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Pediatric ENT in 40 Minutes Gil C. Grimes, MD April 2007.

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Otitis Media Gil C. Grimes, MD June Objectives Describe criteria for diagnosing Acute Otitis Media Describe rationale for therapy for Acute Otitis.

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1 Pediatric ENT in 40 Minutes Gil C. Grimes, MD April 2007

2 Objectives Describe criteria for diagnosing Acute Otitis Media Describe rationale for therapy for Acute Otitis Media Describe Therapy for Serous Otitis Media Describe the role of Tympanostomy Tubes Describe the strategies for diagnosing Strep Pharyngitis Describe Treatment options for Strep Pharyngitis

3 My Bias I am a minimalist If the evidence for intervention is not good I do nothing

4 Acute Otitis Media A diagnosis of AOM requires a history of acute onset of signs and symptoms the presence of middle ear effusion (MEE) signs and symptoms of middle-ear inflammation. Pediatrics 2004 May;113(5): Pediatrics 2004 May;113(5): Level 1a

5 Acute Otitis Media The presence of MEE that is indicated by any of the following: Bulging of the tympanic membrane Limited or absent mobility of the tympanic membrane Air-fluid level behind the tympanic membrane Otorrhea

6 Acute Otitis Media Signs or symptoms of middle-ear inflammation as indicated by either Distinct erythema of the tympanic membrane or Distinct otalgia discomfort clearly referable to the ear(s) and interference with or precludes normal activity or sleep

7 Acute Otitis Media Otitis Media? Yes No

8 Acute Otitis Media Otitis Media? Yes No

9 Acute Otitis Media Prevalence Prevalence 10% US children diagnosed by 3 months 90% by 2 years (1) Prospective cohort of children (2) 62% with AOM by 1 year 83% with AOM by 3 years 9th most common diagnosis during FM visits (3) Coded 3.2% visits (3) 1)Pediatric Infect Dis J 1989 Jan;8(1 Suppl):S9 Level 2b 2)J Infect Dis 1989 Jul;160(1):83 2)J Infect Dis 1989 Jul;160(1):83 Level 2b 3) Ann fam Med 2004 Sep-Oct:2(5)411 3) Ann fam Med 2004 Sep-Oct:2(5)411 Level 2c

10 Acute Otitis Media Etiology Viral pathogens found Tympanocentesis and Nasal Aspirate in AOM RSV and coronavirus RNA in 75% children 5% dual viral infections Bacterial pathogens detected 62% Viral RNA detected in 57% bacteria-negative and 45% bacteria-positive samples Pediatrics 1998 Aug;102(2):291 Pediatrics 1998 Aug;102(2):291 Level 1c

11 Acute Otitis Media Etiology Bacteria shifts Streptococcus pneumoniae S. pneumoniae is the most common bacterial organism identified non-typeable Haemophilus influenzae H. flu identified primarily in children < 5, but reduced with routine immunization Moraxella (Branhamella) catarrhalis May be changing due to heptavalent pneumococcal vaccine decrease in S. pneumoniae and increase in H. influenzae Pediatric Infectious Disease 2004 Sep;23(9Pediatric Infectious Disease 2004 Sep;23(9):824 Level 2b

12 Acute Otitis Media Risk Factors Formula feeding incidence of otitis media is higher in formula-fed infants vs. breast-fed infants incidence of prolonged ear infections was 5x higher among formula-fed infants Duration OM episodes longer (8.8 vs. 5.9 days) J Pediatric 1995 May;126(5 Pt 1):696 J Pediatric 1995 May;126(5 Pt 1):696 Level 2b

13 Acute Otitis Media Risk Factors Day Care Attendance day care associated with increased risk of upper and lower respiratory tract illnesses in first year of life for children with familial history of atopy prospective birth cohort study of 498 children with parental history of allergy or asthma followed prospectively for first year of life Pediatrics 1999 Sep;104(3):495 Pediatrics 1999 Sep;104(3):495 Level 2b

14 Acute Otitis Media Risk Factors. Associated with 2 or more doctor-diagnosed ear infections (odds ratio [OR] 2.4, 95% confidence interval [CI] ) For children attending day care independent predictors of 2 or more doctor-diagnosed ear infections included exposure to pets in day care presence of rug or carpet in area where child slept in day care nonresidential setting for day care Pediatrics 1999 Sep;104(3):495 Pediatrics 1999 Sep;104(3):495 Level 2b

