Professional Documents
Culture Documents
Note: these findings cannot definitely predict the presence of Acute laryngitis
Strep. pyogenes tonsillitis; they can, however, identify persons This is a common clinical syndrome encountered by
for whom the probability of Strep. pyogenes tonsillitis is high GPs in patients of all ages. The symptoms are hoarse-
ness of voice with voice breaks or episodes of aphonia.
Table 2. Features of pharyngitis/tonsillitis due to infection with
All the major respirator y viruses like rhinovirus,
Strep. pyogenes and viruses
influenza, parainfluenza, adenovirus and coronavirus
Because of previously-existing immunity the disease is may cause laryngitis. Also, M. pneumoniae, C. pneumo-
less common in older patients. niae and bacterial respiratory infections have been
Rare causes Although uncommon, diphtheria still associated with lar yngitis. Treatment needs to be
occurs in unvaccinated populations. The characteris- directed at the underlying infectious cause of hoarse-
tic tonsillar or pharyngeal membrane varies in colour ness but, in general, as the aetiology is usually viral,
from light to dark grey and is firmly adherent to the treatment is symptomatic in nature, with voice rest
tonsils and pharyngeal mucosa. and humidification.
Arcanobacterium haemolyticum, Yersinia enterocolitica,
Chlamydia pneumoniae and Mycoplasma pneumoniae are Otitis media
other rare causes of pharyngitis. Also known as inflammation of the middle ear, this is
the most common reason for the prescription of
Diagnosis antibiotics in children. The diagnosis of otitis is usu-
Diagnosis of acute pharyngitis is important to distin- ally followed by antibiotic treatment despite ‘a woeful
guish cases of common viral aetiology from those due lack of substantial evidence on the question of antibi-
to Strep. pyogenes, and to detect and identify the occa- otic therapy’ for this condition.3
sional case due to an unusual or rare cause for which Acute otitis media usually follows a viral infection
treatment is available. The development of rapid anti- of the nasopharynx which disrupts the function of the
gen detection tests (RADTs) for streptococcal pharyn- eustachian tubes. In patients with colds, bacteria and
gitis with a specificity of over 90 per cent and sensitivity viruses from the nasopharynx that reach the middle
of 60-95 per cent has been used in clinical practice.2 ear during pressure equilibration may be cleared by
However, these near-patient tests are rarely used in the the mucociliar y system less effectively than usual.
UK, where the primary method employed is throat Bacteria may replicate in the fluid of the middle ear,
swab for culture. Investigations are rarely necessary and respiratory viruses may infect the mucosa of the
for viral causes of URTIs, as most are self-limiting. middle ear.
Tympanocentesis has revealed Strep. pneumoniae in
Treatment 20-35 per cent of patients, nontypable Haemophilus
Treatment of patients with pharyngitis due to Strep. influenzae in 20-30 per cent, Moraxella catarrhalis in 20
pyogenes is a 10-day course of penicillin or er y- per cent, no bacteria in 20-30 per cent, and viruses with
thromycin (see Table 3). In patients with multiple, or without bacteria in 17-44 per cent of patients.4-6
Illness Drug Duration of was not different from that of 7-10 days of amoxi-
treatment cillin.10
Whether antibiotic therapy reduces the risk of pro-
Pharyngitis/tonsillitis phenoxymethylpenicillin 10 days longed illness in children six months to two years of
erythromycin 7 days age was examined in a trial comparing amoxicillin and
placebo in 240 children in the Netherlands, where the
Otitis media amoxicillin 5 days background rates of resistance to amoxicillin are 1 per
erythromycin 5 days cent for Strep. pneumoniae and 6 per cent for H. influen-
zae.11 Antibiotic therapy had a limited effect, reduc-
second line ing the incidence of persistent symptoms by 13 per
co-amoxiclav 5 days cent on day 4 and shortening the duration of fever by
one day.
