“DO Not Be Snotty:
Treatment of Pediatric Upper
Respiratory Infections”
Stanley E. Grogg, DO, FACOP
Professor of Pediatrics
OSU-CHS
A Common Airway
Thus, URIs may include
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“Colds”
Tonsillitis/pharyngitis/laryngitis
Otitis media
Conjunctivitis
Rhinosinusitis
What is the most common bacterial
infection diagnosed in children?
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Tonsillitis/pharyngitis
Conjunctivitis
Pneumonia
Rhinosinusitis
Acute otitis media
Which of the following bacterial organism is
NOT a common URI pathogen?
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Streptococcus pneumonia
Haemophilus influenzae, nontypable
Moraxella catarrhalis
Group A Beta Hemolytic Streptococcus
(GABHS)
Klebsiella
Should be seen by PCP if?
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Symptoms last longer than 10 days.
Severe sore throat, earache, or headache not
relieved by Tylenol or ibuprofen.
History of tuberculosis, rheumatic fever, kidney
disease, or heart disease.
Severe chest pain or shortness of breath.
You are coughing up thick, green or bloody
sputum.
You have swollen glands on the sides or back of
your neck
What is the best way to decrease
spread of URIs?
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1. See the PCP at the first indication of infection
2. Treat the elevated temperature with antipyretics
3. Use of antibiotics immediately
4. Start OTC antihistamines/decongestants and/or
Vitamin C/Echinacea early in the disorder
5. Good hand washing
Handwashing and Health

Children under 5 years of age in house
holds that received plain soap and hand
washing promotion had 50% lower
incidence of pneumonia
 Incidence of disease did NOT differ
significantly between households given
plain soap compared with those given
antibacterial soap

Luby, SP et al, Lancer 366:225-233, July 16, 2005
How long will cold & flu
symptoms last?

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Fever and sore throat generally improve
within 4 days
Cough and nasal discharge may last 2
weeks or more
 Both are caused by viruses, NOT
bacteria.
 Antibiotics DO NOT work
Antibiotic and “The Common
Cold”

Do families of health
professional parents
prescribe their children
with nasopharyngitis
antibiotic prescriptions
more often than nonhealth professional
parents?

Huang, N, et. al,
Pediatrics Vol. 116,
Oct. 2005
http://www.cdc.gov/ncidod/op/antibiotics.htm
• Viruses cause
• All colds and
flu
• Most coughs
• Most sore
throats
http://www.cdc.gov/ncidod/op/antibiotics.htm

Bacteria cause:
Most ear
infections
 Some sinus
infections
 Strep throat
 Urinary tract
infections
Antibiotics do kill
specific bacteria

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CAM for Immune Support
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Echinacea
Astragalus (Chinese herb)
High-dose Vitamin C
Zinc
Mind-body strategies
 Nutrition
 Exercise
 Prayer

http://nydailynews.healthology.com/nydailynews/14958.htm
Manipulative therapy of URI
infections in children

Case study of over 4,600 incidents of upper
respiratory tract infections
 Only 5% of cases treated with spinal
manipulative therapy developed
secondary complications.
 results are superior to those obtained by
antimicrobial therapy or symptomatic
therapy alone.
 It would seem unnecessary to use any
therapy other than manipulative therapy.

Purse FM.; JAOA, 1966 (MAY)
Consider Safety-Net Antibiotic
Prescription (SNAP)

Disadvantages of
antibiotics
 Adverse effects
 Higher treatment
costs
 Increased
bacterial drug
resistance

Marchetti, F. et al,
Arch. Pediatr.
Adolesc. Med., July
2005
Criteria for ABX or observation for AOM
(AAP/AAFP Guidelines Posted March 9, 2004)
Age
Certain DX
Uncertain DX
< 6 mo
ABX
ABX
6 mo- 2 yr
ABX
ABX if severe,
observe if nonsevere (SNAP?)
> 2 yr
ABX if severe
illness, observe
otherwise?
ABX for AOM/rhinosinusitis
(2004 AAP/AAFP Guidelines)
 First-line
 High-dose
amoxicillin (90mg/kg for 5-
10 days)
 Non-type 1 penicillin allergy
 Cefdinir (Omnicef), cefuroxime
(Ceftin) or cefpodoxime (Vantin)
 Type 1 penicillin allergy
 Macrolide or sulfonamide
 Ceftriaxone (1-3 days) if toxic
AOM/rhinosinusitis Treatment Failures
(2004 AAP/AAFP Guidelines)
High dose amoxicillin/clavulanate
(Augmentin ES) at 90/mg/kg in bid doses
 Cefdinir (Omnicef)
 Cefuroxime (Ceftin)
 Cefpodoxime (Vantin)
 Ceftriaxone (50 mg/kg IM qd 1-3 days)
 Comment: All oral cephalosporins offer
comparable efficacy. TX based on other
factors such as palatability

