Collaborative Advancement of
C A EPrescription Excellence
Rhinosinusitis
Bronchitis
PharyngitisOtitis media
Common cold
Inf luenza
Upper Respiratory InfectionsImproving Symptom Management and Antibiotic Use
Spring 2018
Use non-antibiotic measures to manage upper respiratory infection (URI) symptoms.*
“Management of the common cold, non-specific URI, acute cough illness, and acute bronchitis should focus on symptomatic relief. Antibiotics should not be prescribed for these conditions.”
- American Academy of Pediatrics
• Almost 80 percent of these ADEs were allergic reactions.• Most allergic reactions can only be prevented by avoiding
exposure to a drug.
Avoiding unnecessary antibiotics (abx) reduces adverse drug events (ADEs).
Nearly 20% of all
emergency visits are
due to abx-ADEs
• The rate of frequency for abx-associated emergency department (ED) visits is highest for patients age < 1.
• More than 6 percent of abx-associated ADEs lead to hospitalization.• Reducing antibiotic prescribing by 10 percent may reduce community-
associated C. difficile infection by 17 percent.
Recommending symptom management and ruling out antibiotics improves parent satisfaction and reduces abx prescribing.
• Parents feel frustrated when no specific symptom management treatments are recommended.• Parents are most satisfied when:
» they receive tools to manage their child’s symptoms AND » they have an explanation of the inappropriateness of abx treatment for their child
Parents are 16% more likely to give provider the highest rating
85% decrease in abx prescribing
Symptom management and ruling out antibiotics:
References: 1 - 5*Upper respiratory infections: sinusitis, pharyngitis, tonsillitis, epiglottitis, tracheitis, bronchitis, laryngitis, acute otitis media, rhinitis, influenza
2 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
3
Increase vaccination rates to reduce the need for antibiotics.
Increased rates of flu vaccinations lead to decreased antibiotic prescribing.
Less than 46 percent of eligible U.S. patients receive the annual flu vaccine.
Each year, only 41 percent of Oklahomans are vaccinated for flu.
64%decreasein
abxprescribing
> 54%are not
vaccinated for flu
When universal flu vaccinations are implemented, flu-associated abx prescribing decreases by 64 percent.
Annual flu vaccination is recommended for everyone 6 months and older, including women who are pregnant, and those with egg allergy.
“Vaccination is the single most important step people can take to protect themselves from influenza.”
- Tom Frieden, M.D., M.P.H., infectious disease expert, former director of the Centers for Disease Control and Prevention (CDC)
Increased rates of pneumococcal vaccinations (PCVs) lead to decreased antibiotic prescribing.
PCV-13 administration reduces incidence of AOM by up to 67%.
For children age < 2 years, antibiotic prescription rates decrease by 11 percent, when 90 percent PCV-13 coverage is achieved.
• AOM is the leading cause of antibiotic prescribing among children from 6 months to 12 years of age. • PCV-13 vaccination results in up to 87 percent decrease in resistant pneumococcal disease.
References: 6 - 19
Nearly 20 percent of flu patients receive initial abx without:• underlying secondary infection• contributing comorbidity
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Use shared decision making to improve treatment of upper respiratory infections.
Benefits of using shared decision making (SDM) for URI prescribing may be seen for many years.
54%
27%39%
26%
0%
10%
20%
30%
40%
50%
60%
usual careUR
I pat
ient
s re
ceiv
ing
abx
pres
crip
tion Lasting Effects of SDM
initial 30 days 3.5 yrs later
SDMUR
I pat
ient
s re
ceiv
ing
abx
pres
crip
tion
References: 20 - 23
Treatment-associated-risk knowledge increases 30%
Only 2.6 minutes more provider time
SDM aids require minimal provider time, improve patient knowledge, and increase patient satisfaction when compared to usual care for URIs.
Disease knowledge increases 13%
Patients are 3% more satisfied
30%
13%
3%
2.6
4 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
5
A) There are multiple treatment options
Supportive care Watchful waiting Rest Adequate fluid intakeHumidified air Analgesics Antipyretics DecongestantsAntitussives Antivirals AntibioticsB) Patients have misconceptions
They believe they have only two options:1. “If I don’t take an antibiotic I will stay sick.”2. “If I take an antibiotic, I might stay sick, but I
might get better.”“If I take antibiotics, mostly nothing bad will happen.”“Antibiotics are worth the risk of side effects.” (> 75% believe antibiotics are worth the risk.)
SDM is especially helpful for upper respiratory infection (URI) treatment decisions because:
Use SDM to clarify patient expectations and prescriber perceptions.• 90 percent of URI patients expect to receive information and/or reassurance.• When patients actually expect an antibiotic, prescribers are four times more likely to prescribe
one.• When providers think their patients expect an antibiotic, they are ten times more likely to
prescribe one.• Clarifying expectations and providing information and/or reassurance through SDM can result in
a 40 percent or greater decrease in antibiotic prescribing for URIs.
SDM is endorsed by multiple organizations and is recommended to be implemented whenever possible.
• American Academy of Family Physicians• American Academy of Orthopaedic Surgeons• American Academy of Pediatrics• American College of Physicians• American College of Critical Care• American Osteopathic Association
• American Thoracic Society• Centers for Medicare and Medicaid Services• Health and Medicine Division of the National
Academies of Science (formerly Institute of Medicine)
• U.S. Department of Health & Human ServicesReferences: 24 - 37
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
When antibiotics are necessary, choose the most narrow spectrum possible.
Use narrow spectrum abx to avoid adverse drug reactions (ADRs)Pediatric ADRs compared: diarrhea, rash, upset stomach, vomiting
Amoxicillin-clavulanate, azithromycin, cefdinir, cefprozil, cefuroxime, cephalexin, ceftriaxone, cefadroxil
35.6 percent had ADRs
Penicillin, amoxicillin 25.1 precent had ADRsAdverse drug reactions (ADRs) are more likely with even moderately broad-spectrum antibiotics.
References: 1, 38 - 41
Narrow-spectrum antibiotics are underutilized for URI treatment.
Otitis Media Sinusitis
100
75
50
25
0
Used and adapted with permission: Adam L. Hersh, M.D., Ph.D.
Per
cent
age
When a bacterial URI is reasonably suspected:• First-line agents are used only 52 percent of the time. • First-line agents should be used 80 percent of the time.
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Pharyngitis
Pediatric Patients
Sinusitis Pharyngitis
Adult Patients
First-line:Amoxicillin, penicillinAmoxicillin-clavulanate
Non-first-line:MacrolideBroad cephalosporinFluoroquinoloneOthers
6 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
7
Outcomes were equivalent for:Speed of symptom resolution Duration of fever Hospital admissionChild sleep quality Need for additional child care SepsisNeed for supplemental oxygen Need for second antibiotic Need for intensive careEmergency department admissionMissed work days (parent) or school days (child)
Broad-spectrum antibiotics have not been shown to produce better clinical outcomes when compared to narrow-spectrum antibiotics.
How drug resistance happens:
Use narrow-spectrum antibiotics to reduce drug-resistance.
Narrow-spectrum killing X: Broad-spectrum killing
Lots of bacteria.A few are
drug resistant.
Antibiotics killbacteria causing the
illness, as well as good bacteria.
Drug-resistantbacteria are allowed to
grow and take over.
XX
X
XX
Drug-resistantbacteria give their
resistance to other bacteria, causing more resistance.
Permission granted 8/7/17
Chronology of viral and bacterial sinusitis
Per
cent
of p
atie
nts
ViralAerobes
Anaerobes
3 Months8-10 Days
100
80
60
40
20
0
Used and adapted with permission: Itzhak Brook, M.D.
URIs follow a pattern that supports
choosing narrow-spectrum antibiotics
before broad-spectrum antibiotics.
References: 39, 42-44
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Resources
Collaborative Advancement of
C A EPrescription Excellence
Symptomatic treatment of URIs Pg. 9
Decision support tools: Acute rhinosinusitis Pg. 10 - 13
Decision support tools: Acute bronchitis Pg. 14 - 17
Decision support tools: Acute pharyngitis Pg. 18 - 21
Decision support tools: Acute otitis media Pg. 22 - 25
Decision support tools: Common cold Pg. 26 - 27
Decision support tools: Influenza Pg. 28
Medication record Pg. 29
Bacterial URI pathogens Pg. 30
Ambulatory treatment of bacterial URI Pg. 31 - 36
Ambulatory treatment of cough Pg. 37
Ambulatory treatment of influenza Pg. 38 - 39
Inhaled corticosteroids, probiotics Pg. 40
National quality measures Pg. 41
Child care letter Pg. 42
ACIP immunization schedules Pg. 43 - 50
References Pg. 51 - 56
Additional resources Pg. 57 - 58
8 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
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Symptomatic treatment and supportive care are recommended for treatment of acute, uncomplicated URIs.
References: 1, 31 - 48
adult
Evidence-based symptomatic management Supportive care is recommended for all URI diagnoses • Rest• Hydration• Clean cool mist vaporizer• Avoiding smoke and other
pollutants
Rhino-sinusitis
Bronchitis, tracheitis
Pharyngitis, epiglottitis, laryngitis, tonsillitis
Acute otitis media (AOM)
Common cold
Influenza
> 98% viral, allergic, or
irritant> 90% viral
Adults: > 85% viral
Children: > 70% viral
Up to 96% bacterial
100% viral 100% viral
NSAIDS
Acetaminophen
Warm, moist compress
Topical anesthetics adult
In 4 of 5 patients with bacterial AOM, symptoms resolve:
• within 24 hours
• without antibiotic drug therapy
1st-generation antihistamines age ≥ 6 adults: only as combo therapy
age ≥ 6
Systemic decongestants age ≥ 6 age ≥ 6
Cough suppressants age ≥ 6 age ≥ 6
Beta-2 agonistsif wheezing
present
Honey children: age ≥ 1 age ≥ 1 children: age ≥ 1
Inhaled corticosteroidschildren: high
dose, if wheezingchildren: high
dose, if wheezing
Intranasal corticosteroidsage varies with
agent
Breathe in steam adult
Mast stabilizers
Nasal inhalants children: age ≥ 2
Mucolytics adult
CAM*
Lozenges/hard candy age ≥ 5
Warm liquids
Oral rinses if able to gargle
Ice chips
Topical decongestants
Saline irrigation
Antiviral treatmentwithin 48 hours of symptom onset
*CAM: Complementary alternative medicine (zinc, echinacea, pelargonium, see pg. 13 - 28)
Demonstrated efficacy in absence of antibiotic treatment, may also have role as adjuvant therapy if antibiotics are initiated.
