The Pharmacotherapeutic Management of Common Upper Respiratory Tract Infections

3 Upper Respiratory Tract Infections Catherine Van, PharmD, BCPS Assistant Professor, Pharmacy Practice West Coast Univer sity School of Pharmacy 1 RESPIRATORY TRACT INFECTIONS Upper inflammation of a voiced Lower https://www.google.com/search?rlz=1C1AZAA_enUS743US743&biw=1920&bih=950&tbm=isch&sa=1&q=respiratory+tract+infections&oq=respiratory+tract+infections&gs_l=psyab.3..0j0i7i30k1l3.38953.38953.0.39118.1.1.0.0.0.0.110.110.0j1.1.0....0...1.1.64.psy-ab..0.1.107.hJSaL330Hl0#imgrc=3yuaaneg1Qbm5M: 3 OTITIS MEDIA Inflammation of the middle ear One of the leading reasons for physicians’ office visits and emergency department visits in U.S. More than 709 million cases of otitis media worldwide each year; half of these cases occur in children under 5 years of age Three subtypes Acute otitis media  Subtype with the greatest role for antibiotics Otitis media with effusion 3 Chronic otitis media i Ij to There'snoPED 4 QUESTION Which characteristic(s) below can help differentiate between acute otitis media and otitis media with effusion? A. Middle ear effusion B. Cough C. Ear pain D. Two of the above are correct 5 ACUTE OTITIS MEDIA Acute Otitis Media efarlizepressieof Atmosphereandmiddleear https://nurseslabs.com/otitis-media/ 6 PATHOPHYSIOLOGY  Typically follows a viral URTI that impairs the mucociliary apparatus and causes Eustachian tube dysfunction in the middle ear  Thin, clear tympanic membrane in noninfected ear  Bulging and erythematous tympanic membrane in AOM  Bacteria enter the middle ear, proliferate and cause infection  Children more susceptible to AOM than adults  Shorter and more horizontal Eustachian tube, facilitating bacterial entry into the middle ear 7 AOM https://www.google.com/search?rlz=1C1AZAA_enUS743US743&biw=1910&bih=921&tbm=isch&sa=1&q=acute+otitis+media&oq=acute+otitis+media&gs_l=psyab.3..0i67k1l2j0l2.5866280.5869822.0.5870241.8.8.0.0.0.0.150.738.0j5.5.0....0...1.1.64.psy-ab..3.5.734...0i13k1.dvzc9rlbQTY#imgrc=nf8q0xo38HFcaM:...25876.48257.0.48460.44.42.2.0.0.0.148.3424.30j10.40.0....0...1.1.64.psyab..2.18.1517...0j0i67k1j0i5i30k1j0i24k1j0i13k1j0i13i5i30k1j0i30k1._g1iVWZbwC0#imgrc=tMh7w2hTjQ0rVM: 8 ETIOLOGY  Common bacterial pathogens:  Streptococcus pneumoniae (35-40%) osht  Nontypeable Haemophilus influenzae (30-35%) Efate  Moraxella catarrhalis (15-18%)  All possess resistance to β-lactams  S. pneumoniae through alteration of penicillin-binding proteins  Up to 40% of S. pneumoniae isolates in the US are penicillin nonsusceptible, and up to half of these with high-level penicillin resistance  H. influenzae (30-40%) and M. catarrhalis (> 90%): production of β-lactamases 9 DIAGNOSIS Children should be diagnosed with acute otitis media if they have middle ear effusion and either  (1) Moderate to severe bulging of the tympanic membrane or new onset otorrhea not due to acute otitis externa eardrainage rats of the tympanic membrane and onset  (2) Mild bulging of ear pain within the last 48 hours or intense erythema of the tympanic membrane  Middle ear effusion identified based on pneumatic otoscopy and/or tympanometry Otoscopy: https://www.youtube.com/watch?v=YZbk5Uel55E Tympanometry: https://www.youtube.com/watch?v=iXcI9s_AvDg 10 CLINICAL PRESENTATION OF AOM General Cases often follow viral upper respiratory tract infections. Nonverbal children with ear pain might hold, rub, or tug their ear. Very young children might cry, be irritable, and have difficulty sleeping. Signs and Symptoms • Bulging of the tympanic membrane • Otorrhea • Otalgia (considered to be moderate or severe if pain lasts at least 48 hours) • Fever (considered to be severe if temperature is 39°C [102.2°F] or higher) COMPLICATIONS Infrequent Can include: Mastoiditis Bloodstreaminfection Bacteremiano informationoftissuesurrounds no Meningitis brainor spiralort As Auditory sequelae with the potential for speech and language impairment 12 GOALS OF TREATMENT Reduction in signs