INFECTIOUS DISEASE REVIEW Upper Respiratory Tract Infections

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INFECTIOUS DISEASE REVIEW Upper Respiratory Tract Infections

INFECTIOUS DISEASE REVIEW

Upper Respiratory Tract Infections

A Knowledge-Based Course

The University of Florida College of Pharmacy is accredited by the Accreditation Council for

Pharmacy Education as a provider of continuing pharmacy education.

Upper Respiratory Tract Infections

Goal: to give an overview for the pharmacist to the presentation of the most common infections and drugs and

immunizations for prevention and/or treatment of these infections.

Objectives: The participants who complete this course should be able to:

1. State the most common microbes found on or within the body

2. List the most common pathogens by site(s) and type of infection

3. Describe the common presenting signs, symptoms, and lab tests used to assess ID entities covered.

4. Differentiate the preferred and alternative antimicrobial agents for the ID entities covered or assigned.

5. Discuss the most common infectious diseases and appropriate antimicrobial usage and undesirable effects of agents

covered.

Upper Respiratory Tract Infections: Assessment of Infection, EENT and upper respiratory tract infections (URTIs)

Introduction-

It is essential for the pharmacist assessment of infectious diseases to consider the patients’ overall health status and to make

recommendations to physicians and/or other health professionals. These recommendations should be based on these

findings and knowledge of the preferred drugs and alternatives, as well as complications of the individual infections, with and

without treatment.

I. Principles of Antimicrobial Therapy. Host status, Bugs by site, preferred and alternative agents by organisms, drug failure

and resistance review

Approaching Infectious Diseases (IDs) - Disease states and Drugs that can Mimic IDs include: Cancers (CAs), Autoimmune

diseases, Immune agents, and drug fever

Establishing the presence of Infection - Patient History (Hx), physical and lab findings

History - What are the underlying problems in the patient, e.g. cancer (CA) and chemotherapy, transplant of heart, kidney,

liver, or prosthestic devices, e.g. heart valves, knee or hip joint replacement, COPD, AIDS, elderly, pediatric, acute or chronic

allergies and the history of the present illness (HPI), e.g. did the patient have a cold and cough for the past 2 weeks and a lowgrade

fever? Did the drug history include drugs that predispose to infection? (eg newer immunmodulating agents for

arthritis[Enbrel, Remicade, Orencia and Sustiva] oral corticosteroids and chemo or transplant rejection agents)

Physical - Does the patient have chills, fever, defervescence ( fever “breaking”), local lymphadenopathy or painful/tender

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nodes of neck, groin, and limbs and/or lymphangitis (AKA "red streaks") and swelling of limbs, adequate urine output ( should

be at least 15-20ml/hr unless dehydrated up to 0.5-1.0ml/kg/hr), fast or slow pulse rate (N=60-80BPM), increased respiratory

rate (N=12-20 rpm) tachypnea >30 rpm; 5-8 K/mm3 with "shift to the left"), Lumbar puncture, sputum (PMNs, epithelial cells), skin and soft tissue

scraping or aspiration (e.g. knee), Throat Strep-lysin and C&S are all procedures that may be needed to establish the presence

of infection. More details on individual lab tests are included in each course section.

Note: The correct answers are listed after each case. To assess your learning you should answer the questions before looking

at the answers.

Case 1. A 56-year old female patient presents to you pharmacy with complaints of fever, productive cough, sore throat,

headache and ear ache. She had a “cold and allergies” the past two weeks. Her oral temperature is 101.4, respiratory rate is

32-36 times per minute, BP is 168/104, pulse is 82 to 90 BPM and she has no energy. She has a history, of high blood pressure

and allergies and rheumatoid arthritis. Please see case questions below:

1. Her meds include a. celecoxib 200mg/day b. prednisone 10mg/day c. lisinopril 10mg daily and d. acetaminophen

500mg one q 6h prn pain (4 doses in the past 24 hours). Which of her meds could suppress her temperature

elevation if she was taking them?

a. a and d

b. b and c

c. c and d

d. b and c

2. Her vital signs suggest

a. no problem;

b. active infection;

c. b and maybe in more than one area of her respiratory system;

d. c and poorly controlled blood pressure if she is taking her meds.

3. You check her lymph nodes on the front and back of her neck and several places are tender. She may have

a. no problem;

b. active infection;

c. b in more than one area;

d. c and she needs acute care

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4. Which of her meds could have increased her risk of infection? (Use letters in question 1 please.)

5. Your most appropriate action may be to:

a. recommend regular acetaminophen to suppress fever;

b. a and add an antihistamine;

c. refer to primary care clinician;

d. simply recommend increased fluid intake

KEY--- 1-a, 2-c, 3-d, 4-b, 5-c

Normal versus Pathogenic Flora of the body- Table one lists the most common normal and pathogenic organisms found on

and within the body, as well as those body areas that are normally sterile.

Classification of ID Organisms and Sites of Infection

Table 1. Table of Normal Flora and Most Common Pathogens

SITE

External Ear

Middle Ear

Nasal Passages

NORMAL FLORA

Staphylococcus epidermidis

Alpha-hemolytic streptococci

Coliform bacilli

Aerobic corynebacteria

Corynebacterium acnes

Candida species

Bacillus species

NOTE: IN OLDER PATIENTS

EXCESSIVE WAX MAY ALLOW

DIFFERENT FLORA MIX

Sterile (UNLESS EARDRUM NOT

INTACT)

Staphylococcus epidermidis

Staphylococcus aureus

Diphtheroids

Pneumococci

Alpha-hemolytic streptococci

Nonpathogenic Neisseria

species

PATHOGEN

1. Pseudomonas aeruginosa (or other gramnegative

bacilli)-otitis externa primary pathogen!

2. Staphylococcus aureus

3. Streptococcus pyogenes (Group A)

4. Streptococcus pneumoniae

5. Haemophilus influenzae

(in children)

6. Fungi

1. Streptococcus pneumoniae

2. Haemophilus influenzae

(in children)

3. Streptococcus pyogenes

(Group A)

4. Staphylococcus aureus

5. Anaerobic streptococci

6. Bacteroides

7. Other gram-negative bacilli

e.g. M. catarrhalis (Chronic)

Paranasal Sinuses

1. Streptococcus pneumoniae

2. Streptococcus pyogenes (Group A)

3. Haemophilus influenzae

4. Moraxella catarrhalis

5. Klebsiella (or other gram-negative bacilli)

5. Anaerobic streptococci (Chronic sinusitis)

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SITE

Mouth-NOTE: IN

OLDER PTS. CHECK

FOR DENTURES

AND ABRASIONS

FROM POORLY-

FITTED DENTURES;

ALSO DRY MOUTH

(XEROSTOMIA),

GINGIVAL

HYPERPLASIA AND

LACK OF DENTAL

HYGIENE MAY

PREDISPOSE TO

INFECTIONS OF

GUMS, TEETH AND

BONES

Pharynx &

Tonsils: NOTE, IN

OLDER PTS. THE

USAGE OF

MOUTHWASHES,

INHALED and nasal

CORTICOSTEROIDS

MAY PREDISPOSE

TO infection with

monilial fungi, eg

Candida

(THRUSH) WITH

Advair, Symbicort,

VANCERIL,

AZMACORT,

AEROBID,

DECADRON, ETC.

BY INHALER,

UNLESS

THOROUGH

GARGLING IS

ENCOURAGED

AFTER EACH

INHALATION via

Aerobic corynebacteria 6. Staphylococcus aureus (Chronic sinusitis)

7. Mucor, Asperigillus (especially in diabetics)

NORMAL FLORA

Alpha-hemolytic streptococci

Enterococci

Lactobacilli

Staphylococci

Fusobacteria

Bacteroides species

Diphtheroids

Alpha-hemolytic streptococci

Neisseria species

Staphylococcus epidermidis

Staphylococcus aureus

(small numbers)

Pneumococci

Nonhemolytic (gamma)

streptococci

Diphtheroids

Coliforms

Beta-hemolytic streptococci

(not Group A)

Actinomyces israelii

Haemophilus species

Marked predominance of one

organism may be clinically

significant even if it is a normal

inhabitant.

