Heather VandenBussche
LEARNING OBJECTIVES
Upon completion of the chapter, the reader will be able to:
1. List the most common bacterial pathogens that cause acute otitis media (AOM), acute bacterial rhinosinusitis (ABRS), and acute pharyngitis.
2. Explain the pathophysiologic causes of and risk factors for AOM, bacterial rhinosinusitis, and acute pharyngitis.
3. Identify clinical signs and symptoms associated with AOM, bacterial rhinosinusitis, streptococcal pharyngitis, and the common cold.
4. List treatment goals for AOM, bacterial rhinosinusitis, streptococcal pharyngitis, and the common cold.
5. Develop an appropriate antibiotic regimen for each infection based on patient-specific data.
6. Recommend appropriate adjunctive therapy for a patient with AOM or ABRS.
7. Recommend an appropriate treatment plan for a patient with the common cold.
8. Create a monitoring plan for a patient being treated for each infection using patient-specific information and prescribed therapy.
9. Educate patients about upper respiratory tract infections (URIs) and proper use of antibiotic therapy.
KEY CONCEPTS
Most upper respiratory tract infections (URIs) have nonspecific symptoms, are viral in origin, and resolve spontaneously without significant morbidity.
Antibiotic resistance patterns have greatly affected treatment options for bacterial URIs.
Proper diagnosis of bacterial URIs is crucial to identify patients who require antibiotics to avoid unnecessary antibiotic use.
Antibiotic therapy for acute otitis media (AOM) should be reserved for children who are most likely to benefit from therapy and is dependent upon patient age, illness severity, and diagnostic certainty.
High dose amoxicillin (80–90 mg/kg/day) is the drug of choice for AOM. High dose amoxicillin-clavulanate is an alternative choice for severe illness or when a broader spectrum agent is desired.
Antibiotic therapy for sinusitis should be reserved for patients with moderate persistent symptoms, clinical decompensation, or severe symptoms.
Amoxicillin and amoxicillin-clavulanate are first-line antibiotics for acute bacterial rhinosinusitis (ABRS).
The goals of therapy for streptococcal pharyngitis are to eradicate infection, reduce symptoms and infectivity, and prevent complications.
Penicillin is the drug of choice for streptococcal pharyngitis, but cephalosporins may be appropriate alternative first-line agents owing to increasing failure rates after penicillin therapy.
Treatment for the common cold is focused on symptom relief and is influenced by patient age, comorbid conditions, and balance of medication effectiveness and safety.
Upper respiratory tract infection (URI) is a term that refers to various upper airway infections, including otitis media, sinusitis, pharyngitis, laryngitis, and the common cold. Over 1 billion URIs occur annually in the United States, resulting in millions of physician office visits each year.1 Most URIs have nonspecific symptoms, are viral in origin, and resolve spontaneously without significant morbidity.2Antibiotic use does not enhance resolution of most URIs, and excessive antibiotic use for these infections has contributed to the development of considerable bacterial resistance. Guidelines have been established to reduce inappropriate antibiotic use for viral URIs.2 This chapter focuses on acute otitis media (AOM), sinusitis, and pharyngitis because bacteria frequently cause these infections and appropriate antibiotic therapy can minimize complications. Proper management of the common cold is also reviewed.
OTITIS MEDIA
Otitis media, or inflammation of the middle ear, is the most common reason for prescribing antibiotics in children. It usually results from a nasopharyngeal viral infection and can be subclassified as AOM or otitis media with effusion (OME). AOM is a rapidly developing symptomatic middle ear infection with effusion, or presence of fluid. OME is the presence of middle ear fluid without symptoms of acute illness. It is important to distinguish between AOM and OME because antibiotics are only useful for the treatment of AOM and effusions can be present for up to 6 months after an acute episode.
EPIDEMIOLOGY AND ETIOLOGY
Otitis media is most common in children between 6 months and 2 years of age but can occur in all age groups, including adults. By age 3 years, up to 85% of children have had at least one episode of otitis media, and up to 20% have recurrent infections by age 12 months.3 At least 13 million antibiotic prescriptions are written annually in the United States for otitis media, resulting in $2 billion in direct costs.4Many risk factors (Table 72-1) predispose children to otitis media and can be associated with microbial resistance, such as daycare attendance, prior antibiotic exposure, and age younger than 2 years.3,5,6
Patient Encounter 1, Part 1
A 15-month-old girl presents to the pediatric clinic with 2 days of fever (38.9°C [102°F]), runny nose, and fussiness. Her mother states that she is more irritable than usual and cries many times throughout the night. She is not as interested in eating today. She attends daycare and has a 5-year-old brother who recently had a cold. Physical examination reveals erythema and bulging of the right tympanic membrane and the presence of middle ear fluid. The left tympanic membrane is obscured with cerumen.
What information is suggestive of acute otitis media (AOM)?
Does the child have risk factors for AOM?
Is there any additional information you need to know before recommending a treatment plan?
Table 72–1 Risk Factors for Otitis Media
Bacteria are isolated from middle ear fluid in up to 70% of children with AOM, but viruses also play a predominant role.5 Streptococcus pneumoniae traditionally has been the most common organism, responsible for up to half of bacterial cases.4,7 Haemophilus influenzae and Moraxella catarrhalis cause 15% to 30% and 3% to 20% of cases, respectively. The microbiology of AOM has shifted toward a prevalence of H. influenzae because of routine childhood immunization with pneumococcal conjugate vaccine.8,9 Bacteria that are less frequently associated with AOM include Streptococcus pyogenes, Staphylococcus aureus, and Pseudomonas aeruginosa. Viruses such as respiratory syncytial virus, influenza, parainfluenza, enteroviruses, rhinovirus, and adenoviruses are isolated from middle ear fluid with or without concomitant bacteria in about half of AOM cases.5,10 Lack of improvement with antibiotic therapy is often a result of viral infection and subsequent inflammation rather than antibiotic resistance.
Bacterial resistance has significantly affected treatment options for AOM. Penicillin-resistant S. pneumoniae (PRSP) encompasses both intermediate resistance (minimum inhibitory concentrations between 0.1 and 1.0 mcg/mL) and high-level resistance (minimum inhibitory concentration of 2.0 mcg/mL and higher). Altered penicillin-binding proteins cause resistance in approximately 35% of respiratory pneumococcal isolates, about half of which are highly penicillin-resistant.11 Amoxicillin resistance occurs in less than 5% of pneumococcal isolates.11 PRSP are also commonly resistant to other drug classes, including sulfonamides, macrolides, and clindamycin, and increasingly resistant to fluoroquinolones. Treatment for pneumococcal AOM is recommended because infection caused by S. pneumoniae is unlikely to resolve spontaneously and is the most common cause of recurrent infections.5 β-Lactamase production occurs in 30% and nearly 100% of H. influenzae and M. catarrhalis, respectively.12 Although infections caused by these organisms are more likely to resolve without treatment, they should be considered in cases of treatment failure.