15 Acute Otitis Media Risk Factors Passive Smoking 625 Children Calgary first graders Middle ear disease 2 or more household smokers (crude odds ratio) [OR], 1.85; 95% confidence interval [CI], or more cigarettes smoked by the mother per day (crude OR, 1.68; 95% CI, ) 10 or more cigarettes smoked in total in the household per day (crude OR, 1.40; 95% CI, ) during the first 3 years of life Arch Pediatric Adolescent Med Feb;152(2):127 Arch Pediatric Adolescent Med Feb;152(2):127 Level 2c

16 Acute Otitis Media History Poor predictive value Studies are not good Statistics LR+ greater than 5 good LR- less than 0.5 good Specificity to rule in Sensitivity to rule out Pediatric Infect Dis J 1994; 13: 765 Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633

17 Acute Otitis Media Pediatric Infect Dis J 1994; 13: 765 Pediatric Infect Dis J 1994; 13: 765 Level 3a Reviewed in JAMA 2003 Sep 24;290(12):1633JAMA 2003 Sep 24;290(12):1633

18 Acute Otitis Media Physical Findings Based on prospective study of 8,859 ear-related visits among children years with acute symptoms myringotomy performed if middle ear effusion suspected on exam 51.5% had acute otitis media (i.e. middle ear effusion confirmed on myringotomy) Color not particularly helpful but cloudy membrane predictive red color was not highly predictive cloudy tympanic membrane had 80-96% positive predictive value normal color dramatically reduces likelihood of AOM (2-5% probability of middle ear effusion if normal color) Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1a

19 Acute Otitis Media Physical Continued Position helpful if clearly bulging bulging tympanic membrane had 89-96% positive predictive value retracted tympanic membrane had 47-50% positive predictive value normal position had 22-32% probability of AOM Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37Int J Pediatric Otorhinolaryngol 1989 Feb;17(1):37 Level 1a

20 Acute Otitis Media Mobility helpful if distinctly impaired or clearly normal distinctly impaired mobility had 78-94% positive predictive value slightly impaired mobility had 33-60% positive predictive value normal mobility dramatically reduces likelihood of AOM (2-5% probability of middle ear effusion if normal mobility)

21 Acute Otitis Media Test Name Positive Likelihood Ratio TM position: bulging51.00 TM color: cloudy34.00 TM mobility: distinctly impaired TM color: distinctly red8.40 TM mobility: slightly impaired4.00 TM position: retracted3.50 TM color: slightly red1.40 TM position: normal0.50 TM color: normal0.20 TM mobility: normal0.20

22 Acute Otitis Media Type A pattern is normal Type B pattern is consistent with MEE Type C is seen with retracted TM

23 Acute Otitis Media Prognosis Spontaneous resolution is the norm 81% spontaneously resolve (1) 5000 children with otitis >90% resolved with supportive care 2.7% had a severe course (required antibiotics or myringotomy at 5 days) 1)Arch Pediatr Adolesc Med 2001;155(10):1097Level 1aArch Pediatr Adolesc Med 2001;155(10):1097

24 Acute Otitis Media Prognosis Recurrent otitis media no long term consequences usually spontaneous recovery study of 222 children with recurrent otitis media who received no prophylaxis 4% developed chronic otitis media with effusion 12% continued having recurrent episodes most significant risk factor for continued recurrence was age < 16 months (1) 1)Pediatrics 5 May :1452 Level 1aPediatrics 5 May :1452

25 Acute Otitis Media Prognosis Persistent effusion Watchful Waiting recommended in children without the following: Permanent hearing loss independent of OME Suspected or diagnosed speech and language delay or disorder Autism-spectrum disorder and other pervasive developmental disorders syndromes (e.g., Down) Craniofacial disorders that include cognitive, speech, and language delays Blindness or uncorrectable visual impairment Cleft palate with or without associated syndrome Developmental delay Pediatrics :5; Level 1a

26 Acute Otitis Media Prognosis Persistent effusion Change from B to non-B tympanogram favorable 25% of OME of unknown duration resolves in 3 months Warn parents of decreased hearing while effusion present Recheck every three months Pediatrics 5 May :5; Pediatrics 5 May :5; Level 1a