PATHOGENIC FLORA

1. Herpes viruses

2. Candida albicans

3. Leptotrichia buccalis (Vincent's infections)

4. Bacteroides

5. Mixed anaerobes

6. Treponema pallidum

7. Actinomyces

Throat

1. Respiratory viruses

2. Streptococcus pyogenes (Grp A-beta hemolytic)

3. Neisseria meningitidis or gonorrhea

4. Leptotrichia buccalis (Vincent's infection)

5. Candida albicans

6. Corynebacterium diphtheriae

7. Bordetella pertussis

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lungs or nostrils

WITH PINCH OF

SALT IN HALF-

GLASS WARM

WATER or plain

water.

SITE

Larynx, trachea, &

bronchi-NOTE:

COPD PTS. HAVE

IMPAIRED HOST

DEFENSE AND

TEND TO HAVE

STREP, H-FLU ,

STAPH AND KLEB

COLONIZATIONS

THAT READILY

BECOME

PATHOGENIC

WITH THE

COMMON COLD,

flu OR ALLERGY

ATTACKS

Pleura

SITE

Lungs

NORMAL FLORA

Sterile

Sterile

NORMAL FLORA

Sterile-SEE COPD NOTE ABOVE

PATHOGENIC FLORA

Larynx, Trachea, & Bronchi

1. Respiratory viruses

2. Streptococcus pneumoniae

3. Haemophilus influenzae

4. Streptococcus pyogenes (Group A)

5. Corynebacterium diphtheriae

6. Staphylococcus aureus

7. Gram-negative bacilli

1. Staphylococcus aureus

2. Streptococcus pneumoniae

3. Haemophilus influenzae

4. Gram-negative bacilli

5. Anaerobic streptococci

6. Bacteroides

7. Streptococcus pyogenes (Group A)

8. Mycobacterium tuberculosis

9. Actinomyces, Nocardia

10. Fungi

PATHOGEN

Pneumonia

1. Respiratory viruses

2. Mycoplasma pneumoniae (late)

3. Strep. pneumoniae (early)

4. Haemophilus influenzae

5. Staphylococcus aureus

6. Klebsiella (or other gram-negative bacilli)

7. Streptococcus pyogenes (Group A)

8. Rickettsia

9. Chlamydia psittaci

10. Mycobacterium tuberculosis

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SITE

Stomach Small

intestine: NOTE-

10 TO 15% OF

PATIENTS ALSO

HAVE

EUBACTERIUM

LENTUM AS

NORMAL FLORA-

THESE PTS. MAY

REQUIRE HIGHER

DIGOXIN DOSES,

DUE TO THE

INACTIVATION OF

DIGOXIN BY EU.

LENTUM; WATCH

FOR DIGOXIN

TOXICITY WHEN

BIAXIN,

ERYTHROMYCIN

OR

TETRACYCLINES

ARE GIVEN TO A

PATIENT

STABILIZED ON A

HIGHER DOSE OF

DIGOXIN; ALSO BE

AWARE THAT 40-

70% OR MORE OF

OLDER PTS. ARE

ACHLORHYDRIC

and H-2 blockers

and PPIs may

predispose them

to higher risk of

RTIs

Colon

NORMAL FLORA

Sterile

Sterile in one-third

Scant bacteria in others

Escherichia coli

Klebsiella

Enterobacter

Enterococci

Alpha-hemolytic streptococci

Staphylococcus epidermidis

Diphtheroids

Colon has--->

Abundant bacteria

Bacteroides species

Escherichia coli

Klebsiella

Enterobacter

Paracolons

Proteus species

Enterococci (Group D

streptococci)

Yeasts

(stool is 1/2 or more bacteria by

weight)

11. Anaerobic streptococci

12. Bacteroides

13. Pneumocystis carinii (AIDS)

14. Fungi (AIDS and immunecompr.)

15. Legionella pneumophilia

16. Legionella micdadei (L. pittsburgensis)

PATHOGENS

Gastrointestinal Tract

1. Gastrointestinal viruses

2. Salmonella

3. Escherichia coli

4. Shigella

5. Campylobacter (vibrio) fetus

6. Yersinia enterocolitica

7. Staphylococcus aureus

8. Vibrio cholerae

9. Vibrio parahaemolyticus

10. Treponema pallidum (anus)

11. Neisseria gonorrhoeae (anus)

12. Candida albicans

13. Clostridium difficile

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Urethra, Male-

NOTE; USE OF A

TEXAS or Condom

CATHETER

INCREASES RISK

OF UTI TO THAT

OF INDWELLING

CATHETERS IN

BOTH SEXES

Prostate

SITE

Urethra, Female

and

vagina

Staphylococcus aureus

Staphylococcus epidermidis

Enterococci

Diphtheroids

Achromobacter wolffi (Mima)

Haemophilus vaginalis

Bacillus subtilis

Sterile

NORMAL FLORA

Lactobacillus (large numbers)

Coli-aerogenes

Staphylococci

Streptococci (aerobic and

anaerobic)

Candida albicans

Bacteroides species

Achromobacter wolffi (Mima)

Haemophilus vaginalis

Male Genital Tract

Seminal Vesicles

1. Gram-negative bacilli, mainly E.coli

2. Neisseria gonorrhoeae

Epididymis

1. Gram-negative bacilli

2. Neisseria gonorrhoeae

3. Chlamydia

4. Mycobacterium

Prostate Gland

1. Gram-negative bacilli, E. coli, Proteus

2. Neisseria gonorrhoeae

PATHOGENIC FLORA

Female Genital Tract

Vagina

1. Trichomonas vaginalis

2. Candida albicans

3. Neisseria gonorrheae

4. Streptococcus pyogenes (Group A)

5. Haemophilus vaginalis

6. Treponema pallidum

7. Staphylococcus aureus

Uterus

1. Anaerobic streptococci

2. Bacteroides

3. Neisseria gonorrheae

4. Clostridia

5. Escherichia coli (or other gram-negative

bacilli)

6. Herpes virus, type II (cervix)

7. Streptococcus pyogenes (Group A)

8. Streptococcus, Groups B & C

9. Treponema pallidum

10. Staphylococcus aureus

11. Enterococcus

Fallopian Tubes

1. Neisseria gonorrhoeae

2. Gram-negative bacilli

3. Anaerobic streptococci

4. Bacteroides

5. Chlamydia

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Urine, continent

patients;

incontinent pts.

have 3+ to 4+

bacteriuria which

may be protective

colonization,

rather than clinical

infection of E. coli

and/or Proteus;

stone-formers

typically have

Proteus

Peritoneum

Bones-NOTE: IN

OLDER PTS., WITH

HX HIP

FX/NAILING/BALL

REPLACEMENT OR

OPEN STAGE IV

DECUBITUS, ESP.

IF

MALNOURISHED,

STAPH

OSTEOMYELITIS IS

MORE LIKELY

SITE

Joints

Staphylococci, coagulase

negative

Diphtheroids

Coliform bacilli

Enterococci

Proteus species

Lactobacilli

Alpha- and Beta-hemolytic

Streptococci

Sterile

Sterile

NORMAL FLORA

Sterile

Urinary Tract

1. Neisseria gonorrheae (urethra)

2. Escherichia coli (or other gram-

negative bacilli)

3. Staphylococcus aureus and epidermidis

4. Enterococcus

5. Candida albicans

6. Chlamydia (urethra)

7. Treponema pallidum (urethra)

8. Trichomonas vaginalis (urethra)

Peritoneum

1. Gram-negative bacilli

2. Enterococcus

3. Bacteroides

4. Anaerobic streptococci

5. Clostridia

6. Streptococcus pneumoniae

7. Streptococcus Group B

Bones (Osteomyelitis)

1. Staphylococcus aureus (>30yo)

2. N. gonorrhoeae (30)

2. Streptococcus pyogenes

(Group A)

3. Neisseria gonorrhoeae (


Eye-NOTE: DRY

EYE IN OLDER

PATIENTS

PREDISPOSES TO

BACTERIAL

CONJUNCTIVITIS

AND BLEPHARITIS;

USE OF ARTIFICIAL

TEARS GTTS ii QID

DECREASES

FREQUENCY OF

EYE

INFECTIONS(Coop

er JW Cons Pharm

1988); SUSPECT

MRSA IN NURSING

HOME PTS. WITH

CHRONIC

BACTERIAL

EYE/LID

INFECTIONS

SITE

Spinal Fluid

SITE

Blood-NOTE:

