Updated recommendations for the management of upper respiratory tract infections in South Africa

Abstract

Corresponding author: A J Brink (brinka@ampath.co.za)Background. Inappropriate use of antibiotics for non-severe upper respiratory tract infections (URTIs), most of which are viral, signifi cantly adds to the burden of antibiotic resistance. Since the introduction of pneumococcal conjugate vaccines in South Africa in 2009, the relative frequency of the major bacterial pathogens causing acute otitis media (AOM) and acute bacterial rhinosinusitis (ABRS) has changed. Recommendations. Since URTIs are mostly viral in aetiology and bacterial AOM and ABRS frequently resolve spontaneously, these recommendations include diagnostic criteria to assist in separating viral from bacterial causes and hence select those patients who do not require antibiotics. Penicillin remains the drug of choice for tonsillopharyngitis and amoxicillin the drug of choice for both AOM and ABRS. A dose of 90 mg/kg/d is recommended for children, which should be effective for pneumococci with high-level penicillin resistance and will also cover most infections with Haemophilus influenzae. Amoxicillin-clavulanate (in high-dose amoxicillin formulations available for both children and adults) should be considered the initial treatment of choice in patients with recent antibiotic therapy with amoxicillin (previous 30 days) and with resistant H. influenzae infections pending the results of studies of local epidemiology (β-lactamase production ≥15%). The macrolide/azalide class of antibiotics is not recommended routinely for URTIs and is reserved for β-lactam-allergic patients. Conclusion. These recommendations should facilitate rational anti biotic prescribing for URTIs as a component of antibiotic stewardship. They will require updating when new information becomes available, particularly from randomised controlled trials and surveillance studies of local aetiology and antibiotic susceptibility patterns.

The role of appropriate diagnostic testing in acute respiratory tract infections: An antibiotic stewardship strategy to minimise diagnostic uncertainty in primary care

“…Natural history of the common cold. [8] presence of discoloured sputum should also not be used as an indicator of bacterial as opposed to viral infection, as both of these, and also non-infectious conditions such as asthma, frequently present with purulent or purulent-looking sputum. [18] In most cases, history and physical examination are sufficient to identify more serious conditions requiring chest radiography (CXR).…”

“…Approximately 75% of children have had at least one episode by 3 years of age. [8] Time and clinical acumen is required to visualise the eardrum. Symptom presentation varies with age and, because typical symptoms overlap with other conditions, a clinical history alone is insufficient to predict whether AOM is present or not.…”

“…As AOM is often viral in aetiology (50% of cases) and with most bacterial cases (commonly S. pneumoniae, Haemophilus influenzae) resolving spontaneously, treatment of pain is the most critical aspect of the management of AOM. Antibiotics may be deferred for 48 hours in children ≥2 years of age while symptomatic therapy is administered (particularly where good follow-up is possible) if there is unilateral involvement and if the disease is not severe [8,32] (Fig. 5).…”

“…[8] As a consequence, AOM is frequently mis-or overdiagnosed. Although clear visualisation of the TM is difficult at times, and because AOM is typically self-limiting, a high degree of diagnostic certainty is essential to minimise antibiotic overuse.…”

“…This is a common misperception and hence, even with coughing, which is a normal accompaniment of a postnasal drip, antibiotics are not required. [8] Patients should be advised that the average duration of the illness (before and after seeing the doctor) is in the region of 10 -11 days. [17] Obtaining nasal swabs for culture is strongly discouraged even if the cough is persistent, and is particularly wasteful in resource-challenged low-and middle-income countries.…”