Upper respiratory tract infection pharmacotherapy

Lecture presentation for B Pharmacy 3rd year

1. Upper Respiratory Tract Infection: Pharmacotherapy Dr. Pravin Prasad MBBS, MD Clinical Pharmacology Assistant Professor, Department of Clinical Pharmacology Maharajgunj Medical Campus, Kathmandu 16 June 2020 (2 Asar 2077), Tuesday 1

2. By the end of this discussion, B. Pharm 3 rd Year students will be able to: List the conditions included in Upper respiratory tract infections (URTIs) List the aetiology of URTIs Outline the pathophysiology of URTIs List the clinical presentation of URTIs Explain the therapeutic objectives for URTIs Justify the role of pharmacotherapy in treatment of URTIs 2

3. Introduction Infection of upper respiratory tract common Commonly includes: Otitis media Sinusitis Pharyngitis Also includes Rhinitis, Laryngitis and Epiglottitis 3

4. Etiology and Pathophysiology: Otitis media Viral Bacteria: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis 4

5. Clinical Presentation: Otitis media History: Acute onset of signs and symptoms Ear pain and fever Children: irritable, tug on the involved ear, difficulty sleeping Ear Examination: Discolored (gray), thickened, bulging, eardrum Immobile eardrum Fluid coming from middle ear Previous history of cold symptoms of runny nose, nasal congestion, or cough 5 Laboratory Tests: Gram stain, culture, and sensitivities of draining or aspirated fluid

6. Therapeutic Objectives: Otitis Media Primary prevention of disease Confirm the bacterial aetiology and provide antibiotics Provide symptomatic relief 6

7. Therapeutic Options: Otitis media General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy Stay away from cold Do not put anything in the ear Do not blow nose forcefully Drink warm fluids 7

8. Therapeutic Options: Otitis media General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy Ear toileting Cleaning the ear if discharge present Myringotomy To drain the fluid in the middle ear As secondary prophylaxis 8

9. Therapeutic Options: Otitis media General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy Vaccines Seven valent pneumococcal conjugate vaccine Influenza vaccine Pain management Local anaesthesia (drops) Oral analgesics Antibiotics 9

10. Therapeutic Options: Otitis media General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy If complications develop Mastoiditis, Bacteremia Meningitis Auditory sequelae 10

11. Pharmacotherapy: Otitis media Antibiotics 5-7 days, up to 14 days Amoxicillin High dose if resistant strept . Infection suspected (90mg/kg/day) Amoxicillin + Clavulanic acid Resistant H. influenzae or M. catarrhalis suspected Amoxicillin- 90mg/kg/day, Clavulanic acid- 6.4mg/kg/day Intramuscular ceftriaxone, clindamycin, azithromycin, clarithromycin 11 Can also be used for secondary prophylaxis in recurrent infection with seasonal variation Other option: Tympanostomy with tube insertion

12. Aetiology and pathophysiology: Acute bacterial sinusitis Viral Bacteria: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Uncommon: Streptococcus pyogenes, Staphylococcus aureus, fungi, anaerobes 12

13. Clinical Presentation: Acute Bacterial Sinusitis Signs and Symptoms Nasal discharge/congestion Maxillary tooth pain, facial or sinus pain that may radiate (unilateral in particular), as well as deterioration after initial improvement Severe or persistent (>7 days) signs and symptoms: most likely bacterial Rhinorrhoea , chronic unproductive cough, laryngitis, headache 13

14. Therapeutic Objective: Acute Bacterial Sinusitis Reduce signs and symptoms Achieve and maintain patency of the ostia, Eradicate the bacterial infection Minimize the duration of illness Prevent complications and progression to chronic disease 14

15. Therapeutic Options: Acute Bacterial Sinusitis General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy Use mask Avoid dust and cold Do not blow nose forcefully Drink warm fluids 15

16. Therapeutic Options: Acute Bacterial Sinusitis General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy Steam Inhalation Irrigation of nasal cavity with saline 16

