ENT Infections/Travel Medicine

S. Michael Marcy, MD, Clinical Professor of Pediatrics, Keck School of Medicine of the University of Southern California, and David Geffen School of Medicine, University of California, Los Angeles

Educational Objectives

The goal of this program is to improve the diagnosis and management of selected pediatric upper respiratory tract bacterial infections and to provide health and safety tips for travel with children. After hearing and assimilating this program, the clinician will be better able to:

1.   Discuss the difficulty of using clinical criteria alone to diagnose acute otitis media (AOM).

2.   Describe the latest guidelines for antimicrobial therapy for AOM and treatment recommendations for the peni­cillin-allergic child.

3.   Explain methods that can be used to diagnose group A b-hemolytic streptococcal (GABHS) pharyngitis, and describe antibiotic agents available for its treatment.

4.   Cite recent data on observation vs antibacterial therapy for treatment of pediatric acute bacterial sinusitis.

5.   Describe safety and health precautions and recommended preparations for international travel with children.  

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Marcy has disclosed a financial relation­ship with Merck (vaccine division). He also discusses the off-label use of a therapy, product, or device in his lectures. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Marcy spoke on upper respiratory tract bacterial infections at Clinical Pediatrics, held February 12-15, 2009, in Palm Springs, CA, and sponsored by the American Academy of Pediatrics, California Chapter 2. He gave a lecture on travel with children at 36th Annual UCLA Family Practice Refresher, held May 26-30, 2009, in Los Angeles, CA, and sponsored by the UCLA Office of Continuing Medical Education, the David Geffen School of Medicine, and the UCLA Department of Family Medicine. The Audio-Digest Foundation thanks Dr. Marcy and the sponsors for their cooperation in the production of this program.

Upper Respiratory Tract Bacterial Infections

Acute Otitis Media (AOM)

Clinical definitions: AOM  —  diagnosis requires presence of recent, usually abrupt, onset of signs and symptoms, and middle ear effusion and inflammation; middle ear effusion  —  bulging of tympanic membrane (TM), otorrhea, lim­ited or absent mobility of TM, or air-fluid levels; middle ear inflammation  —erythema of TM or significant otalgia

Diagnosis of AOM in children: usually made in context of upper respiratory tract infection (URI); signs and symptoms  —  pain; irritability; pulling of ear; fever <40°C; purulent drainage; recent abrupt onset important (in younger child, can be difficult to identify source of pain and/or distress); whenever child speaks of ear pain, ask whether pain intermittent or constant, whether it wakes child at night, and whether it interferes with normal activi­ties; tympanocentesis, tympanometry, acoustic reflectometry, and pneumatic otoscopy helpful when history not ad­equate

Comments: many signs and symptoms of AOM also compatible with simple OM with effusion (OME; drawback of current guidelines); bulging TM or otorrhea only symptoms that clearly indicate AOM

Alternative clinical definitions of AOM: 1)  —  speaker’s preferred definition; clinical signs alone adequate (otorrhea or bulging opacified and discolored TM); 2)  —  otorrhea or bulging TM with opacification and discoloration, or bulging TM and significant otalgia

Management of pain in AOM: systemic analgesia  —acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs; current data indicate NSAIDs better than acetaminophen); codeine or analogues (keep in mind that »5% of patients cannot metabolize codeine); homeopathic agents (never shown to work continuously); home remedies; chiropractic or osteopathic manipulation (not recommended); topical agents  — benzocaine drops (temporary re­lief); naturopathic agents; myringotomy  —  provides instant relief of bulging TM

Observation option vs antibacterial therapy: child <6 mo of age  —  diagnosis certain (treat); diagnosis uncertain, but AOM suspected (treat); 6 mo to 2 yr of age  —  diagnosis certain (treat); diagnosis uncertain (if severe illness [moderate to severe pain or temperature ³39°, treat; if nonsevere, observe); >2 yr of age  —diagnosis certain (if se­vere illness, treat; if nonsevere, observe); diagnosis uncertain (observe); caveat  —  children <2 yr of age with bilat­eral OM should not be observed

Microbiology of AOM: Streptococcus pneumoniae (50%-35% [incidence decreasing]); nontypeable Haemophilus influenzae (40%-55% [incidence increasing]); Moraxella catarrhalis (5%-10%); viruses alone (5%-10%); no pathogen (1%-10%)