BACTEREMIA IS

MORE COMMON

Usually sterile

Occasionally small numbers

of diphtheroids and coagulase-

negative staphylococci

NORMAL FLORA

Sterile

NORMAL FLORA

Sterile

8. Mycobacterium tuberculosis and

other mycobacteria

9. Fungi

Eye (Cornea and Conjunctive)

1. Herpes and other viruses

2. Staphylococcus aureus-most common bacterial

infection

3. Neisseria gonorrheae (newborns)

4. Haemophilus aegyptius

(Koch-Weeks bacillus)

5. Streptococcus pneumoniae

6. Haemophilus influenzae

(in children)

7. Moraxella lacunate

8. Pseudomonas aeruginosa

9. Other gram-negative bacilli

10. Chlamydia trachomatic

(trachoma)

11. Chlamydia (inclusion conjunctivitis)

12. Fungi

PATHOGENS

Meninges

1. Viral agents (enterovirus, mumps, herpes

simples, and others)

2. Neisseria meningitidis

3. Haemophilus influenzae (in children)

4. Streptocococcus pneumoniae

5. Streptococcus Group B (infants less than 2

months old)

6. Escherichia coli (or other gram-negative bacilli)

7. Strep. pyogenes (Group A)

8. Mycobacterium tuberculosis

10. Cryptococcus neoformans and other fungi

11. Listeria monocytogenes

12. Enterococcus (neonatal period)

13. Treponema pallidum

14. Leptospira

PATHOGENS

Blood (Septicemia) New born Infants

1. Escherichia coli (or other gram-negative bacilli)

2. Streptococcus Group B

3. Staphylococcus aureus

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IN OLDER PTS.

WITH

PNEUMONIAS,

DECUBITI, UTIs,

INDWELLING

CATHETERS,

ESPECIALLY IF

MALNUTRITION IS

ALSO PRESENT.

Self Assessment Questions-

1. The patient with excessive ear wax may have

a. more risk of ear infections

b. less risk of ear infections

4. Strep. pyogenes (Group A)

5. Enterococcus

6. Listeria monocytogenes

7. Streptococcus pneumoniae

Children

1. Streptococcus pneumoniae

2. Neisseria meningitidis

3. Haemophilus influenzae

4. Staphylococcus aureus

5. Strep. pyogenes (Group A)

6. Escherichia coli) or other gram-negative bacilli)

Adult

1. Escherichia coli (or other gram-negative bacilli)

2. Staphylococcus aureus

3. Streptococcus pneumoniae

4. Bacteroides

5. Strep. pyogenes (Group A)

6. Neisseria meningitidis

7. Candida albicans

8. Neisseria gonorrheae

9. Other Candida species

2. A patient is using a. Nasacort nasal steroid and b. Azmacort inhaled steroid. Which can increase the risk of “thrush”

a. a only

b. b only

c. both a and b.

d. neither a nor b.

3. A patient with COPD is a greater risk of respiratory tract infections due to their

a. COPD

b. colds or flu

c. allergies

d. all, a-c

4. A patient taking digoxin in a higher than normal dose to get therapeutic blood levels is at risk of what change in their

blood levels?

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a. increase with diarrhea

b. decrease with antiinfectives

c. a and increase with antiinfectives, especially macrolides and tetracyclines

d. no change

5. A patient taking H-2 blockers, eg ranitidine and/or PPIs, eg omeprazole is at risk of increased infections of what type

a. RTIs

b. UTIs

c. skin

d. bone

KEY-> 1-a, 2-c, 3-d, 4-c, 5-a

EENT and Upper respiratory tract infections. Includes Pink eye, colds, flu, pharyngitis, sinusitis, otitis media (and allergies).

The following is from JW Cooper, Geriatric drug therapy, by permission.

EYE Infections (ENT=ears, nose and throat infections covered in upper respiratory [URI] section)

Conjunctivitis ("Pink-eye") is a general or nonspecific term that refers to inflammation of the conjunctiva. The

conjunctiva is a thin mucous membrane that covers the posterior surface of the eyelids and the whites of the eye.

The conjunctiva is usually adequately hydrated by the blink response and tears. Please see viral, bacterial and

allergic conjunctivitis types in figures 1, 2 and 3 below.

The conjunctiva may become thinner with aging, which leads to drying of the eye surface and the eye becomes

increasingly more sensitive to irritants; conjunctivitis becomes a common problem. The patient may present with

diffuse redness in one or both eyes, complaints of irritation, itching and tearing or exudation that may be purulent.

If matting of the eyelids, especially on arising is noted on arising from slumber, bacterial infection is often present.

Vision is usually not impaired, unless itching of the eye has abraded the corneal surface. Guarding of the eyes

from light (photophobia) should always raise the suspicion of eye damage that requires referral to an eye care

specialist (i.e. optometrist or ophthalmologist) and recommendation to cover the affected eye(s) with a patch.

Conjunctivitis can be caused by a variety of allergens and infectious and noninfectious agents such as bacteria,

viruses, fungi, toxins, and irritating chemicals. The most common causes of conjunctivitis in the elderly are

bacterial, viral, and allergic.

Figure 1- Allergic Conjunctivitis-note swollen lids and redness of white of eyes-will usually also have itching and

burning of eyes

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.

Allergic Conjunctivitis

Courtesy of http://www.aaaai.org

Figure 2-Viral Conjunctivitis-note diffuse redness in both eyes with NO matting

Viral Conjunctivitis

Picture courtesy of www.eyedrops.info

Figure 3- Bacterial Conjunctivitis-Note matting of both eyes

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Bacterial Conjunctivitis

picture courtesy of www.eyedrops.info

ASSESSMENT

Consider patient referral to an ophthalmologist or to the emergency room. You may want to check the patient for

photophobia (i.e., cannot look at light source without squinting/closing eyes) and for any irregularity of image

reflection on the surface of the cornea. A fluorescent light fixture is a good source of a "rectangular" light image

that you can have the patient look at and observe the reflection of the shape of the light. If either abnormality is

present, get the patient to an ophthalmologist quickly. Call for an appointment STAT while the patient is with you.

1. In dry eyes WITHOUT INFECTION or corneal damage, artificial tears are good for long-term use to decrease the

frequency of eye infections and allergic response. Drugs that are anticholinergic in primary or side effects may

worsen dry eye conditions, e.g., antihistamines and anticholinergics for incontinence, such as cetirizine or

oxybutinin. Make sure that a polymer is part of the formulation, e.g. methylcellulose, or PVP to prolong contact of

the drop with the surface of the eye. Examples are: Adsorbatear, Liquifilm, Tearisol, etc. Dose is 2gtts in each eye

QID CONTINUOUS. NOTE: The regular instillation of artificial tears with this regimen has been shown to reduce the

frequency of bacterial conjunctivitis (JW Cooper, Cons Pharm l988; 3:83.). The use of topical cyclosporine (Restasis)

emulsion for chronic dry eyes is much more expensive and may NOT work if topical NSAIDs or corticosteroids are

in use. Topical Cyclosporine drops (Restasis) should NOT be used in active eye infections.

The need for an antibiotic eye preparation more often than quarterly to semi-annually with change of seasons

suggests the need for regular use of artificial tears. Visual inspection of the eyes that finds apparent dryness for

more than several days at a time, also raises the question of need for continual usage of an artificial tear/polymer

preparation. BE SURE TO APPLY artificial tears LAST or at least 30-60 minutes away from glaucoma topical eye

preparations to prevent occlusion of the eye absorbing surface by the polymer in the artificial tears.

2. For allergic, itchy eyes, artificial tears with a topical vasoconstrictor is preferable, e.g. Visine. In addition, the

younger patient may need diphenhydramine 25mg HS or chlorpheniramine maleate (CTM) 2mg once to BID to

TID for allergy; a non-sedating antihistamine such as loratidine (Claritin/Alavert) 10mg daily may be preferable

in older patients or those who cannot tolerate the sedation, INCREASED FALL RISK and drying side effects of the

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older antihistamines to include the active metabolite of hydroxyzine (ie cetirizine-Zyrtec). Baby shampoo,

several drops on a clean warm water-soaked cloth may help to keep allergens washed away from lid surfaces

and the orbital area of eye. Be sure to recommend that a clean cloth be used for each washing of the

periorbital area, and different portions of the cloth used for each eye, to avoid cross-contamination. See figure

1.