URIs and Complications

In an era of increasing bacterial resistance,
it is crucial for PCP’s
 Make an accurate diagnosis
 Use antimicrobial agents judiciously
 Treat the pain
Prevention of AOM


DO
 Breast feeding
 Vaccines
Avoid
 Daycare
 Smoke
 Allergens
 Pacifiers
 Prophylactic antibiotics
What organism is MOST likely to cause
AOM with conjunctivitis?
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1. Adenovirus
2. Haemophilus
influenzae
3. Klebsiella
pneumoniae
4. Moraxella
catarrhalis
5. Streptococcus
pneumoniae
 2. Haemophilus
influenzae
The MOST likely cause of exudative
tonsillopharyngitis?
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1. Adenovirus
2. Group A betahemolytic
streptococcus
(GABHS)
3. Coxsachie virus
4. EB Virus
5. Rhinovirus
 1. Adenovirus
What organism is the MOST likely etiology of
pharyngitis-conjunctivitis?
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1. Adenovirus
2. Haemophilus
influenzae
3. Klebsiella
pneumoniae
4. Moraxella
catarrhalis
5. Streptococcus
pneumoniae
 1. Adenovirus
Group A Beta Hemolytic Streptococcal
(GABHS) Tonsillitis  Which of the
following symptoms
is NOT likely due to
GABHS
 Nausea/vomiting
 Sore throat
 Adenopathy
 Headache
 Cough/runny
nose
The MOST important reason to treat
GABHS is the following
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1.
2.
3.
4.
5.
Shorten the coarse of the illness
Decrease the carrier state
Prevent rheumatic fever
Decrease the extension of infection
None of the above
Match the type of tonsillopharyngitis
with the organism
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Exudative
Erythematous
Ulcerative
Membranous
URI symptoms
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1. Adenovirus
2. GABHS
3. Coxsachie
virus
4. EB Virus
5. Rhinovirus
Pediatric autoimmune neuropsychiatric disorders
associated with streptococcal infection (PANDAS)
 Children with
multiple streptococcal
infections had a
markedly increased
risk of Tourette’s
syndrome (TS) and
obsessive-compulsive
disorder (OCD)
 Post-infectious
autoimmune
phenomenon?

Mell et al,
Pediatrics, July 2005
T or F: Adenoidectomy and/or Insertion
of Tympanostomy Tubes

Reduce the incidence
of acute otitis media

Procedures of
adenoidectomy
and/or tube
insertions have
taken on many
features of “ritual
surgery”

Hammaren-Malmi et al,
Pediatrics, July, 2005
You are seeing a 6-year-old girl with bilateral
conjunctivitis and moderate discharge.

Which of the following pathogens is the MOST
likely etiologic agent?
 Adenovirus
 Haemophilus influenzae
 Klebsiella pneumoniae
 Moraxella catarrhalis
 Streptococcus pneumoniae
“Pink Eye”

Bacterial
conjunctivitis
 True or False
 Most children
will get better
regardless of
antimicrobial
therapy

AAP Grand Rounds,
Sept. 2005
3 year old with persistent runny
nose and fever of 101
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When would you suspect rhinosinusitis
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URI changes to a “thick yellow” color after
5-7 days
 Usually good sign
What is the best screening test in
children for rhinosinusitis?
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History
Physical
Facial x-ray
MRI
CT Scan (limited)
“A pill for every ill”

Unfortunately, it
takes less time and
less talk to write a
prescription than it
does to extol the
virtues of
observation,
patience and
analgesia
In conclusion

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MOST upper respiratory infections are
viral
Amoxil is NOT a good “cough” medicine
Fever is GOOD: helps the body stimulate
an immune response
Treat discomfort with analgesics
Rapid Strept tests or throat cultures may be
indicated