and symptoms Pain management Eradication of the infection Prevention of complications from the infection Avoid unnecessary antimicrobials Prevent resistance Prevent secondary infections 13 PAIN MANAGEMENT Antibiotic therapy of AOM does not provide symptomatic relief in the first 24 hours Analgesics relieve pain associated with AOM within 24 hours and should be used whether antibiotic therapy is or is not prescribed  Continued as long as needed 14 PAIN MANAGEMENT Treatment Modality Comments Acetaminophen, ibuprofen Effective analgesia for mild to moderate pain. Readily I available. Mainstay of pain management for AOM. Home remedies (no controlled studies that directly address effectiveness) • Distraction • External application of heat or cold • Oil drops in external auditory canal May have limited effectiveness. 15 PAIN MANAGEMENT Treatment Modality Comments Topical agents Benzocaine, procaine, lidocaine Additional, but brief, benefit over acetaminophen in patients older than 5 y Naturopathic agents Comparable to amethocaine/phenazone drops in patients older than 6 y Homeopathic agents No controlled studies that directly address pain Narcotic analgesia with codeine Effective for moderate or severe pain. or analogs Requires prescription; risk of respiratory depression, altered mental status, gastrointestinal tract upset, and constipation Tympanostomy/myringotomy Requires skill and entails potential risk makea cutin eardrum 16 ANTIBIOTIC INDICATION AOM Scenario Treatment Bilateral or unilateral AOM in children 6 Antibiotics months to 12 years with severe signs or upfrontpontoon symptoms (moderate or severe otalgia or otalgia for at least 48 hours or earpad temperature 39°C [102.2°F] or higher) Bilateral AOM in children 6 months Antibiotics zur through 23 months without severe signs upfront or symptoms (mild otalgia for less than so 48 hours and temperature less than 39°C [102.2°F]) 17 ANTIBIOTIC INDICATION AOM Scenario Unilateral AOM in children 6 months to 23 months without severe signs or symptoms (mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]) Bilateral or unilateral AOM in children 24 months to 12 years without severe signs or symptoms (mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]) Treatment Antibiotics or observation with close follow-up Antibiotics or observation with close follow-up 18 ANTIBIOTIC INDICATION  Initial antibiotic therapy  Treatment of AOM with antibiotics prescribed at the time of diagnosis with the intent of starting antibiotic therapy as soon as possible after the encounter  Initial observation  Initial management of AOM limited to symptomatic relief Ey of antibiotic therapy only if the child’s  Commencement condition worsens at any time or does not show clinical improvement within 48 to 72 hours of diagnosis  Mechanism must be in place to ensure follow -up and initiation of antibiotics if the child fails observation 19 AOM TREATMENT Initial Treatment at AOM Diagnosis or After Observation Recommended First-line Treatment (Pediatric dose) Amoxicillin (Amoxil®) 80–90 mg/kg per day in 2 divided doses (max 4000 mg/day) Alternative Treatment (if Penicillin Allergy) Cefdinir (Omnicef®) 14 mg/kg per day in 1 or 2 doses (max 600 mg/day) **or** USNSIko BI Cefuroxime (Ceftin®) Amoxicillin-clavulanate (Augmentin®) 30 mg/kg per day in 2 divided doses (max 500 mg/dose) 90 mg/kg per day of amoxicillin, with ** or ** 6.4 mg/kg per day of clavulanate [amoxicillin to clavulanate ratio, 14:1] Cefpodoxime (Vantin®) in 2 divided doses (max 4000 mg/day) 10 mg/kg per day in 2 divided doses (max 200 mg/dose) ** or ** If received amoxicillin in the last 30 days or has concurrent purulent eye Ceftriaxone (Rocephin®) conjunctivitis, or has a history of intonation50 mg/kg per day IM or IV for 3 days (max 1000 mg/dose) recurrent AOM unresponsive to amoxicillin 20 AOM TREATMENT Antibiotic Treatment After 48–72 h of Initial Antibiotic Treatment Failure Recommended First-line Treatment Amoxicillin-clavulanate (Augmentin®) 