An ongoing CE program of The University of Florida College of Pharmacy and

DRUG TOPICS

CONTINUING

EDUCATION

Content development sponsored through an educational grant from Wyeth Pharmaceuticals

The University of
Florida College of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education ACPE # 012-99905-209-H01

The common cold and other respiratory tract infections

Whitney L. Unterwagner, Pharm.D., Clinical Assistant Professor, Mercer University Southern School of Pharmacy Patrick Devereux, Pharm.D., Community Pharmacy Practice Resident, Mercer University Southern School of Pharmacy and East Marietta Drugs

This lesson is no longer valid for CE credit after 10/31/07.

h-choo! Bless you! These are common sounds heard all over the country during the fall and winter months. Respiratory infections including the common cold, influenza, pharyngitis, and sinusitis are the 10th leading cause of decreased productivity and absenteeism for U.S. employers. Treatment of these illnesses involves both prescription and nonprescription products and account for many questions aimed at pharmacists.

Common cold
Unfortunately, the common cold is all too common for most adults each year and is the No. 1 cause of doctor visits and missed days of work or school. Late August until May is considered the cold season, and it is estimated that the average adult experiences two to four colds per year. This number could increase if those adults have contact with schoolchildren. Since women usually have more contact with children, that population will have more colds than their male counterparts. Other factors that put patients at risk include

To obtain immediate CE credit, take the test on-line at www. drugtopics.com. Just click on the Continuing Education box in the lower right side of the Drug Topics home page, which will take you to the CE site. Log in, find and click on this lesson, and follow the three simple steps. Test results will be displayed immediately and you can print the certificate showing your earned CE credits.

sedentary lifestyle, smoking, elevated stress, and living in a high-density population. When one member of a family becomes infected, two-thirds of others living in the household will develop symptoms. The common cold is a viral infection that is usually self-limiting. Approximately 50% of colds are caused by rhinoviruses, but other pathogens such as coronaviruses, respiratory syncytial virus, influenza viruses, and adenovirus may also be the cause. Transmission of the common cold is via aerosolized secretions or contact with secretions found on animate and inanimate objects and then exposure to the eyes, nose, or mouth. Because this illness is caused by viruses, antibiotic therapy is unwarranted. Once the virus has been introduced into a patients system, it will replicate and cause an inflammatory response with neurogenic mediators. This reaction will cause vasodilatation, stimulate cough and sneeze reflexes, and cause a hypersecretion of nasal fluid. The infection will subside once the system produces enough neutralizing antibodies to end the replica-

For questions concerning PRINT CEs, call (352) 273-6275. For questions concerning ON-LINE CEs, call (866) 261-3558.
DRUG TOPICS OCTOBER 10 2005

www.drugtopics.com

79

Photo: Jim Shive

CONTINUING EDUCATION
GOAL:
To provide information to pharmacists about the common cold and other upper respiratory ailments
ocular pressure, prostatic hypertrophy, and diabetes should obtain medical advice before taking any OTC product. If patients also complain of fever, shortness of breath, or a worsening of symptoms after self-treatment, they should be referred to a physician. There is no known cure for the common cold, therefore symptom relief is the primary goal of treatment. There are several nonpharmacological measures patients can take to help treat the common cold. Patients should be advised to increase fluid intake, especially if the cough is productive. Other measures include rest, adequate nutrition, humidifiers, steam showers, and nasal irrigation if the stuffiness is intolerable. Classic comforts, such as chicken noodle soup and hot tea with honey, do not help with symptoms but will increase the fluid intake and can be recommended for patients. If the patient complains of an irritated nasal mucosa, saline nasal sprays may help to soothe the area and warm saltwater gargles can help to soothe a sore throat. The best option for the treatment of nasal stuffiness is decongestants. Many products containing oral decongestants are combination products, and combinations should only be used when the patient has all of the symptoms the drug will treat. Pseudoephedrine is the most common OTC agent used to treat cold symptoms and is currently one of two oral decongestants on the market. The other is phenylephrine. Decongestants work by causing blood vessel constriction by stimulating the alpha-adrenergic receptors. This action will cause a decrease in the amount of fluid in the nasal passage. The usual adult dose for phenylephrine is 10 mg every four hours and for pseudoephedrine, 60 mg every four to six hours. Child dosing is also recommended at half the dose for children between six and 12 years old and a quarter of the dose for children two to six. Oral decongestants have long been linked to increased blood pressure and heart rate. The incidence of increased blood pressure and heart rate are more common with oral formulations than topical because of the higher doses needed to produce symptom relief. Phenylpropanolamine was removed from the market in 2000 due to concern of an increased risk of hemorrhagic stroke. There is also a risk of stroke with pseudoephedrine but that is more prevalent if the agent is taken at higher-than-recommended doses. Studies have shown that pseudoephedrine can cause an increase of 1 mmHg in systolic blood pressure, no significant effect on diastolic pressure, and an increase of three beats per minute in heart rate. If a patient has controlled hypertension, oral decongestants can be recommended with little concern. For patients with uncontrolled hypertension, closer monitoring is prudent for patients wishing to take these products. The largest population purchasing OTC
www.drugtopics.com