27 Acute Otitis Media Treatment Treat Pain Acetaminophen and ibuprofen (1) 219 children treated with cefaclor evaluated pain at 2 days Ibuprofen 7% with pain NNT 5 Acetaminophen 10% with pain NNT 6 Placebo 25% 1)Fundam Clin Pharmacol. 1996;10(4):387 Level 1cFundam Clin Pharmacol. 1996;10(4):387

28 Acute Otitis Media Treatment Topical analgesics effective 1 Systematic review of 4 RCT Anesthetic ear drops have significant reduction in pain at 30 minutes Naturopathic herbals had similar results at 30 minutes Longer duration of relief with naturopathic drops 1- Cochrane Library 2006 Issue 3:CD Level 1aCochrane Library 2006 Issue 3:CD005657

29 Acute Otitis Media Treatment Initial treatment options are observation or antibiotics for children < 6 months old, antibiotics recommended for children 6 months to 2 years old observation option recommended only if all of the following are present otherwise healthy child uncertain diagnosis non-severe illness follow-up can be ensured so antibiotics can be started if symptoms persist or worsen antibiotics recommended if certain diagnosis of AOM, severe illness, or follow-up cannot be ensured

30 Acute Otitis Media Treatment For children > 2 years old Observation option recommended only if the following are present otherwise healthy child uncertain diagnosis OR non-severe illness follow-up can be ensured so antibiotics can be started if symptoms persist or worsen Antibiotics recommended if certain diagnosis of AOM and severe illness, or follow-up cannot be ensured Am Fam Physician 2004 Jun 1;69(11):2713Am Fam Physician 2004 Jun 1;69(11):2713 Level 1a

31 Acute Otitis Media Treatment No improvement in hours Confirm the diagnosis If AOM certain then begin antibiotics if not already started Change antibiotics if already started

32 Acute Otitis Media Treatment Wait and see approach is reasonable 283 children 6 month to 12 years with acute otitis seen in ER At 4-6 days Wait and see group not to fill Rx unless not better or if worse in 48 hours Everyone got ibuprofen, otic drops and antibiotic Rx 94% follow up 62% of wait and see did not fill RX 13% in standard care (NNT 2)

33 Acute Otitis Media Treatment Wait and See continued No difference in otalgia severity or duration No difference in fever No difference in unscheduled follow up appointment 8% of wait and see vs. 23% of standard care had diarrhea (NNH 7) Data persisted to days and days JAMA 2006 Sep 13;296(10):1235JAMA 2006 Sep 13;296(10):1235 Level 1b

34 Acute Otitis Media Treatment Antibiotics CDC guidelines for management and surveillance of acute otitis media in era of pneumococcal resistance You must know your community 1)Pediatrics 2004;113(5):1452 Level 1aPediatrics 2004;113(5):1452

35 Acute Otitis Media Treatment Amoxicillin mg/kg/day divided TID for 10 days Failure at 3 days switch to one of the following cefuroxime axetil (Ceftin) 15 mg/kg BID for 10 days amoxicillin-clavulanate (Augmentin) Augmentin 45 mg/kg/day divided BID or 40 mg/kg/day divided TID, both for 10 days ceftriaxone (Rocephin) IM 50mg/kg for 3 days 1)Pediatric Infect Dis J Jan;18(1):1 Level 1aPediatric Infect Dis J Jan;18(1):1

36 Acute Otitis Media Treatment Penicillin Sensitive patients Not Type I reaction (no urticaria or anaphylaxis) (1) Cefdinir (Omnicef) 14 mg/kg divided once daily or BID for 5 days (BID dosing) or 10 days (once daily dosing) slightly better taste (2) Cefpodoxime (Vantin) 10 mg/kg once daily for 10 days or divided BID for 5 days Cefuroxime (Ceftin or Zinacef) 30 mg/kg divided BID for 10 days Ceftriaxone (Rocephin) 50mg/kg IM once 1)Pediatrics 5 May 2004;113(5):1452 Level 1aPediatrics 5 May 2004;113(5):1452 2)Pediatrics 2005 Apr;115(4):1048 Level 1aPediatrics 2005 Apr;115(4):1048

37 Acute Otitis Media Treatment Penicillin Sensitive Patients Type I reaction Azithromycin (Zithromax) 10 mg/kg day one then 5 mg/kg days 2-5 Clarithromycin (Biaxin) 15 mg/day divided BID for 10 days Erythromycin/sulfisoxazole (Pediazole) 50 mg/kg daily of erythromycin divided TID to QID for 10 days Sulfamethoxazole-trimethoprim (Bactrim or Septra) 6-10 mg/kg daily of trimethoprim divided BID for 10 days Pediatrics 5 May 2004;113(5):1452 Pediatrics 5 May 2004;113(5):1452 Level 1a