Mixed evidence for efficacy.
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Acute rhinosinusitis: Antibiotics or not?
How long have you had sinus symptoms?Children: 0 - 9 days
Adults: 0 - 6 days
Children: 10 - 14 days
Adults: 7 - 10 days
Have you had any of the following:
Double sickening (getting better, then getting worse) 1 1
Colored nasal discharge 1 1
Facial or sinus pain 1 1
Pain near top molars 1 1
Decongestants not working 1 1
Additional signs from examination:
Purulent discharge in nasal cavity (middle meatus) and/or throat 1 1
Sinus pain on one side 1 1
Abnormal translumination on one side 1 1
Total:
Probability of acute BACTERIAL rhinosinusitis
4 or more 30 % 95 %
3 15 % 75 %
2 5 % 50 %
1 2 % 25 %
0 1 % 5 %
Alerts:
Persistent high fever
Severely ill
Swelling/redness near or around eye(s)
Double vision, bulging eye(s), or neurological signs
References: 61 - 62 Used and adapted with permission: France Légaré, M.D., Ph.D10 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
11References: 61 - 62Used and adapted with permission: France Légaré, M.D., Ph.D
Rating benefits and risks:On a scale of 1 - 5:
How important are these benefits? How important are these risks?
Antibiotic
Having symptoms for a little less time (6 days instead of 7)
Taking medicine for many days
Having additional problems (side effects)
No antibiotic
Feel better/cured without adding drugs Having symptoms for a little more time (7 days instead of 6)
Not having additional problems (side effects)
Any other benefits or risks?
Acute rhinosinusitis: Benefits
If we look at 100 patients with symptoms like yours, here is what we see after 1 week.
AntibioticsNo AntibioticsOnly 10 patients
actually benefit from an antibiotic. They feel
better 1 day sooner.
Acute rhinosinusitis: Risks
If we look at 100 patients with symptoms like yours, here are the additional problems we see from antibiotics.
If you decide to take an antibiotic, there is no way to know for certain if you will be one who benefits, or if you will be one who has additional problems from the antibiotic.
70 feel better/cured.
30 still have symptoms.
85 will not have any additional problems.
15 will have diarrhea, stomach ache, or skin
rash.
An additional 5 patients will have diarrhea, stomach ache, or skin rash from an antibiotic.
AntibioticsNo Antibiotics
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Micromedex
Adults and children age 12 years and older: Acute rhinosinusitis* These medications are not covered through most pharmacy benefits.
Your diagnosis today is acute rhinosinusitis. This means you have a sinus infection, most likely caused by a virus. You will probably feel much better in 7 - 10 days. These activities and medications will help you feel better while your body heals from the infection:
• Warm, moist compress applied to nose and/or forehead to relieve sinus pressure. May be used as often as desired.
• Breathe in steam from bowl of hot water or shower. May be used as often as desired.
• “Normal” saline (salt water) spray or nasal rinse (ex. Neti-pot, etc.). May be used 1 - 3 times in 24 hours.
Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Feve
r and
/or p
ain
Aspirin (age ≥ 20 yr) 325 - 650 mg 4 - 6 HR 4000 mg
Ibuprofen 200 - 400 mg 4 - 6 HR 1200 mg, also < 10 days
Naproxen 500 mg as 1st dose, 250 mg later 6 - 8 HR 1250 mg
Acetaminophen RS 650 mg 4 - 6 HR 3250 mg
Acetaminophen ES 1000 mg 6 HR 3000 mg
Acetaminophen ER 1300 mg 8 HR 3900 mg
Acetaminophen SUPP 650 mg 4 - 6 HR 6 SUPP
Stuf
fy n
ose
Pseudoephedrine 60 mg 4 - 6 HR 240 mg
Pseudoephedrine SR 120 mg 12 HR 240 mg
Pseudoephedrine SR 240 mg 24 HR 240 mg
Phenylephrine 10 - 20 mg (oral) 4 HR 120 mg
Oxymetazoline 2 - 3 sprays in each nostril 12 HR 12 sprays, also < 3 days
Phenylephrine 2 - 3 sprays in each nostril 4 HR
Run
ny n
ose
Chlorpheniramine 4 mg 4 - 6 HR 24 mg
Chlorpheniramine SR 8 - 12 mg 8 - 12 HR 24 mg
Brompheniramine 4 mg 4 - 6 HR 40 mg
Diphenhydramine 25 - 50 mg 4 - 6 HR 300 mg
Cromolyn 1 spray in each nostril 4 - 8 HR 12 sprays
Additional steroid nasal sprays are available by prescription. Over-the-counter and prescription sprays are equally effective. Benefits will usually not be seen until after 2 weeks of use.
Fluticasone 2 sprays in each nostril 24 HR 4 sprays
Fluticasone 1 sprays in each nostril 12 HR
Triamcinolone 2 sprays in each nostril 24 HR 4 sprays*HR: hour RS: Regular Strength ES: Extra Strength ER: Extended Release SUPP: Suppository SR: Sustained release
References: 19, 21, 45 - 46, 50 - 51, 55 - 57, 61 - 88
Today we have decided that you:
do NOT want to be prescribed an antibiotic. do NOT want a prescription steroid spray.
want to be prescribed an antibiotic. want a prescription steroid spray.
are taking the prescription(s) with you today. asked that I send the prescription(s) to your preferred pharmacy.
12 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
13
https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.html
Micromedexfacts & comparisons
Children age 11 years and younger: Acute rhinosinusitis* These medications are not covered through most pharmacy benefits.
Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.Your child’s diagnosis today is acute rhinosinusitis. This means they have a sinus infection, most likely caused by a virus. They will probably feel much better in 7 - 10 days. These activities and medications will help them feel better while their body heals from the infection:
• Warm, moist compress applied to nose and/or forehead to relieve sinus pressure. May be used as often as desired.
• Breathe in steam from bowl of hot water or shower. May be used as often as desired.
• “Normal” saline (salt water) spray or nasal rinse (ex. Neti-potTM, etc.). May be used 1 - 3 times in 24 hours.
Age/weight: Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Feve
r and
/or p
ain 6 MO to 12 YR Ibuprofen 5 - 10 mg/kg 6 - 8 HR 4 doses, also < 10 days
Your child’s ibuprofen dose is:
< 60 kg (132 lb) Acetaminophen 10 - 15 mg/kg 4 - 6 HR Age 1 or younger: 75 mg/kgAge ≥ 1 yr: 100 mg/kg, OR 1625 mgYour child’s acetaminophen dose is:
> 60 kg (132 lb) Acetaminophen RS 650 mg 4 - 6 HR 3250 mg
Stuf
fy n
ose
4 to 5 YR Pseudoephedrine 15 mg 4 - 6 HR 60 mg
6 to 12 YR Pseudoephedrine 30 mg 4 - 6 HR 120 mg
4 to 6 YR Phenylephrine (oral) 5 mg 4 HR 30 mg
6 to 12 YR Phenylephrine (oral) 10 mg 4 HR 60 mg
6 to 12 YR Oxymetazoline 2 - 3 sprays in each nostril 12 HR 12 sprays, also < 3 days
4 to 6 YR Phenylephrine 0.125 % 2 - 3 sprays in each nostril 4 HR 36 sprays, also < 3 days
6 to 12 YR Phenylephrine 0.25 %
Run
ny n
ose
6 to 11 YR Chlorpheniramine 2 mg 4 - 6 HR 12 mg4 to 6 YR Brompheniramine 1 mg 4 - 6 HR 6 mg6 to 12 YR Brompheniramine 2 mg 4 - 6 HR 12 mg4 to 6 YR Diphenhydramine 6.25 - 12.5 mg 4 - 6 HR 75 mg6 to 12 YR Diphenhydramine 12.5 - 25 mg 4 - 6 HR 150 mg≥ 2 YR Cromolyn 1 spray in each nostril 4 - 8 HR 12 spraysAdditional steroid nasal sprays are available by prescription. Over-the-counter and prescription sprays are equally effective. Benefits will usually not be seen until after 2 weeks of use.
≥ 4 YR Fluticasone 1 spray in each nostril 24 HR 4 sprays
2 to 5 YR Triamcinolone 1 spray in each nostril 24 HR 2 sprays
6 to 12 YR Triamcinolone 1 spray in each nostril 24 HR 4 sprays*MO: months YR: year HR: hour RS: regular strength
Today we have decided that you:
do NOT want to be prescribed an antibiotic for your child.
do NOT want a prescription steroid spray for your child.
want to be prescribed an antibiotic for your child. want a prescription steroid spray for your child.
are taking the prescription(s) with you today. asked that I send the prescription(s) to your preferred pharmacy.
References: 21, 45, 56 - 57, 60 - 62, 64, 66 - 67, 69, 70 - 79, 86 - 89
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Acute bronchitis: Antibiotics or not?
Acute bronchitis is considered for a cough lasting less than 3 weeks.
Note: Presence or absence of phlegm/mucus (clear or colored) with cough does not indicate presence or absence of acute bronchitis.
Do you have, or have you recently experienced any of the following?
Pneumonia(Pneumonia is excluded [< 1% probability] only if vital signs and lung exam are both normal)
yes no
COPD with infection yes no
Acute respiratory infection/sinus infection yes no
Whooping cough yes no
Influenza (flu) yes no
Bronchiolitis (children only) yes no
Asthma yes no
Other respiratory condition: ___________ yes no
If all above answers were all “no,” then acute bronchitis is the most probable diagnosis.
Probability of acute BACTERIAL bronchitis 10% or less
References: 61 - 62 Used and adapted with permission: France Légaré, M.D., Ph.D14 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
15References: 61 - 62
Acute bronchitis: Benefits
If we look at 100 patients with a cough like yours, here is what we see after 2 weeks.
AntibioticsNo AntibioticsOnly 10 patients
actually benefit from an antibiotic. They
feel better 1/2 to 1 day sooner.
Acute bronchitis: Risks
If we look at 100 patients with a cough like yours, here are the additional problems we see from antibiotics.
If you decide to take an antibiotic, there is no way to know for certain if you will be one who benefits, or if you will be one who has additional problems from the antibiotic.
70 are not coughing.
30 are still coughing.
85 will not have any additional problems.
15 will have diarrhea, stomach ache, or skin
rash.
An additional 5 patients will have diarrhea, stomach ache, or skin rash from an antibiotic.
AntibioticsNo Antibiotics
Rating benefits and risks:On a scale of 1 - 5:
How important are these benefits? How important are these risks?