PATHOPHYSIOLOGY
Multiple factors play a role in the development of AOM. Viral infection of the nasopharynx impairs eustachian tube function and causes mucosal inflammation, impairing mucociliary clearance and promoting bacterial proliferation and infection. Children are predisposed to AOM because their eustachian tubes are shorter, more flaccid, and more horizontal than adults, which make them less functional for drainage and protection of the middle ear from bacterial entry.5 Clinical signs and symptoms of AOM are the result of host immune response and cellular damage caused by inflammatory mediators such as tumor necrosis factor and interleukins that are released from bacteria.3
Viscous middle ear effusions caused by allergy or irritant exposure may contribute to impaired mucociliary clearance and AOM in susceptible individuals.3 OME occurs chronically in atopic children, and effusion can persist for months after an episode of AOM. Children with chronic OME usually require tympanostomy tube placement to reduce complications such as hearing and speech impairment and recurrent otitis media.
TREATMENT
Desired Outcomes
Therapy for AOM focuses on symptom relief and prevention of complications. The goals of treatment are to alleviate ear pain and fever, if present; eradicate infection; prevent complications; and minimize unnecessary antibiotic use.
General Approach to Treatment
The majority of uncomplicated AOM cases resolve spontaneously without significant morbidity. Untreated AOM improves in 80% of children between days 2 and 7 of illness without increasing the risk of complications.13Antibiotics improve ear pain in only 7% of children between days 2 and 7 of therapy and significantly improve recovery in children younger than 2 years of age and in those with severe AOM symptoms.13 
Therefore, antibiotics should be reserved for children most likely to benefit from therapy and is dependent upon patient age, illness severity, and diagnostic certainty. Children younger than 2 years of age have a higher incidence of penicillin-resistant pneumococcal infections and have higher clinical and bacteriologic failure rates and complications when not treated initially with antibiotics as compared with older children.4 Patients with severe illness, defined by degree of fever and pain severity, have lower spontaneous recovery rates than those with less severe disease.13 Current guidelines recommend stratifying patients based on these criteria in order to identify those most likely to benefit from antibiotic therapy.4
Nonpharmacologic Therapy
Watchful waiting and safety-net antibiotic prescriptions (to be filled only if symptoms do not resolve after 48 hours’ observation) are approaches being used more frequently to attenuate microbial resistance and avoid unnecessary adverse events and costs of antibiotics. Delayed antibiotic therapy in older children and those with less severe disease does not result in more infectious complications, such as mastoiditis or meningitis, when compared with routine initial antibiotic treatment.13,14 Use of an observation approach or use of a safety-net antibiotic prescription that can be filled 48 to 72 hours later if symptoms persist can reduce antibiotic use for AOM by 67% without increasing complications.14 Observation or delayed antibiotic therapy should be considered only in otherwise healthy children without recurrent disease (Fig. 72–1) and only if proper follow-up and good communication exist between clinicians and the parent/caregiver.3,4,14
Clinical Presentation and Diagnosis of AOM
It is important to differentiate AOM from OME because they are treated differently. Patients with AOM usually have cold symptoms, including rhinorrhea, cough, or nasal congestion before or at diagnosis.
Symptoms
• Young children: ear tugging, irritable, poor sleeping and eating habits
• Older patients: ear pain (mild, moderate, or severe), ear fullness, hearing impairment
Signs4,7
• Fever: present in less than 25% of patients; often in younger children
• Middle ear effusion
• Otorrhea (middle ear perforation with fluid drainage): uncommon
• Bulging tympanic membrane
• Limited or absent mobility of tympanic membrane
• Distinct erythema of tympanic membrane
• Opaque or cloudy tympanic membrane obscuring or reducing visibility of middle ear
Laboratory Tests
Gram stain, culture, and sensitivities of ear fluid if draining spontaneously or obtained via tympanocentesis (not performed routinely in practice)
Complications
• Infectious: mastoiditis, meningitis, osteomyelitis, intracranial abscess
• Structural: perforated eardrum, cholesteatoma
• Hearing and/or speech impairment
Diagnosis4
Certain AOM: Requires all the following:
• Rapid onset of signs and symptoms
• Middle ear effusion findings with pneumatic otoscopy
• Inflammation indicated by either otoscopic evidence (distinct erythema) or otalgia
Uncertain AOM: Not all three criteria are present
• Severe AOM: Moderate to severe ear pain or fever of 39°C (102.2°F) or greater
• Nonsevere AOM: Mild ear pain and fever of less than 39°C (102.2°F) in past 24 hours
Other nondrug approaches include the use of external heat or cold to reduce postauricular pain and surgery. Tympanostomy tubes are most useful for patients with recurrent disease or chronic OME with impaired hearing or speech. Adenoidectomy may be necessary for children with chronic nasal obstruction, but tonsillectomy is rarely indicated.3
Pharmacologic Therapy
Antimicrobial Therapy
When antimicrobial therapy is needed, many factors influence initial drug selection. Clinicians must consider drug factors such as antimicrobial spectrum, likelihood of clinical response, middle ear fluid penetration, incidence of side effects, drug interactions, and cost, as well as patient factors, including risk factors for bacterial resistance, allergies, ease of dosing regimen, medication palatability, and presence of other medical conditions. Studies in uncomplicated AOM have not revealed significant differences between antibiotics in clinical response rates but most were confounded by spontaneous resolution in children likely to have had viral illnesses. Bacteriologic response varies among antibiotics and does not always correlate well with clinical response but is considered important when selecting an agent.4,5
Guidelines from the American Academy of Pediatrics and the American Academy of Family Physicians are available for children between 2 months and 12 years of age with uncomplicated AOM (Fig. 72–2) and are based on published trials and expert opinion.4 Amoxicillin remains the drug of choice in most patients because of its proven effectiveness in AOM, high middle ear concentrations, excellent safety profile, low cost, good-tasting suspension, and relatively narrow spectrum of activity (Table 72–2). High-dose amoxicillin (80–90 mg/kg/day) is preferred over conventional doses because higher middle ear fluid concentrations can overcome pneumococcal penicillin resistance without substantially increasing adverse effects.15 In cases of severe illness or when coverage for β-lactamase-producing organisms is desired, high-dose amoxicillin-clavulanate is the preferred agent. Pneumococcal resistance to trimethoprim-sulfamethoxazole and macrolides is problematic and strikingly common in PRSP, making these agents less desirable for most patients.6,11 Patients with penicillin allergies require alternative firstline therapy (see Fig. 72–2). Children who have received an antimicrobial in the previous month are more likely to harbor resistant organisms and should also receive alternative therapy.6 A single dose of intramuscular ceftriaxone is effective for children who cannot tolerate oral medications, but a 3-day course may be preferred because of increasing pneumococcal resistance and failure of single doses.16 Ototopic antibiotics are an alternative to systemic agents for AOM in patients with otorrhea or tympanostomy tubes.17
FIGURE 72–1. Treatment algorithm for initial antimicrobials or observation in children with suspected or certain uncomplicated AOM. (From Ref. 4.)