CREDIT:
This lesson provides two hours of CE credit and requires a passing grade of 70%.*

OBJECTIVES:
Upon completion of this article, the pharmacist should be able to:  Identify signs and symptoms of common respiratory tract infections  Evaluate and recommend treatment options for common respiratory tract infections  Recommend appropriate prevention regimens for these conditions  Describe when self-treatment is appropriate
*To receive credit you must score 70% or higher on the quiz and complete the evaluation. Upon successful completion, the University of Florida College of Pharmacy will mail Statements of Credit for written quizzes within 10 working days. Participants completing the program on-line may print a Statement of Credit after successfully completing the program. tion of the virus. This will usually occur within two weeks after the initial infection. Symptoms of the common cold are gradual and will appear one to three days after transmission. Symptoms include nasal stuffiness with a clear discharge, mild sore throat, scratchy throat, cough and sneezing. Throat symptoms usually resolve by the second or third day of the infection, at which time nasal symptoms will begin. Nasal symptoms start improving by the fourth or fifth day, at which time a nonproductive cough may begin. When a patient presents with symptoms of the common cold, the pharmacist should assess the patients symptoms to determine whether it is indeed a cold and whether over-the-counter therapy is appropriate. Medical history and a complete list of current medication use is also important to ascertain, because many OTCs used to treat the common cold are not advised for patients with certain medical conditions. Treatment options for the common cold are mostly OTCs and should be aimed at treating the symptoms that most bother the patient. Many patients are eligible for self-treatment, but those patients with ischemic heart disease, hypertension, hyperthyroidism, increased intra80
DRUG TOPICS OCTOBER 10 2005

medications is seniors, making counseling on these products crucial to decrease potential adverse effects. Topical decongestants are another option for nasal stuffiness. Phenylephrine, oxymetazoline, naphazoline, and xylometazoline are examples of drugs found in OTC topical decongestants. These products may be advantageous because of a quick onset of action and cost. Dosing of topical decongestants is typically two or three sprays every four to six hours, but newer formulations provide prolonged duration of effect for eight to 12 hours. It is important that they not be used more frequently then every four to six hours and never more than three days due to rhinitis medicamentosa, which can worsen symptoms. Clear nasal discharge or rhinorrhea is another symptom of the common cold and is best treated with antihistamines. Sedating antihistamines are anticholinergic agents and will have a drying effect in the nasal passageway and may also decrease sneezing episodes. Nonsedating OTC antihistamines do not have anticholinergic properties and may not be effective in treating rhinorrhea associated with the common cold. Examples of sedating antihistamines include chlorpheniramine and diphenhydramine; they are typically dosed every six or eight hours depending on the product. Other side effects, besides drowsiness, related to anticholinergic properties are dry mouth, difficult urination, and constipation. Sore throats are most commonly caused by viruses, including those responsible for producing the common cold. Usually in patients who have a cold, the sore throat is also scratchy and may be caused by drainage from the sinuses. If the sore throat is bothersome, patients may take OTC pain relievers, such as acetaminophen, ibuprofen, or naproxen. Lozenges may also offer benefit because many contain local anesthetics to numb the area. Examples of local anesthetics are benzocaine and dyclonine. Throat sprays contain phenol and can help soothe the throat. Lozenges and throat sprays should be used every three to four hours as needed. If patients do not want to take lozenges or use throat sprays, gargling with warm saltwater may also ease symptoms. Usually if a patient complains of a cough, it is dry and nonproductive. Antitussives including dextromethorphan and codeine have not been proven efficacious in treating the cough associated with the common cold. They can be recommended but might have limited effect for the patient. Because the cough that comes with a cold is often nonproductive, expectorants such as guaifenesin are also not effective. Many patients request information on herbal products to treat the symptoms of a cold. Some of the most common herbal products used for this purpose include echinacea, zinc, and vitamins C and E.
www.drugtopics.com

