depending on their own

opinions and clinical experience with its use.

Prevention of Respiratory Infections There are several methods to prevent

spread of community acquired respiratory

infections. Pharmacists can help prevent the

spread of these infections by identifying

patients that qualify for specific vaccines

and encouraging all patients to practice

preventive measures during times of high

prevalence.

Vaccinations

Influenza Vaccine

The influenza vaccine is recommended to

prevent the flu as well as reduce the

incidence of rhinosinusitis, community

acquired pneumonia, and bronchitis. 23,7,36

There were two distinct categories of

influenza vaccines recommended for the

2017-2018 flu season.7 The two categories

are separated by the number of influenza

strains they cover. The trivalent forms cover

three forms of influenza virus, two influenza

A viruses (H1N1, H3N2) and one influenza

B virus. The quadrivalent forms cover the

same strains as the trivalent plus one more

influenza B virus. Within these two

categories of vaccines, there are two forms

of the influenza vaccine, an inactivated form

3

and a recombinant form. The inactivated

form (IIV) is made using a virus grown in

eggs and the recombinant form (RIV) is not

made with eggs. Influenza vaccines should

be chosen based on age of the patient

receiving the vaccine. Several inactivated

vaccines are approved for use in patients

from 6 months old to over 65 years old, but

recombinant vaccines are only approved in

patients 18 years old or older. High dose

inactivated vaccines are available for

patients aged 65 years or older who are at

greater risk of influenza infection and

complications. The influenza vaccine is

recommended annually for all patients 6

months of age and older. Children between 6

months and 8 years should receive two

doses of influenza vaccine at least four

weeks apart once and then one dose every

year.37,38 The flu vaccine has very mild

adverse effects including soreness, redness,

or swelling at the injection site, low grade

fever, and aches.7 The flu vaccine cannot

cause the flu. Vaccines should be offered by

the end of October and should continue as

long as the influenza virus is a threat.

Haemophilus Influenzae type B (Hib)

Vaccine

The Haemophilus influenzae type B (Hib)

vaccine is recommended to prevent

pneumonia.23 There are several brand names

of Hib vaccines, but all of them are

polysaccharide conjugate vaccines.24 The

Hib vaccine series is recommended for

children at least 6 weeks old.37,38 The four-

dose series (ActHIB, Hiberix, Pentacel)

should occur at 2, 4, 6, and 12-15 months

old and the three-dose series (PedvaxHIB)

should occur at 2, 4, and 12-15 months. Hib

vaccination is not routinely recommended in

adult patients unless they have anatomical or

functional asplenia with no previous

vaccination or they are undergoing

hematopoietic stem cell transplant. This

vaccine is typically well tolerated, but

adverse effects can include swelling,

redness, or pain at injection site, fever, and

irritability.24

Pneumococcal Vaccines

Pneumococcal vaccines are recommended

to prevent pneumonia and rhinosinusitis. 18,23 There are two distinct types of vaccines;

PCV13 (Prevnar 13) and PPSV23

(Pneumovax 23).24 PCV13 is a

pneumococcal conjugate vaccine that covers

13 serotypes of S. pneumoniae. It is 45%

effective in preventing pneumococcal

pneumonia caused by the strains covered in

the vaccine in adults over 65 years old.

PPSV23 is a pneumococcal polysaccharide

vaccine that covers 23 types of

pneumococcal bacteria known to cause 60 to

76% of invasive disease. These vaccinations

are recommended in young children and

elderly adults.37 Children should receive

PCV13 at 2, 4, 6, and 12-15 months. They

must be at least 6 weeks old to get PCV13.

PPSV23 is only indicated for children in

special circumstances like chronic heart

disease, chronic lung disease, diabetes

mellitus, and immunosuppressive disorders.

In these special circumstances, it is better for

patients to receive the PCV13 series first

and then to receive one to two doses of

PPSV23 depending on the conditions the

patient has. Healthy adults aged 65 years old

or older should receive one dose of PCV13

and then one dose of PPSV23 one year later

or if PPSV23 was administered first, PCV13

should be administered one year after

PPSV23.38 There are exceptions where

adults between 19 and 64 years old with

certain conditions should receive

pneumococcal vaccines. The conditions

include chronic heart disease, lung disease,

liver disease, alcoholism, diabetes mellitus,

cigarette smoking, and immunosuppressive

disorders. Indications for when to administer

pneumococcal vaccines to these patients

differ based on which conditions the patient

3

has. As pneumonia is not more prevalent at

any time of year, these should be

administered year-round. 24 These vaccines

can cause a few adverse effects including

local injection site reactions, fever, myalgia,

and serious adverse reactions like

anaphylaxis. PCV13 also has the potential to

cause febrile seizures in children.