FIGURE 72–2. Treatment algorithm for uncomplicated AOM in children 2 months to 12 years of age. (From Refs. 4, 6.)
If there is a lack of improvement or worsening with initial therapy during the first 48 to 72 hours, antibiotic selection must be reassessed and other contributing diseases must be excluded.4,6 Tympanocentesis can help to guide therapy in difficult cases.
Duration of therapy, like drug selection, depends on patient age and disease severity. Standard 10-day oral therapy is more effective than shorter courses for uncomplicated AOM in children younger than 2 years of age and those with recurrent infections, as well as in older patients with severe illness.4,18 Exceptions to the 10-day regimen are for azithromycin and ceftriaxone. In older children with mild or moderate illness, antibiotic therapy is needed only for 5 to 7 days.
Adjunctive Therapy
Pain is a central feature of AOM but is often overlooked in its management. Acetaminophen and ibuprofen are commonly used nonprescription agents for mild to moderate pain. Ibuprofen has a longer duration of effect than acetaminophen but is not used routinely in children younger than 6 months of age because of increased toxicity concerns. Alternating ibuprofen with acetaminophen is not recommended because of a lack of safety and efficacy data on combination therapy and the potential for dosing confusion and error. Topical anesthetic drops such as benzocaine (in Auralgan) provide pain relief within 30 minutes of administration and may be preferred over systemic analgesics when fever is absent. Myringotomy provides immediate relief but is performed rarely. Other medications such as decongestants, antihistamines, and corticosteroids have no role in the treatment of AOM and can, in some cases, prolong effusion duration.4,19 Data are lacking on the safety and efficacy of complementary and alternative treatments.
Prevention
Immunizations may prevent AOM in certain patients, such as those with recurrent infections. Influenza vaccine is more effective in preventing AOM in children older than 2 years of age than in younger patients possibly from impaired immune responses and immature host defense in infants and toddlers.20 Pneumococcal conjugate vaccine is protective against infection by vaccine serotypes only with a limited overall benefit for AOM.21 Antibiotic prophylaxis is no longer recommended for otitis-prone children because of increasing resistance. Avoidance or minimization of risk factors associated with otitis media, such as tobacco smoke and bottle feeding, is advised, but the effects of these interventions remain unproven.
Table 72–2 Antibioticsa for the Treatment of AOM
OUTCOME EVALUATION
Improvement of signs and symptoms (i.e., pain, fever, and tympanic membrane inflammation) should be evident by 72 hours of therapy. Children can appear clinically worse during the first 24 hours of treatment but often stabilize during the second day with defervescence and improved eating and sleeping patterns. If symptoms persist or worsen, reevaluation must occur to determine the proper diagnosis and treatment. Counsel patients and caregivers regarding common antibiotic adverse events such as rash, diarrhea, and vomiting that may prompt additional medical attention.
Patient Encounter 1, Part 2
On further questioning, you discover that the child is allergic to penicillin. She developed a nonurticarial rash last year during treatment for pharyngitis. She has not received antibiotics since that time, and this is her first ear infection.
Immunizations: Up to date
Meds: Acetaminophen drops 120 mg orally every 4 to 6 hours as needed for fever or pain
ROS: (+) nasal congestion and rhinorrhea, (-) vomiting, diarrhea, or cough
PE:
• Gen: Irritable child but consolable
• VS: BP 100/60 mm Hg, P 120 bpm, RR 18 breaths per minute, T 38.6°C (101.5°F)
• HEENT: As noted before
Identify your treatment goals for this child.
Given this information, what nonpharmacologic and pharmacologic therapy do you recommend?
Presence of middle ear effusion in the absence of symptoms is not an indicator of treatment failure. Persistent effusion greater than 3 months in duration requires a hearing evaluation in children who are otherwise healthy.22Preschool-aged and younger children or those at risk for developmental difficulties may need reexamination earlier because speech and hearing impairment is more difficult to assess in these populations.
SINUSITIS
Sinusitis, or inflammation of the paranasal sinuses, is often described as rhinosinusitis that also involves inflammation of contiguous nasal mucosa, which occurs in nearly all cases of viral respiratory infections. Acute rhinosinusitis is characterized by symptoms that resolve completely in less than 4 weeks, whereas chronic rhinosinusitis typically persists as cough, rhinorrhea, or nasal obstruction for more than 90 days. Acute bacterial rhinosinusitis (ABRS) refers to an acute bacterial infection of the sinuses that can occur independently or be superimposed on chronic sinusitis. The focus of this section will be on ABRS and appropriate treatment.
EPIDEMIOLOGY AND ETIOLOGY
Rhinosinusitis is one of the most common medical conditions in the United States, affecting about 1 billion people annually.1 It is caused mainly by respiratory viruses but also can be caused by allergies or environmental irritants. Viral rhinosinusitis is complicated by secondary bacterial infection in 0.5% to 2% of adults and 5% to 13% of children.23,24 Upper respiratory infections of less than 7 days’ duration are usually viral, whereas more prolonged disease or severe symptoms are often caused by bacteria. Risk factors for ABRS include prior viral respiratory infection, allergic rhinitis, anatomic defects, and certain medical conditions23,25 (Table 72-3).
Patient Care and Monitoring of AOM
1. Assess the patient’s signs and symptoms. Are they consistent with AOM?
2. Review diagnostic information to determine if acute infection is present. Are all three diagnostic criteria present? Was the proper method used for diagnosis (pneumatic otoscopy)?