3. For a dry, allergic, or infectious red eye, short-term, days to 2 weeks, therapy of topical glucocorticoids (GC)

may be acceptable. If the patient has a history of glaucoma,it is essential that the intraocular pressure be

checked if therapy is to last more than two weeks. YOU MUST ALWAYS use a topical antitinfective in infectious

red eye if a topical GC is used. Use beyond this period of time, increases the risk of higher intraocular pressure

(IOP) and cataract formation. Agents used include prednisolone, hydrocortisone, dexamethasone and

fluoromethalone. An alternative to steroids is levocabastine HCl (Livostin), an H-1 antihistamine for temporary

relief of seasonal allergic conjunctivitis. Livostin dose is one drop in affected eye(s) BID to QID prn. Contains

benzalkonium chloride which may damage soft contact lenses; most persons cannot wear any contact lenses

when conjunctivitis occurs. See figures 1, 2 and 3.

4. Bacterial conjunctivitis (BC) AKA "Pink Eye" is frequently the result of staphylococci, streptococci, both

staph and strep or gram-negative bacteria. BC is common after or with allergic conjunctivitis and is

characterized by a purulent discharge that produces matting of the lids. (see figure 3) The patient usually

complains of difficulty in opening the eyelids in the morning because of dried pus literally gluing the eyelids

shut. Discomfort from bacterial conjunctivitis is usually mild despite marked inflammatory changes because of

the relative lack of pain fibers in the conjunctiva.

Bacterial conjunctivitis is usually self-limited, lasting 7-14 days without treatment and 3 to 4 days with

treatment. A culture of the eye(s) is not considered necessary because conjunctivitis is self-limited. However, a

culture should be obtained in persistent and/or serious infectious problems that last for more than 2 weeks of

topical antibiotic therapy.

NOTE: Blepharitis (Lid infection) may also be present and respond better to the cleansing and use of an

ophthalmic ointment applied BID (e.g. polymyxin or bacitracin) to the affected lid(s). Avoid neomycin

containing eye preparations (e.g., Neosporin) due to risk of sensitization to neomycin and subsequent allergy to

all aminoglycosides (AGs). Chronic bacterial blepharitis is usually a resistant staph infection that causes loss of

eyelashes and may require low-dose suppressive antimicrobial therapy (e.g. oral erythromycin 250mg or

doxycycline 100mg PO daily) to decrease the frequency of acute infections that seed both the lid and

conjunctiva. An external stye (hordeolum) is best treated with hot compresses which will cause it to drain

spontaneously. An internal stye requires hot packs AND a penicillinase resistant pencicillin (PRP) or first

generation cephalosporin, e.g. clox- and dicloxacillin or cephalexin for 7-10 days, as internal styes rarely drain

spontaneously.

A very conservative approach that can be recommended in suspected BC is a sterile normal saline eye wash

(e.g. Collyrium) four times a day for 48 hours before resorting to instillation of any prescribed ophthalmic

medication. RUN hot soapy water in eye cup between uses to avoid self-reinocculation with bacteria.

If signs of redness and symptoms persist longer than 2 days a topical antibacterial (e.g. sulfacetamide) may

then be initiated. In the case of red eye with infection, evidenced by morning matting at corners of eyes, a

sulfacetamide 10% eye drops with baby shampoo cleaning QID and artificial tears used regularly may decrease

incidence of reinfections.

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BC in CONTACT LENS USERS

BC in this group tends to be predominantly Ps. aeruginosa, which has to be aggressively treated with

tobramicin + pipracillin or ticarcillin eye drops q 15-60 minutes for 24-72 hours or FQs ciprofloxacin (Cipro),

ofloxacin (Oflox), levofloxacin (Quixin), moxifloxacin (Vigamox) or gatifloxacin (Zymar) eye drops same schedule

ATC (around-the clock) then slow reduction and lengthening of dosage interval over days to weeks with

ophthalmologist re-check every 1-2 weeks or recurrence of symptoms.

Watch long-term use of any antibacterial if eyes are still infected/reddened. Intermittent use is best for 5-10

days; if eyes are still red or infected the patient may need C&S, a change to another anti-bacterial, and/or

artificial tear chronic use. Check for allergy history, especially if sulfonamide or aminoglycoside allergic

reaction has been previously noted.

Start BC treatment with sodium sulfacetamide 10%. If sulfas do not clear the infection, Try the macrolide

azithromycin 1% (AzaSite) before Polytrim (TMP-polymyxin) or Polysporin (Bacitracin-polymixin), AVOID

neomycin with bacitracin/polymyxin (Neosporin) due to neomycin hypersensitivity to AGs. If an AG is

needed then use AGs gentamicin (Garamycin), then tobramycin (Tobrex) may be considered as eye

antiinfectives. Reserve the fluoroquinolone eye drops for resistant infections that have not responded to all

the other mentioned agents; FQs rapidly induce resistant strains, so should be reserved as last resort to retain

their efficacy. A 10-14 day stop order is essential to monitor effectiveness as well as the possible emergence of

resistant infections.The newest FQs are levofloxacin (Quixin) and moxifloxacin (Vigamox) and gatifloxacin

(Zymar) .

BC is CONTAGIOUS!! Bacterial conjunctivitis is extremely contagious and can be spread by direct contact, most

commonly from hand-to-eye. Hands should be washed before and after application of drops or ointment, and

the tip of the tube or bottle should not touch the eye surface or lid. If contact does occur, then immediately

washing the surface with warm soapy water is essential to minimize spread of the contagion.

Topical steroids may retard infection/wound healing once inflammation is clear. Their legitimate usage is

primarily for post-cataractectomy care. Also, they increase glaucoma/cataract risk with prolonged usage (>2-4

weeks). The addition of corticosteroids (i.e., hydrocortisone) to a topical antibiotic does not increase the

effectiveness of the preparation for bacterial conjunctivitis nor speed the resolution process of the infection.

The combination of steroid-antibacterial preparations (e.g. Cortisporin) is not usually recommended as the

corticosteroid may reduce resistance to bacterial, viral and fungal infections and may mask the signs of a

hypersensitivity reaction to the antibacterial.

Self-Assessment

Case 2-

A 57 year-old female presents to your pharmacy with complaints of (c/o) dry, itchy eyes. On review of her

medication profile for the last 6 months, you notice that she has had several topical antiinfective Rxs for

blepharitis and conjunctivitis.

Self Assessment Questions-

1. What other physical assessments should you do before making a recommendation?

a. check for eye glasses or contacts matting of eyelids and pink eye

b. check for photophobia

c. check her history of colds and allergies

d. all of the above

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2. You have completed the assessment in question 1. She does have eyelid matting, had a cold last week and

has chronic allergies which she has self-treated with CTM. You assess that she needs medications to prevent

eye and lid infections recurrence. Which of the following would you recommend?

a. artificial tears without polymer

b. a with polymer – two drops four times daily.

c. cleansing eye lids with baby shampoo and clean cloth at least daily

d. b and c and referral to her eye care professional

3. The patient takes your recommendations and returns the next week wearing dark glasses. She says that she

cannot look at lights without squinting and eye pain. Which finding in question 1 does this suggest?

4. What is your next step with this patient?

a. offer an antibacterial for her eye

b. offer oral and topical decongestants

c. offer to call her eye care professional

d. a and b

key: 1-D, 2-D, 3-B, 4-C

Viral Eye Infections (see viral conjunctivitis in figure 2 )

Topical antivirals (Herplex, Vira-A, Viroptic) are for short-term Herpes simplex conjunctivitis only. Many viral

organisms may cause viral conjunctivitis. This type of conjunctivitis may be associated with other viral

infections such as viral pharyngitis. Some viruses cause infection of the cornea (keratitis) and the conjunctiva

simultaneously. The viral forms of conjunctivitis are usually bilateral with red eyes, but with a clear drainage

and less exudation than the bacterial forms of conjunctivitis. Herpes simplex is the most common virus for

which there is a specific treatment for viral conjunctivitis (idoxuridine[ IDU, Herplex] for IDU-resistant herpes

vidaribine (Vira-A) and for Vira-A resistant herpes, trifluridine (Viroptic). Herpes zoster opthalmicus is treated

with famciclovir (Famvir) 500mg TID or valacyclovir (Valtrex) 1gTID for 10 days or IV acyclovir to prevent loss of

sight in the affected eye.

