Rational Use of Antibiotics in Respiratory Tract Infections

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Key Points Rational use of Antibiotics in Respiratory Tract Infections

Generalprinciplesofrationalantibioticuse 2

Part 1 Rational use of Antibiotics in Upper Respiratory Tract Infections

1a. Commoncold(viralrhinosinusitis) 3

1b.AcuteSinusitis 4

1c.Acutesorethroat 5

1d.Influenza-likeillness 7

1e.OtitisMediainchildren 9

1f.Croupandepiglottitis 12

1g. Pertussis 13

Part 2 Rational use of Antibiotics in Lower Respiratory Tract Infections in Adults

2a. Acutebronchitis 14

2b.Communityacquiredpneumonia 15

2c. COPD 16

Part 3 Rational use of Antibiotics in Lower Respiratory Tract Infections in Children

3a.Pneumonia 18

3b. Bronchiolitis 20

Appendices SoreThroatScore 21

SummarySheet 22

References 24

Contents

New Zealand general practitioners have done well in moving

toward more rational antibiotic use. Rational use of antibiotics

reducesresistanceratesforthecommunityasawhole(Molstad,

1999,Hefferman,2002).Italsoimportantlyreducesthelikelihood

of individuals developing resistant bacteria. People who take

antibioticshaveincreasedriskofdevelopingresistantstrainsof

bacteria,forexamplearesistantstrainofpneumococcusintheir

nasopharynx(Dowell,1998).

Thesituationhere inNewZealand isunlikeanAmericanstudy,

which reported that 46% of patients presenting to doctors

with thecommoncoldwereprescribedantibiotics for thisviral

infection.Worse,51%oftheantibioticsusedwerebroad-spectrum

(Steinman,2003).Neverthe less,therewerethreequartersof

amillionprescriptionsforamoxicillin-clavulanate(Augmentin®)in

NewZealandin2005(Pharmhousedata).

Evenwhenantibioticsare indicated,theuseofbroad-spectrum

antibiotics such as amoxicillin-clavulanate, second generation

macrolides,cephalosporinsandquinolonesasfirst line therapy

for respiratory tract infections encourages the development of

resistantstrainsandsubstantiallyaddstocosts.

Whenapersontakesanantibiotictotreatanillness,thedrugkillssusceptiblebacteria.Thisleavesbacteriathatcanresist

it-resistantbacteria.Withthereducedcompetition,resistantbacteriacanincreasetheirnumbersexponentially,tobecome

predominant. Broad-spectrum antibiotics kill a wide-range of bacteria allowing resistant strains which were previously an

insignificantminoritytopredominate.

General principles of rational antibiotic use

Avoidprescribingantibioticsforviralinfections.

When antibiotics are indicated, choose the

appropriate dose and duration of an effective

agentwiththenarrowestspectrum,fewestside

effectsandlowestcost.

Application of these principles to the treatment of

respiratorytractinfectionswouldresultinnoprescribing

of antibiotics for viral infections such as the common

cold and a selection between penicillin V, amoxicillin

orerythromycinasfirst line therapy formostbacterial

respiratoryinfections.Thiswouldreducethedevelopment

of organisms resistant to second line agents, reduce

nationalprescribingcosts,and reduceadverseeffects

toantibioticswithoutcompromisingpatientcare.

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Rational Use of Antibiotics in Respiratory Tract Infections

Key Points

“Theprevalenceofantibioticresistanceinacountryreflectsthelocalconsumptionofantibiotics.Themajorityofantibioticsareprescribed

ingeneralpracticeandmostprescriptionsareattributabletotreatmentofrespiratorytractinfections.”(Bjerrum,2004).

2 IbpacnzInfections

Rational Use of Antibiotics in Upper Respiratory Tract

InfectionsAnoverviewofCochranereviewsontheuseofantibioticsforupperrespiratoryinfectionsrevealsalimitedroleforantibiotics

inacuteotitismedia,sorethroatandstreptococcaltonsillitis,commoncoldandacutepurulentsinusitis(Arroll,2005).

Part 1

Principles for rational antibiotic use

for the common cold

Antibiotics are not beneficial for the

commoncold.

Mucopurulent discharge frequently

accompanies the common cold.

It is not an indication for antibiotic

treatmentunless itpersistsfor10to

14days.

1.

2.

1a. Common cold (viral rhinosinusitis)

Mostchildrenwillhave3to8coldsperyear;however10%-15%

will have 12 or more per year. Higher incidences seem to be

related to starting school or day care. The incidence is much

reducedinadultlife.

Commoncold is usually accompanied bymild fever and some

degreeofsinuscongestion.Itfrequentlyresultsinmucopurulent

nasaldischargeorcoughandoftenlastsforupto10days.

Antibioticshavenoeffecton thedurationorseverityofanyof

thesecomponentsofthecommoncoldnordotheydecreasethe

likelihood of progression to bacterial infection. Short term use

oforalor topicalnasaldecongestants ismore likely toprovide

symptomaticrelief.

bpacnzInfectionsI3

1b. Acute Sinusitis

Identifying people who will benefit from antibiotic use

Sinus congestion related to viral rhinosinusitis is approximately 20 to 200

timesmorecommonthanbacterialsinusitis.Rationalantibioticuserequires

prescriberstocorrectlyidentifypatientswhoaremorelikelytohavebacterial

sinusitis.

Theseare:peoplewith:

Severeclassicalsymptomsoffacialpainandswelling,

Temperature>390C,

Toothpainnotofdentalorigin,or

Knownanatomicalblockage.

Orpeoplewith:

Rhinosinusitisandcoughnotimprovingafter10days.

Choice and duration of antibiotic for bacterial sinusitis

Acutebacterialsinusitis isusuallycausedby thesamebacterialpathogens

that cause acute otitis media (Streptococcus pneumoniae, Haemophilus

influenzae,andMoraxella catarrhalis).Nasopharyngealculturesarenotuseful

topredictthesinuspathogen.