AntibioticHaving a cough for a little less time (1/2 to 1 day less, over 2 - 3 weeks total)
Taking medicine for many days
Having additional problems (side effects)
No antibioticFeel better/cured without adding drugs Having a cough for a little more time
(1/2 to 1 day more, over 2 - 3 weeks total)Not having additional problems (side
effects)Any other benefits or risks?
Used and adapted with permission: France Légaré, M.D., Ph.D
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Today we have decided that you:want to be prescribed an antibiotic. do NOT want to be prescribed an antibiotic.
want to be prescribed a cough suppressant, to be used when needed.
want to be prescribed a rescue medication, to be used when needed.
are taking the prescription(s) with you today. asked that I send the prescription(s) to your preferred pharmacy.
Micromedexfacts and comparisons
Adults and children age 12 years and older: Acute bronchitis* Over-the-counter (OTC) medications are not covered through most pharmacy benefits.
Your diagnosis today is acute bronchitis, also known as a “chest cold.” This means you have an infection, most likely caused by a virus. You will probably feel much better in 2 - 3 weeks. These activities and medications will help you feel better while your body heals from the infection:
• Breathe in steam from bowl of hot water or shower or use a clean humidifier/cool mist vaporizer. May be used as often as desired.
Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Cou
gh -
OTC
Diphenhydramine 25 - 50 mg 4 - 6 HR 300 mgPhenylephrine (spray) 2 - 3 sprays in each nostril 4 HR 12 sprays, also < 3 daysPhenylephrine (oral) 10 - 20 mg 4 HR 120 mgDextromethorphan HBr 30 mg 6 - 8 HR 120 mgDextromethorphan Polistirex 10 mL 12 HR 20 mLGuaifenesin IR 200 - 400 mg 4 HR 2400 mgGuaifenesin ER 600 - 1200 mg 12 HR*Additional evidence has shown pelargonium and echinacea to help some patients. FDA does not regulate strength or purity of these products. Pelargonium (11% extract) 30 drops 8 HR 90 dropsEchinacea (dried root) 0.5 - 1 G 8 HR 3 G
Cou
gh -
Rx
• These prescription medications may reduce your cough. • Complete instructions are provided with prescriptions.
* Some medications may not be covered through most pharmacy benefits or may require prior authorization.
Benzonatate (+ guaifenisen) These are cough suppressants/mucolytics. You may use them, if needed, when you are coughing. Codeine (age ≥ 18 YR only)
Albuterol (inhaler or nebulizer)
This is a rescue medication, to be used if you are coughing AND wheezing.
*HR: hour IR: immediate release ER: extended release YR: year
References: 50 - 51, 55, 61 - 62, 67, 73, 77, 80 - 82, 84, 86, 90 - 9516 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
17
https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.html
Children age 11 years and younger: Acute bronchitis* Over-the-counter (OTC) medications are not covered through most pharmacy benefits.
Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.Your child’s diagnosis today is acute bronchitis, also known as a “chest cold.” This means they have an infection, most likely caused by a virus. They will probably feel much better in 2 - 3 weeks. These activities and medications will help them feel better while their body heals from the infection:
• Breathe in steam from bowl of hot water or shower or use a clean humidifier/cool mist vaporizer. May be used as often as desired.
Age/weight: Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Cou
gh -
OTC
4 to 6 YR Diphenhydramine 6.25 - 12.5 mg 4 - 6 HR 75 mg
6 to 12 YR Diphenhydramine 12.5 - 25 mg 4 - 6 HR 150 mg
4 to 6 YR Phenylephrine (oral) 5 mg 4 HR 30 mg
6 to 12 YR Phenylephrine (oral) 10 mg 4 HR 60 mg
4 to 6 YR Phenylephrine 0.125 % 2 - 3 sprays in each nostril
4 HR 36 sprays, also < 3 days
6 to 12 YR Phenylephrine 0.25 %
4 to 5 YR Dextromethorphan HBr
5 mg 4 HR 30 mg
6 to 12 YR 10 mg 4 HR 60 mg
4 to 5 YR Dextromethorphan Polistirex
15 mg 12 HR 30 mg
6 to 12 YR 30 mg 12 HR 60 mg
4 to 5 YR Guaifenesin IR 100 mg 4 HR 600 mg6 to 12 YR Guaifenesin IR 100 - 200 mg 4 HR 1200 mg≥ age 1 Dark honey 2 tsp (10 mL) May be used as often as desired.
*Additional evidence has shown pelargonium to help some patients. FDA does not regulate strength or purity of these products.
6 to 12 YR Pelargonium (11% extract)
10 drops 8 HR 30 drops
Cou
gh -
Rx
• These prescription medications may reduce their cough. • Complete instructions are provided with prescriptions.
* Some medications may not be covered through most pharmacy benefits or may require prior authorization.
≥ age 10 Benzonatate (+ guaifenisen)
These are cough suppressants/mucolytics. You may give them, if needed, when they are coughing.
0 - 12 YR Albuterol (inhaler or nebulizer)
This is a rescue medication, to be used if they are coughing AND wheezing.
0 - 12 YR Inhaled corticosteroid This is an anti-inflammatory to be used daily until the cough is gone.
*YR: year HR: hour IR: immediate release
References: 50 - 51, 55, 55, 60 - 62, 67, 73, 77, 80 - 82, 84, 86, 90 - 94
For your child, today we have decided that you:want to be prescribed an antibiotic. do NOT want to be prescribed an antibiotic.
want to be prescribed a cough suppressant, to be used when needed.
want to be prescribed a rescue medication, to be used when needed.
want to be prescribed a corticosteroid, to be used every day.
are taking the prescription(s) with you today. asked that I send the prescription(s) to your preferred pharmacy.
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Acute pharyngitis: Antibiotics or not?
For patients with a sore throat:
No cough + 1
Temperature > 100.4 °F + 1
Age 3 - 15 years + 1
Age ≥ 44 years - 1
Additional signs from examination:
Swollen, tender lymph nodes + 1
Tonsillar swelling or exudates + 1
Total:
Probability of acute BACTERIAL pharyngitis
(Group A streptococci)
Close contact with Group A strep-infected person within the past 2 weeks,
OR current local Group A strep epidemicno yes
4 or more 50 % 65 %
3 30 % 45 %
2 15 % 45 %
1 8 % 15 %
0 1 % 2 %
Alerts:Stiff neck in childrenLateral shift of the uvulaStridor and dyspneaSkin rash
Additional note:
Rapid antigen detection test (RADT) should be used only when patients do NOT have viral symptoms (rhinorrhea, cough, oral ulcers, and/or hoarseness). Back-up cultures are recommended for a negative strep test in children and adolescents.
References: 47, 61 - 62 Used and adapted with permission: France Légaré, M.D., Ph.D18 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
19
Acute pharyngitis: Benefits
If we look at 100 patients with symptoms like yours, here is what we see after 4 - 5 days.
AntibioticsNo Antibiotics
Only 10 patients actually benefit from
an antibiotic. They feel better 1 day sooner.
Acute pharyngitis: Risks
If we look at 100 patients with symptoms like yours, here are the additional problems we see from antibiotics.
If you decide to take an antibiotic, there is no way to know for certain if you will be one who benefits, or if you will be one who has additional problems from the antibiotic.
70 do not have throat pain.
30 still have throat pain.
85 will not have any additional problems.
15 will have diarrhea, stomach ache, or skin
rash.
An additional 5 patients will have diarrhea, stomach ache, or skin rash from an antibiotic.
AntibioticsNo Antibiotics
Used and adapted with permission: France Légaré, M.D., Ph.D
Rating benefits and risks:On a scale of 1 - 5:
How important are these benefits? How important are these risks?
Antibiotic Having throat pain for a little less time (3 - 4 days instead of 4 - 5 days)
Taking medicine for many days
Having additional problems (side effects)
No antibioticFeel better/cured without adding drugs
Having throat pain for a little more time (4 - 5 days instead of 3 - 4 days)Not having additional problems (side
effects)Any other benefits or risks?
References: 61 - 62Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Today we have decided that you:
do NOT want to be prescribed an antibiotic.
want to be prescribed an antibiotic.
are taking the antibiotic prescription with you today.
asked that I send the prescription to your preferred pharmacy.
Facts & Comaprisons:
Adults and children age 12 years and older: Acute pharyngitis* Over-the-counter (OTC) medications are not covered through most pharmacy benefits.
Your diagnosis today is acute pharyngitis, also known as a “sore throat.” This means you have an infection, most likely caused by a virus. You will probably feel much better in 4 - 5 days. The medications will help you feel better while your body heals from the infection.These non-medicated items will help you feel better and may be used as often as desired:• Ice chips and frozen treats such as popsicles.• Hard candies (may be as effective as medicated lozenges).• Warm salt water rinse/gargle: 1/4 to 1/2 teaspoon of salt + 8 ounces (1 cup) warm water. Do not swallow.• Warm liquids such as tea with or without lemon and/or honey. Limit teas containing caffeine.• Use a clean humidifier or cool mist vaporizer.
Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Feve
r and
/or p
ain
Aspirin (age ≥ 20 yr) 325 - 650 mg 4 - 6 HR 4000 mg
Ibuprofen 200 - 400 mg 4 - 6 HR 1200 mg, also < 10 days
Naproxen 500 mg as 1st dose, 250 mg later
6 - 8 HR 1250 mg
Acetaminophen RS 650 mg 4 - 6 HR 3250 mg
Acetaminophen ES 1000 mg 6 HR 3000 mg
Acetaminophen ER 1300 mg 8 HR 3900 mg
Acetaminophen SUPP 650 mg 4 - 6 HR 6 SUPP
Pain
Medicated throat lozenge 1 lozenge 2 HR 12 lozenges
Medicated throat spray 2 - 3 sprays 6 HR 12 sprays
*HR: hour RS: Regular Strength ES: Extra Strength ER: Extended Release SUPP: Suppository
References: 12, 47 - 48, 55, 60 - 62, 65, 67 - 71, 86, 96 - 9920 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
21
Today we have decided that you:
do NOT want to be prescribed an antibiotic for your child.
want to be prescribed an antibiotic for your child.
are taking the antibiotic prescription with you today. asked that I send the prescription to your preferred pharmacy.
https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.html
Adults and children age 11 years and younger: Acute pharyngitis* Over-the-counter (OTC) medications are not covered through most pharmacy benefits.
Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.