38 Acute Otitis Media Reality Shorter therapy 5 days is likely as beneficial as longer therapy (1) Early treatment with antibiotics may lead to increased resistance (2) Side effects are as common as benefit NNT at 1 week NNH 17 at one week Delayed antibiotics result in decreased use and decreased likelihood of asking for antibiotics in the future (3) 1)JAMA Jun 3;279(21):1736 Level 1aJAMA Jun 3;279(21):1736 2)J Infect Dis Mar 15;183(6):880 Level 4Infect Dis Mar 15;183(6):880 3)BMJ 2001 Feb 10;322:336 Level 1cBMJ 2001 Feb 10;322:336

39 Acute Otitis Media Guideline Review Pediatrics 2004 May;113(5):1451 Summary can be found in Am Fam Physician 2004 Jun 1;69(11):2713 editorial can be found in Am Fam Physician 2004 Jun 1;69(11):2537 commentary can be found in Pediatrics 2004 Sep;114(3):898 commentary can be found in Pediatrics 2005 Feb;115(2):513

40 Serous Otitis Media PtEducENT/Default.htm

41 Serous Otitis Media Causes Causes Overgrowth of lymphoid tissue in the nasopharynx Chronic sinus infection Allergies of nose and nasopharynx Gastric reflux implicated Pepsin seen in MEE 45 of 54 children with SOM (1) Pepsin seen in MEE 59 of 65 children with SOM (2) 1)Lancet 2002 Feb 9;359(9305):493 Level 4Lancet 2002 Feb 9;359(9305):493 2)Laryngoscope Nov;112(11):1930 Level 4Laryngoscope Nov;112(11):1930

42 Serous Otitis Media Complications Permanent hearing loss (?) (5) Tympanosclerosis Fibrosis of middle ear space Balance problems (1) Minor language deficits (+/-) (2) No association with attention or behavior in first 6 years of life (3) Possible behavior problems in teens (4) 1)Pediatrics Mar;99(3):334 Level 4Pediatrics Mar;99(3):334 Level 4 2)Pediatrics May;105(5):1119 Level 2cPediatrics May;105(5):1119 Level 2c 3)Pediatrics May;107(5):1037 Level 1bPediatrics May;107(5):1037 Level 1b 4) Arch Dis Child Aug;85(2):91 Level 1bArch Dis Child Aug;85(2):91 Level 1b 5) Pediatrics Sep;106(3):E42 Level 1cPediatrics Sep;106(3):E42 Level 1c

43 Serous Otitis Media Physical Physical examination Pearly gray Minimal dullness Minimal retraction Presence of effusion

44 Serous Otitis Media Tests Key tests Pneumo-otoscopy with limited movement (1) Sensitivity of 94% (95% CI: 92%-96%) Specificity of 80% (95% CI: 75%-86%) Tympanogram B-curve (2) 81% sensitivity 56% specificity 1)Pediatrics Dec;112(6 Pt 1):1379 Level 1aPediatrics Dec;112(6 Pt 1):1379 Level 1a 2)Clin Otolaryngol Jun;28(3):183 Leve 1cClin Otolaryngol Jun;28(3):183 Leve 1c

45 Serous Otitis Media Prognosis High rate of spontaneous resolution (1) Most resolve in 3 months Meta-analysis 11 trials (2) No significant hearing loss No speech/language delay Tubes have consequences (3) 140 children followed 8 years Sequela higher at 3-5 years 47% for retraction pocket 67% for tympanic membrane atrophy 40% for myringosclerosis 23% for hearing loss 1)J Fam Pract 2000 Jul;49(7):605,612 Level 1aJ Fam Pract 2000 Jul;49(7):605 2)Pediatrics 2004 March; 113(3): e238 Level 1aPediatrics 2004 March; 113(3): e238 Level 1a 3)Arch Otolaryngol Head Neck Surg May;129(5):517 level 1bArch Otolaryngol Head Neck Surg May;129(5):517 level 1b