Amoxicillin issuccessful for the initial treatmentofmostepisodesofacute

bacterial sinusitis, despite beta-lactamase production by some isolates

ofH. influenzae andM. catarrhalis. For the fewpatientswhoget recurrent

infectionsordonotrespondtoamoxicillinin48to72hours,abeta-lactamase-

stable agent, such as amoxicillin-clavulanate is appropriate. Doxycycline,

cotrimoxazoleorcefaclorareappropriatealternativesforpeopleallergicto

penicillin.

Theusualcourseoftreatmentisatleast10daysandthereisnoadvantage

in prolonging treatment more than 7 days beyond the point of substantial

improvementinsignsandsymptoms.

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Principles of rational antibiotic use

for acute sinusitis

Sinuscongestionaccompanyingthe

commoncoldisthemostfrequent

causeofafeelingofpressureinthe

sinuses.

Analgesia and short-term nasal

decongestants usually provide

symptomaticrelief.

Bacterial sinusitis is diagnosed

whentherearespecificsymptoms

whichsuggestbacterialsinusitisor

when rhinosinusitis and cough are

notimprovingafter10days.

Routineradiographsarenotuseful

indeterminingabacterialaetiology

ofsinusitis.

Initial antibiotic treatmentofacute

bacterial sinusitis should be with

the narrowest spectrum agent

that is effective against the likely

pathogens(amoxicillin).

Antibiotics are usually prescribed

foratleast10days.

1.

2.

3.

4.

5.

6.

Further reading:

Acutesinusitisinadults.InstituteofClinical

SystemsImprovement.(2004)

Availablethroughhttp://snipurl.com/temk

4 IbpacnzInfections

1c. Acute sore throat

Clinical signs and symptoms are not reliable in differentiating viral from bacterial sore throats.

Viralandbacterialsorethroatscannotbereliablydifferentiatedbyclinical

signsorsymptoms,severityordurationof illness.Scoringsystemscan

helpdeterminetheprobabilityofapositivethroatswabforGroupAbeta

haemolyticstreptococcus(GABHS)(Appendixone).GABHSpharyngitis is

uncommoninchildrenunderthreeyears.

People with a past history of rheumatic fever or who are at high risk of rheumatic fever with positive throat swab for GABHS are likely to benefit from penicillin.

In countries with low incidences of rheumatic fever (most developed

countries)therisksofantibioticuseoutweightheirbenefitsinpreventing

rheumatic fever. However in New Zealand there are higher rates of

rheumatic fever especially among Pacific peoples and Māori. Professor

Diana Lennon points out that Cochrane reviews often include studies

predominantly performed in developed countries. In some communities

in thenorthernNorth Islandwecontinue to havea high risk thirdworld

type infectiousdiseaseprofileformanythings includingrheumaticfever,

but also suppurative complications of pharyngitis such as otitis media,

mastoiditisandquinsy.

Thecorrectstrategyfordealingwiththisproblemisnotyetdetermined,

andtheNewZealandHeartFoundationiscurrentlypreparingguidelinesfor

sorethroatmanagementwithintheNewZealandcontext.

Asthepreventionofrheumaticfeverisnotcompromisedbydelaysofup

toninedaysinstartingantibiotictreatment,apragmaticstrategymaybe

totakethroatswabsfrompeoplewhoaredeemedtobeathigherriskof

rheumatic fever and give them back-pocket prescriptions to get filled if

swabresultsreturnaspositive.Peopleathighriskinclude:

Māoripeople

Pacificpeople

People with lower socioeconomic status living in overcrowded

accommodation

People living in communities with high prevalence of rheumatic

fever.

•

•

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Principles of rational antibiotic use

for acute sore throat

Most sore throats are viral and

will not benefit from antibiotic

treatment.

Theprincipalindicationforantibiotic

treatment in acute sore throat in

New Zealand is for primary and

secondarypreventionofrheumatic

feverforthoseatincreasedrisk.

People with severe systemic

symptoms may benefit from

antibiotics.

When antibiotics are indicated,

penicillinV(phenoxymethlpenicillin)

isthefirstchoicewitherythromycin

forpeoplewhoareallergictothis.

1.

2.

3.

4.

Pamphlets for patients about back-pocket

prescriptionscanbeorderedordown-loaded

fromwww.bpac.org.nz

bpacnzInfectionsI5

People with severe systemic symptoms or people at risk because of other medical conditions such as immunosupression may benefit from antibiotics.

Peoplewithseveresystemicsymptomsareusuallyexcludedfromclinicaltrialsoftheeffectiveness

ofantibioticsanditisprobablyappropriatetoofferantibioticstothesepeople.

People with severe local symptoms may benefit from penicillin.

Peoplewhohaveatleastthreeofthefollowingcriteriamayhavetheirsymptomdurationreducedby

abouteighthoursbytreatmentwithpenicillin.

Fever

Purulenttonsils

Cervicaladenopathy

Absenceofcough

Penicillin V is first choice when antibiotics are indicated for sore throat

Phenoxymethylpenicillin (penicillin V) is first choice because it remains effective againstGABHS.

Itistheonlyantibioticthathasbeenshowntoeffectivelypreventprimaryandsecondaryattacks

of rheumatic fever.Twoor threedailydosesareaseffectiveas fourdailydosesbut,when the

indicationfortreatmentistoeradicateGABHSforrheumaticfeverprevention,a10-daycourseis

required.Itmustbetakenonanemptystomach.

Broad-spectrum antibiotics are no more effective and increase the risk of developing resistant

organisms.Inadditionthesyntheticpenicillinssuchasamoxicillinoramoxicillin-clavulanatearelikely

toproducearashifthepersonhasglandularfever;resultinginthemistakenassumptionthatthe

personisallergictopenicillin.