Your child’s diagnosis today is acute pharyngitis, also known as a “sore throat.” This means they have an infection, most likely caused by a virus. They will probably feel much better in 4 - 5 days. The medications will help them feel better while their body heals from the infection.These non-medicated items will help them feel better and may be used as often as desired:• Ice chips and frozen treats such as popsicles and ice cream.• Hard candies (may be as effective as medicated lozenges). Age ≥ 5 YR.• Warm salt water rinse/gargle (age ≥ 6 YR and able to gargle): 1/4 to 1/2 teaspoon of salt + 8 ounces (1 cup)
warm water. Do not swallow.• Warm liquids such as tea with or without lemon and/or honey (honey: age ≥1 YR). Limit teas containing caffeine.• Use a clean humidifier or cool mist vaporizer.
Age/weight: Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Feve
r and
/or p
ain
6 MO to 12 YR Ibuprofen 5 - 10 mg/kg 6 - 8 HR 4 doses, also < 10 days
Your child’s ibuprofen dose is:
< 60 kg (132 lb) Acetaminophen 10 - 15 mg/kg 4 - 6 HR Age 1 or younger: 75 mg/kg
Age ≥ 1 yr: 100 mg/kg, also 1625 mg
Your child’s acetaminophen dose is:
> 60 kg (132 lb) Acetaminophen RS 650 mg 4 - 6 HR 3250 mg
Pain
≥ age 5 Medicated throat lozenge
1 lozenge 2 HR 12 lozenges
≥ age 1 Honey 2 tsp (10 mL) May be used as often as desired.
*MO: month YR: year HR: hour RS: regular strength
References: 12, 47, 60 - 62, 67, 69, 71, 86, 96, 98 - 102
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Acute otitis media: Antibiotics or not?
For patients with suspected AOM, or suspicion of AOM by parent(s):
Signs from examination:
Inflammation:
Erythema of ear drum no yes
Fluid in the middle ear
Bulging of ear drum no yes
Limitied mobility/loss of mobility of ear drum no yes
Air-fluid level behind ear drum no yes
Ear discharge no yes
Probability of AOM
Do you have distinct and sudden ear pain that interferes with normal activities or sleep?
no yes
Inflammation AND fluid 99 % 99 %
Fluid only 40 % 85 %
Inflammation only 20 % 60 %
No inflammation, no fluid < 1 % 3 %
Alerts:
Persistent high fever
Severely ill
References: 61 - 62 Used and adapted with permission: France Légaré, M.D., Ph.D22 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
23References: 61 - 62
Acute otitis media: Benefits
If we look at 100 patients with symptoms like yours, here is what we see after 2 - 3 days.
AntibioticsNo AntibioticsOnly 10 patients
actually benefit from an antibiotic. They
feel better a few hours sooner.
Acute otitis media: Risks
If we look at 100 patients with symptoms like yours, here are the additional problems we see from antibiotics.
If you decide to take an antibiotic, there is no way to know for certain if you will be one who benefits, or if you will be one who has additional problems from the antibiotic.
70 do not have ear pain.
30 still have ear pain.
85 will not have any additional problems.
15 will have diarrhea, stomach ache, or skin
rash.
An additional 5 patients will have diarrhea, stomach ache, or skin rash from an antibiotic.
AntibioticsNo Antibiotics
Rating benefits and risks:On a scale of 1 - 5:
How important are these benefits? How important are these risks?
Antibiotic Having ear pain for a little less time (a few hours less, over 2 - 3 days total)
Taking medicine for many days
Having additional problems (side effects)
No antibioticFeel better/cured without adding drugs
Having ear pain for a little more time (a few hours more, over 2 - 3 days total)Not having additional problems (side
effects)Any other benefits or risks?
Used and adapted with persmission: France Légaré, M.D., Ph.D
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Today we have decided that you:
do NOT want to be prescribed an antibiotic.
want to be prescribed an antibiotic.
are taking the antibiotic prescription with you today.
asked that I send the prescription to your preferred pharmacy.
Micromedexfacts and comparisons
Adults and children age 12 years and older: Acute otitis media* These medications are not covered through most pharmacy benefits.
Your diagnosis today is acute otitis media. This means you have an ear infection, which may be caused by bacteria or a virus.
Even if the infection is from bacteria, 4 out of 5 people feel better in 24 hours, without adding an antibiotic.
You will probably feel much better in 2 - 3 days. These activities and medications will help you feel better while your body heals from the infection:
• Warm, moist compress applied to the ear. May be used as often as desired.
Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Feve
r and
/or p
ain
Aspirin (age ≥ 20 yr) 325 - 650 mg 4 - 6 HR 4000 mg
Ibuprofen 200 - 400 mg 4 - 6 HR 1200 mg, also < 10 days
Naproxen 500 mg as 1st dose, 250 mg later 6 - 8 HR 1250 mg
Acetaminophen RS 650 mg 4 - 6 HR 3250 mg
Acetaminophen ES 1000 mg 6 HR 3000 mg
Acetaminophen ER 1300 mg 8 HR 3900 mg
Acetaminophen SUPP 650 mg 4 - 6 HR 6 SUPP
*HR: hour RS: Regular Strength ES: Extra Strength ER: Extended Release SUPP: Suppository
References: 21, 55 - 56, 60 - 62, 65, 67 - 71, 86, 10324 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
25
Today we have decided that you:
do NOT want to be prescribed an antibiotic for your child.
want to be prescribed an antibiotic for your child.
are taking the antibiotic prescription with you today. asked that I send the prescription to your preferred pharmacy.
Micromedexfacts and comparisons
Children age 11 years and younger: Acute otitis media* These medications are not covered through most pharmacy benefits.
Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.Your child’s diagnosis today is acute otitis media. This means your child has an ear infection, which may be caused by bacteria or a virus.
Even if the infection is from bacteria, 4 out of 5 children feel better in 24 hours, without adding an antibiotic.
Your child will probably feel much better in 2 - 3 days. These activities and medications will help them feel better while their body heals from the infection:
• Warm, moist compress applied to the ear. May be used as often as desired.
Age/weight: Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Feve
r and
/or p
ain
6 MO to 12 YR Ibuprofen 5 - 10 mg/kg 6 - 8 HR 4 doses, also < 10 days
Your child’s ibuprofen dose is:
< 60 kg (132 lb) Acetaminophen 10 - 15 mg/kg 4 - 6 HR Age 1 or younger: 75 mg/kg
Age ≥ 1 yr: 100 mg/kg, also 1625 mg
Your child’s acetaminophen dose is:
> 60 kg (132 lb) Acetaminophen RS 650 mg 4 - 6 HR 3250 mg
*MO: months YR: year HR: hour RS: regular strength
References: 4, 13, 21, 65, 60 - 62, 67, 69, 71, 103 - 106
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Zinc, Cold Eeze facts & comparisons
Adults and children age 12 years and older: Common cold* These medications are not covered through most pharmacy benefits.
Your diagnosis today is the common cold. This means you an infection, caused by a virus. You will probably feel much better in 10 days. These activities and medications will help you feel better while your body heals from the infection:• “Normal” saline (salt water) spray or nasal rinse (ex. Neti-pot, etc.).
May be used 1 - 3 times in 24 hours.• Breathe in steam from bowl of hot water or shower.
May be used as often as desired.• Zinc lozenges (acetate or gluconate), started within the first 24 - 48 hours of symptoms.
May be used up to six times per day (age > 18); up to four times per day (age 12 - 17 YR).Drug: Dose: May use
every:In 24 hours,Do NOT take more than:
Feve
r and
/or p
ain
Aspirin (age ≥ 20 yr) 325 - 650 mg 4 - 6 HR 4000 mg
Ibuprofen 200 - 400 mg 4 - 6 HR 1200 mg, also < 10 days
Naproxen 500 mg as 1st dose, 250 mg later 6 - 8 HR 1250 mg
Acetaminophen RS 650 mg 4 - 6 HR 3250 mg
Acetaminophen ES 1000 mg 6 HR 3000 mg
Acetaminophen ER 1300 mg 8 HR 3900 mg
Acetaminophen SUPP 650 mg 4 - 6 HR 6 SUPP
Stuf
fy n
ose Pseudoephedrine 60 mg 4 - 6 HR 240 mg
Pseudoephedrine SR 120 mg 12 HR 240 mg
Pseudoephedrine SR 240 mg 24 HR 240 mg
Phenylephrine 10 - 20 mg (oral) 4 HR 120 mg
Run
ny n
ose Chlorpheniramine 4 mg 4 - 6 HR 24 mg
Chlorpheniramine SR 8 - 12 mg 8 - 12 HR 24 mg
Brompheniramine 4 mg 4 - 6 HR 40 mg
Diphenhydramine 25 - 50 mg 4 - 6 HR 300 mg
Cou
gh -
OTC
Dextromethorphan HBr 30 mg 6 - 8 HR 120 mg
Dextromethorphan Polistirex
10 mL 12 HR 20 mL
*Additional evidence has shown echinacea to help some patients. FDA does not regulate strength or purity of these products.Echinacea (dried root) 0.5 - 1 G 8 HR 3 G
Cou
gh -
Rx
• These prescription medications may reduce your cough. • Complete instructions are provided with prescriptions.• Some medications may not be covered through most pharmacy benefits or may require prior
authorization.Benzonatate (+ guaifenisen) These are cough suppressants/mucolytics.
You may use them, if needed, when you are coughing.Codeine (age ≥ 18 YR)
Ipratropium*HR: Hour RS: Regular Strength ES: Extra Strength ER: Extended Release SUPP: Suppository SR: Sustained release YR: Year
References: 21, 47, 52 - 53, 60 - 62, 65, 67 - 73, 75 - 77, 91, 93 - 95, 107 - 10826 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
27
Children age 11 years and younger: Common cold* These medications are not covered through most pharmacy benefits.
Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.Your child’s diagnosis today is the common cold. This means they have an infection, caused by a virus. They will probably feel much better in 10 days. These activities and medications will help them feel better while their body heals from the infection:
• “Normal” saline (salt water) spray or nasal rinse (ex. Neti-pot, etc.). May be used 1 - 3 times in 24 hours.
• Zinc sulfate syrup, 15 mg/5 mL, age 1 to 10 YR, started within the first 24 - 48 hours of symptoms. May give once daily, up to 30 mL per day.