17. Therapeutic Options: Acute Bacterial Sinusitis General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy Antibiotics Decongestants Local Oral 17

18. Therapeutic Options: Acute Bacterial Sinusitis General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy If complications develop Mental status changes Immunosuppressive illness, significant coexisting illnesses, risk factors for β -lactam-resistant strains Isolated frontal or sphenoid sinusitis, or intense periorbital swelling, erythema, and facial pain Unilateral findings History of antibiotic failure 18

19. Decongestants in Acute Bacterial Sinusitis Helps by decreasing nasal blockade and improve aeration to sinuses Acts by causing vasoconstriction Local decongestants: oxymetazoline, phenylephrine Oral decongestants: pseudoephedrine, phenylephrine Intra-nasal glucocorticoids Antihistamines: NOT recommended 19

20. Antibiotics: Acute Bacterial Sinusitis 20

21. Aetiology: Acute Pharyngitis Viruses Rhinovirus Coronavirus Influenza, parainfluenza virus Adenovirus Herpes simplex virus, Epstein-Barr virus Bacteria Group A beta haemolytic Streptococci (S. pyogens , GABHS) Others: C and G Streptococcus, Corynebacterium diphtheriae, Neisseria gonorrhoeae, Mycoplasma pneumoniae, Arcanobacterium haemolyticum , Yersinia enterocolitica, and Chlamydia pneumoniae. 21

22. Aetiology and Pathophysiology: Acute Pharyngitis 22 Asymptomatic carrier (GABHS) Altered host immunity Invasion of pharyngeal mucosa Colonisation of mucosa with bacteria

23. Clinical Presentation: Acute Pharyngitis Signs and Symptoms Sore throat, Pain on swallowing Fever, h eadache , nausea, vomiting, and abdominal pain Conjunctivitis, Coryza, Cough, Diarrhoea Suggestive of Viral Pharyngitis 23

24. Clinical Presentation: Acute Pharyngitis Local Examination: Erythema/inflammation of the tonsils, pharynx +/- patchy exudates Enlarged, tender lymph nodes Red swollen uvula, petechiae on the soft palate Laboratory Tests: Throat swab and culture Rapid antigen detection testing (RADT) 24

25. Therapeutic Objectives: Acute Pharyngitis Improve clinical signs and symptoms Minimize adverse drug reactions Prevent transmission to close contacts, Prevent acute rheumatic fever and suppurative complications 25

26. Therapeutic Options: Acute Pharyngitis General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy Avoid cold Do not shout or scream Drink warm fluids Use mask 26

27. Therapeutic Options: Acute Pharyngitis General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy Non-prescription lozenges and sprays Menthol Topical anaesthetics Tonsillectomy 27

28. Therapeutic Options: Acute Pharyngitis General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy Antipyretic, analgesic management Acetaminophen Antibiotics 28

29. Therapeutic Options: Acute Pharyngitis General information and advice Non pharmacological therapy Pharmacological therapy Referral therapy If suppurative complications develops 29

30. Antibiotics: Acute Pharyngitis Benzathine Penicillin Amoxicillin in children Penicillin allergic patients: Cephalosporins (Cefalexin), Macrolides (Erythromycin, Azithromycin) Macrolide resistant: Clindamycin Recurrent episodes: Amoxicillin-clavulanic acid, clindamycin Chronic prophylaxis: benzathine penicillin, sulfadiazine 30

31. Antibiotics: Acute Pharyngitis 31

32. Conclusion URTIs commonly includes otitis media, sinusitis and pharyngitis Viral causes are more common aetiology for URTIs Blockade of normal drainage is critical in development of Otitis media and Sinusitis; host compromise in critical for pharyngitis Symptoms are commonly local and are associated with systemic signs Control of bacterial infection is pivotal for the management of URTIs Due to better efficacy, safety, cost-effectiveness and experience, penicillins are preferred for treatment of URTIs 32

33. Questions?? Thank you… 33