Measles Vaccine

The measles vaccine is recommended to

prevent pneumonia, especially in children. 23,24 There is no vaccine for measles

protection alone. 24 The live attenuated

measles vaccine is available combined with

either mumps and rubella vaccines (MMR)

or mumps, rubella, and varicella vaccines

(MMRV). As varicella will be discussed in

another section, this will focus on the MMR

vaccine. As mentioned prior, the measles

induced complication of pneumonia is most

common in children, so vaccination of

children with MMR is very important.

Children should receive a two-dose series of

MMR starting at 12 to 15 months and

completing at 4 to 6 years old.37 In adults,

the main complication of measles infection

is acute encephalitis, not pneumonia.24

However if adults have no evidence of

immunity including being born before 1957,

documentation of vaccination, or positive

titer they should receive a dose of MMR.38

The MMR vaccine can cause some adverse

events like arthralgias in women, and rash,

pruritus, or purpura in all patients.24 It is

important to note that there is no evidence to

suggest that any vaccine, including MMR,

causes autism or autism spectrum disorder.

Pertussis Vaccine

Pertussis vaccination is recommended to

prevent pneumonia.23 Complications of

pertussis include secondary bacterial

pneumonia in children, adolescents, and

adults.24 There is no vaccine that covers

pertussis alone. Two combination vaccines

contain acellular inactivated pertussis as

well as tetanus and diphtheria toxoids; DTaP

and Tdap. Children should receive a five-

dose series of DTaP (diphtheria, tetanus, and

acellular pertussis) at 2, 4, 6, and 15 to 18

months and 4 to 6 years.37 Adults should

receive one dose of Tdap (tetanus,

diphtheria, and pertussis) as an adult or

adolescent (11 to 12 years old) and then

have a booster of Td which excludes

pertussis every ten years.38 Also, pregnant

women should receive a dose of Tdap

during each pregnancy during weeks 27 to

36 of gestation. DTaP can cause a few

adverse reactions like pain, redness, or

swelling at injection site, fever of 101°F,

and rarely more serious adverse reactions

like anaphylaxis.24 Tdap and Td can also

cause pain, redness, or swelling at injection

site, and a fever of 101.4°F or higher.

Varicella Vaccine

Varicella vaccination is recommended to

prevent pneumonia. 23 A common

complication of varicella infection is viral or

bacterial pneumonia.24 More commonly this

pneumonia is caused by viral infections, but

in very young children (< 1 year old)

secondary bacterial infections are more

common. There are three live attenuated

varicella vaccines and one recombinant

vaccine.24,39 The live attenuated vaccines

include one varicella vaccine for children

(Varivax), one combination measles,

mumps, rubella, and varicella (MMRV)

vaccine, and one herpes zoster vaccine for

adults (Zostavax).24 The recombinant

vaccine is also a herpes zoster vaccine for

adults (Shingrix).39 Children should receive

a two-dose series of Varivax or MMRV

starting at 12 to 15 months and completing

at 4 to 6 years old.37 Adults should receive

either a two-dose series of Shingrix

separated by 2 to 6 months starting at age 50

or one dose of Zostavax at age 60.38 If

patients have already received the Zostavax

3

vaccine, they should receive a two-dose

series of Shingrix. Shingrix is preferred as it

has higher efficacy than Zostavax, so if

possible administer Shingrix. Adverse

effects of Varivax and MMRV include pain

and redness at site of injection and

generalized rash.24 Adverse effects of

Zostavax include pain, swelling, and redness

at site of injection. There is also risk of

transmission of varicella virus after

vaccination with live vaccines, and it is

recommended that patients receiving

vaccines should avoid contact with people

who have no evidence of immunity to

varicella. For Shingrix, the adverse effects

are similar, including pain, redness, or

swelling at site of injection, fever, and

headache.39 Without the live component of

varicella in this vaccine, there is no risk of

transmission after receiving this vaccine.

Lifestyle Methods

Hand Washing

Properly washing your hands is one way to

reduce respiratory tract infections. The CDC

has specific recommendations for when and

how to wash your hands to best prevent

spread of infections (see Figure 2 and Table

12).40

Figure 2 Handwashing Technique:40

If clean, running water or soap are not

available, an alcohol-based hand sanitizer

with at least 60% alcohol is an option.40 It

may not be as effective as washing hands

with water and soap especially if hands are

visibly dirty or greasy. Recommendations

for how to use hand sanitizer are similar to

soap and water. Apply the appropriate

amount of gel to the palm of one hand then

rub your hands together and rub gel over all

surfaces of your hands and fingers for at

least 20 seconds or until your hands are dry.