3. Does the patient require antibiotic therapy, or is observation an appropriate option?
4. Obtain a complete medication history, including prescription drugs, nonprescription drugs, and natural product use, as well as allergies and adverse effects.
5. Determine what medication should be used for pain, if present.
6. If applicable, determine which antibiotic to use and the duration of therapy.
7. Develop a plan to assess effectiveness of the chosen therapy and course of action to take if the patient does not improve or worsens.
8. Provide patient education on:
• What to expect from prescribed medication, including potential adverse effects
• Avoidance of antihistamines and decongestants
• Signs of treatment failure
9. Stress the importance of adherence to therapy, including antibiotic resistance concerns.
10. Determine the need for influenza and pneumococcal vaccinations.
11. Educate the family regarding risk factors for otitis media.
Bacterial pathogens that cause sinusitis are similar to those that cause AOM. S. pneumoniae and H. influenzae are responsible for over half of the cases in all patients, with an additional 20% of cases caused by M. catarrhalis in children.23,25 Similar to AOM, an increased prevalence of H. influenzae has been reported in ABRS, and risk factors can predict the presence of drug-resistant pathogens.1,26 Other pathogens that cause sinusitis include S. pyogenes(up to 5%), anaerobic bacteria such as Bacteroides and Peptostreptococcus spp. (up to 9% of adults), and S. aureus (up to 10% of adults).23,27 Chronic infections are commonly polymicrobial with a higher incidence of anaerobes, gramnegative bacilli, and fungi.
Patient Encounter 2
A 36-year-old female presents to her primary care physician with purulent nasal/postnasal discharge, nasal congestion, headache, and fatigue. She reports that her symptoms began 7 days ago and have worsened over the past 2 days. She states that she has severe facial pressure when she bends forward and she has noticed that her upper molars ache when eating or brushing. She has taken ibuprofen and pseudoephedrine with little to no relief. She has a history of frequent sinus infections (1-2 per year). Her last course of antibiotics was 4 months ago for sinusitis when she received amoxicillin.
Immunizations: Up to date
Meds: Loratadine 10 mg orally daily, intranasal mometasone one spray each nostril daily, ibuprofen 400 mg orally as needed, pseudoephedrine 60 mg orally as needed
Allergies: Dust mites, cat dander, no medications
PE:
Gen: Tired-appearing, moderate distress, appears uncomfortable
VS: BP 102/60 mm Hg, P 88 bpm, RR 14 breaths per minute, T 38.2°C (100.8°F), wt 62 kg (136 lb)
HEENT: Thick, purulent green-brown postnasal discharge; nasal mucosal irritation and edema; facial pain (right maxillary) and upper molar hypersensitivity upon tapping; no oral lesions; erythematous pharynx with mild tonsillar hypertrophy
What information is suggestive of ABRS?
What risk factors are present?
What other diagnostic studies, if any, should be performed?
What are the treatment goals for this patient?
Create a care plan for this patient that includes nonpharmacologic and pharmacologic therapies and a monitoring plan.
Clinical Presentation and Diagnosis of ABRS
Sinusitis symptoms typically last 7 to 10 days after a viral infection and are caused by activation of the immune system and parasympathetic nervous system.
Acute Signs and Symptoms23,24,28,29
• Adults: Nasal congestion or obstruction, purulent nasal/postnasal discharge, facial pain or pressure or fullness (especially unilateral in a sinus area), diminished sense of smell, fever, cough, maxillary dental pain, fatigue, ear fullness or pain.
• Children: Purulent nasal/postnasal drainage, congestion and mouth breathing, persistent cough (particularly at night) or throat clearing, fever, pharyngitis, ear discomfort, halitosis, morning periorbital edema or facial swelling, fatigue, facial or tooth pain.
Complications
Orbital cellulitis or abscess, periorbital cellulitis, meningitis, cavernous sinus thrombosis, ethmoid or frontal sinus erosion, chronic sinusitis, and exacerbation of asthma or bronchitis.
Diagnosis23,24,28
• Clinical diagnosis: Most common method; acute rhinosinusitis signs and symptoms (as above) that have not resolved after 10 days or that worsen within 10 days after initial improvement. Sputum color is unreliable for diagnosis of bacterial infection because neutrophil presence causes color and can be found in viral sinusitis.
• Radiographic studies: Useful for assessing presence of abscess or intracranial complication.
• Paranasal sinus puncture: “Gold standard”; not performed routinely but can be useful in complicated or chronic cases.
• Laboratory studies/nasopharyngeal cultures: Not recommended for routine diagnosis.
Table 72–3 Risk Factors for ABRS
PATHOPHYSIOLOGY
Rhinosinusitis is caused by mucosal inflammation and local damage to mucociliary clearance mechanisms from viral infection or allergy. Increased mucus production and reduced clearance of secretions can lead to blockage of the sinus ostia, or the opening of the sinuses to the upper airway. This environment is ideal for bacterial growth and promotes a cycle of local inflammatory response and mucosal injury characterized by increased concentrations of interleukins, histamine, and tumor necrosis factor.23,25 Factors that contribute to bacterial invasion include nose blowing, reduced local immunity, viral virulence, and nasopharyngeal colonization with bacteria.23,28 Damage to the host defense system perpetuates bacterial overgrowth and persistence of infection.
TREATMENT
Desired Outcomes
The goals of treatment for ABRS are to eradicate bacteria and prevent serious sequelae. Specific aims are to relieve symptoms, normalize the nasal environment, use antibiotics when appropriate, select effective antibiotics that minimize resistance, and prevent development of chronic disease or complications.
General Approach to Treatment
Initial management of rhinosinusitis focuses on symptom relief for patients with mild disease lasting less than 10 days. Clinicians often inappropriately prescribe antibiotics for clinically suspected rhinosinusitis that usually is viral, self-limiting, and infrequently complicated by bacterial infection. Studies comparing antimicrobials to placebo in ABRS report only modest symptom improvements but increased adverse events in patients treated with antibiotics and a high spontaneous improvement rate of over 70% at 7 to 12 days after diagnosis of nonsevere ABRS.28,30 Therefore, watchful waiting is an option in nonsevere ABRS for up to 7 days after diagnosis if adequate follow-up can be assured.28 Antibiotic therapy should be reserved for persistent, worsening, or severe ABRS: patients with moderately severe symptoms that have persisted for greater than 10 days or worsened within 10 days after initial improvement and patients with severe disease regardless of duration.23,24,28 Empirical selection is often employed and should target likely pathogens because sinus cultures are rarely obtained.
