Drug Topics- August 11, 2008

55 Studies suggest that between 70%-90% of children have resolution of symptoms without antibiotic treatment in seven to 14 days. Thus antibiotic treatment in certain cases may initially be delayed. Yet during this time symptomatic treatment is recommended. Acetaminophen at doses of 15mg/kg every four to six hours and ibuprofen at 10mg/kg every six hours may be used to alleviate pain in children, especially during the first two days of symptoms. The use of topical otic suspension of antipyrine/benzocaine offers an alternative for pain relief. While the oral decongestants may be used in some children for congestion, they do not alter the symptoms or treat acute otitis media. Corticosteroids and antihistamines offer no therapeutic benefits in treatment either. The recommendations for use of antibiotic treatment are based upon age and symptomatology. Those with definite infections between the ages of six months and two years and those with severe infection (indicated by symptoms) who are older than two years of age should receive antibiotics immediately. Patients who are septic or classified as immunosuppressed should also receive immediate treatment. For all others there is a “wait and see” recommendation for 48 to 72 hours—this is assuming there is a reliable caregiver involved for symptomatic monitoring. If there is a concern about the caregiver’s reliability or access to health care is in question (i.e., transportation or funding etc.), this may alter the provider’s decision. High-dose amoxicillin (80-90mg/kg) twice daily for 10 days is the treatment of choice for those children six years or younger. The duration declines to five to seven days in patients older than seven years of age. The use of a one-time dose of azithromycin of 30mg/kg, clarithromycin 15mg/kg/day divided three times a day, or clindamycin 30-40mg/kg/day divided four times a day may also be used as therapeutic substitutions in this setting. Once treatment is offered, its effectiveness should be reassessed in 48 to 72 hours. If symptoms are not improving and adher- ence has been validated, a second-line option is recommended. Second-line options include high-dose amoxicillin-clavulanate at 90mg/kg, cephalosporins, or the previously mentioned macrolides. In cases of poor tolerance (i.e., vomiting) or adherence, single daily doses of 50mg/kg of ceftriaxone for three days remain a viable option. Finally, if symptoms continue, the use of clindamycin at 30-40mg/kg divided four times a day and tympanocentesis are the last step. The use of levofloxacin, although not FDA-approved for use in children, has also been utilized with successful outcomes. It is important to note that effusion without symptoms or effusion after treatment is not indicative of infection when there is resolution of symptoms. Oral and topical corticosteroids may assist with quicker symptomatic improvement but do not offer any additional benefits long term. Children with speech difficulties, hearing loss, or cognitive declines need to be assessed for insertion of ventilation tube surgery immediately. Removal of the adenoids may also offer some benefit for children with nasal obstruction. A brief review of symptoms of upper respiratory tract infections may be found in Table 1. While infections involving the upper respiratory tract are fairly common, infections in the lower respiratory tract are often limited. Those patients with other medical conditions that alter the host immune response or increase their risk of exposure to particularly virulent pathogens are obviously at greater risk. Discussions of infections of the lower respiratory tract will be limited to community-acquired pneumonia in the outpatient setting. A complete review of the pneumonia guidelines may be found at the IDSA Web site at www.idsociety.org/. Community-acquired pneumonia The etiology of community-acquired pneumonia (CAP) may be of either bacterial or viral origin. Common organisms in the TABLE 1 Differentiation of respiratory disorders Illness Bacterial throat infection Cold Croup Influenza Otitis media Pneumonia or bronchitis Sinusitis Whooping cough Signs and symptoms Sore throat, fever, exudate, tender anterior cervical adenopathy Sore throat, nasal congestion, rhinorrhea, sneezing. May also have low-grade fever, chills, headache, malaise, myalgia, and cough. Fever, rhinitis, and pharyngitis initially. Progresses to cough (may be “barking” cough), stridor, and dyspnea Myalgia, arthralgia, fever, sore throat, nonproductive cough, moderate-severe fatigue Ear popping, ear fullness, otalgia, otorrhea, hearing loss, dizziness Chest tightness, wheezing, dyspnea, productive cough, changes in sputum color, persistent fever Tenderness over the sinuses, facial pain aggravated by Valsalva’s maneuver or postural changes, fever >101.5°F (38.6°C), tooth pain, halitosis, upper respiratory tract symptoms for >seven days with poor response to decongestants Initial catarrhal phase (rhinorrhea, sneezing, mild cough, sneezing) of one to two weeks, followed by one to six weeks of paroxysmal coughing http://www.idsociety.org/

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Drug Topics- August 11, 2008 Contents Latebreakers Letters DEA Proposes Rule To Allow Electronic Prescriptions for Controlled Substances Merger, Medicare Reform Could Mean Broader E-Prescribing Adoption New Combination Pill Approved for Type 2 Diabetes New Eczema Guildlines Promote Use of Emollients, Then Topical Corticosteroids Agencies Flush Original Strategies in Favor of Promoting Drug Take-Back Programs JP at Large: You Laughing at Me? Pharmacists Find Themselves at Mercy of Prior Authorization State Law Requiring PBM Transparency See Some Gains, Some Losses Global Counterfeiting Still Growing, Says U.S. Commerce Official FDA Saftey Page: Prophylthiouracil Still Confused with Purinethol (mercaptopurine) New Products Bring Lice Treatment to a Head NACDS Marketplace Showcases New Product that Fill Unmet Needs Update on Respiratory Tract Infections Execs Share War Stories About Adopting Technology in their Stores New Products Advertisters Index Classified Viewpoint: Medicare Part D Revisions sorely needed

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