Echinacea angustifolia has been used to treat the common cold since the late 1800s, but studies have not proven efficacy. Echinacea is an immunostimulant that will help the body fight an infection from common rhinoviruses. According to recent studies, the effects of echinacea are still unproven, with no significant effect on the infection or illness caused by rhinoviruses. Due to the many formulations, product standards, and variability in dosing, future research is needed to determine true efficacy. If patients want to try echinacea, there is no consensus on the dose, and instructions on the package should be followed. Common adverse reactions linked to echinacea include skin rash, gastrointestinal disturbances, and sore throat. Zinc, usually in lozenge form, has also been linked to the treatment of the common cold. The mechanism of action for zinc is to block the rhinovirus from adhering to the nasal epithelium. In vitro, zinc may also inhibit the replication of viruses known to cause the common cold. Some studies have found zinc to be effective in symptom improvement, but other studies have also shown no benefit over placebo in treating the common cold. For zinc to be most beneficial, it should be started at the first sign of symptoms, be in doses of at least 13.3-mg elemental zinc, and be continued for the duration of the cold. The most common side effect of zinc lozenges is metallic taste. Vitamin C has been traditionally associated with preventing the common cold, with 67% of the population believing that taking vitamin C will decrease symptoms. Doses of more than 1 gm per day may decrease the duration of illness by one day or less and decrease the severity of symptoms by 20%. This is true only if vitamin C supplementation is started at the onset of symptoms. Patients should be reminded that doses of 1 gm or more daily can cause GI disturbances including diarrhea. Vitamin E has also been studied for its effects on the common cold. Nutritional status is important for the body to fight infection, and vitamin E has been thought to improve immune response, especially in the elderly population. Studies have shown no benefit from 200 International Units per day on the number of days of infection, but they did show that fewer patients got a cold when taking vitamin E for an extended period of time. Based on this information, vitamin E can be recommended at that dose for patients who do not get adequate nutrition. Pregnant women are not exempt from the occasional sniffle or a common cold. Treatment options for this special population are more limited than for the general public. Since there is no cure for the common cold, any treatment should be reserved for those patients who experience extreme discomfort due to symptoms. For
DRUG TOPICS OCTOBER 10 2005

81

CONTINUING EDUCATION
Table 1 noviruses can remain alive on the skin for up to three hours. Hands should be washed often with soap and warm water for at least 15 to 20 seconds. If soap and water is not available, disposable alcohol hand wipes or alcohol-based gels are options. Other preventive measures include covering the mouth and nose when sneezing or coughing; sneezing or coughing into a tissue; avoiding contact with mouth, nose, or eyes before hand washing; and staying at home when sick. The common cold is contagious during the first two to three days of infection. To date, there is no evidence that the common cold is caused by exposure to cold or damp weather, but psychological stress may increase a patients chances of illness.

Symptoms of the common cold and influenza

Symptom Fever Headache Aches/pains Nasal congestion Sore throat Sneezing Exhaustion Cough Common cold Rare to never Rare Possible Yes Yes Yes Rare Hacking Influenza Yes Yes Yes Possible Possible Possible Yes Dry, sometimes severe

Bronchitis
Bronchitis is another common respiratory tract infection that peaks in the winter. Bronchitis is divided into acute and chronic, with the chronic version being caused most commonly by cigarette smoking. For the purpose of this article, only acute bronchitis will be discussed. The definition of bronchitis is an inflammation of the trachea and bronchioles. In acute bronchitis, infection by viruses is usually the causative factor. This includes the viruses that cause the common cold such as rhinovirus, influenza, and adenovirus. Other organisms that are implicated include Chlamydia pneumoniae and Mycoplasma pneumonia. Secondary infections with bacteria such as Streptococcus pneumoniae and Staphylococcus spp are also common and would require antibiotic therapy. These bacteria are found in the normal flora and are not thought to be the cause of acute bronchitis. Secondary infection is most likely to occur in the presence of other triggers, including smoke and other air pollutants. Like the common cold, acute bronchitis is usually a self-limiting illness. Symptoms most patients experience are fever, cough, and hoarseness. The fever appears most commonly with adenovirus, influenza virus, and M. pneumonia infection. The cough will present with symptoms usually associated with a cold, such as sore throat and congestion. Once the sore throat and congestion improve, the cough will continue and become worse and productive. In many cases, the patients cough will prohibit a good nights rest and, therefore, be one of the main symptoms to treat. The main goal of therapy for patients with acute bronchitis is to control the cough, especially at night. An antitussive, such as dextromethorphan, codeine, or diphenhydramine are options for cough suppression. Antitussives should be used with caution if a productive cough is present. Dextromethorphan acts centrally in the system to block the cough reflex and should be recommended at a dose of 10 to 20 mg every four hours. An
www.drugtopics.com

the treatment of nasal congestion, oral pseudoephedrine is an option but should be used with caution in the first trimester and should be used at the lowest possible dose regardless of trimester. Nasal decongestants should also be used with caution, because systemic absorption can occur but is lowest with oxymetazoline. Saline nasal solutions are fine for this population and should be recommended over any drug product. If the patient is complaining of a cough and would like treatment, dextromethorphan, with or without guaifenesin, is the drug of choice. If an antihistamine is needed, chlorpheniramine is the most appropriate choice. Pediatrics is another special population to consider when recommending cold products. Children typically have twice as many colds each year compared with adults. When treating colds in children, aspirin products should never be recommended due to the risk of Reye syndrome. Children under the age of one should be treated only based on physician recommendation. In infants the side effects caused by oral decongestants may include irritability, hallucinations, and irregular heartbeat. Nonpharmacologic options for children include petroleum jelly applied under the nose to soothe rawness, warm baths or heating pad for aches, and steam from the shower to help with breathing. Children should be referred to a physician if they are unusually lethargic, have a prolonged productive cough, suffer from a fever of 103F. or higher, or report swollen glands. As the winter months near, prevention of the common cold should be on the minds of many. There are several simple steps the public can take to decrease the chances of catching a cold. Adequate hand washing is the most important aid in prevention because rhi82
DRUG TOPICS OCTOBER 10 2005