Nonpharmacologic Therapy
Ancillary treatments such as humidifiers, vaporizers, and saline nasal spray or drops are used to moisturize the nasal canal and impair crusting of secretions along with promoting ciliary function. Although many patients report benefit from such therapies, there are no controlled studies that support their use.24 Nasal irrigation with isotonic or hypertonic saline washes may improve quality of life, reduce medication usage, and improve symptoms especially in patients with recurrent or chronic sinusitis.28
Pharmacologic Therapy
Adjunctive Therapy
Supportive medications that target symptoms of viral URIs are used widely in patients with rhinosinusitis, particularly in the early stage of infection. There is a lack of evidence supporting their use in ABRS, but they may provide temporary relief in certain patients.24,28 Analgesics can be used to treat fever and pain from sinus pressure. Oral decongestants relieve congested nasal passages but should be avoided in children younger than 4 years of age and patients with ischemic heart disease or uncontrolled hypertension. Intranasal decongestants can be used for severe congestion in most patients 6 years of age or older, but use should be limited to 3 days or less to avoid rebound nasal congestion. Guaifenesin is often used as a mucolytic with no evidence to support its use in rhinosinusitis. Antihistamines should be avoided because they thicken mucus and impair its clearance, but they may be useful in patients with predisposing allergic rhinitis or chronic sinusitis. Similarly, intranasal corticosteroids usually are reserved for patients with allergies or chronic sinusitis, but they may be beneficial as monotherapy or with antibiotics in ABRS.31
Antimicrobial Therapy
Although many clinical studies have been performed evaluating antibiotics for ABRS, no randomized, double-blind, placebo-controlled studies have used pre- and post-treatment sinus aspirate cultures as an outcome measure. In some studies, antimicrobials result in faster symptom resolution and lower failure rates and complications compared with no treatment, particularly in more severe disease.24,28 Since diagnosis is based on clinical presentation and not sinus aspirate cultures, clinicians must attempt to differentiate ABRS from viral rhinosinusitis. 
Therefore, it is important to limit antimicrobial use to cases where infection is unlikely to resolve without causing prolonged disease: patients with moderately severe symptoms that persist for greater than 10 days or worsen after initial improvement and patients with severe symptoms.23,24,28
Treatment guidelines reflect antimicrobial choices that are likely to result in favorable clinical and bacteriologic outcomes based on pathogen distribution, spontaneous resolution rates, and nationwide resistance patterns.23,24,28 These guidelines (Figs. 72–3 and 72–4) stratify therapy based on severity of disease and risk of infection with resistant organisms, defined as prior antibiotic use within 4 to 6 weeks. Other risk factors for resistance include daycare attendance or frequent exposure to children in daycare and recurrent disease. Severe disease requires evaluation and treatment in conjunction with specialized physicians such as otolaryngologists.
Antimicrobial therapy (Table 72-4) is targeted against S. pneumoniae, but consideration must be given to other pathogens such as H. influenzae, M. catarrhalis, S. aureus, and PRSP. Patients with mild disease and no prior antimicrobial exposure should receive initial therapy with amoxicillin or amoxicillin-clavulanate. Amoxicillin is effective for most mild infections and can be used in high doses to cover PRSP. It is less expensive and better tolerated than amoxicillin-clavulanate, which provides expanded coverage against β-lactamase-producing bacteria. Patients who are allergic to penicillins can be treated with an appropriate cephalosporin; severe penicillin allergies require treatment with alternative agents that may be less effective based solely on microbial resistance trends and not clinical data11,23,24 (see Fig. 72–3). Initial therapy for patients with moderate symptoms or those with recent antimicrobial exposure includes high-dose amoxicillin-clavulanate or a respiratory fluoroquinolone23,24 (see Fig. 72–4).
Table 72–4 Antimicrobialsa for the Treatment of ABRS
FIGURE 72–3. Treatment algorithm a for ABRS in patients with mild disease without recent antibiotic exposure. a Antimicrobials are listed in order of predicted efficacy based on predicted clinical and bacteriologic efficacy rates, clinical studies, safety, and tolerability. Doses can be found in Table 72–4. bCephalosp orins should be considered for patients with nontype I hypersensitivity to penicillins; they are more likely to be effective than the alternative agents. cHigh doses are recommended for adults with daycare contacts or frequent infections and most children. (From Refs. 23, 24.)
FIGURE 72–4. Treatment algorithma for ABRS in patients with mild disease and recent antibiotic exposure or moderate disease. aAntimicrobials are listed in order of predicted efficacy based on predicted clinical and bacteriologic efficacy rates, clinical studies, safety, and tolerability. Doses can be found in Table 72–4. bCephalosporins should be considered for patients with nontype I hypersensitivity to penicillins; they are more likely to be effective than the alternative agents. cRespiratory fluoroquinolone = levofloxacin, moxifloxacin. dCombination therapy should provide gram-positive and gram-negative coverage. Examples are highdose amoxicillin or clindamycin plus rifampin or cefixime. There are no published clinical studies to support such combinations. (From Refs. 23, 24.)
Patient Care and Monitoring of ABRS
1. Assess the patient’s signs and symptoms. Are they consistent with ABRS?
2. How long have the patient’s symptoms been present? If symptoms are mild and present for fewer than 10 days, viral sinusitis is likely. Persistent moderate or acute severe symptoms are more indicative of bacterial infection.
3. Does the patient require antibiotic therapy? Avoid antibiotic use in viral disease.
4. Obtain a complete medication history, including prescription drugs, nonprescription drugs, and natural product use, as well as allergies and adverse effects.
5. Determine what adjunctive therapies should be used for symptoms, such as pain and congestion.
6. If applicable, determine which antibiotic to use and the duration of therapy.
7. Develop a plan to assess effectiveness of the chosen therapy and course of action to take if the patient does not improve or worsens.
8. Provide patient education on
• What to expect from the antibiotic and other medications, including potential adverse effects
• Avoidance of antihistamines, if appropriate
• Signs of treatment failure
• Role of viral infections in sinusitis and how to prevent disease transmission
9. Stress the importance of adherence to therapy, including antibiotic resistance concerns.
Failure to respond to initial therapy within 7 days requires reevaluation to consider changing therapy to cover resistant pathogens and to examine for complications.28 Antimicrobials traditionally have been given for at least 10 to 14 days, with up to 21 days needed for resolution in some patients.23 Five-day treatment courses of some fluoroquinolones or cephalosporins are as effective as longer courses in adults with uncomplicated acute maxillary sinusitis.32Treatment success is influenced by medication adherence to the prescribed regimen, where once- or twice-daily agents are preferred over multiple daily doses.