Rhinosinusitis phenoxymethylpenicillin 7 days Recurrent otitis media is usually defined as three or
amoxicillin 7 days more episodes of acute otitis within six months, or
erythromycin 7 days four episodes within 12 months. One strategy for the
prevention of recurrent acute otitis media is the use of
second line antibiotic prophylaxis with co-trimoxazole (Septrin)
co-amoxiclav 7 days or amoxicillin, but a meta-analysis of antibiotic pro-
ciprofloxacin + metronidazole 7 days phylaxis showed an average decrease of 0.11 episodes
per child-month, or about one episode of acute otitis
Influenza zanamivir 5 days per year, in qualifying children.12 This small benefit is
oseltamivir 5 days generally outweighed by the disadvantage of promot-
ing antibiotic resistance. Also, the indications for use
Table 3. Antimicrobial prescribing for URTIs
of co-trimoxazole are restricted in the UK due to its
Diagnosis side-effect profile.
Acute otitis media can be diagnosed by the presence Resistant bacterial otitis media is recognisable by the
of inflammation and fluid in the middle ear (see persistence of fever, otalgia and bulging red tympanic
Figure 1). Inflammation of the middle ear may be sig- membranes or by persistent otorrhoea after three or
nified by local or systemic findings such as ear pain, more days of antibiotic therapy.13,14 Culture of puru-
erythema of the tympanic membrane, fever and cold lent fluid yielded bacteria that were resistant to the
symptoms. prescribed antibiotic in only one-third of cases.13,15
In the absence of data on the efficacy of antibiotics
Treatment for resistant bacterial otitis, one expert panel rec-
Once acute otitis media has been diagnosed, the cen- ommended high-dose co-amoxiclav, cefuroxime
tral issue is whether antibiotic therapy will be in the axetil (Zinnat) or intramuscular ceftriaxone for
child’s best interest. A meta-analysis of randomised, three days.14
placebo-controlled trials found that acute otitis had Delayed antibiotic therapy is used in the Netherlands.
resolved at one week in 81 per cent of placebo recip- Children under two years of age are closely monitored,
ients as compared with 94 per cent of those given and a seven-day course of antimicrobial therapy is
antibiotics.7 In general, the rate of clinical resolution begun only when there is no improvement in symp-
was similar in placebo and antibiotic recipients on the toms within one to two days in children younger than
first day of therapy, but slightly higher at three to five two and within three days in children who are two
days and at seven days among those who received years of age or older.
antibiotic therapy.8,9 The effectiveness in general practice of this
Amoxicillin is as effective as any other drug, even delayed prescribing strategy was assessed in a ran-
though at least a quarter of Strep. pneumoniae strains domised trial involving 315 children six months to 10
have increased resistance to penicillin and amoxi- years of age with acute red ear (41 per cent were three
cillin, a quarter to a third of H. influenzae strains are years of age or younger).9 The parents of only 36 of
resistant in vitro to amoxicillin (beta-lactamase posi- the 150 children in the delayed-antibiotics group (24
tive) and virtually all strains of M. catarrhalis are resis- per cent) picked up the antibiotic prescription, reflect-
tant to amoxicillin (beta-lactamase positive). The ing the fact that the parents recognised that the symp-
clinical effect of a single dose of ceftriaxone toms were resolving on their own within three days in
(Rocephin) or five days of azithromycin (Zithromax) the majority of children.
Epiglottitis Table 4. NICE guidance on the use of zanamivir, oseltamivir and amantadine for the
Acute epiglottitis is a cellulitis of the epiglottis and treatment of influenza
adjacent structures that has the potential for causing
abrupt complete air way obstruction. Tachycardia, tract. Sinusitis in turn may be complicated by serious
fever, inspiratory stridor and hoarseness may occur. intracranial infections such as bacterial meningitis and
The diagnosis is confirmed by an oedematous ‘cherry- epidural, subdural and brain abscesses.
red’ epiglottis. H. influenzae, pneumococci, staphylo- The microbial aetiology of acute sinusitis is Strep.
cocci and streptococci have been isolated from pneumoniae (31 per cent), H. influenzae (21 per cent),
cultures of blood or epiglottis. The incidence of anaerobic bacteria (6 per cent), Gram-negative bac-
epiglottitis due to H. influenzae has decreased dra- teria (9 per cent) and viruses (20 per cent). This infor-
matically since the introduction of H. influenzae type mation comes from studies in which specimens for
b (Hib) vaccination. culture were obtained by direct sinus puncture and
The role of viruses in epiglottitis has not been aspiration to avoid contamination by nasopharyngeal
established. flora.