90 mg/kg per day of amoxicillin, with 6.4 mg/kg per day of clavulanate in 2 divided doses (max 4000 mg/day) Ceftriaxone (Rocephin®) 50 mg/kg per day IM or IV for 3 days (max 1000 mg/dose) Alternative Treatment Ceftriaxone for 3 days **or** Clindamycin (Cleocin®) 30–40 mg/kg per day in 3 divided doses (max 1800 mg/day if given PO) (with or without second- or thirdgeneration cephalosporin) Clindamycin (30–40 mg/kg per day in 3 divided doses) plus second- or thirdgeneration cephalosporin Tympanocentesis Consult specialist 21 QUESTION needtolookup on lexicon package Needtolookup insert A nurse asked you how much diluent (lidocaine 1%) she should add to a 500 mg ceftriaxone vial to make an IM injection for a patient. What is the appropriate amount of diluent (in mL) if the final concentration of the injection is 350 mg/mL? A. 1 mL B. 1.8 mL C. 2.1 mL D. 3.6 mL 22 AOM Treatment Antibiotic duration For children younger than 2 years and children with severe symptoms, a standard 10-day course is recommended. 7-day course of oral antibiotic appears to be equally effective in children 2 to 5 years of age with mild or moderate AOM. For children 6 years and older with mild to moderate symptoms, a 5- to 7-day course is adequate treatment. 23 RECURRENT AOM Defined as:  At least three episodes in 6 months OR  Four episodes in 1 year, with one episode in the preceding 6 months Children younger than 3 years of age at high risk for hearing loss and language and learning disabilities Clinicians should not prescribe antibiotics as prophylaxis against recurrent episodes but may offer tympanostomy tubes (T tubes) 24 AOM PREVENTION Vaccination Pneumococcal conjugate vaccine to all children according to the vaccination schedule Annual influenza vaccine to all children Others Encourage exclusive breastfeeding for at least 6 months Encourage avoidance of tobacco smoke exposure 25 QUESTION Which medication is considered to be a firstline recommendation for the treatment of a 1 year-old child with acute otitis media and a fever of 103°F (39.4 °C)? The child has NKDA. Noknownallergy Treatpt seasontyg A. Azithromycin B. Amoxicillin C. Ceftriaxone D. Cefuroxime 26 QUESTION Calculate the antibiotic dose for the child and determine the duration of treatment. Weight: 9 kg 40,0mm 801g Concentration of antibiotic: 400 mg/5 mL 2din'ddose 1kg a song Amocikin 90 9 408 810mg perday 810 2 403 SypoBID for todays 27 ACUTE BACTERIAL RHINOSINUSITIS Sinha mention of sinusand nascority 28 SINUSITIS An inflammation and/or infection of the paranasal sinuses 29 PATHOPHYSIOLOGY  Acute bacterial rhinosinusitis often preceded by a viral respiratory tract infection that causes mucosal inflammation É5  Obstruction of the sinus ostia — pathways that drain the sinuses  Mucosal secretions become trapped, local defenses are impaired, and bacteria from adjacent surfaces begin to proliferate  Maxillary and ethmoid sinuses most frequently involved 30 ETIOLOGY Most common: S. pneumoniae and H. influenzae  50% to 70% of bacterial causes in both adults and children M. catarrhalis sometimes implicated in adults and children (approximately 8%-16%) Less frequently: Streptococcus pyogenes, Staphylococcus aureus, gramnegative bacilli, and anaerobes 31 DIAGNOSIS Lack of simple and accurate diagnostic test Gold standard: sinus puncture with recovery of bacteria in high density (10 4 colony-forming units/mL [107 cfu/L] or greater) Invasive and costly, and can be painful Not routinely done Sinus radiography can help, but not routinely recommended Rely on clinical findings to diagnose 32 CLINICAL PRESENTATION OF ABRS General There are 3 clinical presentations that are most consistent with acute bacterial versus viral rhinosinusitis: •Onset with persistent symptoms or signs compatible with acute pb lasting for ≥10 days without any evidence of clinical rhinosinusitis, improvement •Onset with severe symptoms or signs of high fever (≥39°C [102.2°F]) and purulent nasal discharge or facial pain lasting for at least 