Age/weight: Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Feve
r and
/or p
ain 6 MO to 12 YR Ibuprofen 5 - 10 mg/kg 6 - 8 HR 4 doses, also < 10 days
Your child’s ibuprofen dose is:
< 60 kg (132 lb) Acetaminophen 10 - 15 mg/kg 4 - 6 HR Age 1 or younger: 75 mg/kg
Age ≥ 1 yr: 100 mg/kg, OR 1625 mg
Your child’s acetaminophen dose is:
> 60 kg (132 b) Acetaminophen RS 650 mg 4 - 6 HR 3250 mg
Stuf
fy n
ose 4 to 5 YR Pseudoephedrine 15 mg 4 - 6 HR 60 mg
4 to 12 YR Pseudoephedrine 30 mg 4 - 6 HR 120 mg
4 to 6 YR Phenylephrine (oral) 5 mg 4 HR 30 mg
6 to 12 YR Phenylephrine (oral) 10 mg 4 HR 60 mg
Run
ny n
ose
6 to 11 YR Chlorpheniramine 2 mg 4 - 6 HR 12 mg
4 to 6 YR Brompheniramine 1 mg 4 - 6 HR 6 mg
6 to 12 YR Brompheniramine 2 mg 4 - 6 HR 12 mg
4 to 6 YR Diphenhydramine 6.25 - 12.5 mg 4 - 6 HR 75 mg
6 to 12 YR Diphenhydramine 12.5 - 25 mg 4 - 6 HR 150 mg
Cou
gh -
OTC
4 to 5 YR Dextromethorphan HBr 5 mg 4 HR 30 mg
6 to 12 YR 10 mg 4 HR 60 mg
4 to 5 YR Dextromethorphan Polistirex 15 mg 12 HR 30 mg
6 to 12 YR 30 mg 12 HR 60 mg
2 to 12 YR Vapor Rub thin film 6 - 8 HR 4 times
*Additional evidence has shown pelargonium to help some patients. FDA does not regulate strength or purity of these products.
6 to 12 YR Pelargonium (11% extract) 10 drops 8 HR 30 drops
≥ age 1 Dark honey 2 tsp (10 mL) May be used as often as desired.
Cou
gh -
Rx • Complete instructions are provided with prescriptions.
Some medications may not be covered through most pharmacy benefits or may require prior authorization.
≥ age 10 Benzonatate (+ guaifenisen) To be given as needed when coughing.
0 - 12 YR Inhaled corticosteroid To be used daily until the cough is gone.
2 - 11 YR Inhaled acetylcysteine
*MO: months YR: year HR: hour RS: regular strength
References: 4, 21, 52 - 53, 60 - 62, 67, 69, 71 - 73, 75 - 77, 91, 93 - 94, 105, 108 - 111
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Adults and children age 12 years and older: Influenza A or B* These medications are not covered through most pharmacy benefits.
Your diagnosis today is influenza (flu). This means you have an infection, caused by a virus. You will probably feel much better in 3 - 4 days. You should get plenty of rest and fluids. These medications and activities will help you feel better while your body heals from the infection:• Use a clean humidifier or cool mist vaporizer.
May be used as often as desired.
Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Feve
r and
/or p
ain
Aspirin (age ≥ 20 yr) 325 - 650 mg 4 - 6 HR 4000 mg
Ibuprofen 200 - 400 mg 4 - 6 HR 1200 mg, also < 10 days
Naproxen 500 mg as 1st dose, 250 mg later 6 - 8 HR 1250 mg
Acetaminophen RS 650 mg 4 - 6 HR 3250 mg
Acetaminophen ES 1000 mg 6 HR 3000 mg
Acetaminophen ER 1300 mg 8 HR 3900 mg
Acetaminophen SUPP 650 mg 4 - 6 HR 6 SUPP
Rx Oseltamivir Complete instructions are provided with prescriptions.
Zanamivir*HR: hour RS: Regular Strength ES: Extra Strength ER: Extended Release SUPP: Suppository
Children age 11 years and younger: Influenza A or B* These medications are not covered through most pharmacy benefits.
Multi-symptom “cough and cold” products are NOT recommended for children. These products are a leading cause of death for children < 5 years old.Your child’s diagnosis today is influenza (flu). This means they have an infection, caused by a virus. They will probably feel much better in 3 - 4 days. They should get plenty of rest and fluids. These medications and activities will help them feel better while their body heals from the infection:• Use a clean humidifier or cool mist vaporizer.
May be used as often as desired.
Age/weight: Drug: Dose: May use every:
In 24 hours,Do NOT take more than:
Feve
r and
/or p
ain
6 MO to 12 YR Ibuprofen 5 - 10 mg/kg 6 - 8 HR 4 doses, also < 10 days
Your child’s ibuprofen dose is:
< 60 kg (132 lb) Acetaminophen 10 - 15 mg/kg 4 - 6 HR Age 1 or younger: 75 mg/kg
Age ≥ 1 yr: 100 mg/kg, OR 1625 mg
Your child’s acetaminophen dose is:
> 60 kg (132 lb) Acetaminophen RS 650 mg 4 - 6 HR 3250 mg
Rx Oseltamivir Complete instructions are provided with prescriptions.
Zanamivir*MO: months YR: year HR: hour RS: regular strength
References: 61 - 62, 65, 67 - 71, 112 - 12028 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
29
Med
icat
ion
Rec
ord:
Med
icat
ion
nam
e:D
ose:
Tim
e:D
ose:
Tim
e:D
ose:
Tim
e:D
ose:
Tim
e:D
ose:
Tim
e:D
ose:
Tim
e:
Not
es:
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Recommended empiric antibiotic treatment: Bacterial URI pathogens
Pen
icill
in G
Pen
icill
in V
K
Am
pici
llin
Am
oxic
illin
Am
ox-c
lav
Cef
dini
r (3r
d)
Cef
dito
ren
(3rd
)
Cef
adro
xil (
1st)
Cep
hale
xin
(1st
)
Cef
aclo
r (2n
d)
Cef
proz
il (2
nd)
Cef
urox
ime
(2nd
)
Cefi
xim
e (3
rd)
Cef
tibut
en (3
rd)
Cef
podo
xim
e (3
rd)
Cef
triax
one
(3rd
)
TMP
-SM
X
Dox
ycyc
line
Ery
thro
myc
in
Azi
thro
myc
in
Cla
rithr
omyc
in
Clin
dam
ycin
Levo
floxa
cin
Mox
iflox
acin
Gem
iflox
acin
Cip
roflo
xaci
n
Line
zolid
Aerobic bacteria: 0-10 days of URI symptomsStrep. pneumoniae w w w w w w w fw fw fw w
H. influenza w w w w w w w fw fw fw fw
Staph. aureus w w w w w w w fw fw fw fw
M. catarrhalis w w w w w w w fw fw fw fw
Strep. groups w w w w w w w w w w w
Enterobacter sp. w w w w w w w fw fw fw fw
P. aeruginosa w w w w w w w fw fw fw fw
Anaerobic bacteria: more than 10 days of URI symptomsPeptostrep. sp. w w w w w w w fw fw fw fw
P. acnes w w w w w w w w w fw fw
P. melaningenica w w w w w w w w fw fw fw
F. necrophorum w w w w w w w fw fw fw fw
Rare URI pathogensC. trachomatis w w w w w w w fw fw fw fw
B. pertussis w w w w w w w fw fw fw fw
Chlamydophila sp. w w w w w w w fw fw fw fw
M. pneumoniae w w w w w w w fw fw fw fw
S. aureus (CA-MRSA) w w w w w w w fw fw fw fw
C.diptheriae w w w w w w w fw fw fw fw
N. gonorrhoeae w w w w w w w fw fw fw fw
T. pallidum w w w w w w w fw fw fw fw
F. tularensis w w w w w w w fw fw fw fw
Arcanobacter sp. w w w w w w w fw fw fw fw
Y. enterocolitica w w w w w w w fw fw fw fw
Y. pestis w w w w w w w fw fw fw fw
Recommended: Agent is a first-line therapy: reliably active in vitro, clinically effective, guideline recommended, recommended as a first-line agent or acceptable alternative agent in the Sanford Guide to Antimicrobial Therapy or Infectious Diseases Society of America clinical guidelines
Active: Agent is a potential alternative agent (active in vitro, possesses class activity comparable to known effective agents or a therapeutically interchangeable agents and hence likely to be clinically effective, but second-line due to overly broad spectrum, toxicity, limited clinical experience, or paucity of direct evidence of effectiveness)
Variable: Variable activity such that the agent, although clinically effective in some settings or types of infections, is not reliably effective in others, or should be used in combination with another agent, and/or its efficacy is limited by resistance which has been associated with treatment failure
Not Recommended: Agent is a poor alternative to other agents because resistance is likely to be present or occur, due to poor drug penetration to site of infection or an unfavorable toxicity profile, or limited or anecdotal clinical data to support effectiveness
Insufficient Data: Insufficient data to recommend use
f: United States Food and Drug Administration (FDA) advises that risks of significant, potentially permanent side effects outweigh the benefit of use unless no treatment alternatives are available.
w: This antibiotic has been placed in the “WATCH” group by the World Health Organization (WHO) due to higher resistance potential. WHO recommends to use as first or second choice only for a specific, limited number of indications.References: 21, 45 - 46, 60, 67, 97, 121 - 134
30 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
31
Ambulatory treatment of acute BACTERIAL rhinosinusitis: Adults Antibiotic Dose Administration
Initi
al e
mpi
ric th
erap
y
First-lineTx: 5 - 7 days
Amox-clav 500/125 mg PO, TID
Amox-clav 875/125 mg PO, BID
Second-lineTx: 7 - 10 days
Amox-clav 2000/125 mg PO, BID
Doxycycline 100 mg PO, BID200 mg Daily
Indications for second-line:• age > 65 • immunocompromised • recent hospitalization
• antibiotic use within the last month
• fever ≥ 102 °F + threat of suppurative complications
Peni
cilli
n al
lerg
y
Type I OR Non-type ITx: 5 - 7 days
Doxycycline 100 mg PO, BID200 mg Daily
Levofloxacinfw 500 mg PO, Daily
Moxifloxacinfw 400 mg PO, Daily
Type I hypersensitivity (reactions within minutes of administration):• angioedema • bronchospasm • pruritus
• diarrhea • anaphylaxis • urticaria
• vomiting
Non-type I hypersensitivity: may use full dose 3rd-generation cephalosporins, test-dose PCN (1/10 to 1/4 of full dose)• neutropenia • thrombocytopenia • serum sickness
• rash • arthralgias • lymphadenopathy
• glomerulonephritis • urticaria (after 1 - 3 weeks) • vasculitis
• hemolytic anemia • fever
• allergic contact dermatitis or macropapular drug rash (2 to 7 days after cutaneous drug exposure)
Faile
d in
itial
th
erap
y
Worsening or no improvement (after 3 - 5 days)
Tx: 5 - 7 days
Amox-clav 2000/125 mg PO, BID
Levofloxacinfw 500 mg PO, Daily
Moxifloxacinfw 400 mg PO, Daily
Recommended: Agent is a first-line therapy: reliably active in vitro, clinically effective, guideline recommended, recommended as a first-line agent or acceptable alternative agent in the Sanford Guide to Antimicrobial Therapy or Infectious Diseases Society of America clinical guidelines
Active: Agent is a potential alternative agent (active in vitro, possesses class activity comparable to known effective agents or a therapeutically interchangeable agents and hence likely to be clinically effective, but second-line due to overly broad spectrum, toxicity, limited clinical experience, or paucity of direct evidence of effectiveness)
Variable: Variable activity such that the agent, although clinically effective in some settings or types of infections, is not reliably effective in others, or should be used in combination with another agent, and/or its efficacy is limited by resistance which has been associated with treatment failure
f: United States Food and Drug Administration (FDA) advises that risks of significant, potentially permanent side effects outweigh the benefit of use unless no treatment alternatives are available.
w: This antibiotic has been placed in the “WATCH” group by the World Health Organization (WHO) due to higher resistance potential. WHO recommends to use as first or second choice only for a specific, limited number of indications.