46 Serous Otitis Media Treatment Medications Antibiotics not beneficial (1) Most rigorous meta-analysis find no benefit long-term Some short-term benefit may exist Steroids Nasal steroids no evidence of benefit (2) Systemic steroids no difference long term (3) 1)J Fam Pract Apr;52(4):321 FPIN network answerJ Fam Pract Apr;52(4):321 FPIN network answer 2)Cochrane Library 2006 Issue 3:CD Level 1aCochrane Library 2006 Issue 3:CD )Pediatrics Dec;110(6):1071 Level 2bPediatrics Dec;110(6):1071

47 Serous Otitis Media Treatment Antihistamines or decongestants are not beneficial Cochrane review of trials of limited quality Systematic review of 14 RCT No benefit found for any outcome Antihistamines were associated with side effects (NNH 8) Cochrane Library 2006 Issue 4:CD003423Cochrane Library 2006 Issue 4:CD Level 2a

48 Serous Otitis Media Treatment Surgery no clear evidence of benefit RCT of a birth cohort that developed MEE (1) Randomized to early tube placement or delay of 6 months (unilateral MEE) to 9 months (bilateral MEE) Delayed group had better outcomes cognition, language (not significant) at age 3 Follow up through 11 years of age no developmental or speech delay 3 Reduced time with MEE but no change in language or hearing (2) No change in quality of life 1)N Engl J Med Apr 19;344(16):1179 Level 1bN Engl J Med Apr 19;344(16):1179 2)Cochrane Library 2005 Issue 1:CD Level 1aCochrane Library 2005 Issue 1:CD )N Engl J Med 2007 Jan18:356(3):248 Level 1bN Engl J Med 2007 Jan18:356(3):248

49 Serous Otitis Media Treatment Surgery no clear evidence of benefit Cohort 30,099 children born in the Netherlands Routine hearing screening at age 9 months 1,081 who failed 3 successive hearing screens were referred to ENT surgeon 386 found to have persistent bilateral otitis media with effusion for 4-6 months 187 children (mean age 19.5 months) were randomized to ventilation tubes vs. watchful waiting and followed for 1 year with language tests Ventilation tubes reduced diagnoses of bilateral otitis media with effusion at all measurements (NNT 2-4), No differences in language development Pediatrics 2000 Sep;106(3):e42 Pediatrics 2000 Sep;106(3):e42 Level 1c

50 Serous Otitis Media Treatment Post-tube precautions unrandomized trial in 533 children who underwent tympanostomy tube placement parents self-selected into 1 of 3 "treatments" to prevent complications of swimming no additional precautions antibiotic drops following swimming ear molds worn during swimming control group consisted of children who never went swimming all were given precautions against deep water swimming (> 180 cm), diving and soapy water in ears during bathing no benefit was noted from antibiotic ear drops or ear plugs Arch Otolaryngol Head Neck Surg Mar;122(3):276 Level 2b

51 Strep Pharyngitis

52 Strep Pharyngitis Basics Bacteria Streptococcus pyogenes AKA Group A beta-hemolytic streptococcus (GABHS) More than 80 sero-types based on M protein Transmission Person-person Aerosol Water NOT household pets (1) Incubation period 2-4 days Pediatric Infect Dis J 1995 May;14;372

53 Strep Pharyngitis Risk Factors More common during school year Crowded living situation Exposure to GABHS Youth Immunosuppression Smoking Excessive alcohol consumption Diabetes mellitus Recent illness Griffin's 5 Minute Clinical Consult from InfoRetriever Level 5

54 Strep Pharyngitis Complications Acute Rheumatic Fever (1) Develops in 1-3% children with GABHS Only throat infections not skin Common in developing nations (2) 30 million children in the developing world have heart disease due to rheumatic fever 70% of whom will die prematurely at average age of 35 Acute Glomerulonephritis Less common than rheumatic fever Most patients recover Tonsillitis Peritonsillar Abscess 1)Pediatrician. 1986;13(4):180 Level 3Pediatrician. 1986;13(4):180 2)Tropical Doctor 1999 Jul;29(3):129 Level 5

55 Strep Pharyngitis History Abrupt onset of symptoms Fever may last 4-5 days Constitutional symptoms Fever and chills Myalgias Headache Nausea and vomiting Unlikely to have runny nose, cough, conjunctivitis, hoarseness, diarrhea Exposure to strep throat infection in previous 2 weeks associated with increased likelihood of strep throat