Antibacterial treatment: antimicrobial resistance factors  —resistance of S pneumoniae to b-lactam agents due to penicillin–binding protein (can be overcome by high serum levels in »80% of patients); »50% of AOM due to H in­fluenzae and »95% due to M catarrhalis  b-lactamase positive and will not respond to penicillin or amoxicillin; suggested antimicrobial therapy (2008)  —  for nonsevere illness, amoxicillin, 80 to 90 mg/kg per day in 2 divided doses for 5 to 10 days; with severe illness or symptoms for ³48 hr, use amoxicillin-clavulanate 80 to 90 mg/kg per day; or cefdinir, cefuroxime, or cefpodoxime; or ceftriaxone 50 mg/kg intramuscularly (IM); cefdinir has advan­tage of pleasant taste

Antimicrobial treatment for penicillin-allergic patients (2008): history of non-IgE-mediated and nonserious reaction  —  safe to administer repeated courses of same or related antibiotic (recommendations changed since 2004 to include amoxicillin as option); incidence of allergic reaction to cephalosporins among penicillin-allergic patients varies; history of severe IgE-mediated reaction  — cephaloridine, cephalothin, or cefoxitin should be used with cau­tion; if allergic reaction followed administration of amoxicillin, cephalexin, cephadrine, cefatrixine, cefadroxil, ce­faclor, or cefprozil should be used with caution; other cephalosporins no more likely to produce allergic reactions in penicillin- or amoxicillin-allergic patients than in nonallergic patients; anaphylaxis or severe reaction to penicillin  —  cefdinir, cefuroxime or cefpodoxime (2004 recommendations excluded use of all cephalosporins in fa­vor of alternatives such as azithromycin); if reaction uncertain, do penicillin skin testing

Indications for IM ceftriaxone: vomiting; inability to tolerate oral medication; uncertain compliance due to refusal of medication or unreliable caregiver (new recommendation)

Failure to respond to primary treatment within 48 to 72 hr: reassess to confirm AOM; begin antibacterial treat­ment if initially managed via observation; change antibacterial agent if currently treating with medication; recom­mended antimicrobial therapy  —  amoxicillin-clavulanate (90 mg/kg per day); cefdinir, cefuroxime or cefpodoxime; or IM ceftriaxone (50 mg/kg) for 1 to 3 days (one dose often adequate)

Prevention of AOM through reduction of risk factors: breastfeeding rather than bottle feeding; reduce frequency of group day care attendance (smaller centers preferable); eliminate passive tobacco smoke; no proof that supine bottle feeding or pacifier use causes AOM; influenza and pneumococcal immunizations; look for atopy or immuno­deficiency

Group A b-Hemolytic Streptococcal (GABHS) Pharyngitis

Diagnosis: 4 methodologies available

Clinical syndromes: diagnosis and decision to treat simple if child has recognizable scarlet fever (rash with perioral sparing; “strawberry” appearance of tongue); however, signs of GABHS often present in non-GABHS clinical syndromes; high likelihood (95%) of positive throat culture if child has palatal petechiae, redness and edema of pharynx, tonsillar exudates, and tender cervical adenitis (must have all 4 findings to make diagnosis); “donut pe­techiae” pathognomonic of group A streptococcal infection; clinical findings suggestive of viral etiology  —  rhinorrhea; cough; hoarseness; conjunctivitis; vesicles; diarrhea

Antigen detection tests (ADTs): make diagnosis rapidly; Centers for Disease Control and Prevention (CDC)/Amer­ican Academy of Pediatrics (AAP) recommendations for use of ADTs  —  throat culture from 2 swabs; if ADT neg­ative, must confirm with throat culture, as £28% of ADTs have false-negative results

Throat culture: look for b-hemolysis; data show that »20% of throat cultures in patients with pharyngitis positive for GABHS; when sampling, must touch both tonsils and posterior pharynx with swab

Exoenzyme antibody tests: useful in child with recurrent infections, but also when GABH infection questionable; positive test defined by recovery of organism plus subsequent rise in titer of antistreptococcal antibodies (may not see rise in titer if infection treated early); antistreptolysin (ASO) and antideoxyribonuclease B (DNase B) used most often to retrospectively diagnose strep throat; tests can also identify GABHS carriers

Treatment of GABHS: who  —  all symptomatic patients with GABHS present in pharynx; why  —  to prevent rheu­matic fever, nephritis, and suppurative complications; reduce spread of infection; shorten duration of illness (possi­bly);  shorter period of infectivity; delaying treatment until throat culture results return reduces unnecessary therapy

Agents used for treatment: benzathine penicillin G; penicillin V potassium (VK); amoxicillin; erythromycin; clindamycin; cephalosporins; study by Kaplan et al found treatment with benzathine penicillin G failed in »33% of cases; suggested that clinicians should be using cephalosporins more often; studies show clinical cure and bacterio­logic cure much more likely with oral cephalosporin or amoxicillin than with penicillin VK; comparison study of amoxicillin vs cephalosporins not yet done