References: 21, 45, 67, 122 - 128, 131 - 132, 134 - 142
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
https://www.fda.gov/Drugs/DrugSafety/ucm5530.htm
Ambulatory treatment of acute BACTERIAL rhinosinusitis: Children Antibiotic Total daily dose Administration
Initi
al e
mpi
ric th
erap
y First-lineTx: 5 - 7 days
Amox-clav 45 mg/kg (amox dose) PO, BID
Second-lineTx: 7 - 10 days
Amox-clav 90 mg/kg (amox dose) PO, BID
Indications for second-line:
• attendance at day care • immunocompromised • age < 2
• recent hospitalization • antibiotic use within the last month
• fever ≥ 102 °F + threat of suppurative complications
Peni
cilli
n al
lerg
y
Type I Levofloxacinfw 10 - 20 mg/kg PO, every 12 - 24 HR
Non-type ITx: 5 - 7 days
Dual therapy Clindamycin 30 - 40 mg/kg PO, TID
Cefiximew 8 mg/kg PO, BID
Cefpodoximew 10 mg/kg PO, BID
Type I hypersensitivity (reactions within minutes of administration):• angioedema • bronchospasm • pruritus
• diarrhea • anaphylaxis • urticaria
• vomiting
Non-type I hypersensitivity: may use full dose 3rd-generation cephalosporins, test-dose PCN (1/10 to 1/4 of full dose)• neutropenia • thrombocytopenia • serum sickness
• rash • arthralgias • lymphadenopathy
• glomerulonephritis • urticaria (after 1 - 3 weeks) • vasculitis
• hemolytic anemia • fever
• allergic contact dermatitis or macropapular drug rash (2 to 7 days after cutaneous drug exposure)
Faile
d in
itial
ther
apy
Worsening or no improvement (after 3 - 5 days)
Tx: 5 - 7 days
Amox-clav 90 mg/kg (amox dose) PO, BID
Dual therapy Clindamycin 30 - 40 mg/kg PO, TID
Cefiximew 8 mg/kg PO, BID
Cefpodoximew 10 mg/kg PO, BID
Levofloxacinfw 10 - 20 mg/kg PO, every 12 - 24 HR
Recommended: Agent is a first-line therapy: reliably active in vitro, clinically effective, guideline recommended, recommended as a first-line agent or acceptable alternative agent in the Sanford Guide to Antimicrobial Therapy or Infectious Diseases Society of America clinical guidelines
Active: Agent is a potential alternative agent (active in vitro, possesses class activity comparable to known effective agents or a therapeutically interchangeable agents and hence likely to be clinically effective, but second-line due to overly broad spectrum, toxicity, limited clinical experience, or paucity of direct evidence of effectiveness)
f: United States Food and Drug Administration (FDA) advises that risks of significant, potentially permanent side effects outweigh the benefit of use unless no treatment alternatives are available.
w: This antibiotic has been placed in the “WATCH” group by the World Health Organization (WHO) due to higher resistance potential. WHO recommends to use as first or second choice only for a specific, limited number of indications.References: 21, 45, 67, 122 - 128, 131 - 132, 134, 136, 138, 140 - 14532 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
33
Ambulatory treatment of acute rhinosinusitis: All Ages, all etiologies
Initi
al e
mpi
ric th
erap
yTreatment: 15 - 21 days
Age/weight Drug Dose (IEN) May use every: In 24 hours,Do NOT take more than:
4 to 11 YR Beclomethasone (QnaslTM)
1 spray 24 HR 2 sprays
≥ 12 YR 2 sprays 24 HR 4 sprays
6 to 12 YR Beclomethasone (Beconase AQTM)
1 spray 12 HR 8 sprays
≥ 12 YR 1 or 2 sprays 12 HR 8 sprays
6 to 12 YR Budesonide (RhinocortTM)
1 spray 24 HR 2 sprays
≥ 12 YR 1 spray 24 HR 4 sprays
≥ 6 YR Ciclesonide (OmnarisTM)
2 sprays 24 HR 4 sprays
≥ 12 YR Ciclesonide (ZetonnaTM)
1 spray 24 HR 2 sprays
2 to 12 YR Fluticasone furoate (VeramystTM)
1 spray 24 HR 4 sprays
≥ 12 YR 2 sprays 24 HR 4 sprays
2 to 12 YR Mometasone (NasonexTM)
1 spray 24 HR 2 sprays
≥ 12 YR 2 sprays 24 HR 4 sprays
*YR: year IEN: in each nostril HR: hour
References: 88, 146 - 149
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Ambulatory treatment of acute bronchitis: All agesAll major guidelines on bronchitis, including those from the American College of Chest Physicians, National Committee for Quality Assurance, and the American Academy of Pediatrics, recommend against using antibiotics for acute bronchitis.
Recommend treatment:• Supportive care• Symptom management
Ambulatory treatment of acute BACTERIAL pharyngitis: All ages
Initi
al e
mpi
ric th
erap
y
Treatment: 10 days unless otherwise notedAge Antibiotic Dose Administration
Children Penicillin V (oral) 250 mg PO, BID - TIDAdolescents and adults 250 mg PO, 4 times daily
500 mg PO, BIDAll Amoxicillin 50 mg/kg (NTE 1000 mg) PO, daily
25 mg/kg (NTE 500 mg) PO, BIDPenicillin G (IM) < 27 kg: 600,000 units IM, 1 dose
≥ 27 kg: 1,200,000 units
Peni
cilli
n al
lerg
y Non-type I:• May use full dose
3rd-generation cephalosporins.
• May use test-dose PCN (1/10 to 1/4 of full dose)
Cephalexinb 20 mg/kg (NTE 500 mg/dose)
PO, BID
Cefadroxilb 30 mg/kg (NTE 1 G) PO, dailyClindamycin 7 mg/kg
(NTE 300 mg)PO, TID
Azithromycinw 12 mg/kg (NTE 500 mg) PO, daily for 5 daysClarithromycinw 7.5 mg/kg (NTE 250 mg) PO, BID
Recommended: Agent is a first-line therapy: reliably active in vitro, clinically effective, guideline recommended, recommended as a first-line agent or acceptable alternative agent in the Sanford Guide to Antimicrobial Therapy or Infectious Diseases Society of America clinical guidelines
Active: Agent is a potential alternative agent (active in vitro, possesses class activity comparable to known effective agents or a therapeutically interchangeable agents and hence likely to be clinically effective, but second-line due to overly broad spectrum, toxicity, limited clinical experience, or paucity of direct evidence of effectiveness)
Variable: Variable activity such that the agent, although clinically effective in some settings or types of infections, is not reliably effective in others, or should be used in combination with another agent, and/or its efficacy is limited by resistance which has been associated with treatment failure
f: United States Food and Drug Administration (FDA) advises that risks of significant, potentially permanent side effects outweigh the benefit of use unless no treatment alternatives are available.
w: This antibiotic has been placed in the “WATCH” group by the World Health Organization (WHO) due to higher resistance potential. WHO recommends to use as first or second choice only for a specific, limited number of indications.
NTE: Not to exceed IM: Intramuscular
b: Avoid initial full dose in patients with Type I hypersensitivity to penicillin, may consider test dose.
References: 21, 47 - 48, 55, 67, 80, 97, 102, 128, 131, 133 - 134, 140 - 142, 150 - 15534 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
35
JAMA 2017 Clarifying a PCN allergy
Ambulatory treatment of BACTERIAL acute otitis media: Adults Antibiotic Total daily dose Administration
Watchful waiting:Unilateral OR bilateral, mild symptoms, < 102.2° F
Treatment duration, unless otherwise noted: 5 - 7 days: mild - moderate illness10 days: severe illness
Initi
al e
mpi
ric th
erap
y(im
med
iate
or d
elay
ed)
First-line Amoxicillin (mild - moderate)
500 mg PO, BID250 mg PO, TID
Amoxicillin (severe)
875 mg PO, BID500 mg PO, TID
Amox-clava 500 mg (amox dose) PO, BID250 mg (amox dose) PO, TID875 mg PO, BID500 mg PO, TID
Second-linec
non type I hypersensitivity to penicillin • May use full
dose 3rd- or 4th-generation cephalosporins.