A child even suspected of having acute epiglottitis Prolonged and repeated episodes of infection may
should be handled as a medical emergency because lead to irreversible changes in the mucosal lining of
of the potential for complete respiratory obstruction. the sinus, resulting in chronic sinus disease. Cultures
of surgical specimens obtained from patients with
Sinusitis chronic sinus disease have grown a wide variety of
Acute sinusitis is an infection of one or more of the Gram-positive and -negative bacteria.
paranasal sinuses that usually complicates a common Common symptoms include purulent nasal
cold or other viral infections of the upper respiratory and postnasal discharge (see Figure 2), headache, and
VM
terial infection. Treatment should be directed against
the known sinus pathogens. A 10-day course of treat-
ment with one of the antimicrobials such as co-amox-
iclav is recommended.18 Nasal decongestants should
be used in supportive treatment. Patients with severe
sinus infection may require early surgical drainage.
Once sinusitis has reached a chronic state, bact-
erial colonisation of the sinus cavity is usual, but the
condition no longer responds to antimicrobial
treatment.18
Conclusion
There is no single course of action that will suit all
patients when treating URTIs. The evidence must be
applied in different ways according to different local
conditions; these will include environmental, histori-
cal and social factors. GPs put as much weight on
social factors as on the physical examination in decid-
ing whether or not to use antibiotics.19
Recently, there has been much discussion as to the
Figure 1. Discharge of fluid is a symptom of otitis media. Con- appropriateness of prescribing antibiotics for patients
ventional antibiotic treatment has a limited effect with uncomplicated URTI.20 According to a recent
disorder of smell. In a small number of patients ery- paper there has been a fall of 50 per cent in antibi-
thema and tenderness of the involved sinus are present. otics prescribing for children with URTIs, without an
Sinus X-rays and CT (computed tomography) accompanying increase in hospital admission for peri-
scans may be used to diagnose acute sinusitis. tonsillar abscess or rheumatic fever. 21 This rapid
decline in antibiotic usage appears to be a combina-
Treatment tion of fewer prescriptions and ‘delayed prescribing’
Although viruses may play a role in the initiation of – a strategy documented in 1994.22 So should GPs stop
acute sinusitis, the disease should be treated as a bac- prescribing antibiotics in uncomplicated URTI com-
pletely? Clearly no, as it is impossible on the first con-
VM
References
1. Royal College of General Practitioners, Office of
Population Censuses and Surveys, Department of Health.
Morbidity statistics from general practice. Fourth national study,
1991-1992. London: HMSO, 1995.
2. Bisno AL, Gerber MA, Gwaltney JM Jr, et al. Practice
guidelines for the diagnosis and management of group A
streptococcal pharyngitis. Clin Infect Dis 2002;35:113-25.
3. Chan LS, Takata GS, Shekelle P, et al. Evidence assessment
of management of acute otitis media. II. Research gaps and
priorities for future research. Pediatrics 2001;108:248-54.
4. Heikkinen T, Thint M, Chonmatree T, et al. Prevalence
of various respiratory viruses in the middle ear during acute
otitis media. N Engl J Med 1999;340:260-4.
Figure 2. Sinusitis should be treated as a bacterial infection 5. Pitkaranta A, Virolainen A, Jero J, et al. Detection of rhi-
novirus, respiratory syncytial virus, and corona virus infec- media; management and surveillance in an era of pneu-
tions in acute otitis media by reverse transcriptase poly- mococcal resistance – a report from the Drug Resistant
merase chain reaction. Pediatrics 1998;102:291-5. Streptococcus pneumoniae Therapeutic Working Group. Pediatr
6. Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumo- Infect Dis J 1999;18:1-9.
coccal conjugate vaccine against acute otitis media. N Engl 15. Schwartz RH, Rodriguez WJ, Khan WN. Persistent puru-
J Med 2001;344:403-9. lent otitis media. Clin Pediatr 1981;20:445-7.