Erythromycinissuitableforpeoplewhoareallergictopenicillin.

Antibiotics do not prevent glomerulonephritis, local respiratory tract complications or progression to pneumonia.

AntibioticsdonotsignificantlyreducetheincidenceofglomerulonephritissecondarytoGABHS.

Thenumberneededtotreat(NNT)topreventprogressiontootitismedia,sinusitis,quinsyorother

suppurativecomplications ishigh.Forexampleantibioticsneedtobegiventoabout150adults

withsorethroatstopreventoneprogressingtootitismedia.TheNNTforchildrenisabout30and

thereforeitmaybeworthwhilegivingpenicillintochildrenwithahistoryofotitismediaorthosewith

ahigherriskofprogressiontosuppurativecomplicationsbecauseofdemographicfactors.

Antibioticsdonotpreventprogressionofupperrespiratorytractinfectionstopneumonia.

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6 IbpacnzInfections

1d. Influenza-like illness

TheNewZealandcasedefinitionforaninfluenza-likeillness

is“anacuterespiratorytractinfectioncharacterisedby

an abrupt onset of two of the following: fever, chills,

headache and myalgia”. It is a significant health issue

with10to20%ofNewZealandersaffectedeachyear.

Influenzaisdifficulttodistinguishclinicallyfromthewide

range of other viruses and bacteria that cause similar

symptoms. Diagnostic testing is not usually indicated

exceptforsurveillancepurposes.

Principles of rational antibiotic use in

influenza-like illness

Immunisation is the best protection against

influenza.

Antibiotics are not beneficial in influenza-

like illnesseswhen bacterial causes such as

pneumoniahavebeenclinicallyexcluded.

Peoplewithinfluenza-likeillnessesneedwritten

informationaboutwarningsignsandactionsto

takeforseriousillnesssuchasmeningococcal

disease.

1.

2.

3.

A–Allpeople65yearsofageandolder

B–Peopleunder65yearsofage,includingchildrenwith:

cardiovasculardisease(ischaemicheartdisease,congestiveheartfailure,rheumaticheart

disease,congenitalheartdisease,cerebrovasculardisease)

chronic respiratory disease (asthma if on regular preventive therapy; other chronic

respiratorydiseasewithimpairedlungfunction)

diabetes

chronicrenaldisease

anycancer,excludingbasalandsquamousskincancersifnotinvasive

other conditions (autoimmune disease, immune suppression, human immunodeficiency

virus (HIV), transplant recipients, neuromuscular and central nervous system diseases,

haemoglobinopathies,childrenonlongtermaspirin).

•

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•

•

•

•

Immunisation is the best protection against influenza

AnnualimmunisationisfreeinNewZealandforthefollowinggroupsofpeople:

bpacnzInfectionsI7

Meningococcal disease may present as a flu-like illness

Meningococcal meningitis often presents with a headache but

meningococcalsepticaemiaoftendoesnotand ismuchmoredifficult to

diagnose.MeningococcaldiseasecanaffectanyonebutratesamongMāori

andPacificpeoplesarehigh.Onaverage,Māoricontractmeningococcal

diseaseatdoubletherateofEuropeans;andPacificpeoplesatfourtimes

therateofEuropeans.Approximately80%ofcasesoccurinpeopleaged

0-19years.

Forallethnicgroups,therateofdiseaseisparticularlyhighamongchildren

underfive-yearsold.Abouthalfofallmeningococcaldiseasecasesoccur

inthisagegroup.Oneinevery117Māorichildrenwillgetmeningococcal

diseasebythetimetheyreachfiveyears.Oneinevery66Pacificchildren

andone inevery438childrenofotherethnicitieswillgetmeningococcal

diseasebythetimetheyturnfive.

Theoccurrenceofmeningococcal disease is expected to drop following

theintroductionoftheMeNZBvaccineprogramme,andtheearlysignslook

encouraging.Inthemeantime,peoplewithflu-likeillness,especiallythose

undertheageof20yearsshouldbegivenwritteninformationaboutlooking

forsignsofmeningococcaldiseaseandwhattodoshouldtheyoccur.

Order pamphlets

YoucanorderordownloadMinistryofHealthpamphlets.Availablethrough:

http://snipurl.com/sgg8

Further reading:

MeningococcalDisease.MinistryofHealth.MeningococcaldiseaseinNew

Zealand.Factsheetone.

Availablethrough:http://snipurl.com/sgfp

8 IbpacnzInfections

1e. Otitis Media in children

Differentiating between AOM and OME

Acute otitis media isapurulentmiddleear infection.Earache

usually occurs in association with systemic upset such as

irritability,restlesssleepandfever.

Typicalchangesofthetympanicmembraneinclude:

Bulgingwithlossofnormallandmarks,

Changeincolour(usuallyredoryellow),and

Reducedmobility.

These symptoms and signs may have resolved because of

perforationofthetympanicmembraneanddischargeofpus.

When acute symptoms have settled AOM frequently leaves a

persistentmiddleeareffusion.

Otitis media with effusionismiddleeareffusionwithnosigns

ofacuteinflammation.Themainsymptomishearingloss.

Examinationrevealsreducedmobilityofthetympanicmembrane

on pneumo-otoscopy or tympanometry; and several of the

followingfeaturesonvisualisationofthetympanicmembrane:

Abnormalcoloursuchasyellow,amber,orbluish;

Opacificationotherthanduetoscarring;

Retraction;and

Airbubblesoranair/fluidlevel.

Table 1: Diagnostic features of AOM and OME

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Principles for rational antibiotic use in otitis

media

Episodesof otitismedia need tobeclassified

asacuteotitismedia(AOM)orotitismediawith

effusion(OME).

Acute Otitis Media

MostchildrenwithAOMcanbetreated

withappropriateanalgesia

Antibioticuseisreservedfor:

Childrenwithsystemicsymptoms,

Children under three years with

severeorbilateralAOM,and

Childrenundersixmonths.

