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Icsi.org

Health Care Guideline
Diagnosis and Treatment of Respiratory Illness in
Children and Adults
How to cite this document:Snellman L, Adams W, Anderson G, Godfrey A, Gravley A, Johnson K, Marshall P, Myers C, Nesse R, Short S. Institute for Clinical Systems Improvement. Diagnosis and Treatment of Respiratory Illness in Children Copies of this ICSI Health Care Guideline may be distributed by any organization to the organization's employees but, except as provided below, may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc. If the organization is a legally constituted medical group, the ICSI Health Care Guideline may be used by the medical group in any of the following ways: • copies may be provided to anyone involved in the medical group's process for developing and implementing clinical guidelines; • the ICSI Health Care Guideline may be adopted or adapted for use within the medical group only, provided that ICSI receives appropriate attribution on all written or electronic documents and • copies may be provided to patients and the clinicians who manage their care, if the ICSI Health Care Guideline is incorporated into the medical group's clinical guideline program.
All other copyright rights in this ICSI Health Care Guideline are reserved by the Institute for Clinical Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any adap- tations or revisions or modifications made to this ICSI Health Care Guideline. Copyright 2013 by Institute for Clinical Systems Improvement

Health Care Guideline:
Diagnosis and Treatment of Respiratory Illness in
Children and Adults
Fourth Edition
Text in blue in this algorithm January 2013
indicates a linked corresponding Symptoms of non-infectious
• Pruritis of the eyes, nose, palate, ears• Watery rhinorrhea• Sneezing • Nasal congestion• Postnasal drip Consult or schedule visit with provider Symptoms of bacterial sinusitis:
Upper-respiratory symptoms
present 10-14 days.
One or more of the followingfactors present at a point of 10-14days after onset: Hoarseness, cough • Facial pain or sinus pain, or nasal symptoms particularly if aggravated by postural changes or by valsalva maneuver• Purulent nasal drainage Symptoms of VURI:
• Fever• Hoarseness • Injection of the conjunctiva Symptoms/signs of strep
pharyngitis:
• Close exposure to strep throat
• Sudden onset of sore throat • Exudative tonsilitis Strep Pharyngitis • Tender anterior cervical adenopathy• Fever• Headache (only when present with above symptoms)• Abdominal pain (only when present with above symptoms)• Absence of rhinorrhea, cough, hoarseness Copyright 2013 by Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Penicillin is the drugof choice for oral pills or intramuscular treatment. Amoxicillin is the drug of choice for those requiring liquid or chewable medicine.
Alternative antibiotics:1. Macrolides2. Cephalosporins3. Clindamycin Antibiotics to avoid:
1. Nitrofurantion
(Macrodantin)
2. Tetracycline
Rapid strep test Text in blue in this algorithm indicates a linked corresponding Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Text in blue in this algorithm indicates a linked corresponding Consider referral to • Continue treatment• Follow-up• Patient education Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Text in blue in this algorithm indicates a linked corresponding Schedule visit within Consider second-line antibiotic imaging or further evaluation, alternative diagnosis or referral Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Work Group Leader
Algorithms and Annotations . 1-50
Leonard Snellman, MD Pediatrics, HealthPartners Medical Group Work Group Members
Fairview Health Services
Internal Medicine and HealthPartners Medical
Group and Regions
Peter Marshall, PharmD Mayo Clinic
Greg Anderson, MD Family Practice South Lake Pediatrics
Andrea Gravley, RN, MAN, Stillwater Medical Group
Quality Improvement Support . 51-63
and Lakeview Hospital
Ramona Nesse, RN, C-NP Family Practice Supporting Evidence. 64-79
Clinical Systems Clinical Systems Document History and Development . 85-86
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Literature Search
A consistent and defined process is used for literature search and review for the development and revision of
ICSI guidelines. The literature search was divided into two stages to identify systematic reviews, (stage I) and randomized controlled trials, meta-analysis and other literature (stage II). Literature search terms used for this revision are respiratory tract infections, antimicrobial treatment, streptococcus, sinusitis, rhinitis and acute respiratory pharyngitis. The search includes literature from June 2010 through June 2012.