7. Rosenfeld RM, Vertrees JE, Carr J, et al. Clinical efficacy 16. Clements DA, Langdon L, Bland C, et al. Influenza A vac-
of antimicrobial drugs for acute otitis media: meta-analysis cine decreases the incidence of otitis media in 6- to 30-
of 5400 children from thirty-three randomised trials. J Pediatr month-old children in day care. Arch Pediatr Adolesc Med
1994;124:355-67. 1995;149:1113-7.
8. Del Mar C, Glasziou P, Hayen M. Are antibiotics indi- 17. Black S, Shinefield H, Fireman B, et al. Efficacy, safety
cated as initial treatment for children with acute otitis and immunogenicity of heptavalent pneumococcal conju-
media? A meta-analysis. BMJ 1997;314:1526-9. gate vaccine in children. Pediatr Infect Dis J 2000;19:187-95.
9. Little P, Gould C, Moore M, et al. Pragmatic randomised 18. Mandell GL, Bennett JE, Dolin R, et al. Principles and prac-
control trial of two prescribing strategies for childhood acute tice of infectious diseases. 5th ed. Philadelphia, London:
otitis media. BMJ 2001;322:336-42. Churchill Livingstone, 2000;1:651-88.
10. Takata GS, Chan LS, Shekelle P, et al. Evidence assess- 19. Butler CC, Rollnick S, Pill R, et al. Understanding the
ment of management of acute otitis media. I. The role of culture of prescribing: qualitative study of general practi-
antibiotics in treatment of uncomplicated acute otitis media. tioners’ and patients’ perceptions of antibiotic for sore
Pediatrics 2001;108:239-47. throats. BMJ 1998;317:637-42.
11. Damoiseaux RA, van Balen FA, Hoes AW, et al. Primary 20. Little P. Delayed prescribing of antibiotics for upper res-
care based randomised, double blind trial of amoxicillin ver- piratory tract infection. BMJ 2005;331:301-2.
sus placebo for acute otitis media in children aged under 2 21. Sharland M, Kendall H, Yeates D, et al. Antibiotic pre-
years. BMJ 2000;320:350-4. scribing in general practice and hospital admissions for peri-
12. Williams RL, Chalmers TC, Strange KC, et al. Use of tonsillar abscess, mastoiditis and rheumatic fever in children:
antibiotics in preventing recurrent otitis media and in treat- time trend analysis. BMJ 2005;331:328-9.
ing otitis media with effusion: a meta-analytic attempt to 22. Little PS, Williamson I. Are antibiotics appropriate for sore
resolve the brouhaha. JAMA 1993;270:1344-51. [Erratum, throats? Costs outweigh the benefits. BMJ 1994;309:1010-1.
JAMA 1994;271:430.]
13. Gehanno P, N’Guyen L, Derriennic M, et al. Pathogens
isolated during treatment failures in otitis. Pediatr Infect Dis Dr Virgincar is consultant in microbiology at the Royal
J 1998;17:885-90. Berkshire Hospital, Reading, and Dr Spencer is consultant
14. Dowell SF, Butler JC, Giebink GS, et al. Acute otitis in microbiology at Bristol Royal Infirmary
Resources
Guidelines Useful websites
Scottish Intercollegiate Guidelines Network (SIGN). Health Protection Agency. Antibiotic prescribing guid-
Guideline No 34. Management of sore throat and indica- ance for primary care. Web-based guidance at www.
tions for tonsillectomy. Website: www.sign.ac.uk/guide hpa.org.uk/infections/topics_az/antimicrobial_
lines/published/numlist.html. resistance/guidance.htm.
PRODIGY. Guidance on sinusitis, acute sore throat A virtual hospital site gives useful guidelines for treat-
and acute otitis media. Website: www.prodigy.nhs.uk. ment at www.vh.org.
National Institute for Health and Clinical Excellence. www.generalpractice.co.uk has many links including
Guidance on prophylaxis and treatment of influenza. the Medical Algorithms Project, which displays treat-
Website: www.nice.org.uk/catta1.asp?c=153. ment algorithms for all conditions including infec-
tious diseases.
Further reading
BMJ Collected Resources. All articles published in the Patient information
BMJ since Januar y 1998. http://bmj.bmjjournals. www.netdoctor.co.uk includes extensive health
com/collections. information for patients.