extended-release version is available and should be dosed every 12 hours. Codeine is equally as effective as dextromethorphan with the added benefit of causing sedation. This would be beneficial to those patients with interrupted sleep due to the cough. Codeine can be found most commonly in combination with guaifenesin and is a C-V exempt narcotic in most states. Codeine also acts centrally to block the cough reflex, and the dose is 10 to 20 mg every four to six hours. Diphenhydramine is also considered an antitussive but should be used only if a patient cannot take dextromethorphan or codeine. Diphenhydramine has the same mechanism of action as dextromethorphan and codeine but has many more side effects. Those side effects are due to the anticholinergic properties of the drug. Dosing for diphenhydramine is 25 mg every four hours, but caution should be used if the agent is taken during the day, due to sedation. Since acute bronchitis is usually self-limiting, bed rest and adequate fluid intake may be all the patient needs. Fluid intake is especially important to help loosen respiratory tract secretion. If the patient is complaining of a productive cough, a product that also contains an expectorant would be a good option. The most common expectorant is guaifenTable 2

esin, which will help loosen the secretions found in the lower respiratory tract. The usual dose for guaifenesin is 100 to 400 mg every four hours. It should be taken with plenty of water to help loosen the secretions. An extended-release product of guaifenesin 600 mg, with or without dextromethorphan, is now available and is dosed every 12 hours. When treating the cough associated with acute bronchitis in children, the adult dose should be cut in half for children age six to 12. The dosing for children age two to six should be one-quarter of the adult dose. If the patient has a fever associated with acute bronchitis, antipyretics may be needed. Acetaminophen is one such antipyretic and can be given to both adults and children. For adults, the dose is 650 mg every four hours, not to exceed 4 gm per day. In children, the acetaminophen dose is 10 to 15 mg/kg every four to six hours. Ibuprofen is another option for an antipyretic and 200 to 400 mg every four to six hours for adults and 5 to 10 mg/kg every six to eight hours for children. Aspirin can be used for adults but not for children. In some cases, the cause of acute bronchitis is bacterial. Antibiotics should not be used unless sputum cultures reveal the presence of bacteria or if the patient has symptoms that last more than six days. Since the infec-

Dosing guidelines for select products

Decongestant Pseudoephedrine Adult dose Tablets: 60 mg q 4-6 h with a maximum of 240 mg/day Extended-release capsules and tablets: 120 mg q 12 h or 240 mg q 24 h Adults: 2-3 sprays or drops of a 0.25% or 0.5% solution in each nostril q 4 h p.r.n. Pediatric dose Oral solution: 4 mg/kg/day in 4 divided doses

Nasal phenylephrine

Children ages 2-6: 2-3 drops of a 0.125% solution or 0.16% solution in each nostril q 4 h p.r.n. Children ages 6-12: 2-3 sprays or drops of a 0.25% solution in each nostril q 4 h p.r.n. Children ages 6 and older: Same as adults Children ages 2-12: 2 to 3 drops or sprays of the 0.05% solution in each nostril every 8 to 10 hours with a maximum of 3 doses per 24 hours Not recommended for children under 6. Children over 6 can use the adult dose 2-6 drops or sprays in each nostril every 2 hours p.r.n.

Nasal oxymetazoline Nasal xylometazoline

2-3 drops or sprays of 0.05% solution q 10-12 h both nostrils 1 to 3 drops or sprays of the 0.1% solution in each nostril every 8 to 10 hours with a maximum of 3 doses per 24 hours 1-2 inhalations in each nostril while blocking the other nostril not more than every 2 hours 2-6 drops or sprays in each nostril every 2 hours p.r.n.

Nasal decongestant inhalers (propylhexedrine, l-desoxyephedrine) Nasal sodium chloride

Adapted from United States Pharmacopeia Drug Information: Drug Information for the Health Care Professional. Vol. 1. 25th ed. Greenwood Village, CO: Thomson Micromedex; 2005.