A five-day course of high dose

amoxicillin is appropriate for most

childrenwhenantibioticsareindicated.

Otitis Media with Effusion

Persistent middle ear effusion (OME)

after AOM is expected and does not

requiretreatment.

Antibiotic treatment is not usually

recommended.

•

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•

Earache

Fever

Irritability

Middle

ear

effusion

Opaque

drum

Bulging

drum

Impaired

drum

mobility

Hearing

loss

AOM Present Present Present Maybepresent Present Present

OME Usuallyabsent Present Maybeabsent Usuallyabsent Present Usuallypresent

bpacnzInfectionsI9

Most children with AOM do not benefit from antibiotics.

Most episodes of AOM settle spontaneously without

ongoingproblems.Antibioticshavelimitedbenefits;about

17 children with AOM need to be treated with a broad-

spectrumantibioticforonechildtobenefit,andtheiruse

isassociatedwithaneardoublingoftheriskofvomiting,

diarrhoeaorrashes(Glasziouu,2002).

Anappropriatestrategyistotargettheminorityofchildren

athigherriskofpooroutcomebyreservingantibioticsfor:

Childrenwithsystemicfeatures(hightemperatureor

vomiting)(Little,2002),

Children under three years with severe or bilateral

AOM,and

Childrenundersixmonths(Kaleida,1991).

Anotherusefulstrategyistogiveabackpocketprescription

for antibiotics, to be collected at the parents’ discretion

after72hoursifthechildhasnotimproved.Mostparents

arecomfortablewiththisapproachanditreducesantibiotic

use(Little,2001;Arroll,2003).

Five days of high dose amoxicillin is appropriate when antibiotics indicated in AOM.

Streptococcus pneumoniae and Haemophilus influenzae

areusually implicated inbacterialAOM.Amoxicillin is the

drugofchoice ifanantibiotic istobeused.HIghdoses

are used to combat non-susceptible S.pneumoniae. The

recommended dose is 15mg/kg (up to 500mg) TDS or

30mg/kg(upto1000mg)BD,forfivedays.Cotrimoxazole

andcefaclorareeffectivealternatives.

Decongestants and antihistamines are not useful in AOM.

Giventhelackofbenefitandincreasedriskofsideeffects,

theuseofdecongestant,antihistamine,ortheircombination

isnotusefulforchildrenwithAOM(Flynn,2002).

•

•

•

Paracetamol is the best option for analgesia in AOM.

Paracetamolatadoseof15mg/kgfourtimesperdayis

themostappropriateoptionforpainreliefinAOM.However

parentsshouldbewarnedofthedangersofoverdosage.

Although non-steroidal anti-inflammatory drugs such as

ibuprofenareeffective,cautionshouldbeexerciseddueto

thesideeffectprofileofthisclassofdrugs.

Two randomised controlled trials show no benefit of

insertingoilsinreducingpaininAOM.

Referral for AOM

Thereareno trialsofwhenreferral is indicated forAOM.

This is usually appropriate and urgent when there are

seriouscomplications,suchasmastoiditis;anditmaybe

requiredwhenapatienthasseveralrecurrencesinashort

timespan;oraperforationisslowinhealing.

Management of OME

OME is a very common condition that usually resolves

spontaneouslyanddespitecommonbelieftheevidencefor

itsimpactonlearningdifficultiesislimited.

Antibiotics are not usually helpful for children with OME.

Thereissomeshort-termbenefitfromtheuseofantibiotics.

Howevertheyhave little influenceon long-termoutcomes

andtheincidenceofsideeffectsincludingdiarrhoea,skin

rashes,allergydevelopment,anaphylaxisanddevelopment

ofresistantstrainsoforganismisconsiderable.

10 IbpacnzInfections

There is no evidence to support the routine use of antihistamines, decongestants or mucolytics in the management of OME.

Studies considering interventions with antihistamines, decongestants

ormucolyticsshownoconvincingbenefitsontheclearanceofmiddle

eareffusions.

Topical or systemic steroid therapy is not recommended in OME.

Reviewoftheliteratureconcludedthattheuseofsteroidscouldnotbe

recommendedforOME(Butler,2002).

Referral

ForchildrenunderthreeyearswithOMEandmildtomoderatehearing

loss(<25dB)andnootherproblems,thereisconsistentevidencethat

watchfulwaitingisasgoodasearlysurgery(Paradise,2000,Rovers,

2000). It should be noted that children in these trials all underwent

audiometrytoexcludeamoreseriousdegreeofhearingloss.

Some trials,which includedchildrenover threeyearsand thosewith

behavioural or language problems have shown some benefit (Maw,

1999,Wilks,2000).

Further reading:

Scottish Intercollegiate Guidelines Network. (2003) Diagnosis and

managementofchildhoodotitismedia.Guideline66.Availablefrom:

http://www.sign.ac.uk/guidelines/fulltext/66/index.html

bpacnzInfectionsI11

1f. Croup and epiglottitis

Croup can be clinically diagnosed in children with typical barking cough, stridor,

hoarsevoice,othersignsofrespiratorydistressandrelativelymildsystemicupset.

It may be confused with epiglottitis, inhaled foreign body, bacterial tracheitis or

retropharyngealabscess.

Most children with croup can be treated at home

Childrenwithcroupwiththefollowingfeaturesmaybesuitableformanagementat

home:

Minimalstridoratrest,

Nosternalretraction,

Nosignsofhypoxia,and

Notsignificantlydistressed.

Forchildrenmanagedathomeoralsteroidsstartedondayonemayhelpprevent

deteriorationondaytwoorthree.Prednisolone(Redipred®)atadoseof1to2mg/

kgperdayisgivenfor3to4days.