• May use test-dose PCN (1/10 to 1/4 of full dose)
Cefdinir 300 mg PO, BID
Cefpodoximew 200 mg PO, BID
Ceftriaxonew 1 to 2 G (NTE 4 G) IM, daily to BID
Afte
r em
piric
failu
re
After 48 hours of failure of first-line
Amoxicillin 875 mg PO, BID
500 mg PO, TID
Ceftriaxonew 1 to 2 G (NTE 4 G) IM, daily to BID
After 48 hours of failure of second-line
Ceftriaxonew 1 to 2 G (NTE 4 G) IM, daily to BID
Clindamycin 150 - 300 mg PO, 4 times daily
Clindamycin may be used with OR without a 3rd-generation cephalosporin:
3rd-
gene
ratio
n ce
phal
ospo
rins Cefdinir 300 mg PO, BID
Cefiximew
400 mg PO, daily, for 10 days if due to S. pyogenes
200 mg PO, BID, for 10 days if due to S. pyogenes
Cefpodoximew
200 mg PO, BID
Ceftibutenw
400 mg daily for 10 days
Recommended: Agent is a first-line therapy: reliably active in vitro, clinically effective, guideline recommended, recommended as a first-line agent or acceptable alternative agent in the Sanford Guide to Antimicrobial Therapy or Infectious Diseases Society of America clinical guidelines
Active: Agent is a potential alternative agent (active in vitro, possesses class activity comparable to known effective agents or a therapeutically interchangeable agents and hence likely to be clinically effective, but second-line due to overly broad spectrum, toxicity, limited clinical experience, or paucity of direct evidence of effectiveness)
w: This antibiotic has been placed in the “WATCH” group by the World Health Organization (WHO) due to higher resistance potential. WHO recommends to use as first or second choice only for a specific, limited number of indications.
a: May be considered in patients who have received amoxicillin in the previous 30 days, or who have otitis-conjunctivitis syndrome
c: Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to exhibit cross-reactivity with penicillin allergy due to their structure.References: 13, 21, 52, 45, 60, 67, 105, 128, 131, 134, 136, 140 - 145, 151, 156 - 159
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Ambulatory treatment of acute BACTERIAL otitis media: Children Antibiotic Total daily dose Administration
Watchful waiting:6 - 23 MO: unilateral, mild symptoms> 2 YR: unilateral OR bilateral, mild symptoms,< 102.2° F
Treatment duration, unless otherwise noted: 5 - 7 days: 6 - 12 YR with mild - moderate illness7 days; 2 - 5 YR with mild - moderate illness10 days: < 2 YR OR severe illness
Initi
al e
mpi
ric th
erap
y(im
med
iate
or d
elay
ed)
First-line Amoxicillin 80 - 90 mg/kg PO, BID
Amox-clava 90 mg/kg (amox dose) PO, BID
Second-linec
non type I hypersensitivity to penicillin: • May use full dose
3rd- or 4th- genera-tion cephalosporins.
• May use test-dose PCN (1/10 to 1/4 of full dose)
Cefdinir 14 mg/kg PO, BID
Cefpodoximew 10 mg/kg BID
Ceftriaxonew 50 mg/kg (NTE 1 g) IM, daily OR for 3 days
Afte
r em
piric
failu
re
After 48 hours of failure of first-line
Amox-clava 90 mg/kg (amox dose) PO, BID
Ceftriaxonew 50 mg/kg (NTE 1 g) IM, for 3 days
After 48 hours of failure of second-line
Ceftriaxonew 50 mg/kg (NTE 1 g) IM, for 3 days
Clindamycin 30 - 40 mg/kg PO, TID
Clindamycin may be used with OR without a 3rd-generation cephalosporin:
Cefdinir 6 MO to 12 YR 14 mg/kg PO, daily to BID
Cefiximew
6 MO to 12 YR 8 mg/kg Daily, for 10 days if due to S. pyogenes
4 mg/kg BID for 10 days if due to S. pyogenes
Cefpodoximew
6 MO to 12 YR 10 mg/kg PO, BID
Ceftibutenw
6 MO to 12 YR 9 mg/kg (NTE 400) PO, daily
Recommended: Agent is a first-line therapy: reliably active in vitro, clinically effective, guideline recommended, recommended as a first-line agent or acceptable alternative agent in the Sanford Guide to Antimicrobial Therapy or Infectious Diseases Society of America clinical guidelines
Active: Agent is a potential alternative agent (active in vitro, possesses class activity comparable to known effective agents or a therapeutically interchangeable agents and hence likely to be clinically effective, but second-line due to overly broad spectrum, toxicity, limited clinical experience, or paucity of direct evidence of effectiveness)
w: This antibiotic has been placed in the “WATCH” group by the World Health Organization (WHO) due to higher resistance potential. WHO recommends to use as first or second choice only for a specific, limited number of indications.
a: May be considered in patients who have received amoxicillin in the previous 30 days, or who have otitis-conjunctivitis syndrome
c: Cefdinir, cefuroxime, cefpodoxime, and ceftriaxone are highly unlikely to exhibit cross-reactivity with penicillin allergy due to their structure.
References: 4, 13, 21, 60, 67, 105, 128, 131, 134, 136, 141 - 145, 151, 156 - 158 36 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
37
Ambulatory treatment of cough: All agesDrug Age/weight Dose Administration, every:
Bet
a-2
agon
ists
Albuterol (MDI) ≥ 4 YR 2 puffs 4 - 6 HR1 puffs 4 HR
Albuterol (0.083%) ≥ 2 YR, ≥ 15 kg 2.5 mg 6 - 8 HRAlbuterol (0.5%) 2 - 12 YR 0.1 - 0.15 mg/kg
(+NS to 3mL total vol-ume)
≥ 12 YR 2.5 mg (+2.5 mL NS)Albuterol (syrup, tablets) 2 - 5 YR 0.1 mg/kg 8 HR
6 - 12 YR 2 mg 6 - 8 HR≥ 12 YR 2 or 4 mg
Albuterol (ER tablets) 6 - 12 YR 4 mg 12 HR≥ 12 YR 8 mg
Levalbuterol (MDI) ≥ 4 YR 2 puffs 4 - 6 HR1 puffs 4 HR
Levalbuterol 0 - 4 YR 0.31 - 1.25 mg 4 - 6 HR5 - 11 YR 0.31 - 0.63 mg 8 HR
0.31 mg/mL
0.63 mg/mL
1.25 mg/mL
1.25 mg/0.5mL
≥ 12 YR 0.63 - 1.25 mg 6 - 8 HR
Cou
gh s
uppr
essa
nts
Benzonatate ≥ 10 YR 100 or 200 mg 8 HR
Codeine ≥ 18 YR 15 - 60 mg 4 HR, NTE 360 mg/24 HR
• All opioid-containing cough and cold medicines, including codeine and hydrocodone, are only indicated for adult use, age ≥ 18 YR.
• Safety information about risks of misuse, abuse, addiction, overdose, death, and slowed breathing have been added to the existing Boxed Warning
• Codeine and Tramadol are CONTRAINDICATED for treating pain or cough for children younger than 12 YR. They are not FDA-approved or recommended for patients 0 - 18 YR for any indications. Tramadol is not indicated for cough suppression for any age group.
• Breastfeeding is not recommended when taking codeine.
Muc
olyt
ic Ipratropium (MDI, 0.017 mg/puff))
≥ 12 YR 2 - 4 puffs 6 HR
Ipratropium (0.02%) ≥ 12 YR 2 - 4 vials 6 HR
YR: year NS: normal saline ER: extended release NTE: not to exceed
References: 21 - 51, 67, 129 - 130, 160 - 167
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Treatment/prophylactic group
Potential benefit/harm
Adults 16.8 HR shortened symptomsAdults No effect on hospital admissionAdults 1% lower risk of patient-reported pneumonia (NNT = 100)Adults 3.66% higher risk of nausea (NNH = 28)Adults 4.56% higher risk of vomiting (NNH = 22)Adults 3.05% lower risk of developing symptoms with prophylaxis dose (NNT = 33)Adults Up to 2.76% higher risk of psychiatric adverse events with prophylaxis (NNH = 94)Adults 3.01% higher risk of headache with prophylaxis (NNT = 32)
Children No effect on: bronchitis, AOM, sinusitis, or any serious complicationChildren 29 HR shortened symptoms in otherwise healthy childrenChildren with asthma No effectChildren 5.34% higher risk of vomiting (NNH = 19)
Based on these results, Cochrane reviewers have called into question the use of oseltamivir and zanamivir for prevention of flu-associated complications. The CDC continues to recommend their use.
Unvaccinated infants Age < 2 YR Cancer Age > 65 YRAmerican Indians/Alaska Natives
Extreme obesity (BMI > 40)
HIV infection or immunosuppression
Women who are pregnant or 2-weeks post-partum
Sickle cell anemia, other hemoglobinopathies
Chronic metabolic disease such as diabetes mellitus
Hemodynamically significant cardiac disease
Chronic cardiovascular, hepatic, or renal dysfunction
Residents of nursing homes or other long-term care institutions
Age < 19 with long-term high-dose aspirin use such as: rheumatoid arthritis, Kawasaki disease
Neuromuscular disorders, seizure disorders, cognitive dysfunction that may compromise handling secretions
Chronic pulmonary diseases such as asthma, cystic fibrosis (in children) or chronic pulmonary obstructive disease (in adults)
References: 168 - 17238 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
39
Oseltamivir antiviral treatment of influenza A and BAge/weight/kidney function
Treatment Dose (5 days)
Prophylaxis Dose (10 days)
Volume suspension per dose (6 mg/mL)
Number of bottles to dispense
Number of capsules to dispense
Age 2 weeks to ≤ 1 YR: weight-based dosing (suspension, refrigerate after reconstitution)2 weeks to < 1 YR 3 mg/kg BID 3 mg/kg daily (> 3 MO
old)0.5 mL/kg 1 NA
Age 1 to 12 YR: weight-based dosing (suspension to be used if patients cannot swallow capsules)≤ 15 kg 30 mg BID 30 daily 5 mL 1 1015.1 to 23 kg 45 mg BID 45 mg daily 7.5 mL 2 1023.1 to 40 kg 60 mg BID 60 mg daily 10 mL 2 20 (30 mg)≥ 40.1 kg 75 mg BID 75 mg daily 12.5 mL 3 10Adults, normal and impaired kidney functionNormal kidney function 75 mg BID 75 mg daily 12.5 mL 3 10> 60 to 90 mL/min 75 mg BID 75 mg daily 12.5 mL 3 10> 30 to 60 mL/min 30 mg BID 30 daily 5 mL 1 10> 10 to 30 mL/min 30 daily 30 mg every other day 5 mL 1 5ESRD (≤ 10 mL/min) 30 mg immediately
after dialysis, then after each dialysis cycle
30 mg immediately after dialysis, then after every other dialysis cycle
5 mL 1 5
ESRD, on continuous ambulatory peritoneal dialysis
30 mg, single dose 30 mg single dose, then once weekly
5 mL 1 5
ESRD, not on dialysis Not recommendedYR: year MO: months NA: not applicable ESRD: end stage renal disease min: minute
Zanamivir antiviral treatment of influenza A and BAge Treatment Dose (5 days) Prophylaxis Dose (10 days
household, 28 days community outbreaks)
Age 7 YR and older (without underlying airway disease)
10 mg BID
(initiate treatment within 36 hours for children)
10 mg daily (may be used age ≥ 5 YR)
YR: year
The WHO recently moved oseltamivir from the essential to the complementary medication list due to disappointing impact on clinical outcomes.
Zanamivir has never met criteria for inclusion in either the essential or complementary list.