www.drugtopics.com

DRUG TOPICS OCTOBER 10 2005

83

CONTINUING EDUCATION
tion will usually clear after four to six days, prolonged symptoms could indicate a bacterial infection. If a patient has not had symptoms for more than four days, the acute bronchitis is considered uncomplicated, and antibiotics should not be prescribed. Currently, respiratory tract infections account for 67% of the antibiotic use with 87% of that use being in children. Antibiotics of choice used to treat common pathogens found in acute bronchitis include erythromycin, azithromycin, clarithromycin, levofloxacin, and cefprozil. A newer agent such as telithromycin, which is a ketolide, is also an option. indicated only for healthy patients between the ages of five and 49 years. All patients who are at risk of getting the flu should be vaccinated, with high-risk patients getting vaccine first. High-risk groups include patients aged 65 or older; nursing home or long-term care residents; pregnant patients; anyone with chronic lung, heart, or kidney disease; immunocompromised patients; and children. Healthcare providers or those who come in contact with high-risk patients are at risk of passing the influenza virus to those patients and should be among the first to be vaccinated. Other preventive measures for influenza are the same as those noted for the common cold. Since the flu is a virus, antibiotics are not warranted. If a patient is treated, the mainstay of therapy is antiviral agents such as amantadine, rimantadine, zanamivir (Relenza), and oseltamivir (Tamiflu). These drugs should be recommended only in cases of uncomplicated influenza illness and must be started early in the disease process (first 48 hours) because of the short duration of illness. The goal of drug therapy in the treatment of the flu is to decrease the duration of the illness. Amantadine and rimantadine have an unknown mechanism of action but are thought to work by inhibiting the release of nucleic acid into the host cell from the infectious virus. Amantadine can also be used to help prevent the influenza virus in patients exposed to an outbreak. The adult dosage for amantadine is 200 mg daily for 10 days following a known exposure or 24 to 48 hours after the disappearance of symptoms. Rimantadine is dosed at 200 mg daily for seven days in adults. This dosage has been found to decrease the duration of symptoms by a maximum of two days. Using these drugs for prophylaxis against the influenza virus is up to 90% effective in preventing illness caused by influenza A subtypes. Side effects of these two drugs are mostly limited to the central nervous system and include anxiety, dizziness, and headache. Zanamivir and oseltamivir are newer antiviral agents and are active against both influenza A and B viruses. The mechanism of action for these agents is to block the neuraminidase of the virus, which leads to a decreased viability of the virus. The dosing for oseltamivir is 75 mg twice daily for five days in adults and children over the age of 13. The prophylactic dose is 75 mg daily for a minimum of seven days. Zanamivir comes in the dosage form of a powder inhaler and should be given as two inhalations every 12 hours for five days. Two doses should be taken on the first day of treatment whenever possible, provided there are at least two hours between doses. Currently, zanamivir has not received an indication for the prophylaxis of the influenza virus. Patient
www.drugtopics.com

Influenza
Many symptoms related to other common respiratory tract infections can mimic those of the influenza virus. This is especially true for symptoms of the common cold. Table 1 outlines the difference in symptoms of the flu and the common cold. Another difference in symptoms is the fact that the nasal discharge associated with the flu is usually more watery than with the common cold. Also, headache and fever are often more severe with the flu. Because the flu can cause more aches and pains, lost productivity from work or school is more common with the flu. Flu season usually begins in October, peaks in midFebruary, and ends in March. It is estimated that 10% to 20% of the U.S. population will get the flu each year. Active illness is from one of three types of virus: A, B, or C. Transmission of the flu is via nasal droplets, and once a patient becomes infected, the incubation period is one to four days. Patients who have the flu will be contagious from the day before symptom onset until five days later. For children, the contagious period can extend for 10 days after the onset of symptoms. In most patients, the flu is self-limiting and will resolve within seven days. Influenza is a serious disease in some patient populations. Children and adults who have underlying conditions are at risk for developing pneumonia. In elderly patients (more than 65 years of age), the risk of developing complications, being hospitalized, and death is higher than that in healthy adults. More than 90% of deaths associated with influenza are in this population. The most powerful tool available to prevent influenza is the inactivated trivalent influenza vaccine. The vaccine contains three strains of influenza virus, which can change yearly based on epidemiologic data. This vaccine does not contain active virus and, therefore, cannot produce illness in patients who receive the vaccine. Another type of vaccine is an intranasal, live attenuated influenza vaccine, which was approved in 2003. This vaccine is in a nasal spray formulation and contains a weakened form of the virus. Currently, this vaccine is
84
DRUG TOPICS OCTOBER 10 2005