3 to 4 consecutive days at the beginning of illness •Onset with worsening symptoms or signs characterized by newonset fever, headache, or increase in nasal discharge following a typical viral URI that lasted 5 to 6 days and were initially improving (“double sickening”) CLINICAL PRESENTATION OF ABRS Signs and Symptoms ji Ja •Purulent anterior nasal discharge, purulent or discolored posterior nasal discharge •Nasal congestion or obstruction •Facial congestion or fullness, facial pain or pressure •Fever, headache •Ear pain/pressure/fullness •Halitosis, dental pain •Cough •Fatigue 34 GOALS OF TREATMENT  Reduction in signs and symptoms  Achieving and maintaining patency of the ostia  Eradication of the infection  Prevention of complications from the infection  Prevention of progression from acute disease to chronic disease  Minimize duration of illness  Avoid unnecessary antimicrobials Prevent resistance Prevent secondary infections 35 ABRS TREATMENT IDSA Recommended Treatments for ABRS Children Initial Empirical Therapy 1st Line Amoxicillin–clavulanate (Augmentin®) 45 mg/kg/day PO twice daily (i.e. divided q12 hours) Max 1750 mg/day 22SmgldoseBID Alternative Treatment (β-lactam Allergy or Failed Initial Therapy) Clindamycin plus cefixime or cefpodoxime (Cleocin®, Suprax®, Vantin®) - Non–type 1 allergy Clindamycin (30–40 mg/kg/day PO three times daily) plus cefixime (8 mg/kg/day PO twice daily) or cefpodoxime (10 mg/kg/day PO twice daily) Levofloxacin (Levaquin®) 10–20 mg/kg/day PO every 12–24 hours (max 500 mg/day) Type 1 allergy 2nd Line Amoxicillin–clavulanate (Augmentin®) 90 mg/kg/day PO twice daily Anaphylaxis (i.e. divided q12 hours) Max 4000 mg/day (Preferred if risk for ABX resistance) du Severe Infection Requiring Hospitalization Ampicillin–sulbactam (Unasyn®) 200–400 mg/kg/day IV every 6 hours Ceftriaxone (Rocephin®) 50 mg/kg/day IV every 12 hours Cefotaxime (Claforan®) 100–200 mg/kg/day IV every 6 hours Levofloxacin (Levaquin®) 10–20 mg/kg/day IV 36 every 12–24 hours 4s ngi ksIposepoBID tons Fargo ABRS TREATMENT Tendontiftggonest IDSA Recommended Treatments for ABRS Adults Alternative Initial Empirical Therapy Treatment (β-lactam Allergy) st 1 Line Doxycycline Amoxicillin–clavulanate (Vibramycin®) (Augmentin®) 100 mg PO twice 500 mg/125 mg PO three daily or 200 mg times daily, or 875 mg/125 PO once daily mg PO twice daily 2nd Line Levofloxacin Amoxicillin–clavulanate (Levaquin®) (Augmentin®) 500 mg PO once 2,000 mg/125 mg PO daily twice daily 2nd Line Doxycycline (Vibramycin®) 100 mg PO twice daily or 200 mg PO once daily Moxifloxacin (Avelox®) 400 mg PO once daily Risk for Antibiotic Resistance or Failed Initial Therapy Amoxicillin– clavulanate (Augmentin®) 2,000 mg/125 mg PO twice daily Levofloxacin (Levaquin®) 500 mg PO once daily N Severe Infection Requiring Hospitalization Ampicillin–sulbactam (Unasyn®) 1.5–3 g IV every 6 hours Levofloxacin (Levaquin®) 500 mg PO or IV once daily Moxifloxacin (Avelox®) Moxifloxacin (Avelox®) 400 mg PO once daily 400 mg PO or IV once daily Ceftriaxone (Rocephin®) 1–2 g IV every 12–24 hours Cefotaxime (Claforan®) 2 g IV every 4–6 hours 37 HIGH DOSE AMOXICILLINCLAVULANATE Preferred in the following situations a  Geographic regions with high endemic rates (10% or greater) of invasive penicillin-nonsusceptible S. pneumoniae 2  Severe infection  Evidence of systemic toxicity with fever of 39°C (102.2°F) or higher, and threat of suppurative complications (orbital cellulitis, intracranial extension of infection) 3 infectionof  Attendance at daycare fastand aAge < 2 or > 65 years around theeyes s  Recent hospitalization (within past 5 days) 6Antibiotic use within the last month 7Immunocompromised persons loan 38 ABRS TREATMENT  ABX duration:  Adults with uncomplicated ABRS: 5–7 days  Adults with ABRS and risk for resistance: 7 -10 days i  Children: 10–14 days recommended  Intranasal saline irrigation (either physiologic or hypertonic saline): recommended as an adjunctive treatment in adults with ABRS  