There is no evidence that inhaled mist or steam is helpful but some children do

improvewithachangeinairtemperature.Reviewwillbenecessaryiftherearesigns

ofdeteriorationsuchassternalretraction,restlessnessorlethargy.

When epiglottitis is suspected parenteral antibiotics may be indicated

Epiglottitis is rarenowthanks to theuseofHib immunisation.The following table

from the Starship Children’s Health Clinical Guideline helps distinguish epiglottitis

fromseverecroup.

Table 2: Guidance to help distinguish epiglottitis from severe Croup

•

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•

Croup Epiglottitis

Onset Days Hours

Fever ++ +++

Cough +++ -

Drooling + ++

Activity Upset Lethargic

Signs of

obstruction+++ +

Stridor Inspiratory,highpitched Softexpiratorysnore

Principles of rational antibiotic use

in croup and epiglottits

Antibioticsarenotindicatedinthe

treatmentofcroup.

Epiglottitis is rare but may be

confusedwithseverecroup.

Parenteralantibioticsareindicated

whenepiglottitisissuspected.

1.

2.

3.

Further reading:

Croup.StarshipChildren’sHealth

ClinicalGuideline.Availablethrough:

http://snipurl.com/se8o

Although epiglottitis is rare,

practitioners, especially those in

rural areas, need to be ready if

theyencounter it.Localitiesvary

inthesystemstheyhaveinplace

for dealing with this emergency

and practitioners need to know

whatthelocalsystemisandhow

toinitiateit.

12 IbpacnzInfections

1g. Pertussis

PertussiscontinuestocauseproblemsinNewZealandprimarilybecausewedonot

immuniseourchildrenadequately.

Pertussis has an incubation period of 7 to 20 days. The clinical case definition in

NewZealandiscoughformorethan14dayswithoneormoreofwhoop,cyanosis,

post-tussivevomitingorapnoeaforwhichthereisnootherknowncause.Thepeakof

severityusuallydoesnotoccuruntilthecoughhasbeenpresentforthreeweeks.

Pertussisshouldbesuspectedbeforethe14dayswhenthesesymptomsarepresent

particularly if there are no signs of tachypnoea, wheeze or crackles because it is

highlycommunicableintheearlystages.Thecommunicableperiodcontinuesforthree

weeksinpersonsnottreatedwithantibiotics,oruntil5daysofa14-daycourseof

erythromycin.

Diagnosis of Pertussis is usually confirmed by pernasal swab.

Confirmationofthediagnosisisusuallybyapernasalswab,whichispassedgently

along the base of the nasal cavity to reach the posterior nares. Cultures are only

positiveinthecatarrhalphaseandthefirstweekofparoxysmalcoughing.Serology

canalsobedonebuttheinterpretationoftheresultscanbeproblematic.

Erythromycin is recommended for treatment and prophylaxis

Erythromycin is the recommended treatment for cases andprophylaxis for certain

contacts.Theinitiationoferythromycinisnotdelayeduntiltheresultsoftheswabare

available.Thedoseis40-50mg/kgperday(maximum2gperday)individeddoses

for14days.Cotrimoxazoleisanalternativebutitisnotaseffective.

Treatallhouseholdmemberswitha14-daycourseoferythromycinifthehousehold

includeseither:

Achildunderoneyearotherthanthecase,or

Awomanlateinthethirdtrimester.

Reducing the spread of infection

Excludeallpre-schoolersfrompre-schooliftheyhavehadpertussisandexclude

childrenunder10-yearswhoarenotfullyimmunisedfromschool,untilthey:

havehadfivedaysofa14-daycourseoferythromycin,or

for14daysaftertheirlastexposuretoinfection.

Considerswabbingothersymptomaticsiblings.

NotifycasestotheMedicalOfficerofHealth.

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Principles of rational

antibiotic use for pertussis

Theevidenceofbenefitfor

erythromycinonthecourse

of the illness is relatively

poor.

Erythromycin reduces the

length of time that people

with pertussis are culture

positive.

1.

2.

Further reading:

Pertussis.StarshipChildren’sHealthClinical

Guideline.

Availablethrough:http://snipurl.com/se8j

Petussis: GP flowchart, Immunisation

AdvisoryCentre.Availablethrough:

http://snipurl.com/oez4

bpacnzInfectionsI13

2a. Acute bronchitis

Acutebronchitisisdiagnosedclinicallywhenapreviouslywellperson

presentswithcoughwithsputumproduction,dyspnoeaorwidespread

wheeze. Localised, focal chest signs or severe systemic upset are

absent.Itisusuallyamild,self-limitingvirusinfection.Thereissome

doubt whether the condition actually exists. Most cases are in fact

either the common cold, asthma, pneumonia or an exacerbation of

COPD(Arroll,2001).

Previouslyhealthypeoplewithacutebronchitisdonotgetsignificant

benefit from antibiotic use. Patient understanding of this may be

improvedifthetermviralbronchitisisused.

Coughmaylastforfourweeksbutdurationorseverityofsymptoms

is not significantly changed by antibiotics, beta-agonist or cough

medicines.Smokeavoidance isbeneficialandparacetamolandhigh

fluidintakemaybehelpfulifthepatienthasahighfever.

Ifapatienthasasignificantcomorbidity,lookssickorisover55years

empiricaltreatmentwithamoxicillin,erythromycinordoxycyclinemay

beappropriate.Amoxicillin-clavulanate isbetter reserved for the few

occasionswherefirstlineagentshavenotbeeneffective.

Principles for rational antibiotic

use for acute bronchitis

Antibioticsarenotindicatedfor

previously healthy peoplewith

acutebronchitis.

Thepresenceofmucopurulent

sputumisnotanindicationfor

antibioticuse.

Antibiotics may be useful for

people over the age of 55

yearswholooksick.

1.

2.

3.