counseling is especially important with zanamivir to ensure patients understand Table 3 how to use the inhaler to get the appropri- Antibiotic treatment for sinusitis ate dose. Side effects for these agents are Adult dose also based in the central nervous system Drug and include dizziness and headache. In Penicillins/cephalosporins addition, zanamivir may cause a cough Amoxicillin/clavulanate 250-500 mg q 8 h due to the dry powder inhalations. Cefpodoxime proxetil 200 mg q 12 h New advances in technology have Cefuroxime axetil 250 mg q 12 h added to the diagnostic tests for the influCefdinir 300 mg q 12 h or 600 mg q 24 h enza virus. Viral culture is still the gold Ceftriaxone 1 gm/day Cefprozil 250-500 mg q 12 h standard, but other options are also available. Rapid diagnostic tests can determine whether a patient has the flu within 30 Macrolide antibiotics Azithromycin 500 mg/day for 3 days minutes. Different variations of these tests Clarithromycin 500 mg q 12 h can detect only if the virus present is type Telithromycin 800 mg/day A, but others can determine if the virus present is type A or B. Some types of rapid Quinolone antibiotics tests are waived from the Clinical LaboraGatifloxacin 400 mg/day tory Improvement Amendments (CLIA) Levofloxacin 500 mg/day and can be used in an outpatient setting, Moxifloxacin 400 mg/day including the pharmacy. Monitoring and treatment of patients Other antibiotics SMZ-TMP (sulfamethoxazole- 800 mg/160 mg b.i.d. with the flu is important to prevent comtrimethoprim) plications. The most common complicaLoracarbef 400 mg q 12 h tions are primary viral pneumonia, secondary bacterial pneumonia, exacerba- Adapted from Wright WL. Viral or acute bacterial rhinosinusitis? Determining the difference. Nurse tion of chronic pulmonary disease and Practitioner. 2005;5:30-43. heart disease, and central nervous system complications. Central nervous system complications have children or work closely with children. A bacterial include seizures and acute encephalitis. Most of these diagnosis can be done with rapid antigen detection tests, complications occur in the elderly, but cases have also which will detect the presence of bacteria and the need for antibiotic therapy. These rapid antigen detection tests been documented in healthy patients. are also CLIA-waived and may be performed in a community pharmacy. Pharyngitis Transmission of pharyngitis is also through nasal Another common viral respiratory tract infection is pharyngitis. Pharyngitis is an infection of the nasophar- droplets, and cases will peak in the winter and early ynx or oropharynx, which can cause acute inflamma- spring. Once patients are infected, the incubation period tion. Viral pharyngitis can occur as a complication relat- is up to five days. If pharyngitis is left untreated, complied to the common cold or the influenza virus. If pharyn- cations, including glomerulonephritis, rheumatic fever, gitis is a result of the flu, the symptoms will be more and reactive arthritis, could arise. Sore throat, pain with swallowing, fever, erythemasevere than if it is a result of a cold. Other viruses that can cause pharyngitis are herpes simplex virus, Epstein tous tonsils and pharynx, enlarged nymph nodes, headache, and patchy exudates in the mouth are classic Barr virus, adenovirus, and coronavirus. Although viruses are the most common cause of symptoms of pharyngitis. Children may also complain pharyngitis, bacteria can also be a causative factor. If the of abdominal pain with nausea and vomiting. Pharyncause is bacterial, the pathogen is most likely S. pyogenes, gitis may also present with many nonspecific sympwhich is a group A beta-hemolytic streptococcus. This toms that could appear to be other viral or bacterial leads to the common name of strep throat for the bacte- infections. These symptoms include cough, diarrhea, rial version of the illness. The distinction between viral and conjunctivitis. The preferred method for diagnosing strep pharyngiand bacterial illness can be difficult based on symptoms. Most cases of bacterial infection occur in children tis is a throat culture, but as stated earlier, testing can between the ages of five and 15 years and adults who occur in the ambulatory setting, including the commuwww.drugtopics.com DRUG TOPICS OCTOBER 10 2005