Table 12

When to Wash Your Hands40

Before Eating food

Before and After Food preparation

Caring for sick people

Treating a cut or wound

After Blowing nose

Coughing

Sneezing

Touching animals, animal food, animal waste, or garbage

Using the toilet

Changing diapers or cleaning child who used the toilet

Wet hands with clean, running

water Turn off tap Apply soap

Lather hands by rubbing them together with soap

(remember backs of hands, between fingers,

and under nails)

Scrub hands for at least 20 seconds

Rinse your hands well under clean,

running water

Dry your hands with

a clean towel or air dry them

3

Other Tips for Preventing Infections 6,7,23,36,41,42

• Avoid allergens and irritants

● Avoid people who are sick with respiratory tract infections

● Clean areas that are touched often

● Cover mouth and nose with a tissue, elbow, or sleeve when sneezing, don’t use your hands

● Avoid touching your eyes, nose, or mouth to avoid spreading pathogens to these sensitive

areas

Table 13

Summary of Vaccine Recommendations Disease State Vaccine Recommendations

Rhinosinusitis Influenza vaccine

Pneumococcal vaccine (PCV13)

Strep Throat No vaccine

Community Acquired

Pneumonia

Influenza vaccine

Haemophilus Influenzae type B (Hib)

Pneumococcal vaccine (PCV13 and PPSV23)

Measles vaccine (MMR)

Pertussis vaccine (DTaP or Tdap)

Varicella vaccine

Influenza Influenza vaccine

Acute Bronchitis Influenza vaccine

Antimicrobial Stewardship in the

Outpatient Setting The pharmacist’s role in outpatient

antimicrobial stewardship has been less

defined than that of an inpatient pharmacist.

As medication experts, pharmacist should be

aware of the most common causes of

respiratory infections and should be able to

identify the appropriate management

approach. This includes being familiar with

local resistance patterns and knowing when

it is appropriate to initiate antibiotic therapy.

Pharmacists should be able to recognize the

recommended dose and duration based on

indication. By evaluating all aspects of

prescriptions, pharmacists ensure patients

are receiving the most appropriate care for

their conditions. Table 14 summarizes

opportunities for community pharmacists to

participate in antimicrobial stewardship.

Table 14

Outpatient Antimicrobial Stewardship Options for Community Pharmacist

Benefits Pharmacist Opportunity Improve Patient Safety and

Adherence for Antibiotics ● Appropriate antibiotic counseling to educate patients

about potential side effects and adherence.

● Provide patient education materials

● Screen for drug interactions

● When an antibiotic is indicated and prescribed it is

important for pharmacist to help make sure the patient

gets the antibiotic in a timely fashion, suggest cost-

appropriate alternative and equal antibiotics

● Promoting and screening patients for vaccinations

3

Benefits Pharmacist Opportunity

Improve the rate of antibiotic

overuse when antibiotics are not

indicated

● Be up to date with clinical guidelines and

recommendations

● Educate both patients and prescribers that most

respiratory infections are viral and do not require

antibiotic therapy

● Recommending appropriate OTC and non-

pharmacologic therapies to patients for symptomatic

relief

● Administer point of care diagnostic test (i.e. influenza

test or RADT test for GAS pharyngitis)

Improving the appropriate selection

of an antibiotic regimen ● Educating prescribers on the appropriate selection, dose,

and duration of antibiotics when indicated

● Be familiar with the local and statewide antibiograms to

make suggestions and recommendations to physicians

● Suggest that clinicians provide a diagnosis when

prescribing antibiotics

● Be familiar and up to date with current guideline

recommendations

Community outreach and

collaboration ● Participate in antimicrobial stewardship programs

● Collaborate with other healthcare professionals

Conclusion

In summary, pharmacists have a large role to play in acute respiratory infection treatment.

Through an improved understanding of these infections and the pathogens that cause them,

pharmacists can encourage proper antimicrobial stewardship and educate patients and

prescribers.

“the public will demand [the drug and]…then will

begin an era…of abuses. The microbes are educated

to resist penicillin and a host of penicillin-fast organisms

is bred out which can be passed to other individuals

and perhaps from there to others until they

reach someone who gets a septicemia or a pneumonia

which penicillin cannot save. In such a case the

thoughtless person playing with penicillin treatment

is morally responsible for the death of the man who

finally succumbs to infection with the penicillin-resistant

organism. I hope the evil can be averted.”43

-Sir Alexander Fleming June 26, 1945

3

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