Frequency of treatment: qid, tid, and bid therapy have proven equally effective; selected antibiotics can now be given once daily (in several studies, once-daily amoxicillin as good as bid or tid dosing, but must use 750 mg to 1.0 g)

Duration of treatment: treatment with amoxicillin or penicillin VK should be for »10 days (failure rate with penicil­lin VK 2 times greater if treatment »7 days and 3 times greater if »5 days); 5-day short-course therapies available for some antibiotics

Suggested causes of clinical failure: bacteriologic failure  —patients noncompliant with medication regimen; carri­ers of GABHS; b-lactamase inactivated amoxicillin in pharynx; coexistent viral infection  —  much more likely

Treatment of recurrent streptococcal pharyngitis: speaker uses amoxicillin-clavulanate or clindamycin

Prevention of GABHS infection: for children with rheumatic fever; tonsillectomy (rarely recommended); M protein and group A carbohydrate vaccines being developed

Treatment of Bacterial Sinusitis

Observation without antibiotics: option for adults and children with uncomplicated acute bacterial sinusitis and mild illness

Antibacterial therapy of acute bacterial sinusitis in adult: study looked at »13 randomized placebo-controlled tri­als; on days 3 to 5 and 14 to 15 of therapy, no significant difference between placebo and antibiotics (on days 7-12, »15% advantage with antibiotics); 2008 article in Lancet stated that only watchful waiting and symptomatic relief warranted for almost all adult patients with acute rhinosinusitis-like complaints

Treatment for acute pediatric bacterial sinusitis: 2001 study found no difference in resolution of symptoms  be­tween placebo and antibiotic groups

Traveling with Children

Child safety precautions: identification necklace or bracelet; personal information card on child’s clothing (name; date of birth; passport number and country; local address and phone; address of local embassy; contact cell phone number); for international travel with one parent, need letter of permission from unaccompanying parent; safety seats in rental cars; childproof lodgings; childproof medication bottles

Health information card: including child’s immunization record; current medical problems; current medications (trade and generic names); known drug allergies; phone, fax, and e-mail contacts for physician or health mainte­nance organization and for close relative or friend

Emergency preparedness: international cell phone; health insurance  —  verify coverage out of area, as well as spe­cific and total coverages; consider taking out supplemental health insurance as needed; be informed about interna­tional health services and physicians (International Association for Medical Assistance to Travelers publishes book that lists physicians in every major city who speak English and have agreed to a set fee; photocopy passport, visas, and credit card cancellation information

Basic travel medical kit: prescription medications; topical and systemic antibiotics (amoxicillin-clavulanate for URIs; mupirocin or retapamulin [Altabax] ointment, cephalexin, clindamycin for skin and soft tissue infections; azithromycin powder, fluoroquinolone, rifaximin for traveler’s diarrhea); antidiarrheals and antiemetics; oral rehy­dration packets; analgesics and anti-inflammatory drugs; sunscreen (broad-spectrum [UVA and UVB], with sun protection factor [SPF] of 30-45; assume »66% efficacy; apply »20 min before exposure every 2-4 hr and after swimming); sun-protective clothing; adhesive bandages, gauze pads, and elastic wrap bandages useful; extra eye­glasses and lens prescription

Optional for travel medical kit: sedatives and jet lag relief (diphenhydramine; hydroxyzine [for children]; zoldi­pem; melatonin); insect repellant (N,N-diethyl-meta-toluamide [DEET]; permethrin pre-soak and/or spray for clothing); motion sickness prevention (dimenhydrinate; meclizine; cyclizine; scopolamine patch [for adolescents and adults]; wrist pressure device [efficacy unproven]; ginger); high altitude sickness prevention (acetazolamide 250 mg bid [reduce dose for children]); laxatives (eg, bisacodyl [Dulcolax]; oral or suppositories); decongestants (speaker uses topical spray [eg, oxymetazoline {Afrin}]; oral drugs effective but make children nervous); cortico­steroid cream for insect bites; antifungal medication (for skin or vaginal infections); sterile closures for cuts (eg, SteriStrips); moleskin; lip balm

Travel immunizations: speaker now includes human papillomavirus (HPV; for older children) in standard vaccina­tions; recommended and suggested vaccinations  —  hepatitis A; typhoid (if necessary); Meningococcus (particu­larly if traveling to sub-Saharan Africa); influenza; rabies; plague; Japanese encephalitis (very specific for location, season, duration of exposure, and activity); do not rely on travel agents or destination country for advice on immu­nizations; yellow fever still required (for travelers to South America and periequatorial Africa); cholera no longer required for travel to any country