References: 14, 118 - 119, 134, 171, 173 - 176
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
GINA 2017 AsthmaFacts & Comparisons
High-dose, episodic inhaled corticosteroids for pediatric treatment of viral URI with wheezing
Age 11 years and younger: High Dose ICS Daily dose (mcg)
Beclomethasone dipropionate (HFA) > 200
Budesonide (DPI) > 400
Budesonide (nebules) > 1000
Ciclesonide (HFA) > 160
Fluticasone propionate (DPI) > 400
Fluticasone propionate (HFA) > 500
Mometasone furoate (MDI, DPI) ≥ 440
HFA: hydrofluoroalkane propellant DPI: dry powder inhaler
References: 177 - 17940 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
41
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References: 180 - 184
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
Date: / /
Dear Child Care Profession
I have carefully evaluated and have diagnosed him/her as having:
Cold Middleearfluid(OtitisMediawithEffusion,OME)
Cough Viral sore throat Flu Other:
Thisillnessiscausedbyavirus.Antibiotictreatmentwillnotcureaviralillness(antibioticsonlyareeffectiveintreatingbacterialinfections).Infact,ifantibioticsaregivenwhentheyarenotneeded,theymaybeharmfulbyincreasingthechild’sriskofaresistantinfection.
Thischildmayreturntodaycarewhenhe/shedoesnothaveafever.Atthatpointmostchildrencanparticipateinactivities,anddonotrequiresomuchcarethatthehealthandsafetyofotherchildrenwouldbejeopardized.Excludingchildrenwithviralillnessdoesnotdecreasethespreadofinfectiontootherchildrenbecausevirusesarelikelytobespreadevenbeforesymptomsofillnessoccur.
Sincerelyyours,
P.S.Herearesomeexpertreviewsthatsupporttheserecommendations.
CentersforDiseaseControlandPrevention.TheABC’sofSafeandHealthyChildCare;AHandbookforChild’sProviders.Atlanta,GA:CentersforDiseaseControlandPrevention,DepartmentofHealthandHumanServices,U.S.PublicHealthService,1996.
American Public Health Association and American Academy of Pediatrics. Caring forOurChildren.NationalHealthandSafetyStandards:GuidelinesforOut-of-HomeChild Care Programs.AnnArbor,MI:AmericanPublicHealthAssociationandAmericanAcademyofPediatrics,1992.
www.cdc.gov/antibiotic-useCS281338B
Dear Child Care Professional
References: 18542 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
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References: 18644 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
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References: 18646 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
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References: 18648 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
49References: 186
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References: 18650 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
51
References1. Fleming-Dutra KE, Hersh AL. Prevalence of Inappropriate
Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. May 2016. 315(17):1864-1873.
2. Shehab N, Patel PR, et al. Emergency Department Visits for Antibiotic-associated Adverse Events. Clin Infect Dis. Aug 2008. 47:735-743.
3. Dobson EL, Klepser ME, et al. Outpatient Antibiotic Stewardship: Interventions and Opportunities. J Am Pharm Assoc. Mar 2017. 57(2017):464-473.
4. Hersh AL, Jackson MA, et al. Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics. J Pediatr. Dec 2013.132(6):1146-1154.
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144. Cefixime. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Nov 2017. Accessed 1/16/18.
145. Cefpodoxime. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Nov 2017. Accessed 1/16/18.
146. Beclomethasone Dipropionate Intranasal. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Jul 2015. Accessed 1/16/18.
147. Budesonide Intranasal. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; May 2017. Accessed 1/16/18.
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149. Mometasone Furoate Intranasal. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Aug 2016. Accessed 1/16/18.
150. Penicillin. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Sep 2017. Accessed 1/16/18.
151. Amoxicillin. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Jan 2018. Accessed 1/16/18.
152. Cephalexin. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Mar 2017. Accessed 1/16/18.
153. Cefadroxil. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Oct 2017. Accessed 1/16/18.
154. Azithromycin. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Jan 2018. Accessed 1/16/18.
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156. Ceftibuten. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Feb 2017. Accessed 1/16/18.
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158. Cefdinir. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Mar 2017. Accessed 1/16/18.
159. Bakaletz LO. Bacterial Biofilms in Otitis Media. Pediatr Infect Dis J. Sep 2007. 26(10 Suppl):S17-19.
160. Albuterol. Drug Facts and Comparisons. Facts & Comparisons [database online]. St. Louis, MO: Wolters Kluwer Health, Inc; Nov 2017. Accessed 1/16/18.
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Additional ResourcesFor Clinicians:American Board of Internal Medicine
• www.choosingwisely.orgTopics: Sinusitis, Charting a Fifty Percent Drop in Antibiotic use, Avoiding Antibiotics Overuse, many others
Centers for Disease Control and Prevention (CDC)• www.cdc.gov/vaccines/schedules/syndicate.
html#easy-read Immunization schedules and patient quizzes for embedding in clinic websites, technical assistance
• www.cdc.gov/antibiotic-use/Patient & provider resources, inpatient, outpatient, long-term care, printable in English & Spanish
Sanford Guide to Antimicrobial Therapy• www.sanfordguide.com/
Annually updated print and ecopy, for purchase ($25 - $48)
Nelson’s Pediatric Antimicrobial Therapy• multiple sources (Amazon. Barnes & Noble,
etc.)Annually updated, for purchase ($34 - $36)
Infectious Diseases Society of America• www.idsociety.org/Guidelines_mobile/
Practice guidelines for mobile device, evidence summary, pocketcards, combination free/for purchase ($6.99 - $9.95)
The Pew Charitable Trusts• www.saveantibiotics.org
Monthly alerts, multimedia resources, podcasts
Kognito Patient Simulations• https://www.conversationsforhealth.com/
Practice antibiotic conversations, building patient conversation skills
• www.youtube.com/watch?v=fyRyZ1zKtyA“Rise of the Superbugs” from It’s Okay to be Smart (7.5 minutes)
• www.youtube.com/watch?v=1gfznWXsxcY“Get Smart About Antibiotics” from CDC (4 minutes)
• https://www.youtube.com/watch?v=JiMrcOc3HBM“Get Smart About Antibiotics” from U.S. Food and Drug Administration (2 minutes)
• https://www.youtube.com/watch?v=e5qP891fy9E“Snort. Sniffle. Sneeze. No Antibiotics Please!” from CDC (4 minutes)
• https://www.youtube.com/watch?v=sKlpRjgriGM“Neti Pot Instruction Video” from NeilMed (1.5 minutes)
For Patients and Caregivers:American Academy of Pediatrics
• www.healthychildren.orgParent instructions for managing cough, nasal congestion, sinus pain, symptom checker, antibiotic questions answered
CDC• www.cdc.gov/features/getsmart/
When antibiotics are/are not needed, prevention, symptom checker
Videos for Individual Patient Education Opportunities
Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
CDC: 1.0 or greater AMA PRA category 1, ANCC, ACPE, webcasts also available for non-credit
• https://www.cdc.gov/vaccines/ed/youcalltheshots.htmlYou Call the Shots: 16 disease-specific vaccination courses, exp. 8/2018 - 3/2020,
Stanford University School of Medicine: 1.0 or greater AMA PRA category 1
• https://med.stanford.edu/cme/courses/online/improving-antibiotics-pcs.htmlTo Prescribe or Not to Prescribe? Antibiotics and Outpatient Infections: exp. 10/2018
American Medical Association: 1.0 or greater AMA PRA category 1
• https://cme.ama-assn.org/Activity/5644029/Detail.aspxJournal-based CME: Should Physicians Consider the Environmental Effects of Prescribing Antibiotics: exp. 9/2019
Medscape: 0.25 or greater AMA PRA Category 1, ANCC, ACPE
• www.medscape.org/viewarticle/877581Guidelines and Antibiotic Prescribing: Where are we now: exp. 4/2018
• www.medscape.org/viewarticle/882990Are All Penicillin Allergies in Children Real: exp. 8/2018
• www.medscape.org/viewarticle/885120Which Kids Benefit From Antibiotics for Acute Otitis Media: exp. 9/2018
• www.medscape.org/viewarticle/887253MDROs, Serious Bacterial Infections, and Good Stewardship: exp. 10/2018
• www.medscape.org/viewarticle/886292Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season: exp. 10/2018
• www.medscape.org/viewarticle/865078Patient Requests for Specific Care: exp. 7/2018
Additional ResourcesFree CME Credits Available:
58 Pharmacy Management Consultants (OU College of Pharmacy) Rev. 2/2018
The content appearing in this educational material, prepared by the Oklahoma Health Care Authority (OHCA), University of Oklahoma (OU), College of Pharmacy, and Pharmacy Management Consultants (PMC), is intended to provide helpful clinical information for the health professional community. It is made available with the understanding that individual clinicians will make their own choices with respect to individual patient care. The content should not be considered complete, and does not cover all diseases, ailments, physical conditions or their treatment. It should not be used in place of clinical judgment by individual providers.
Any information about drugs contained within the content is general in nature, and does not cover all possible uses, actions, precautions, side effects, or interactions of the medicines mentioned. The content is not intended as medical advice for individual patients or for making an evaluation as to the risks and benefits of taking a particular drug.
OHCA), OU, College of Pharmacy, and PMC, and the author of the content specifically disclaim all responsibility for any liability, loss, or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the content in this material.*Adapted from: Drugs.com
OU, in compliance with all applicable federal and state laws and regulations, does not discriminate on the basis of race, color, national origin, sex, sexual orientation, genetic information, gender identity, gender expression, age, religion, disability, political beliefs, or status as a veteran in any of its policies, practices or procedures. This includes, but is not limited to: admissions, employment, financial aid and educational services. Inquiries regarding non-discrimination policies may be directed to: Bobby J. Mason, University Equal Opportunity Officer and Title IX Coordinator, (405) 325-3546, [email protected], or visit www.ou.edu/eoo.
This publication, printed by PMC is issued by the University of Oklahoma. 150 copies have been prepared and distributed at no cost to the taxpayers of the state of Oklahoma.
Upper Respiratory Infections
4) Use shared decision making.• Especially helpful for URI decisions• Minimal time, improved knowledge, and increased satisfaction• Clarifies expectations and perceptions• Endorsed by multiple organizations and recommended whenever possible• Benefits seen for years
3) Choose narrow spectrum.• Frequently underutilized• Less likely to cause ADRs• Reduces development of resistance• Comparable clinical outcomes
1) Manage symptoms.• Reduces ADRs• Improves satisfaction and reduces abx usage• Recommended by clinical guidelines for all patients
2) Increase vaccination rates.• Reduces inappropriate prescribing• Reduces primary and secondary infections• Reduces prevalence of resistant bacteria
Collaborative Advancement of
C A EPrescription Excellence