OUTCOME EVALUATION
Clinical improvement should be evident within 7 days of therapy, as demonstrated by defervescence, reduction in nasal congestion and discharge, and improvements in facial pain or pressure and other symptoms. Monitor for common adverse events and refer to a specialist if clinical response is not obtained with first- or second-line therapy. Referral is also important for severe, recurrent, or chronic sinusitis or acute disease in immunocompromised patients. Surgery may be indicated in complicated cases.
PHARYNGITIS
Pharyngitis is an acute throat infection caused by viruses or bacteria. Other conditions, such as gastroesophageal reflux, postnasal drip, or allergies, also can cause sore throat and must be distinguished from infectious causes. Acute pharyngitis is responsible for 1% to 2% of adult physician visits and 6% to 8% of pediatric visits but generally is self-limited without serious sequelae.33,34 Antimicrobials are prescribed in 50% to 70% of cases in adults and children because of the inability to easily distinguish between viral and bacterial pathogens and fear of untreated streptococcal illness.34,35
EPIDEMIOLOGY AND ETIOLOGY
Pharyngitis is usually a component of upper respiratory infections caused by rhinovirus, coronavirus, adenovirus, influenza virus, parainfluenza virus, or Epstein-Barr virus. Group A Streptococcus, or S. pyogenes, is the most common bacterial cause of acute pharyngitis, responsible for 15% to 30% of cases in children and 5% to 10% of adult infections.33,36 Infection is most common in late winter and early spring and is spread easily through direct contact with contaminated secretions. Clusters of infection are common within families, classrooms, and other crowded areas. Less common causes of bacterial pharyngitis are Corynebacterium diphtheriae, groups C and G streptococci, Chlamydia pneumoniae, Mycoplasma pneumoniae, and Neisseria gonorrhoeae. This section will focus on group A streptococcal disease in which antimicrobial therapy is indicated.
PATHOPHYSIOLOGY
Pharyngeal colonization with group A streptococci occurs in up to 20% of children and is a risk factor for developing streptococcal pharyngitis after a break in mucosal integrity.37 Clinicians should recognize that the symptoms of streptococcal pharyngitis usually are self-limited and resolve within 2 to 4 days of onset without treatment.36 Historically, untreated or inappropriately treated disease caused acute rheumatic fever, potential permanent heart valve damage, and infectious complications such as peritonsillar and retropharyngeal abscesses. Delayed antimicrobial therapy given up to 9 days after symptom onset can prevent these particular sequelae, so proper diagnosis is important to minimize unnecessary antimicrobial use for viral disease and complications of untreated streptococcal infection.36,37
Clinical Presentation and Diagnosis of Streptococcal Pharyngitis
Children between 5 and 15 years of age have the highest incidence of streptococcal pharyngitis. Parents and adults with significant pediatric contact are also at increased risk.
Signs and Symptoms of Streptococcal Pharyngitis3637
• Sudden onset of sore throat with severe pain on swallowing
• Fever
• Headache, abdominal pain, nausea, or vomiting (especially in children)
• Pharyngeal and tonsillar erythema with possible patchy exudates
• Tender, enlarged anterior cervical lymph nodes
• Swollen and red uvula
• Soft palate petechiae
• Scarlatiniform Rash
• General absence of conjunctivitis, hoarseness, cough, rhinorrhea, discrete ulcerations, and diarrhea (suggestive of viral etiology)
Diagnosis33,37
• Rapid antigen detection test (RADT): 80% to 90% sensitivity; results available within minutes.
• Throat swab and culture: “Gold standard”; results available within 24 to 48 hours. Should be performed in all negative RADTs in children, adolescents, and adults with significant pediatric contact. Also recommended in outbreaks and to monitor for antibiotic resistance.
• These tests should be performed only if there is a clinical suspicion of streptococcal pharyngitis. Pharyngeal carriage of group A streptococci is 5% to 20% in children.
TREATMENT
Desired Outcomes
The goals of therapy for streptococcal pharyngitis are to eradicate infection in order to prevent complications, shorten the disease course, and reduce infectivity and spread to close contacts. Antimicrobial use only prevents peritonsillar or retropharyngeal abscesses, cervical lymphadenitis, and rheumatic fever. Immune-mediated, nonsuppurative complications of streptococcal infection that are not impacted by antimicrobial treatment include acute glomerulonephritis, reactive arthritis, and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus infection (PANDAS) that commonly presents with obsessive-compulsive or tic symptoms following streptococcal infection.33,38
Pharmacologic Therapy
Antimicrobials should be used only in cases of laborator y-3 documented streptococcal pharyngitis associated with clinical symptoms in order to avoid overtreatment33,36,37 (Fig. 72–5). Effective therapy (Table 72–5) reduces the infectious period from approximately 10 days to 24 hours and shortens symptom duration by 1 to 2 days.33 Treatment guidelines recommend penicillin as the drug of choice because of its narrow antimicrobial spectrum, documented safety and history of nasopharyngeal streptococcal eradication, and low cost.33,37 Studies proving that antimicrobials prevent rheumatic fever used intramuscular procaine penicillin, but other antimicrobials can also eradicate nasopharyngeal streptococci and presumably are effective for preventing rheumatic heart disease.37 organisms that inactivate penicillin, improved eradication of commensal streptococci that are protective against group A streptococcal disease, and improved pharyngeal tissue penetration of cephalosporins. Usual duration of therapy is 10 days, but evidence is mounting that 5-day courses of certain cephalosporins are just as effective for bacterial eradication as 10 days of penicillin.40
Table 72–5 Antibioticsa for the Treatment of Streptococcal Pharyngitis
FIGURE 72–5. Treatment algorithm for management of pharyngitis in children and adults. aRapid antigen detection tests (RADTs) are preferred if the test sensitivity exceeds 80%. bParents, teachers, or other adults with significant pediatric contact should also be cultured if RADT is negative. (From Refs. 36, 37.)