Rational Use of Antibiotics in Lower Respiratory Tract

Infections in Adults

Part 2

14 IbpacnzInfections

2b. Community acquired pneumonia

Communityacquiredpneumoniacanbediagnosedclinically,

without the need for microbiological and radiological

investigations,whenapatientacquiresalowerrespiratory

tractinfectioninthecommunityandhas:

Newfocalchestsigns,

Systemicillnesssuchassweating,achesandpains

ortemperature>380C,and

Nootherexplanationfortheillness.

Many adults with CAP can be treated safely at home

AdultswithCAPwhoarelessthan50yearsofageandhave

nosignificantcomorbiditiesandnopsychosocialbarriersto

homecarecanbemanagedathomeasnon-severeCAPas

longastheyhaveallofthefollowingfeatures:

Nonewmentalconfusion,

Respiratoryrate<30/min,

SystolicBP>90anddiastolic>60,and

pO2(ifavailable)of>85.

Peoplewhodonotmeetthesecriteriaforhomecareare

likelytobenefitfromhospitalassessmentoradmission.

Amoxicillin remains the first line agent for CAP in the community

ThepreferredantibioticforCAPtreatedinthecommunityis

amoxicillin500mg–1.0gthreetimesdaily.Erythromycin

500mgfourtimesdailyisasuitablealternativeforthose

peoplewhoareallergictopenicillin.

•

•

•

•

•

•

•

Principles for antibiotic use in

community acquired pneumonia (CAP)

Only a small range of pathogens cause

CAP,thecommonestisS. pneumoniae.

People with non-severe community

acquired pneumonia can be given

empirical antibiotic treatment at home

withouttheneedformicrobiologicaland

radiologicalinvestigations.

People with severe CAP need hospital

admission and empirical antibiotics may

bestartedifadelaytoadmissionofmore

thantwohourswilloccur.

Amoxicillin at higher doses remains the

preferredagentforcommunitymanaged

CAPwitherythromycinforthosewhoare

allergictopenicillin.

Acombinationof these twoagentsmay

be appropriate in localities with high

prevalenceoflegionella.

1.

2.

3.

4.

5.

bpacnzInfectionsI15

TheseantibioticsarealsoappropriateforpatientswithsevereCAPwhowillexperiencesomedelayinreceivinghospital

treatment.PatientswhocannottakeoralmedicationmaybegivenpenicillinGorerythromycinparentally.

ThisrecommendationoftheBritishThoracicSocietytakesintoaccounttherarityoffailuresofpenicillintreatmenteven

amongpenicillinresistantpneumococcalpneumonia,theuncommonoccurrenceofbeta-lactamaseproducingstrainsof

H. influenzaeorM. catarrhalisascausesofCAP,andconcernsaboutthesafetyofneweragentsandthedevelopment

ofresistantstrainstothem.

When there is higher prevalence of legionella in the local community it is appropriate to combine amoxicillin and

erythromycinasfirstlinetherapy.

Aviewthatspecificpathogensareassociatedwithothercomorbidities,suchasCOPDorinfluenza,isnotsupported

bytheliterature.

Patientswhoaremanagedathomewhonolongerfitthecriteriaforhomecareordonotimprovein48hoursrequire

hospitalassessmentandprobableadmission.

Further reading

Guidelinesforthemanagementofcommunityacquiredpneumoniainadults.BritishThoracicSociety.2001updated

2004.Availablethroughhttp://snipurl.com/sccm

Principles of rational antibiotic use

in COPD

Prophylacticantibiotictherapyisnot

recommended in the management

ofstableCOPD.

People with exacerbations but

without more purulent sputum or

signs of pneumonia do not need

antibiotictherapy.

People with exacerbations

accompaniedbyincreaseinpurulent

sputumproductionmaybenefitfrom

amoxicillinordoxycycline.

1.

2.

3.

2c. COPD

Studiesontheroleofantibioticsinthemanagementofexacerbationsof

COPDaredifficulttointerpretowingtohighratesofbacterialcolonisation

in the sputum of people with COPD. There is increasing evidence that

manyexacerbationsarecausedbyvirusesandotherunidentifiedcauses.

Itappearsthatbacterialinfectionplayseitheraprimaryorsecondaryrole

inapproximately50%ofexacerbationsofCOPD.

16 IbpacnzInfections

Antibiotics are only indicated in COPD exacerbations with more purulent sputum or clinical signs of infection.

Exacerbations with clinical signs of infection (increased

volume and change in colour of sputum and/or fever,

leucocytosis)maybenefitfromantibiotictherapy.Theearlier

this is commenced the better and patients benefit from

havingahomesupplyofantibioticssothattheycaninitiate

treatmentthemselves.

When antibiotics are indicated either amoxicillin or

doxycycline for 7 to 10 days is appropriate as first line

therapy.Aresponseisusuallyseenwithinthreetofivedays.

Ifthereisnotasatisfactoryresponsebythenachangeto

amoxicillin–clavulanatecanbemade.

Signsofpneumoniashouldbesoughtand if found treated

appropriately.

Systemicglucocorticoidsreducetheseverityofandshorten

recoveryfromacuteexacerbations.

Influenza vaccination is beneficial for people with COPD

In people with COPD annual influenza vaccination reduces

the risk of exacerbations, hospitalisation and death from

respiratorydiseaseandallcauses.

Thevaccineusuallycontainsthreestrainswhichareadjusted

annually according to epidemiological data. The vaccine

shouldbegiveninearlyautumntoallpatientswithmoderate

tosevereCOPD.Asecondvaccination inwinter increases

antibody levels and should be considered for severely

immunocompromisedpatients.

Influenza vaccine is available fully subsidised on the

Pharmaceutical schedule between 1 March and 30 June

eachyearforpatientswithchronicrespiratorydisease.