Treatment: Cool compresses and vasoconstrictor drops (i.e., naphazoline) may provide some symptomatic

relief. Symptoms generally resolve within 7-10 days in healthy individuals with or without specific antivirals.

Meticulous hygiene is necessary to avoid transmission of viral conjunctivitis. Hand washing by the patient and

health care providers who come in contact with the patient is essential in avoiding transmission of this VERY

contagious condition. Ophthalmologic consult is needed for topical antiviral (eg Stoxil) use longer than 21 days.

ALLERGIC Conjunctivitis and Eye Infections (see figure 1)

Topical cromolyn (Crolom), lodoxamine (Alomide), nedocromil (Alocril) and pemirolast (Alamast) are mast cell

stabilizers for chronic allergic conjunctivitis, not for acute attacks. They may worsen an acute attack. Other

alternatives are mast cell stabilizer/antihistamines , azelastine (Astelin/Optivar), epinastine (Elestat), ketotifen

(Zaditor) and olapatadine (Patanol), the H-1 antihistamines emedastine (Emadine), livocabastine (Livostin) , and

the NSAID ketorolac (Acular) and other NSAIDs (although not approved for this usage-be sure to check for ASA

allergy). Topical steroids are not recommended for allergic conjunctivitis due to risk of glaucoma and cataracts

with long-term use. Patients with refractory chronic allergic eye problems may require oral antihistamines to

suppress the allergic eye process. (Medical Letter 26 Apr 2004; 46:35-6).

Never use Chlormycetin (chloramphenicol) eye or topical (Elase/Chlormycetin) preparation for prolonged

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periods (> 2 weeks) as aplastic anemia has been reported via these routes.

Topical Aminoglycosides (gentamicin, neomycin or tobramycin) may add to systemic aminoglycoside levels if

peak and/or trough blood levels are being done. Cross-allergenicity between topical and injectable

aminoglycosides (e.g. neomycin, streptomycin, gentamicin, tobramycin, amikacin and netilmicin.

CASE-3

H.P. a 52 year-old female with recurrent bacterial conjunctivitis developed swollen, reddened eyes after

neomycin/polymyxin/bacitracin (Neosporin) Ophthalmic drops usage for 2 days. Six months later she required

a course of injectable tobramycin for a pseudomonal UTI and immediately broke out in a florid macular itching

rash with the first dose. Even though her chart had AMINOGLYCOSIDE allergy stamped on the front, the prior

exposure to the aminoglycosides neomycin in Neosporin and tobramycin did not prevent a re-exposure to

these drops. On the first instillation of Tobrex eye drops, she developed an anaphylactoid reaction, which

required intravenous steroids.

1. What eye drop would you recommend for her next BC?

a, gentamicin

b. ciprofloxacin

c. TMP

d. polymycin-bacitracin

2. She now has an internal stye. What do you recommend?

a. hot compresses

b. an oral PRP or first generation cephalosporin

c. a and b

d. neomycin/bacitracin/polymyxin (Neosporin)

3. She is asking for contact lens to replace her eyeglasses. What do you recommend?

a. a local eye care professional

b. a preventive antiinfective eye drop

c. a continuance of her eye glasses

d. none of the above

Key: 1-b, 2-c, 3-a

Monitoring Upper Respiratory Tract Infections (URTIs) (Nose, sinus, ears and throat problems.

ACUTE URTIs

In acute problems an oral temperature is essential, with no hot or cold beverages 10-15 minutes before taking

temperature. Remember that in older persons, the baseline oral temperature may be 95-97 degrees. Also

watch for acetaminophen, non-acetyl salicylate, NSAID or oral glucocorticoid usage masking febrile state.

Differential Assessment- always check throat, ears and sinuses together

In the presence of sinusitis, with facial fullness and frontal headache with even slight temperature elevation,

there is a great likelihood of bacterial infection in the sinus area, requiring the same antibiotics as you would

see in otitis media.

In the patient with sore throat and/or sub-mandibular lymphadenopathy (tender to touch and palpable

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anterior and/or posterior chain of nodes on the front and back of throat), any temperature elevation is usually

an indication of possible strep throat. Use office strep lysin test to confirm. Keep in mind that the strep lysin

has only about 60% sensitivity (i.e. true positive in strep disease) and 60-95% specificity ( true negative in

health, i.e. if strep not present). About half with a positive strep lysin are actually infected; the rest are strep

carriers who can give the disease to others, but may NOT be acutely infected. Symptomatic contacts of infected

patients should also probably be evaluated for strep throat.

Acute Pharyngitis-inflammatory process of pharynx and tonsils (Waldeyer's ring) "sore throat" NOTE: always

check ears and sinuses when a patient complains of (c/o) sore throat!

Pharyngitis is more common in cold and flu seasons (may precede cold)

CONCEPT: Some 70-90% or more of sore throats are viral (at least to start).

Viral bugs - rhinovirus, parainfluenza, coronavirus, adenovirus, Herpes simplex and influenza.

Viral pharyngitis Symptoms-nasal Symptoms and cough usually present, sore throat may not be main

complaint but has "cold" and/or hay fever or allergy ; rarely systemic complaints of muscle or joint aches (e.g.

arthralgias or myalgias) unless its the flu

NOTE: VIRAL can quickly go to bacterial sore throat in immune compromised pts.; more slowly or if viral

precedes (always suspect if viral lasts longer than 2-3 days) or low-grade fever starts, with anterior chain

lymphadenopathy, or stomach ache in younger as well as older patients.

Bacterial bugs - S. pyogenes, H. flu, Chlamydia or Mycoplasma pneumoniae, N. gonorrhea (if STD check GU &

GI also)

Bacterial pharyngitis Symptoms - Sore throat primary complaint, painful cervical lymphadenopathy (swollen

anterior neck chain nodes; posterior also if OM/Sinusitis), elevated WBC count with "Shift to the left" and fiery

red throat with exudate on pharynx and tonsil/adenoids. In children and some adults stomach pain may be a

frequent complaint with Strep throat. See picture below for classic appearance.

Differentiate Strep pharyngitis by rapid screening (Strep lysin), but only 60-95% sensitivity (positive in disease

and 90-95 % specificity (negative in healthy state)-- and throat culture for Strep: NOTE only half of positive pts.

are actually infected' rest are presumably carriers of S. pyogenes. Always check that contacts of infected pts.

have been evaluated (e.g. siblings, classmates, friends and parents/guardians).

Acute Treatment – Generally use standard pen V, amoxicillin, procaine or Benzathine Pen G, Pen G PO (doubledose

of V), most beta lactams (except 3rd generation cephalosporins) and macrolides (erythromycin,

clarithromycin (Biaxin), azithromycin (Zithromax) work for Streptococcus. AVOID: same as for otitis media

(OM)-NOTE: if OM is also present pen V may not be effective. Many ID specialists prefer amoxicillin with or

without clavulanate (Augmentin). Moxatag is a new, extended-release amoxicillin for once a day usage. The

objective of treatment is to prevent heart and joint (scarlet and rheumatic fever) but not kidney damage (strep

glomerulonephritis).

CASE 4- A 35 year-old female (yof) presents with a sore throat and wants to know what gargle to use. Her

throat is in the picture below.

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1. 1.What should you do before the 3 Rs (refill, refer or recommend)

a. assess for fever, anterior chain neck lymphadenopathy

b. check ears and sinuses

c. check Hx of cold and/or allergies

d. all of the above

2. The patient has suspected strep throat. What do you recommend?

a. Pen V 250mg B-QID or 500mg BID X 10 days

b. erythromycin 250mg QID or 500mg BID X 10 days-except in older adults

c. First generation Cephalosporin X 10 days

d. Any of a-c or a or c

3. The patient has just started taking a low estrogen content oral contraceptive (OC) last month. Are there any

precautions you may want to suggest?

a. report any breakthrough bleeding while taking the antiinfective in 2 to whomever prescribed the OC

b. suggest secondary contraceptives for both partners during course of treatment

c. if the patients gets diarrhea from the antiinfective these recommendations are even more critical to

follow

d. all of the above

The correct answer for all three questions is d.