Patient Encounter 3
A 7-year-old boy presents to the pediatrician with a sore throat and fever of 39.2°C (102.6°F) for 24 hours. His mother reports that other children in his class have had “strep throat” recently. He also complains of pain on swallowing and is not eating or drinking very much. He does not have any other symptoms and has no known drug allergies. Physical examination reveals pharyngeal and tonsillar erythema with exudates and painful cervical lymphadenopathy.
Does this child have streptococcal pharyngitis?
Is antibiotic therapy indicated? If so, what agent should be initiated and for how long?
What education should be provided to his mother regarding treatment?
Patient Care and Monitoring of Streptococcal Pharyngitis
1. Assess the patient’s signs and symptoms. Are they consistent with streptococcal pharyngitis? Are symptoms of viral infection present?
2. Perform laboratory testing to confirm the presence of group A streptococci.
3. Does the patient require antibiotic therapy? Avoid antibiotic use in viral disease.
4. Obtain a complete medication history, including prescription drugs, nonprescription drugs, and natural product use, as well as allergies and adverse effects.
5. Recommend antipyretic or analgesic therapy, if needed.
6. If applicable, determine which antibiotic to use and the duration of therapy.
7. Develop a plan to assess effectiveness of chosen therapy and course of action to take if the patient does not improve or worsens.
8. Provide patient education on:
• What to expect from the antibiotic, including potential adverse effects
• Avoidance of close contacts for 24 hours
• Signs of treatment failure
9. Stress the importance of adherence to therapy, including antibiotic resistance concerns.
Cephalosporins are more effective than penicillin in producing bacteriologic and clinical cure and can be considered as first-line therapy alternatives in children and adults.39 Possible reasons for improved cephalosporin efficacy include the copresence of β-lactamase-producing organisms that inactivate penicillin, improved eradication of commensal streptococci that are protective against group A streptococcal disease, and improved pharyngeal tissue penetration of cephalosporins. Usual duration of therapy is 10 days, but evidence is mounting that 5-day courses of certain cephalosporins are just as effective for bacterial eradication as 10 days of penicillin.40
Antimicrobial resistance plays a smaller role in pharyngitis therapy compared with other URIs. Penicillin resistance has not yet been documented in group A streptococci, but resistance and clinical failures occur more frequently with tetracyclines, trimethoprim-sulfamethoxazole, and to a lesser degree macrolides. As such, patients with penicillin allergies should be treated with a first-generation cephalosporin (if nontype I allergy), a macrolide/azalide, or clindamycin. Recurrent infections caused by reinfection, poor adherence to therapy, or true penicillin failure can be treated with amoxicillin-clavulanate, clindamycin, or penicillin G benzathine.37
OUTCOME EVALUATION
Antimicrobials relieve symptoms over 3 to 5 days, and patients can return to work or school if improved clinically after the first 24 hours of therapy. Follow-up cultures are not recommended to test for bacterial eradication. Lack of improvement or worsening of symptoms after 72 hours of therapy requires reevaluation. Recurrent symptoms following an appropriate treatment course should prompt reevaluation for possible retreatment.
COMMON COLD
The common cold is a self-limiting viral URI that occurs frequently throughout life. It is responsible for many missed days of school and work and is associated with significant health care resource utilization, including physician office and emergency department visits and nearly universal use of cough and cold medication for treatment or prevention.41,42 It is important for clinicians to be aware of evidence regarding the use of cough and cold products in order to make appropriate treatment recommendations for this commonly encountered condition.
EPIDEMIOLOGY AND ETIOLOGY
Over 200 viruses cause the common cold, including rhinoviruses (most common), coronaviruses, parainfluenza viruses, respiratory syncytial virus, and adenoviruses.43 Infection rates increase during the fall through spring seasons and are highest in the winter months. Adults experience 2 to 4 colds each year while children average 6 to 10 colds per year.41,43,44 Each episode can persist for up to 10 to 14 days and can lead to bacterial superinfections, including AOM and ABRS. Factors associated with an increased incidence of colds are young age, contact with school-age children, crowded conditions and poorly ventilated areas, and cigarette smoking. Children transmit viruses more rapidly than adults because of poorer hand hygiene, closer casual contacts, and sharing of toys.42 Viral antigenic drifts and host immune system evasion contribute to the persistence of URIs in the community.
Clinical Presentation and Diagnosis of the Common Cold
Symptoms begin 24 to 72 hours after infectious contact. They usually peak around day 3 to 4 and begin to wane by day 7; colds typically last 10 to 14 days.
Signs and Symptoms41,42,45
• Onset: malaise, fatigue, headache, pharyngitis, low-grade fever (can be higher in infants and children); symptoms usually resolve over a few days.
• Secondary: Nasal/postnasal drainage (often clear at onset, but can become thick and purulent); nasal congestion; cough and/or throat clearing; sneezing; conjunctivitis; irritability; loss of smell or taste.
Complications
AOM, bacterial sinusitis, chronic bronchitis, bronchiolitis (in infants and children under 2 years of age), pneumonia, asthma exacerbation.
Diagnosis45
• Clinical diagnosis: Most common method; based on history, presence of symptoms, and physical examination.
• Radiographic studies: Not recommended routinely; useful for assessing complications such as pneumonia.
• Laboratory studies: Not recommended routinely; rapid viral antigen tests and nasopharyngeal cultures helpful for epidemiology and diagnosis in acutely ill young infants.
PATHOPHYSIOLOGY
Viruses enter the upper respiratory tract mucosa via inhalation of aerosols or infected droplets or direct contact with contaminated secretions. After cell entry, viral replication and shedding occur for several days to weeks. Clinical symptoms are a result of epithelial cell damage, inflammation, vasodilation, edema from increased vascular permeability, increased mucus production, and impaired mucociliary clearance from neutrophil migration, cytokine release, and cytotoxic immune responses.42,45 Tracheobronchial inflammation and irritation induce cough via afferent nerve impulse transmission to the medulla.42 Antibody production halts viral replication and inflammation as symptoms wane.
TREATMENT
Desired Outcomes
The treatment goal for the common cold is to minimize discomfort from symptoms to allow patients to function as normally as possible. Antiviral use is not effective for cure. Preventative measures are also a focus to limit the spread to others.
General Approach to Treatment
Antimicrobials have no role in the treatment of the common cold. They are often prescribed inappropriately to patients with viral URIs and purulent secretions that has led to increased antimicrobial resistance.2 Antimicrobials do not shorten symptom severity or duration and do not prevent bacterial complications from occurring in patients with the common cold.2,41 Treatment measures should focus on symptomatic relief.