85

CONTINUING EDUCATION
nity pharmacy. The test is a rapid antigen-detection test (RADT). One benefit of using a RADT is that it is typically less expensive than throat cultures and the time to results is also less. This is important so treatment is not delayed. If the RADT comes back negative, a throat culture is recommended if the patient is still symptomatic. If the pharyngitis is determined to be of viral origin, antibiotics should not be prescribed. In this case, the patient can take OTC products to help treat the symptoms. Lozenges and throat sprays can help relieve the pain associated with a sore throat. Pain relievers such as acetaminophen and ibuprofen can also be added to help ease the sore throat pain. Antipyretics should be used if the patient has a fever. If the RADT or throat culture indicate the presence of bacteria, antibiotic therapy is helpful to cure the infection and decrease the number of days the patient experiences illness. The drug of choice to treat group A betahemolytic streptococcus is penicillin. Penicillin VK should be prescribed for 10 days at 250 mg three to four times daily or 500 mg twice daily. If compliance is an issue, one intramuscular injection of penicillin benzathine can be administered. Amoxicillin 500 mg three times daily is also an option. If patients have a penicillin allergy, erythromycin, azithromycin, clarithromycin, or cephalexin can be prescribed and will be as effective as penicillin. Current literature is looking at the possibility of decreasing the duration of treatment from 10 days with penicillin to six days with amoxicillin or possible shorter courses with other antibiotics. Anytime a pharmacist is counseling a patient regarding antibiotic use, it is crucial to reiterate the importance of finishing the entire course of therapy to decrease antibiotic resistance. a feeling of fullness in the area. The pain can occur in the forehead, ear, cheek, teeth, and above or behind the eyes. Periorbital swelling with or without pain may be present. Sometimes a clear nasal discharge is present and is typically a sign of viral sinusitis, which does not require antibiotic therapy. Sinusitis can also be caused by allergic rhinitis. Treatment of viral sinusitis is aimed at alleviating the sinus symptoms and making the patient more comfortable. Symptoms may last as long as three to seven days in viral sinusitis. The mainstay of treatment is OTC decongestants. Treatment may also include analgesics and antihistamines if the patient has symptoms of pain and nasal drainage, respectively. Antihistamines can also be helpful if the sinusitis is being caused by allergic rhinitis. Table 2 lists the OTC decongestants available as well as their dose and duration. Pseudoephedrine is an effective oral decongestant but should be used with caution in patients with cardiovascular disease, hypertension, diabetes, hyperthyroidism, benign prostatic hyperplasia, and glaucoma. It should be avoided altogether in patients with severe hypertension and coronary artery disease. Potential side effects include nervousness, restlessness, insomnia, fast or pounding heartbeat, and dizziness. Nasal phenylephrine, oxymetazolone, and xylometazolone have a low incidence of systemic side effects since they are used nasally and work locally. However, they still carry the potential of causing sympathomimetic side effects like those of pseudoephedrine. Therefore, they should be used with caution in patients with cardiovascular disease and hypertension. Nasal spray decongestants are known for their potential to cause rebound congestion so the recommended maximum duration of use is three days. These agents should help alleviate some of the nasal symptoms involved. OTC antihistamines are effective in patients who experience nasal drainage along with sinus symptoms. Loratadine and diphenhydramine are available in combination products with pseudoephedrine for patients who require treatment for both sinus congestion and drainage. Many combination products that contain both an analgesic and a decongestant are available. Patients who do not respond to OTCs or have symptoms lasting longer than seven days may require a physician referral, as this may be a sign of bacterial sinusitis. A fever could be present as well as a purulent mucoid nasal discharge and a cough. In children, the presence of halitosis without causes such as pharyngitis or poor dental hygiene may exist. Patients who recently had an upper respiratory virus are predisposed to bacterial sinusitis because of physiologic changes in the nasal mucosa. The two most common bacterial causes of sinusitis are S. pneumoniae and Haemophilus influenzae. There are many choices for antibiotic therapy and choice of antibiotic
www.drugtopics.com

Sinusitis
Winter months are on the horizon and so are sinus problems. It is important to know when a patient can be treated with OTC remedies and when referral to their physician is warranted. Sinusitis is a common winter ailment and has both bacterial and viral origins. Many times, antibiotic treatment is not necessary and relieving symptoms is the primary goal of therapy. The sinus cavities are connected by tubular openings called the sinus ostia. These openings facilitate drainage from the sinuses into the nasal cavity. Both viral and bacterial infections as well as allergic inflammation can cause these openings to become obstructed and this leads to retention of secretions. Approximately 40% of sinusitis patients will have a resolution of symptoms without antibiotic therapy within 48 hours. Patients will usually present with a headache that is not responding to analgesics and corresponds with the sinus cavities. The patient will complain of a dull ache or
86
DRUG TOPICS OCTOBER 10 2005

depends on prior use of antibiotics and patient hypersensitivities. Patients are typically treated for 10 to 14 days with antibiotics in bacterial sinusitis. Penicillins can be used; however, H. influenzae has a high incidence of resistance due to beta-lactamase production. Therefore a combination of penicillin and a beta-lactamase inhibitor product should be considered in cases where this organism is a likely cause. Antibiotic options in bacterial sinusitis are listed in Table 3. In addition to antibiotic

treatment, the patient may still use OTC decongestants to help alleviate the symptoms involved with sinusitis. The role of the pharmacist is very important when making recommendations for patients regarding respiratory tract infections. It is important for the pharmacist to understand how to assess the patients symptoms, make the appropriate recommendations, and understand when it is time to refer the patient to a physician. References are available upon request.

TEST QUESTIONS
Write your answers on the answer form appearing on page 88 (photocopies of the answer form are acceptable) or on a separate sheet of paper. Mark the most appropriate answer.
1. Which of the following viruses is the most common 9. Which of the following flu treatments comes in a

cause of the common cold?

a. Coronavirus b. Rhinovirus c. Influenza virus d. Adenovirus

dry powder inhaler?

a. Amantadine b. Rimantadine c. Zanamivir d. Oseltamivir

2. Which of the following is the best option to treat

10. Which of the following is the gold standard for

nasal stuffiness caused by the common cold?

a. Dextromethorphan b. Amoxicillin c. Phenylpropanolamine d. Pseudoephedrine

diagnosing strep pharyngitis?

a. RADT b. CLIA c. Throat culture d. Tonsil culture

3. The cough associated with the common cold is

11. Which of the following bacteria is a common

best described as:

a. Productive b. Dry and nonproductive c. Wet d. Hacking

pathogen that causes bacterial sinusitis?

a. E. coli b. S. aureus c. H. influenzae d. Pneumocystis carinii

4. What is the maximum daily dose of vitamin C? a. 1 gm c. 3 gm b. 2 gm d. 4 gm 5. When one is washing ones hands to prevent the