56 Strep Pharyngitis Therapy Reasons patients visit the physician for sore throat 298 patient >12 year old in Belgium Most frequent reasons for visit Establish cause (85.5%) Pain relief (84.5%) Information on disease course (82.7%) Seriousness of problem (76.4%) Time to recovery (75.7%) Education on treatments (73.2%) Desire antibiotic (37.6%) Ann Fam Med 2006 Nov-Dec;4(6):494Ann Fam Med 2006 Nov-Dec;4(6):494 Level 3c

57 Strep Pharyngitis Tests Rapid Strep Tests Results available in 5-10 minutes 76-87% sensitivity > 95% specificity depending on specific test kit used Genzyme's OSOM Ultra Strep A test 92.6% sensitivity 92.8% specificity Biostar's Strep A OIA Max Test 75.5% sensitivity 97.1% specificity Pediatric Infect Dis J 2002 Oct;21(10):922 Level 1c

58 Strep Pharyngitis Tests Rapid strep test 15% false positive rate in adults (1) Study of 522 adults with acute pharyngitis and/or tonsillitis who had positive rapid antigen detection test results 77 (15%) had negative cultures for group A streptococci Low sensitivity If sensitivity below 90% consider backup culture (3) Physicians should validate the sensitivity of their own Rapid strep tests 1)J Infect Dis Apr 1;183(7):1135 Level 2bJ Infect Dis Apr 1;183(7):1135 Level 2b 2)Br J Gen Pract 1998 Feb;48;959 Level 2bBr J Gen Pract 1998 Feb;48;959 Level 2b 3)Pediatrics 2004 Apr;113(4):924Pediatrics 2004 Apr;113(4):924

59 Strep Pharyngitis Rules Canadian Approach One Point Each Temp >38 C No Cough Tender anterior lymph nodes Tonsillar swelling or exudate Age 3-14 years No Points Age years Subtract One point Age >44 years CMAJ Jan 13;158(1):75 Level 1c

60 Strep Pharyngitis Rules ScoreOverall (%)Cx (-)Cx(+)LR(+) 0160 (31.8)156(97.5)4(2.5) (27.4)131(94.9)7(5.1) (19.5)87(88.8)11(11.2) (10.7)39(72.2)15(27.8) (10.5)25(47.2)28(52.8)6.43

61 Strep Pharyngitis Strategies Canadian Scoring System Authors' recommendations withhold antibiotics and culture if score 0-1 culture if score 2-3 empiric antibiotics if score 4-5 CMAJ Oct 3;163(7):811 CMAJ Oct 3;163(7):811 Level 1a

62 Strep Pharyngitis Strategies Study of 621 patients seen by 97 Canadian family physicians 600 had throat culture of which 17% were positive risk of strep throat was 1% if score 0 or -1 10% if 1 17% if 2 35% if 3 51% if 4 or 5 following clinical rule would have reduced unnecessary antibiotic prescriptions by 64% and use of throat cultures by 35% CMAJ Oct 3;163(7):811 CMAJ Oct 3;163(7):811 Level 1a

63 Strep Pharyngitis Rules Centor clinical prediction rule validated in 3 adult populations 1 point if tonsillar exudate 1 point if swollen tender anterior cervical nodes 1 point if absence of cough 1 point of history of fever 0-1 points suggests very low risk 3-4 points suggests increased risk for strep throat JAMA 2000 Dec 13;284(22);2912 JAMA 2000 Dec 13;284(22);2912 Level 1a

64 Strep Pharyngitis Strategies CDC evidence-based guidelines Adults (1) 4 empiric treatment 3 empiric treatment or rapid antigen testing with treatment only if positive 2 rapid antigen testing (treatment only if positive) or no testing or antibiotic treatment 1 or 0 no testing or antibiotic treatment 1) Ann Intern Med 2001 Mar 20;134(6):479 Level 1a Ann Intern Med 2001 Mar 20;134(6):479

65 Strep Pharyngitis Therapy Comfort Medications systemic analgesics and antipyretics - such as acetaminophen (Tylenol) or NSAIDs (e.g., ibuprofen [Motrin]) topical analgesics (e.g., nonprescription throat sprays) and anesthetics (e.g., viscous lidocaine 2%) warm salt water gargles throat lozenges, hard candy or frozen desserts soft foods or cold thick liquids (e.g., ice cream, nectars, pudding) humidifier

66 Strep Pharyngitis Therapy Antibiotics Penicillin is the gold standard for prevention of Rheumatic Fever (Historically) Benzathine penicillin G 1.2 million U ( ,000 U if age < 12) IM once Penicillin V 500 mg PO tid for 10 days In children, penicillin VK mg/kg/day divided bid to qid CDC Recommendations