Pneumococcal vaccination prevents pneumococcal pneumonia

Pneumococcal vaccination is very effective in preventing

invasivebacteraemicpneumococcalpneumonia,butmaybe

lesseffectiveinelderlyorimmunosuppressedpatients.There

isnofirmevidencethatthevaccineiseffectiveinpreventing

pneumococcal exacerbations of COPD but there are over-

ridingbenefitsinpreventingpneumoniainpatientswithalready

reduced respiratory reserve. Pneumococcal vaccination

(polyvalent covering 23 virulent serotypes – Penumovax-23)

is recommended but not currently funded for patients with

chronic pulmonary disease. Vaccination should be avoided

in patients with severely compromised cardiovascular or

pulmonaryfunction inwhomasystemicreactionwouldpose

agreaterrisk.

No evidence that Haemophilus influenzae vaccination beneficial in COPD

There is no evidence that currently available vaccines for

Haemophilus influenzae in New Zealand are effective in

reducingtheincidenceorseverityofbronchiticepisodes.

Further reading

TheCOPD-XPlan:AustralianandNewZealandGuidelinesfor

themanagementofChronicObstructivePulmonaryDisease,

2006.Availablethrough:

http://snipurl.com/sfuz

COPDPOEM.bpacnz.April2005.Availablethrough:

www.bpac.org.nz

bpacnzInfectionsI17

Pneumonia,bronchiolitisandasthmaareallcommoninchildren.Childrenwithpneumoniaarelikelyto

benefitfromantibiotictreatmentbutchildrenwithbronchiolitisorasthmaarenot.

Principles of rational antibiotic use in LRTI

in children

The diagnosis of pneumonia needs to be

considered.

Many children with pneumonia and no

significantco-morbiditiescanbetreatedat

home.

Theprincipalguidetoantibioticchoicefor

community management of pneumonia is

theageofthechild.

Antibiotics are not indicated in the

managementofbronchiolitisorasthma.

Antibiotics do not prevent pneumonia

in children with upper respiratory tract

infections.

1.

2.

3.

4.

5.

Rational Use of Antibiotics in Lower Respiratory Tract

Infections in children

Part 3

3a. Pneumonia

Tachypnoea Indrawing*

Wheezeandahistoryofwheeze

Childdoesnothavepneumonia

Childhaspneumonia

Figure 1: Child presents with cough or breathing difficulty

18 IbpacnzInfections

*Indrawingindicatesseverepneumonia.Achildwithindrawingwithafirstepisodeofwheezingshouldbetreatedasifthisillness

isseverepneumoniaeventhoughthediagnosismaybeprovedincorrectinthesubsequent24-48hours.

AdaptedfromWHOalgorithmfordiagnosingpneumonia.

Tachypnoea, chest indrawing and absence of wheeze are the principle signs for the diagnosis of pneumonia in pre-school children

A pre-school child can be assumed to have pneumonia if they have

tachypnoeaorchestindrawinganddonothaveacurrentwheezewitha

pasthistoryofwheeze.Nasalflaring,gruntingorcrepitationsincrease

theprobabilityofpneumonia.Atypicalpresentationsincludeabdominal

painandmeningismus.

The absence of tachypnoea reduces the likelihood of pneumonia. If

there is no respiratory distress, tachypnoea, crackles or decreased

breathsoundsthereisnopneumonia.

Thepresenceorabsenceoffeverisnotausefulsigninthediagnosisof

pneumoniainyoungchildren.

Many children with pneumonia can be treated at home

Children with pneumonia and no significant co-morbidities with the

followingfeaturesmaybesuitablefortreatmentathome.

Over6months

Donotlooktoxic

Mildrespiratorysymptoms

Drinkingwell

Abletotakeoralmedication

Noskinabscesses

Pneumonia is not a consequence of chickenpox, influenza or

measles.*

*Thepresenceofskinabscessesorrecentchickenpox,influenzaor

measlesmaybeassociatedwithstaphylococcalpneumoniawhichisa

paediatricemergency.

•

•

•

•

•

•

•

Age

Tachypnoea

Respiratoryrate

countedover60

seconds

<2monthsold>60breathsper

minute

2-12months>50breathsper

minute

12monthsto5years>40breathsper

minute

Table 3: The WHO definition of tachypnoea is

age dependent

bpacnzInfectionsI19

Age of the child is the best guide to antibiotic use in community management of childhood pneumonia

Sputumsamples,swabs,CBC,CRPorCXRdonotusuallydetermine

ifpneumoniaisviralorbacterialorwhichantibioticwouldbemost

appropriate. Age is the best guide to the causative agent and

thereforeantibioticchoice.

For children with pneumonia suitable for treatment at home the

followingantibioticsarerecommendedinTable4.

3b. Bronchiolitis

Bronchiolitis can be diagnosed clinically when a child up to the

ageof12monthsdoesnotmeet thecriteria for adiagnosisof

pneumoniaandhascough,tachypnoeaorhyperinflationofthechest

andexaminationrevealswidespreadcrepitationsandwheeze.Itis

oftendifficulttodifferentiatebetweenbronchiolitisandanepisode

ofacuteasthma.Thepresenceofatopy,previouswheezeorstrong

familyhistoryofatopyincreasesthelikelihoodofasthma.

Antibiotics are not indicated for bronchiolitis

Bronchiolitisisaviral infection(usuallyrespiratorysyncytialvirus)

anddoesnotrespondtoantibiotics.Thesymptomspeakat2to

3daysandresolveover7to10daysbutcoughmaypersistfor

severalweeks.

Many children with bronchiolitis can be managed at home

Childrenwithbronchiolitiswhoarefeedingandbehavingnormally

maybesuitableforcommunitymanagementiftheyhave:

Onlymildwheeze,

Noormildchestindrawing,

Nocyanosis,

Heartrate<160,and

Respiratoryrate<60.

Steroids or beta-agonists are not indicated in the community

managementofbronchiolitis.