12. Symptoms of sinusitis include all of the following

except:
a. Periorbital swelling b. Feeling of fullness in the sinus area c. Earache d. Dizziness 13. Which of the following disease states requires cau-

spread of illness, what is the appropriate length of time to wash with soap and water?
a. One second b. 15-20 seconds c. 30 seconds d. One minute

tion when using pseudoephedrine?

a. Colon cancer b. Diabetes mellitus c. Psoriasis d. Influenza

6. A patient with symptoms of bronchitis should be

referred to a physician after how many days?

a. Two days b. Four days c. Six days d. Eight days

14. How many days of sinusitis symptoms warrant re-

ferral to the patients physician?

a. Two days b. Three days c. Five days d. Seven days

7. Which of the following antibiotics can be used to

treat bronchitis?
a. Erythromycin b. Penicillin c. Cephalexin d. Amoxicillin

15. What percentage of sinusitis patients will have res-

olution of symptoms without antibiotic treatment?

a. 15% b. 30% c. 40% d. 100%

8. All of the following populations are considered

high risk for getting influenza except:

a. Patients over the age of 30 b. Nursing home residents c. Healthcare providers d. Immunocompromised patients
www.drugtopics.com

16. What is the recommended pediatric dose of pseu-

doephedrine solution?
a. 2 mg/kg/day b. 4 mcg/kg/day c. 4 mg/kg/day d. 12 mg/kg/day
DRUG TOPICS OCTOBER 10 2005

87

TEST QUESTIONS
17. Which of the following is the recommended dose 19. Which of the following side effects is likely with

of telithromycin in bacterial sinusitis?

a. 600 mg b.i.d. b. 800 mg daily c. 1,200 mg daily d. 1,500 mg daily

pseudoephedrine?
a. Drowsiness b. Dry mouth c. Musculoskeletal pain d. Rapid heartbeat

18. What is the recommended maximum duration of

20. What concentration of nasal phenylephrine is indi-

decongestant nasal sprays?

a. One day b. Three days c. Six days d. Eight days

cated in pediatric patients age two to six?

a. 0.9% b. 0.45% c. 0.425% d. 0.125%

Evaluation of CE
Drug Topics is conducting an evaluation of this CE article. Please  box that best reflects your opinion of the evaluation questions. Please keep this evaluation attached to your answer form.
Strongly Agree 1. The program objectives were met. 2. The program content was useful and relevant. 3. The program was educational and not promotional. 4. The program was fair, objective, balanced, and of scientific rigor. 5. The program will help me in my practice. Agree Disagree Strongly Disagree

2005 CEU CREDIT REQUEST

To obtain immediate CE credit, take the test on line at www.drugtopics.com. Just click on the Continuing Education box in the lower right side of the Drug Topics home page, which will take you to the CE site. Log in, find and click on this lesson, and follow the three simple steps. Test results will be displayed immediately and you can print the certificate showing your earned CE credits.

ANSWER FORM
THE COMMON COLD AND OTHER RESPIRATORY TRACT INFECTIONS

OCTOBER 10, 2005 012-999-05-209-H01

Test questions start on preceding page

1. 2. 3. 4.

a. a. a. a.

b. b. b. b.

c. c. c. c.

d. d. d. d.

5. 6. 7. 8.

a. a. a. a.

b. b. b. b.

c. c. c. c.

d. d. d. d.

9. 10. 11. 12.

a. a. a. a.

b. b. b. b.

c. c. c. c.

d. d. d. d.

13. 14. 15. 16.

a. a. a. a.

b. b. b. b.

c. c. c. c.

d. d. d. d.

17. 18. 19. 20.

a. a. a. a.

b. b. b. b.

c. c. c. c.

d. d. d. d.

No longer valid for CE credit after 10/31/07

Amount enclosed: $6.00 for this lesson $54.00 for any 12 lessons you take over the next year, starting from the date you sign up Already series-enrolled for 2005

Submit your check (payable to The University of Florida) and form to:
University of Florida College of Pharmacy, P.O. Box 100482, Gainesville, FL 32610 E-mail address: continuinged@cop.ufl.edu Fees not refundable or transferable

Are you employed by a chain? If so, which one?

For questions concerning the PRINT CEs, call (352) 273-6275. For questions concerning the ON-LINE CEs, call (866) 261-3558. REGISTRANT INFORMATION

Name:
(Last) (First) (M.I.) Phone

Address:
(Street)

E-mail address: State: Zip:

City:

ATTENTION FLORIDA PHARMACISTS: The State of Florida has changed to a new record maintenance system for all continuing education, using a private company, cebroker.com. The University of Florida is registered with the Florida Board of Pharmacy as a Provider, and will report continuing education records for all pharmacists who are registered in Florida. Please provide your license number ___________________________

88

DRUG TOPICS OCTOBER 10 2005

www.drugtopics.com