67 Strep Pharyngitis Therapy Amoxicillin in children, mg/kg/day divided bid to tid short-course amoxicillin (1 g PO bid for 6 days) as effective as penicillin 500 mg tid for 10 days in trial of 338 patients > 15 years old (1) clinical cure rate was 96.4% vs. 96.5% at 72 hours after treatment and 93.5% vs. 96.3% at 1 month 10 vs. 6 recurrences throat pain resolved more quickly on amoxicillin 3% vs. 5.2% adverse effects 1) Scand J Infect Dis. 1996;28(5):497 Level 1cScand J Infect Dis. 1996;28(5):497

68 Strep Pharyngitis Therapy Amoxicillin once-daily amoxicillin 750 mg PO qd for 10 days No significant difference in clinical or bacteriologic responses at hour follow-up visit 5% vs. 11% bacteriologic treatment failures at subsequent follow-up visits over 4 days through 3 weeks, 16% vs. 21% had positive throat cultures many were considered a "new acquisition" since the organism was a different strain of group A beta-hemolytic streptococci; among 79 patients in amoxicillin group 2 had macular rash 3 had diarrhea 3 had abdominal pain Pediatrics Jan;103(1):47 Pediatrics Jan;103(1):47 Level 1c

69 Strep Pharyngitis Therapy Oral Cephalosporins Systematic review and meta-analysis of 35 randomized trials with 7,125 children Most trials were low quality 59% with Jahad Score 0-2 Jahad score rates quality of study 0 (low) to 5 (high) Bacteriologic cure rates (92.6% vs. 80.6%, NNT 8) Clinical cure rates (93.6% vs. 85.8%, NNT 13) Differences in clinical cure occurred among studies of cefuroxime and loracarbef Pediatrics 2004 Apr;113(4):866 Pediatrics 2004 Apr;113(4):866 Level 1a

70 Strep Pharyngitis Therapy Clarithromycin for 5 days as effective as penicillin for 10 days 349 patients aged with acute strep Randomized to clarithromycin modified-release 500 mg once daily for 5 days vs. penicillin 590 mg tid for 10 days No significant differences in clinical cure rates (88% vs. 92%) or eradication rates (83% vs. 84%) Open Label Phase III Study J Antimicrob Chemother 2002 Feb;49(2):337 J Antimicrob Chemother 2002 Feb;49(2):337 Level 2c

71 Strep Pharyngitis Therapy Azithromycin 60 mg/kg total dose more effective than lower doses 20 mg/kg/day for 3 days 12 mg/kg/day for 5 days Systematic review of 19 low to poor quality trials NNT 7 for 60 mg/kg dose NNH 6 for 30 mg/kg dose Clin Infect Dis 2005 Jun 15;40(12):1748Clin Infect Dis 2005 Jun 15;40(12):1748 Level 2c

72 Strep Pharyngitis Therapy Dexamethasone 0.6 mg/kg up to 10 mg PO or IM in single dose associated with faster pain relief (median 4 hours) and may reduce return visits; 118 patients >15 years old presenting to emergency department Randomized to dexamethasone 10 mg PO vs. dexamethasone 10 mg IM vs. double placebo All patients given penicillin VK 500 mg (erythromycin 333 mg if penicillin-allergic) PO tid for 10 days and 6 doses of acetaminophen for 24 hours Pain measured on 0-10 scale Laryngoscope 2002 Jan;112(1):87Laryngoscope 2002 Jan;112(1):87 Level 2b

73 Strep Pharyngitis Therapy Median reduction in pain scores IM dexamethasone 12 hours hours -5 19% resolution at 24 hours PO dexamethasone 12 hours hours -4 20% resolution pain at 24 hours Placebo 12 hours hours -4 3% resolution of pain at 24 hours

74 Strep Pharyngitis Therapy Time to onset of pain relief was 5.8 hours with IM dexamethasone 6 hours with PO dexamethasone 10.1 hours with placebo (p = 0.029) Return Visits within 5 days No patients receiving IM dexamethasone 7% receiving PO dexamethasone 16% receiving placebo returned to emergency department for sore throat within 5 days (p = 0.23)

75 Strep Pharyngitis Guidelines Sore Throat Encounter Form form.html form.html American Family Physician 2003 Sep1;68(5):938

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