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Adult Treatment - Upper Respiratory Tract Infections

1

Influenza

Annual vaccination is essential for all those “at risk” of influenza.[1D]

First line treatment for “at risk” patients: five days oseltamivir,[1D] when influenza is circulating in the community, and ideally within 48 hours of onset.

Or if severe immunosuppression or oseltamivir resistance: use zanamivir for up to 10 days and seek advice.[4D]

See PHE Influenza guidance for treatment.

See NICE Influenza for prophylaxis

Medicine Calendar

Antivirals are not recommended for healthy adults.[1D,2A+]

At risk: pregnant (including up to two weeks post-partum); adults 65 years or older; chronic respiratory disease (including COPD and asthma); significant cardiovascular disease (not hypertension); severe immunosuppression; diabetes mellitus; chronic neurological, renal or liver disease; morbid obesity (BMI>40); or in a care home where influenza is likely.[1D,2A+4D]

Oseltamivir (oral)

75mg BD

5 days

Zanamivir

10mg BD (2 inhalations by diskhaler)

5-10 days

Acute otitis externa

CKS OE

First line: analgesia for pain relief,[1D,2D] and apply localised heat (eg a warm flannel).[2D]

Second line: topical acetic acid or topical antibiotic +/- corticosteroid: similar cure at 7 days.[2D,3A+,4B-]

If cellulitis or disease extends outside ear canal, or systemic signs of infection, start oral flucloxacillin and refer to exclude malignant otitis externa.[1D]

Medicine Calendar

First line:
analgesia and apply localised heat

Second line
topical acetic acid 2%

1 spray TDS

7 days

OR topical neomycin sulphate with corticosteroid

3 drops TDS

7 days minimum to 14 days maximum1A+

If cellulitis: flucloxacillin

250mg QDS

if severe: 500mg QDS

7 days

Sinusitis (acute)

NICE-CKS RS

Symptoms <10 days:[1A+] do not offer antibiotics as most resolve in 14 days without,[2A+] and antibiotics only offer marginal benefit after 7 days (NNT15).[3A+]
Symptoms >10 days:[1A+] no antibiotic, or back-up antibiotic[4D] if several of: purulent nasal discharge;[1A+] severe localised unilateral pain; fever; marked deterioration after initial milder phase.[1A+]
Systemically very unwell, or more serious signs and symptoms:[1A+] immediate antibiotic.[1A+,5A-]Suspected complications: eg sepsis, intraorbital or intracranial, refer to secondary care.[1A+]
Self-care: paracetamol/ibuprofen for pain/fever.6D Consider high-dose nasal steroid if >12 years.[1A+] Nasal decongestants or saline may help some.[1A+]

Medicine Calendar

No antibiotics: self-care

First line for delayed: phenoxymethylpenicillin

500mg QDS

5 days

Penicillin allergy or intolerance: doxycycline

200mg STAT then 100mg OD

5 days

OR clarithromycin

500mg BD

5 days

Very unwell or worsening: co-amoxiclav

500/125mg TDS

5 days

Mometasone (nasal spray)

2 actuations (50 micrograms/actuation) in each nostril BD

14 days

Acute Sore Throat

NICE-CKS

Avoid antibiotics as 82% resolve in 7 days 1 A+, and pain is only reduced by 16 hours 2 A+.

Use FeverPAIN Score: Fever in last 24h, Purulence, Attend rapidly under 3 days, severely Inflamed tonsils, No cough or coryza.3 B+ 4 B+

Score 0-1: 13-18% streptococci, use NO antibiotic strategy
Score 2-3: 34-40% streptococci, use 3 day delayed/back-up antibiotic
Score 4 or more: 62-65% streptococci, use immediate antibiotic if severe, or 48hr short delayed/back-up prescription.5 A-

Advise paracetamol, self-care, and safety net.

Complications are rare: antibiotics to prevent quinsy NNT >4000 4 B-, otitis media NNT 200 2 A+

RCT in <18yr olds shows 10 days penicillin had lower relapse vs 5 days 8

Medicine Calendar

Fever pain 0-1: self-care

Fever pain 2-3: 3-day delayed/back up prescription of phenoxymethylpenicillin 5 B-

500mg QDS OR 1g BD (if mild)

5-10 days

Fever pain 4 or more: phenoxymethylpenicillin (if severe) or 48hr delayed/back-up prescription

500mg QDS OR 1g BD (if mild)

5-10 days

If Penicillin Allergic:
Clarithromycin

250mg BD

If severe 500mg BD

5 days

Penicillin allergy in pregnancy:
Erythromycin

250-500mg QDS

5 days

The POCAST project is funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and by the Imperial College Healthcare Charity (Grant Ref No:7006/P36U).