Malaria prophylaxis: schedule daytime activities; cover arms and legs dusk to dawn; permethrin-treated clothes and netting (highly effective); mosquito repellant  —  DEET repellant of choice (microencapsulated formulations); do not get combination sunscreen-mosquito repellant; screens, fans, air-conditioned rooms; chemoprophylaxis  —  chloroquine; mefloquine (for chloroquine-resistant areas); doxycycline (for mefloquine-resistant areas); atova­quone and proguanil (Malarone) for resistant areas (must be taken daily); primaquine and sulfadoxine pyrimeth­amine (Fansidar) not appropriate for prophylaxis (recommended only for standby self-treatment)

Editor’s Note

Sources of travel information: CDC website (www.cdc.gov); International Travelers Clinic; CDC Health Information for International Travel (available on internet); Young EC: The Travel and Tropical Medicine Manual.

Suggested Reading

Arrieta A, Singh J: Management of recurrent and persistent acute otitis media: new options with familiar antibiotics Pediatr Infect Dis J 23(2 Suppl):S115, 2004; Block SL et al: Oral beta-lactams in the treatment of acute otitis media. Diagn Microbiol Infect Dis 57(3 Suppl):19S, 2007; Brook I: Current issues in the management of acute bacterial sinusitis in children. Int J Pediatr Otorhinolar­yngol 71(11):1653, 2007; Casey JR, Pichichero ME: Meta-analysis of cephalosporin versus penicillin treatment of group A strepto­coccal tonsillopharyngitis in children. Pediatrics 113(4):866, 2004; Casey JR, Pichichero ME: The evidence base for cephalosporin superiority over penicillin in streptococcal pharyngitis. Diagn Microbiol Infect Dis 57(3 Suppl):39S, 2007; Christenson JC: Prepar­ing families with children traveling to developing countries. Pediatr Ann 37(12):806, 2008; Clark E et al: A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics 119(3):460, 2007; Curtin CD et al: Efficacy of cephalexin two vs. three times daily vs. cefadroxil once daily for streptococcal tonsillopharyngitis. Clin Pediatr (Phila) 42(6):519, 2003; Giovanetti F: Immunisation of the travelling child. Travel Med Infect Dis 5(6):349, 2007; Johnson NC, Holger JS: Pediatric acute otitis media: the case for delayed antibiotic treatment. J Emerg Med 32(3):279, 2007; Len­non DR et al: Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis. Arch Dis Child 93(6):474, 2008; Leung AK, Kellner JD: Group A beta-hemolytic streptococcal pharyngitis in children. Adv Ther 21(5):277, 2004; Lin MH et al: Predictive value of clinical features in differentiating group A beta-hemolytic streptococcal pharyngitis in chil­dren. J Microbiol Immunol Infect 36(1):21, 2003; Marcy SM: New guidelines on acute otitis media: an overview of their key princi­ples for practice. Cleve Clin J Med 71 Suppl 4:S3, 2004; Middleton DB et al: Standardized symptomatic treatment versus penicillin as initial therapy for streptococcal pharyngitis. J Pediatr 113(6):1089, 1988; Neumann K: Family travel: an overview. Travel Med In­fect Dis 4(3-4):202, 2006; Pichichero ME: A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients. Pediatrics 115(4):1048, 2005; Pichichero ME, Wright T: The use of tympanocentesis in the diagnosis and management of acute otitis media. Curr Infect Dis Rep 8(3):189, 2006; Rosenfeld RM et al: American Academy of Otolaryngology--Head and Neck Surgery Foundation. Clinical practice guideline: acute otitis ex­terna. Otolaryngol Head Neck Surg 134(4 Suppl):S4, 2006; Rosenfeld RM et al: Clinical practice guideline: adult sinusitis. Otolar­yngol Head Neck Surg 137(3 Suppl):S1, 2007; Shetty AK, Woods CR: Prevention of malaria in children. Pediatr Infect Dis J 25(12):1173, 2006; Spiro DM, Arnold DH: The concept and practice of a wait-and-see approach to acute otitis media. Curr Opin Pediatr 20(1):72, 2008; Stauffer W et al: Preparing children for international travel. Travel Med Infect Dis 6(3):101, 2008; Varrasso DA: Acute otitis media: antimicrobial treatment or the observation option? Curr Infect Dis Rep 11(3):190, 2009; Young J et al: Anti­biotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet 371(9616):908, 2008.