CASE 5- A parent brings in an Rx for amoxicillin suspension 125mg/5ml, 200ml Sig: i tsp QID for her child for

strep pharyngitis and otitis media 1. What should you do before filling this Rx?

a. check the child=s weight

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. check Hx of beta lactam usage

c. check for the intended use (Throat vs. Ears vs. Sinus vs. All)

d. All of the above

The correct answer is d.

Complications of Group A beta hemolytic strep infection include scarlet fever (rare), glomerulonephritis

(treatment does not prevent), acute and chronic rheumatic fever (RF) and endocarditis are complications that

can occur. Manifestations and Evidence for RF diagnosis include heart damage which is primarily valvular and

results in murmurs and polyarthritis. Prophylactic regimen drugs for prevention of bacterial endocarditis (JAMA

1997;277:1794-1801) may include amoxicillin, a macrolide or cephalosporin.

The American Heart Association’s Endocarditis Committee, together with national and international experts on

Bacterial Endocarditis (BE), extensively reviewed published studies to determine whether dental,

gastrointestinal (GI) or genitourinary (GU) tract procedures are possible causes of BE. These experts

determined that no conclusive evidence links dental, GI or GU tract procedures with the development of BE.

The current practice of giving patients antibiotics prior to a dental procedure is no longer recommended

EXCEPT for patients with the highest risk of adverse outcomes resulting from BE. The committee cannot

exclude the possibility that an exceedingly small number of cases, if any, of BE may be prevented by antibiotic

prophylaxis prior to a dental procedure. The Committee recognizes the importance of good oral and dental

health and regular visits to the dentist for patients at risk of BE.

The committee no longer recommends administering antibiotics solely to prevent BE in patients who undergo a

GI or GU tract procedure.

Changes in these guidelines do not change the fact that the patient’s cardiac condition puts him at increased

risk for developing endocarditis. If he should develop signs or symptoms of endocarditis – such as unexplained

fever – refer him to his doctor right away. If blood cultures are necessary (to determine if endocarditis is

present), it is important for the doctor to obtain these cultures and other relevant tests BEFORE antibiotics are

started.

SORE THROAT PATIENT EDUCATION CONSIDERATIONS

A sore throat should be a transitory problem as part of a cold, post-nasal drip, or seasonal allergy. If prolonged

and fever OR SWOLLEN NECK is present, a more serious problem may exist and you need to consult your

doctor. If an occasional sore throat bothers you, a pinch of salt in a half glass of warm water with a deep gargle

4 to 6 times a day frequently brings relief. Mouthwashes such as Listerine and Lavoris may also be gargled. If

throat pain is very uncomfortable, a spray or lozenge such as Chloraseptic may be used for a short period of

time (24-48 hours). Patients who use inhaled steroids such as those found in Advair, Symbicort, Vanceril,

AeroBID, Azmacort etc. may get a sore throat and/or hoarseness if they do not thoroughly gargle after each

inhalation of the steroid.

CASE 6- An elderly man wants something for his cold. You notice a harking and barking deep productive cough

and a pack of cigarettes in his front pocket. What questions do you ask him or check in his profile?

a. Has he had any antibiotics in the last weeks to months?

b. Does he have any COPD meds?

c. has he had a cold or allergies recently; check for fever, sputum color change and amount and check

for HBP and cardiovascular problems

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d. all of the above

The correct answer is d.

Common Cold Treatment-

There is some evidence that zinc gluconate lozenges (ColdEze R ) taken regularly (QID) at the onset of cold

symptoms for 3-5 days may shorten the length of symptoms of the cold in adults, but not children. Zicam® may

be a useful topical zinc for the nasal passages, but PERMANENT loss of smell has been associated with this

dosage form-AVOID ZICAM!. The use of antihistamines and decongestants may bring symptomatic relief as

long as there is not a history of falls, HBP, angina, past MIs. TIAs nor CVAs. Adequate hydration is essential.

Topical decongestants e.g. Afrin are best avoided, unless used sparingly e.g. only at bedtime when patient can

not breath comfortably. Otherwise the chronic use of these topical decongestants can lead to rhinitis

medicamentosa (RM). The features of RM are severe rebound nasal and sinus congestion that requires

intranasal corticosteroids (e.g. Vancenase, Nasalcort, Flonase) to taper one off the decongestant. The common

cold can quickly progress to acute bronchitis and/or bronchopneumonia in the immune-compromised patient

e.g. those receiving chemotherapy or high-dose (>7.5mg prednisone equivalent/day) corticosteroids, transplant

recipients,AIDS, diabetics, frail elderly or any malnourished patient. Echinacea has mixed reviews but usually do

NOT recommend.

Low vitamin D levels (less than 10-30ng/ml) are also associated with increased

Risk of colds : Ginde AA, Mansbach JM, Camargo CA Association between serum 25-hydroxyvitamin D level

and upper respiratorytract infection in the Third National Health and Nutrition Examination Survey.Arch

Intern Med. 2009 Feb 23;169(4):384-9

Recent studies suggest a role for vitamin D in innate immunity, including the prevention of respiratory tract

infections (RTIs). The hypothesis was that serum 25-hydroxyvitamin D (25[OH]D) levels are inversely associated

with self-reported recent upper RTI (URTI). A secondary analysis of the Third National Health and Nutrition

Examination Survey was made, a probability survey of the US population conducted between 1988 and 1994.

An examination of the association between 25(OH)D level and recent URTI was made in 18,883 participants 12

years and older. The analysis adjusted for demographics and clinical factors (season, body mass index, smoking

history, asthma, and chronic obstructive pulmonary disease). The results were that: The median serum

25(OH)D level was 29 ng/mL (to convert to nanomoles per liter, multiply by 2.496) (interquartile range, 21-37

ng/mL), and 19% (95% confidence interval [CI], 18%-20%) of participants reported a recent URTI. Recent URTI

was reported by 24% of participants with 25(OH)D levels less than 10 ng/mL, by 20% with levels of 10 to less

than 30 ng/mL, and by 17% with levels of 30 ng/mL or more (P < .001). Even after adjusting for demographic

and clinical characteristics, lower 25(OH)D levels were independently associated with recent URTI (compared

with 25[OH]D levels of > or =30 ng/mL: odds ratio [OR], 1.36; 95% CI, 1.01-1.84 for


cuts rates of hospitalization in premature birth and those infants with COPD (Med Letter 2001;43:13-14)

EAR INFECTIONS

Monitoring Ear Infection Needs.

General Considerations for ear problems include excessive wax, and otitis externa, and otitis media as well as

the use of myringotomy/tympanostomy tubes. The elderly are predisposed to cerumen accumulation and

keratosis obturnas because cerumen is not as easily expelled in the older as in the younger adult.

1. Ears should be carefully checked with an otoscope. If decreased hearing is reported, wax should be removed

and/or obstruction should be cleared by a professional. CAVEAT: Patients should not purchase "home doctor

kit" otoscopes, as the careless introduction of the speculum into the ear canal has resulted in perforation of the

tympanic membrane in small children as well as adults.

2.Ear cleaners (Murine Ear Cleaner, Debrox, half-strength peroxide, or equal parts of 95% ethanol and

saturated solution of boric acid (SSBA, made by dissolving 4.25gm boric acid CRYSTALS in 100 ml. dist. water

and filter, dispense in 15, 30, or 60ml dropper bottle with 6 month expiration date) should be used regularly

if chronic wax buildup is a problem.

3. Otitis externa (swimmer's ear) - Symptoms- greenish/yellow discharge with itching after water stays in ears-

may need 1:4 vinegar: distilled water solution or a 1:1 SSBA/95%EtOH solution. Use several drops BID to

cleanse ear canal. Stop and refer to an Ear, Nose, and Throat specialist (ENT) if persistent redness/itching is

present in ear or if the canal is swollen. BE SURE TO ASK IF MYRINGOTOMY TUBES ARE IN PLACE, OR IF THE

TYMPANIC MEMBRANE COULD BE RUPTURED AS ANY ALCOHOL-CONTAINING SOLUTION AND MOST EAR

AND EYE DROPS USED OFF-LABEL IN THE EAR CAN CAUSE EXTREME PAIN DUE TO DESICCATION OF THE

MIDDLE EAR NERVE ENDINGS.