Intranasal corticosteroids: recommended as an adjunct to antibiotics in the empiric treatment of ABRS, primarily in patients with a history of allergic rhinitis  Topical and oral decongestants, antihistamines : NOT recommended as adjunctive treatment Go dryout 39 ABRS TREATMENT If symptoms worsen after 48 to 72 hours or fail to improve despite 3–5 days of appropriate initial antibiotic therapy: reevaluate and consider alternative antibiotics If symptoms persist or worsen despite 72 hours of treatment with a second-line regimen: refer to a specialist for more aggressive evaluation, potentially with direct sinus aspiration or contrast-enhanced computed tomography 40 QUESTION Agum Which medication is considered to be a first-line recommendation for the treatment of a 68 -yearold man with a 2-week history of persistent nasal congestion and sinus pain? The man received 10 days of clindamycin when he was hospitalized for a skin abscess 2 months ago. o 76 Mighdge as A. Amoxicillin-clavulanate B. Clarithromycin C. Levofloxacin D. Amoxicillin 41 REVIEW When is high dose Augmentin® preferred for ABRS treatment? 765 I 52 daycare songs immuno AntibitoicwithinCastmonth hospitalpostsdays severeinfection geographic 42 PHARYNGITIS Acute infection of the oropharynx or nasopharynx 44 PATHOPHYSIOLOGY Not well defined Possible alteration in host immunity of asymptomatic pharyngeal carriers of the organism (e.g., a breach in the pharyngeal mucosa)  Bacteria of the oropharynx migrate to cause an infection Pathogenic factors associated with the organism  Pyrogenic toxins, hemolysins, streptokinase, and proteinase 45 ETIOLOGY Viruses: majority of acute pharyngitis cases  Rhinovirus (20%), coronavirus (5%), adenovirus (5%), herpes simplex virus (4%)  Influenza virus (2%), parainfluenza virus (2%), Epstein– Barr virus (1%) Bacterial etiology: less likely  Group A β-hemolytic Streptococcus (GABHS, S. pyogenes) most common (10%-30% of persons of all ages with pharyngitis) East  Children 5 to 15 years of age most susceptible  Incidence highest in winter and early spring 46 DIAGNOSIS  Rapid antigen-detection test (RADT) -When positive, no back-up culture (cx) needed: high specificity -If RADT negative,  In children and adolescent: back-up throat cx needed  In adults: routine use of back-up throat cx not required, because low incidence of GAS pharyngitis in adults -Anti-streptococcal antibody titers: NOT recommended  Reflect past but not current events  Culture of Throat swab (24-48 hrs) -Gold standard, more expensive than RADT -Some pts may be carriers → Tx the patient, Not the lab DIAGNOSIS Who needs testing of GAS Pharyngitis? Not recommended for signs/symptoms of viral etiology  Cough, rhinorrhea, hoarseness, and oral ulcers Not indicated for children < 3 years old  Acute rheumatic fever is rare and incidence of streptococcal pharyngitis and classic presentation of streptococcal pharyngitis are uncommon  If having an older sibling with GAS infection, may be considered for testing DIAGNOSIS Who needs testing of GAS Pharyngitis? (Cont.) Follow-up post-treatment throat cultures or RADT NOT recommended routinely Diagnostic testing or empiric treatment of asymptomatic household contacts of patients with acute streptococcal pharyngitis NOT routinely recommended Rapid Group A Strep Test: https://www.youtube.com/watch?v=ewOGD3CbwKs CLINICAL PRESENTATION OF GABHS General A sore throat of sudden onset that is mostly self-limited Fever and constitutional symptoms resolving in 3 to 5 days Clinical signs and symptoms are similar for viral and nonstreptococcal bacterial causes Signs and Symptoms of GABHS Pharyngitis •Sore throat •Pain on swallowing •Fever •Headache, nausea, vomiting, and abdominal pain (especially in children) •Erythema/inflammation of the tonsils and pharynx with or without patchy exudates •Enlarged, tender lymph nodes •Red swollen uvula, petechiae on the soft palate, and a scarlatiniform rash Signs Suggestive of Viral Cause: cough, conjunctivitis, and