•

•

•

•

•

Further reading:

Acute pneumonia in infants and children. Starship

Children’sHealthClinicalGuideline.Availablethrough:

http://snipurl.com/se3q

Bronchiolitis. Starship Children’s Health Clinical

Guideline.Availablethrough:http://snipurl.com/scii

Ageunder5years

Amoxicillin50mg/kgperday

(max500mgperdose)in

threedivideddosesfor7to

10days

Ageover5years

Erythromycin40mg/kgper

day(max500mgperdose)in

fourdivideddailydoses

Table 4: Age guide for antibiotic use

20 IbpacnzInfections

Appendix one

Table 5: A clinical score to reduce unnecessary antibiotic use in patients with sore throat

Criteria Point Score

Temp>38oC 1

Nocough 1

Tenderanteriorcervicaladenopathy 1

TonsilllarySwellingorexudates 1

Age3-14yr 1

Age15-44yr 0

Age≥45yr -1

Total score =

Ifyouscore4thenyouhaveahighlikelihoodofgrowingGABHSonthroatswab.

McIssacWJetalAclinicalscoretoreduceunnecessaryantibioticuseinpatientswithsorethroat.CanMedAssocJ1998;158:75-83.

Appendices

bpacnzInfectionsI21

Appendix two Summary table

Upper respiratory Tract Infections

Illness Comments Antibiotic (if indicated)

Consider delayed antibiotic prescriptions for upper respiratory tract infections

Influenza Annual vaccination is essential for all those at risk of influenza.

Pharyngitis,

sore throat &

tonsillitis

The majority of sore throats are viral; most patients do not benefit from antibiotics.

Main indications is rheumatic fever prophylaxis to those at high risk.

PatientswithseveresymptomsorchildrenwithhistoryofotitismediamaybenefitfromantibioticsA-.Antibioticsonlyshorten

durationofsymptomsby8hoursA+.Youneedtotreat30childrenor145adultstopreventonecaseofotitismedia.A+

Twice daily higher dose can be used.A- QDS

maybemoreappropriateifsevere.D

1st linephenoxymethylpenicillin500mgBD-QDSfor10days

if allergic to penicillin

erythromycin500mgBDor250mgQDS(lesssideeffects)for10days

Otitis media

(child doses)

Many are viral. Resolves in 80% without antibiotics.A+

Pooroutcomeunlikelyifnovomitingortemp<38.5oC.A-Useparacetamol.A-forpainrelief.

Antibioticsindicatedforchildrenundersixmonths,youngchildrenwithseverelocalsymptomsorchildrenwithsystemic

symptoms.

Antibioticsdonotreducepaininfirst24hours,

subsequent attacks or deafness.A+ Need to

treat20children>2yrsandseven6-24mold

togetpainreliefinoneat2-7days.A+B+

Haemophilusisanextracellularpathogen,thus

macrolides, which concentrate intracellularly,

arelesseffectivetreatment.

1stlineamoxicillin15mg/kg(upto500mg)TDS,or

30mg/kg(upto1000mg)BD

if allergic to penicillin cotrimoxazole8/40mg/kg/dayfor5days

dividedinto12hourlydoses

2nd line

amoxicillin-clavulanate1 - 6 yrs156mgTDSfor5days

6 - 12 yrs312mgTDSfor5days

Rhinosinusitis

acute or

chronicManyareviral.ReserveantibioticforsevereB+

orsymptoms>10days.

If failure to respond use another first line

antibiotic

amoxicillinA+500mgTDSfor7daysor,

doxycycline200mgstat/100mgODfor7days or,

erythromycin250mgQDS/500mgBDfor7daysor,

phenoxymethylpenicillinA+500mgTDSfor7days

22 IbpacnzInfections

Lower Respiratory Tract Infections

Illness Comments Antibiotic (if indicated)

Note: Avoid tetracyclines in pregnancy. Low doses of penicillins are more likely to select out resistance.

Acute bronchitis

Systematicreviewsindicateantibioticshave

marginalbenefitsinotherwisehealthyadults.A+

Reserveantibioticsforolderpeoplewholook

sick.Patientleafletscanreduceantibioticuse.B+

amoxicillin500mgTDSfor5daysor,

doxycycline200mgstat/100mgODfor5days

Acute

exacerbation of

COPD

Approximately50%bacterial.

Antibioticsnotindicatedinabsenceofpurulent/

mucopurulentsputum.B+

Mostvaluableifincreaseddyspnoeaand

increasedpurulentsputum.B+Inpenicillinallergy

useerythromyciniftetracyclinecontraindicated.

amoxicillin500mgTDSfor5daysor,

doxycycline200mgstat/100mgODfor5days

erythromycin250-500mgQDSfor5days

2nd line

amoxicillin-clavulanate625mgTDSfor5days

Community-

acquired

pneumonia -

treatment in the

community

Start antibiotics immediately.B- If no response in

48 hours or local high prevalence of legionella

consideramoxicillinpluserythromycinC

Inseverelyillgiveparenteralbenzylpenicillinbefore

admissionCandseekriskfactorsforLegionella.

amoxicillin500mg-1gTDSforupto10days or,

erythromycin500mgQDSforupto10days

Meningitis

Suspected

meningococcal

disease

Transferallpatientstohospitalimmediately.

Administerbenzylpenicillinpriortoadmission,

unlesshistoryofanaphylaxis,B-NOTallergy.

IdeallyIVbutIMifaveincannotbefound.

IVorIMbenzylpenicillinChildren< 1 yr300mg

Children1 - 9 yr600mg

Children10 yr and over1200mg

Note:Dosesareoralandforadultsunlessotherwisestated.PleaserefertoBNFforfurtherinformation.

AdaptedfromHealthProtectionAgency,UK.Originaltableavailablethroughhttp://snipurl.com/sqi4

Lettersindicatestrengthofevidence:A+=systematicreview:D=informalopinion

Produced2001-ReviewedApril2006-AmendedMay2006.

bpacnzInfectionsI23

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