4. If otitis media is recurrent after several courses of correct dose oral antibiotics (amoxicillin, co-trimoxazole or

SMX/TMP, clarithromycin, azithromycin, amoxicillin/clavulanate, 1 st (cephalexin or cefadroxil) or 2nd

generation (cefuroxime, cefprozil) cephalosporin, erythromycin/sulfas) by non-EENT specialist, the patient may

need an ENT consult. Discourage use of fluoroquinolones (FQs) for any respiratory infection unless there have

been at least of the above agents tried in proper dosage taken properly. FQs induce bacterial resistance with

repeated use, but have a very broad spectrum so should be reserved for resistant infections. The best FQ to use

in the case of high levels of pneumococcal and/or hemophilus resistance are moxifloxacin and levofloxacin, but

FQs should not be used those under 18 years of age. Again otoscopic exam is necessary to inspect ear canal and

drum; this must be carefully done to prevent damage to the ear canal or drum. Never routinely recommend

patient use of otoscope available OTC.

5. How to instill ear drops: (BE SURE TO TELL PATIENT TO STOP USE IF ANY SEROUS or BLOODY DRAINAGE

OCCURS, AS THIS MAY BE EVIDENCE THAT THE TYMPANIC MEMBRANE HAS RUPTURED)

a. Clean outer ear carefully and thoroughly with a warm wet cloth.

b. Warm ear drops by holding in your hands for several minutes. Do not heat up drops container in a

pan of boiling water.

c. Tilt head to the side or lie on side with ear to be treated up.

d. Drop the prescribed amount into the ear canal, without touching dropper to ear.

e. Stay in the same position for 5 minutes after medication administration.

f. Dry the external ear thoroughly and reverse sides to treat other ear, repeating steps a through .DO

22


NOT use ear solution if it has changed color or appearance since purchased, or beyond expiration

date. Eye solutions may be used in the ear, if prescribed, but never use ear preparations in the eye.

Clean dropper with cotton soaked in rubbing alcohol after use.

MIDDLE EAR INFECTIONS

Otitis Media (OM) - inflammation and fluid in middle ear AT.

OM cause- Eustachian tube (ET) dysfunction and obstruction with subsequent bacterial super infection; ET

differences between infants and adults

Assessment/Diagnosis - History of antecedent or concurrent URTI (e.g. cold, sore throat and/or sinusitis)

OM Symptoms - ear pain, pressure, drainage, fluid in middle ear, "stopped-up head", vertigo, nystagmus,

tinnitus

Bacteria “Bugs”- 3 MOST COMMON:S. pneumoniae, H. influenzae and M. catarrhalis. Less common: S.

pyogenes (if strep throat concurrent/antecedent), M. Pneumoniae, S. aureus and anaerobes

Treatment - older drugs: TMP-SMX-DS, amoxicillin rather than ampicillin, erythromycin-sulfas; newer (more

expensive agents) amoxicillin/clavulanate, oral 1st and 2nd gen. cephalosporins except cefaclor . Clarithomycin

or azithromycin are excellent choices in the beta-lactam allergic person.

Less preferred or to be avoided drugs (REASON): cefixime (poor S. aureus coverage), cefaclor (poor H. flu

coverage), FQs (resistance) and tetracyclines (age-young and poor coverage of all 3 pathogens), erythromycins

(less H. flu coverage and death risk in older adults), pen G or V (poor H. Flu and M. Cat. coverage), ampicillin

(more diarrhea/thrush and QID vs. TID)

CASE 7- A middle-aged women c/o ear ache and wants her OTC Auralgan she used to be able to buy. Her

eardrum appeared as below. How do you proceed to help this person?

a. find an otic product that has benzocaine for her

b. check for fever, lymphadenopathy, colds, allergies

c. Recommend a primary care clinician if otitis media is suspected*

d. prescribe amoxicillin 500mg TID X 21 doses

23


NEVER SELL or encourage the use of home otoscopes by untrained persons/parents - see right side above for

what happened when such a person checked their child’s ear!!

OM Treatment in those with Myringotomy/Tympanostomy Tubes

Some 1.5 to 2 million children and young adults receive tubes each year for 6-18 month periods to relieve middle

and inner ear pressure from recurrent OM. These patients can develop otorrhea due to otitis externa, acute OM,

tube-associated otorrhea and granulation tissue that forms around these tubes. Ciprofloxacin/Dexamethasone

(Ciprodex®) and Ofloxacin (Floxin®) otic are the only currently approved drugs for acute OM in those with tubes

and have been shown to be as efficacious as amoxicillin/clavulanate PO in Pneumococcal, H. flu, S. aureus and M.

Cat. and much better than Augmentin for Ps. Aeruginosa OMs in those with tubes. Goldblatt EL et al. Int. J. Pediatr

Otolaryngol 1998; 46:91-101). Ciprodex otic may be superior to Floxin Otic (Waycaster C et al. P&T 2004;29:721-

730).

The common use of eye drops in the ears should also be avoided in those with tubes as most of these solutions or

suspensions are low pH 2-3.5 (FQs are 6-6.5) which can cause severe pain and the aminoglycosides found in many

eye drops can cause ototoxicity, especially when directly introduced into the middle ear via the tubes. AVOID

The use of moxifloxacin (Vigamox), levofloxacin (Zymar) and gatifloxacin (Quixin) FQ eye drops is off-label and may

also cause severe pain as they were not formulated to be safe in the middle ear.

NOTE: 30% or more of OMs are due to the flu - the use of FluMist intranasal flu vaccine in children reduced the

OM frequency from 18% to 1% in a 2100 child trial (NEJM 1998)- vaccine out as of fall 2003 for those 5-49yo AND

FLU SHOTS RECOMMEND FOR THOSE CHILDREN 2-5 years of age (YO) AS OF 2008-09!

Chemoprophylaxis of OM- Prevnar, a Pneumococcal 7-valent Conjugate Vaccine with Diphtheria CRM 197 protein

is indicated for infants and toddlers to reduce the risk of S. pneumoniae- associated meningitis, pneumonia, OM

and sinusitis in the very young ( Pneuomovax-23 is now indicated once for all those 50 or older who are healthy)

and may help prevent RTIs in older adults.

Pneumococcal Vaccine- MMWR Morb Mortal Wkly Rep 2000 Oct 6;49(Rr-9):1-35. Preventing pneumococcal

disease among infants and young children. Recommendations of the Advisory Committee on Immunization

Practices (ACIP). In February 2000, a 7-valent pneumococcal polysaccharide-protein conjugate vaccine (Prevnar,

marketed by Wyeth Lederle Vaccines) was licensed for use among infants and young children. CDC's Advisory

Committee on Immunization Practices (ACIP) recommends that the vaccine be used for all children aged 2-23

months and for children aged 24-59 months who are at increased risk for pneumococcal disease (e.g., children

with sickle cell disease, human immunodeficiency virus infection, and other immunocompromising or chronic

medical conditions). ACIP also recommends that the vaccine be considered for all other children aged 24-59

months, with priority given to a) children aged 24-35 months, b) children who are of Alaska Native, American

Indian, and African American descent, and c) children who attend group day care centers. This report includes

ACIP's recommended vaccination schedule for infants at ages 2, 4, 6, and 12-15 months. This report also includes a

pneumococcal vaccination schedule for infants and young children who are beginning their vaccination series at an

older age and for those who missed doses.

In addition, this report updates earlier recommendations for use of 23-valent pneumococcal polysaccharide

vaccine among children aged > or =2 years. Among children aged 24-59 months for whom polysaccharide vaccine

is already recommended, ACIP recommends vaccination with the new conjugate vaccine followed, > or =2 months

later, by 23-valent polysaccharide vaccine.

The May 2009 guidelines from the Centers for Disease control and Prevention recommend that many adults should

receive the pneumococcal conjugate vaccine:

All adults 65 years of age and older

Anyone 2 through 64 years of age how has a long-term health problem such as: heart disease, lung

disease, sickle cell disease, diabetes, alcoholism, cirrhosis, leaks of cerebrospinal fluid or cochlear implant

25


Anyone 2 through 64 years of age who has a disease or condition that lowers the body’s resistance to

infection, such as: Hodgkin’s disease; lymphoma or leukemia; kidney failure; multiple myeloma; nephrotic

syndrome; HIV infection or AIDS; damaged spleen, or no spleen; organ transplant.