coryza Labs Throat swab and culture Rapid antigen-detection test COMPLICATIONS  Acute rheumatic fever tray  Acute glomerulonephritis  Reactive arthritis  Peritonsillar abscess  Retropharyngeal abscess  Cervical lymphadenitis  Mastoiditis  Otitis media  Rhinosinusitis  Necrotizing fasciitis 51 ACUTE RHEUMATIC FEVER  Non-suppurative, delayed sequela occurring 1-5 weeks after group A streptococcal pharyngitis  Characterized by fever and affects multiple organ systems  Cardiovascular: carditis (cardiomegaly, new onset heart murmur, pericardial friction rub, pericardial effusion, and congestive heart failure)  Musculoskeletal: polyarthritis affecting elbows, wrists, knees, and ankles  Integumentary: subcutaneous nodules  Central nervous system: chorea  Neurological disorder characterized by abrupt, purposeless, non rhythmic, involuntary movements that is often associated with muscle weakness and emotional lability GOALS OF TREATMENT Reduction in signs and symptoms Eradication of the infection Minimize adverse drug reactions Prevent transmission to close contacts Prevent acute rheumatic fever and other complications Avoid unnecessary antimicrobials Prevent resistance Prevent secondary infections 53 PHARYNGITIS TREATMENT IDSA Recommended Treatments for GABHS Pharyngitis Drug Adult dose Pediatric Dose Duration Preferred Antibiotics Penicillin V (Pen-V®) 250 mg PO four times 250 mg PO twice daily or 10 days daily or 500 mg PO three times daily twice daily Penicillin G benzathine 1.2 million units IM 0.6 million units IM (< 27kg) 1 dose ® (Bicillin L-A ) 1.2 million units IM (≥ 27 kg) Amoxicillin (Amoxil®) 50 mg/kg once daily (maximum 1,000 mg); 25 mg/kg (maximum 500 mg) twice daily 10 days Penicillin Allergy Cephalexin (Keflex®) Cefadroxil (Duricef®) 20 mg/kg/dose orally twice daily (maximum 500 mg/dose) 30 mg/kg orally once daily (maximum 1 g) 10 days 10 days Clindamycin (Cleocin®) 7 mg/kg/dose orally three times daily (maximum 10 days 300 mg/dose) Azithromycin 12 mg/kg orally once daily (maximum 500 mg) for 1 ® (Zithromax ) day, then 6 mg/kg orally once daily (maximum 250 5 days mg ) x 4 days Clarithromycin 15 mg/kg orally per day divided in two doses 10 days ® (Biaxin ) (maximum 250 mg twice daily) 54 ADJUNCTIVE TREATMENT Consider analgesic/antipyretic agent such as acetaminophen or an NSAID for treatment of moderate to severe symptoms or control of high fever associated with GAS pharyngitis Aspirin should be avoided in children Adjunctive therapy with a corticosteroid not recommended 57 TRANSMISSION PREVENTION  Cover mouth and nose with tissue when coughing or sneezing  Put used tissue in waste basket  Cough or sneeze into upper sleeve or elbow, not hands, if no tissue available  Wash hands often with soap and water for at least 20 seconds  After coughing and sneezing and before preparing foods or eating  Use an alcohol-based hand rub if soap and water are not available  Wash glasses, utensils, and plates after someone who is sick uses them  Take antibiotic as prescribed; finish course of treatment unless advised by clinicians  Infected individuals should stay home from work, school, or daycare until afebrile AND have taken antibiotics for at least 12 hours 58 QUESTION The most appropriate therapy for a young adult (weighing 70 kg) diagnosed with GABHS pharyngitis and has a penicillin allergy (anaphylaxis) is: A. Tetracycline 500 mg PO BID for 10 days B. Levofloxacin 750 mg PO daily for 10 days C. Penicillin V 500 mg PO twice daily for 10 days D. Azithromycin 500 mg PO once daily for one day, then 250 mg once daily for 4 days 59 QUESTION A local daycare reports several cases of GABHS pharyngitis. How many days must pass before the risk of additional cases is no longer a concern? The daycare is closed since the 23 outbreak. days A. 1 day B. 5 days C. 10 days D. 14 days 60 SUMMARY Upper Respiratory Tract Infections Otitis Media: Amoxicillin (Amoxil®) Sinusitis: Amoxicillin/Clavulanate (Augmentin ®) Pharyngitis: PCN or Amoxicillin (Amoxil ®) 61