Nonpharmacologic Therapy
Supportive measures that assist with patient comfort include cool mist air humidification, use of intranasal saline drops or sprays with or without bulb suctioning, increased fluid intake, throat lozenges or saline gargles, and rest. Nasal strips have been advocated to relieve congestion by lifting the nares and opening the anterior nasal passages. These nondrug measures are particularly important for infants, children under 6 years of age, and pregnant women where medication safety is a significant concern. Although studies proving their benefits are lacking, these nondrug treatments are safe.
Pharmacologic Therapy
Nonprescription cough and cold preparations are used frequently to manage cold symptoms despite the lack of evidence to support their safety and efficacy. Over 10% of children per week receive nonprescription cough and cold remedies with highest use among children under 5 years of age.46 Reports of serious adverse events and deaths have led to efforts to eliminate use of nonprescription cough and cold medications in young children.47 Manufacturers have removed product labeling for children under 4 years of age while the FDA is reviewing their use in all children under 12 years.
Over 800 products are available to manage cold symptoms. Choice of therapy is influenced by patient age, presence of comorbid conditions, and balance of effectiveness and safety. Single ingredient agents are preferred over multi-ingredient products to target only active symptoms and to minimize the toxicity and overdose risk that can result from confusion and lack of knowledge on active components in marketed formulations. Cautious use of nonprescription preparations is warranted in certain patient populations: pregnant and/or lactating women, elderly, those with cardiovascular disease including hypertension, patients with diabetes, and glaucoma. Table 72–6summarizes some of the available nonprescription agents used for cold symptoms. Analgesics can be used for fever, pain, and discomfort from cold symptoms but only as single-ingredient formulations. Local anesthetics (e.g., benzocaine, dyclonine) relieve throat pain and are available in lozenges and sprays. Nasal decongestants cause vasoconstriction that can modestly improve nasal airway resistance and congestion, but use of intranasal products should be limited to 3 days to avoid rebound congestion.41,49
Table 72–6 Select Nonprescription Medications for the Common Cold for Patients 6 Years of Age and Above
Antihistamines should be avoided when treating cold symptoms: first-generation antihistamines may help dry watery secretions via anticholinergic effects, but they impair mucociliary clearance of thick mucus which can worsen congestion and studies have not shown clear benefits for cough or cold symptoms.41,49 Cough suppressant use is not supported by strong evidence showing benefit, and they can cause significant side effects and have been linked to abuse by teens for their euphoric effects in high doses.41–43,49 Guaifenesin, an expectorant, may reduce cough frequency and sputum thickness in adults but has been poorly studied in children.49 Routine high-dose vitamin C (more than 200 mg/day) treatment does not significantly impact cold severity or duration, but prevention in certain populations exposed to severe physical exercise or cold stress may be effective.49 Use of Echinacea purpurea extracted from aerial parts may have benefit in adults when started early for treatment but its use is discouraged for prevention and in all children.50 Other forms of echinacea have not shown consistent benefit for treatment of cold symptoms. Zinc lozenges are not effective for treating cold symptoms and concerns exist regarding the loss of smell with intranasal zinc preparations, so they should be avoided.44
Patient Encounter 4
A 25-year-old female presents to her family physician with a “sinus infection.” Three days ago, she developed a sore throat, sneezing, and a “watery runny nose.” Today, the nasal discharge is a thicker, yellow-green color and she has a mild headache. She also has some minor nasal congestion and a dry, nonproductive cough that started yesterday. She took acetaminophen 500 mg this morning which provided some headache relief. She has no medical conditions, but she does experience colds 4 to 5 times per year. She works in a daycare center and she has a 20-month-old son who developed a fever (38.0°C [100.4°F]) and clear rhinorrhea yesterday.
Immunizations: Up to date; needs influenza vaccine this season
Meds: Vitamin C 1,000 mg orally daily, Ortho Tri-Cyclen orally daily
Allergies: None
PE:
Gen: No apparent distress; pleasant
VS: BP 120/70 mm Hg, P 66 bpm, RR 16 breaths per minute, T 37.5°C (99.5°F), wt 80 kg (176 lb)
HEENT: Bilateral conjunctivitis with no discharge; green-yellow nasal discharge with mucosal hypertrophy and narrowed passages; erythematous pharynx with no exudates; no facial pain upon palpation; tympanic membranes normal appearing
Lungs: Clear to auscultation; occasional wheeze with cough; no crackles
What signs and symptoms are suggestive of the common cold? Which are suggestive of ABRS?
What other diagnostic studies, if any, should be performed?
Create a care plan that includes nonpharmacologic and pharmacologic therapies and a monitoring plan. Include preventative measures in your plan.
Patient Care and Monitoring of Common Cold
1. Assess the patient’s signs and symptoms. Are they consistent with the common cold?
2. How long have the patient’s symptoms been present? If symptoms have been present for fewer than 7 to 10 days, the common cold is likely. Persistent moderate or acute severe symptoms are more indicative of bacterial infections.
3. Has the patient tried any medications or nonpharmacologic methods to treat the symptoms? If yes, do they provide any relief?
4. Obtain a medication and medical history, including prescription and nonprescription drugs, natural product use, allergies, and current medical conditions.
5. Determine if nonprescription medications should be used to alleviate symptoms, such as pain and congestion.
6. Develop a treatment plan (including use of nonpharmacologic measures) to assess effectiveness of the chosen therapy and course of action to take if the patient does not improve or worsens.
7. Provide patient education on:
• Role of viruses in colds, symptom resolution expectations, and how to prevent transmission to others
• What to expect from the chosen therapy, including proper dosing and potential adverse effects
• Avoidance of antibiotics to treat colds
• When to seek additional medical care
8. Stress the importance of handwashing and limiting spread to others.
Prevention
Minimizing contact with infected people and secretions is key to preventing the common cold. Frequent handwashing with soap and water or use of alcohol-based products is the cornerstone of prevention. Coughing and sneezing into the sleeve should be taught rather than using tissues or covering the mouth and nose with hands. Other methods that are often advocated include smoking cessation, maintenance of a healthy lifestyle through diet and exercise, and minimizing stress.
OUTCOME EVALUATION
Most colds will resolve within 7 to 10 days. Monitor patients for worsening symptoms and complications such as wheezing, difficulty breathing, moderate to severe facial or ear pain, and high fevers. If complications are suspected, referral to a physician is warranted.
Abbreviations Introduced in This Chapter
Self-assessment questions and answers are available at http://www.mhpharmacotherapy.com/pp.html.
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