Anyone 2 through 64 years of age who is taking a drug or treatment that lowers the body’s resistance to

infection, such as: long-term steroids, certain cancer drugs, radiation therapy

Any adult 19 through 64 years of age who is a smoker or has asthma

The efficacy of Prevnar against acute OM in a Finnish pediatric population given the vaccine at 2,4,6, and 12

months of age found that the number of AOM episodes due to serotypes cross-reactive with those in the vaccine

decreased by 57%, but episode due to other serotypes increased by 33% ( Eskola J, et al. NEJM 2001:

Length of OM - A JAMA 1998;279:1736 meta analysis suggested that 5 days of the shorter-acting (SA) oral

antibiotics is just a effective as 10 days, or one ceftriaxone injection or azithromycin 500mg stat and 250mg daily X

5 days and 7 days of SA PO treatment of otitis media (OM).

NOTE: The common pathogens in OM, pharyngitis and sinusitis as well as in bronchiolitis and croup are most

commonly viral, with bacterial tracheitis and supraglottitis infections with pneumococcus, S. pyogenes, H. flu, M.

Cat. and S. aureus less frequently seen than the viral forms.

Case 8-A patient presents with an Rx for her fourth OM in the last two months. Your profile shows prior Rxs for

amoxicillin, amoxicillin/clavulanate, and cefixime. What is the most rational Rx to try in this patient?

a. moxifloxacin, ciprofloxacin or levofloxacin

b. Doxycyline

c. TMP/SMX

d. clarithromycin, azithromycin or erythromycin/sulfas

The correct answer is d.

Rhinitis considerations

There are three types of rhinitis: allergic (AR), infectious (IR) and vasomotor (VR) or non-allergic. AR is usually due

to environmental allergens such as dust, animal dander, and pollens. After avoidance of allergens, systemic

antihistamines and decongestants if not contraindicated, nasal Atrovent and steroids may be indicated. Drugs that

may be associated with rhinitis include ACE inhibitors, aspirin and other NSAIDs, and alpha-blockers (e.g., Flomax,

Uroxaltra). Some 70% of acute rhinitis is IR and is usually associated with cold and sinus infections (see above). The

treatment for the latter is an appropriate antibiotic for the infection. In VR there are no effective therapies, except

perhaps Atrovent nasal spray. The topical decongestants (Afrin, Otrivin, Privine, Neosynephrine) should not to

be used in any rhinitis due to the risk of rhinitis medicamentosa, that may require the use of intranasal steroids

to treat and taper the patient off the decongestant. Overuse of intranasal decongestants can also cause nonallergic

rhinitis due to rebound nasal congestion.

Case 9-A 56 year-old male has sore throat and wants an OTC recommendation. His med profile includes

Theophylline, albuterol inhaler, steroid inhaler and buspirone.

1. What physical findings do you need to check?

a. throat, sinus and ear gross inspection

b. neck lymph nodes

c. body temperature and history of antecedent colds and allergies

d. all of the above

2. What med may contribute to sore throat if patient doses not gargle after use?

a.Theophylline

b. albuterol inhaler

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c. steroid inhaler

d. buspirone

3. The patient has white patches around Waldeyers ring, tender anterior nodes and a PO temp of 99.2. He gargles

well after use of his inhalers. The pharyngitis is more than likely a________ infection?

a. viral

b. bacterial

c. fungal

d. ricketsial

4. Which medication is/are likely to be active/preferred against this pathogen?

a. beta lactam

b. macrolide

c. a or b

d. an azole antifungal

Key- 1-d, 2-c, 3-b, 4-c

SINUSITIS

Sinusitis- Any allergic state predisposes the patient, as does viral URTI (cold), sinus tract obstruction, foreign

bodies, trauma, tumors, dental infections. The complications of sinusitis include orbital cellulitis, osteomyelitis

Bacterial Bugs: most commonly same as those in OM

Symptoms - History of coryzal (cold) and/or flu or allergies (check eyes for conjunctivitis), frontal headache pain,

pressure, headache, fever, purulent discharge (clear discharge is cold/allergy without bacterial infection), stoppedup

nose, maxillary toothache nasal quality to voice, halitosis, malaise and lethargy. Symptoms usually have to be

present for 5 or more days and involve color change to mucous and frontal headache to merit treatment with an

antibacterial. When 4 or more signs and symptoms are present there is a high likelihood of acute bacterial

sinusitis; when fewer than 2 are present, bacterial sinusitis may be ruled out as more likely due to viral and/or

allergic causes.

Assessment - Sinus transillumination is simply done with small flashlight held inside mouth and over top of eyes in

darkened room. Look for symmetrical light passage through sinuses. Non-passage on either or both sides indicates

maxillary and/or frontal sinus congestion. Palpation of all sinuses also indicates fullness and tenderness. Be sure to

check both anterior and posterior neck lymph nodes for tenderness, as well as ears and throat for concurrent URIs.

ENT referral is usually done after two to three tries of beta lactam and macrolides: x-ray and sinus puncture and

aspiration usually reserved for ENT

Treatment -The same drugs as for OM and strep throat are indicated, but sinusitis tends to hang on/recur so drug

selections may drop amoxicillin unless it also has clavulanate (Augmentin), cefaclor (poor H. influenzae coverage)

and possibly cefiximex (poor Staph coverage), but TMP-SMX, erythromycin/ sulfas (Pediazole) are standard.

Clarithromycin, azithromycin, cefuroxime axetil, and cefpodoxime proxetil cover all 3 but may be more expensive.

AVOID: same drugs as in OM section plus possibly dirithromycin (Dynabac) due to poor H. inflenzae coverage) ,

Save newer FQs. e.g. levofloxacin and moxifloxacin unless there is a high degree of pneumococcal, H. influenzae

and M. catarrhalis resistance to beta lactams and macrolides. (I.e. >20-30% of isolates) or in a smoker who has had

repeated courses of antiinfectives for prior acute sinusitis. There is some evidence that the newer FQs may result

in lower rates of hospitalizations and death for mild to moderate lower respiratory tract infections (LRTIs) such as

acute exacerbations of chronic bronchitis and community-acquired pneumonia but not for URIs.

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Case10- a 64 year old smoker has 5 positive signs and symptoms of sinusitis and has received four prior treatment

courses with beta lactams, macrolides, doxycycline and trimethoprim/sulfamethoxazole (TMP/SMX) DS for 10 to

14 days with each episode,

Which of the following do you now recommend?

a. augmentin

b. cefixime

c. moxi-orlevofloxacin

d. azithromycin

The correct answer is c.

Pediatric infections that may have an upper respiratory component that is easily passed to the older adult

include:

Pertussis- "whooping cough" – A macrolide is the preferred drug to treat (Erythromycin, azithromycin or

clarithromycin) and the DPT shot schedule in the immunization section - Up to 25% of chronic cough in adults may

be undetected pertussis- the Pertussis vaccine has been added to the tetanus-diphtheria vaccine as tetanusdiphtheria-pertussis

vaccine for adults every 10 years in the future. It is a separate vaccine for adults and

adolescents (Adacel and Boostrix) ages 11-64. The importance of adequate vaccination of both children and adults

is that subclinical to clinical whooping cough may be passed on to older relatives if both the younger and older

patients are not adequately immunized.

Probiotic milk and Ezcema, RT and GI Infections in Children within Day Care Centers

A randomized double blind study (RDBT) study of the use of probiotic (i.e. Lactobacillus GG) milk in Helsinki,

Finland population given an average of 260ml/day slightly (11-19%) reduced sick days, number of children

suffering from and needing antibiotics for RTIs. (Hataka K, et al. BMJ 2001;322L1327) diarrhea and atopic eczema

(Van Niel CW et al. Pedicatrics 2002;109:678-84 www.pediatrics.org). The importance of reducing childhood

infections is that they are readily passed not only between the children but to older adults. Similar results with

yogurt in older adults may be seen to improve immune status AND decrease the likelihood of antiinfective-related

diarrhea!

Summary- This course has reviewed the presentation of infections, bugs most commonly found on and within the

body and the assessment and treatment of upper respiratory tract infections. The next three courses will cover

Lower Respiratory Tract Infections (LRTIs), UTIs, STDs, AIDS, Skin and soft tissue infections, GI, CNS, bone and CV

infections and surgical coverage to prevent infections.

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