GRADE Methodology
Following a review of several evidence rating and recommendation writing systems, ICSI has made a decision
to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
GRADE has advantages over other systems including the current system used by ICSI. Advantages include: • developed by a widely representative group of international guideline developers;• explicit and comprehensive criteria for downgrading and upgrading quality of evidence ratings;• clear separation between quality of evidence and strength of recommendations that includes a transparent process of moving from evidence evaluation to recommendations; • clear, pragmatic interpretations of strong versus weak recommendations for clinicians, patients and • explicit acknowledgement of values and preferences; and• explicit evaluation of the importance of outcomes of alternative management strategies.
This document is in transition to the GRADE methodology
Transition steps incorporating GRADE methodology for this document include the following:
• Priority placed upon available Systematic Reviews in literature searches. • All existing High Quality Evidence (RCTs) studies have been considered as high quality evidence unless specified differently by a work group member.
• All existing Class B, C and D studies have been considered as low quality evidence unless specified differently by a work group member.
• All existing Class M and R studies are identified by study design versus assigning a quality of evidence. Refer to Crosswalk between ICSI Evidence Grading System and GRADE.
• All new literature considered by the work group for this revision has been assessed using GRADE Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Evidence Grading
Fourth Edition/January 2013 Crosswalk between ICSI Evidence Grading System and GRADE
ICSI GRADE System
Previous ICSI System
High, if no limitation
Class A: Randomized, controlled trial
Class B: [observational]
Class C: [observational]
Non-randomized trial with concurrent or historical controls Case-control study Population-based descriptive study Study of sensitivity and specificity of a * Following individual study review, may be elevated to Moderate or High depending upon study design Class D: [observational]
Cross-sectional study Class M: Meta-analysis
Systematic Review
Systematic review Decision Analysis
Decision analysis Cost-Effectiveness Analysis
Cost-effectiveness analysis Class R: Consensus statement
Consensus report Narrative review Guideline
Class R: Guideline
Class X: Medical opinion
Evidence Definitions:
High Quality Evidence = Further research is very unlikely to change our confidence in the estimate of effect.
Moderate Quality Evidence = Further research is likely to have an important impact on our confidence in the
estimate of effect and may change the estimate.
Low Quality Evidence = Further research is very likely to have an important impact on our confidence in the
estimate of effect and is likely to change the estimate or any estimate of effect is very uncertain.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 The goals of the guideline are threefold educational: to assist patients to be competent and comfortable with home care of respiratory illness, to assist medical personnel to differentiate respiratory illness from more severe illness, and to improve the appropriateness of care and antibiotic use for respiratory illness while decreasing the cost of that care.
The Diagnosis and Treatment of Respiratory Illness in Children and Adults guideline encompasses acute conditions in infants greater than three months, children, adolescents and adults who are in good health.
1. Increase the percentage of patients diagnosed with viral upper-respiratory infection who receive appro- priate treatment. (Annotation #12) 2. Reduce excessive antibiotic treatment through decreased empiric treatment of patients with strep phar- yngitis. (Annotations #16, 20, 25, 27) 3. Increase the use of recommended first-line medications for patients diagnosed with strep pharyngitis. (Annotations #20, 25, 27) 4. Increase patient/caregiver knowledge about strep pharyngitis and pharyngitis care. (Annotations #20, 5. Decrease the use of injectable corticosteroid therapy for patients diagnosed with allergic rhinitis. (Anno- tation #34) • Patients and/or parents of children presenting or calling with symptoms suggestive of the common cold should be evaluated for other symptoms and the presence of more serious illness. (Annotations #2, 4; • The primary treatment of viral upper-respiratory infection is education based; education is to take place in the clinic, on the telephone, at the work site and in newsletters. Patients and/or parents should receive home care and call-back instructions. (Annotation #12; Aim #1) • Reduce unnecessary use of antibiotics. Antibiotic treatment should be reserved for a bacterial illness. (Annotations #16, 20, 25, 27; Aim #2) • Diagnosis of group A beta streptococcal pharyngitis should be made by laboratory testing rather than clinically. (Annotations #18, 25; Aims #2, 4) Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Foreword
Fourth Edition/January 2013 • Patients should be educated on strep pharyngitis, including the importance of following the prescribed medication regimen, use of home remedies to relieve symptoms, actions to take if symptoms worsen, and the importance of eliminating close contact with family members or visitors to the home while group A beta streptococcal may be contagious. (Annotations #20, 24, 27; Aim #4) • Prescribe intranasal steroids for moderate or severe allergic rhinitis. (Annotation #34; Aims #5, 6) • Treat patients diagnosed as having allergic seasonal rhinitis with prophylactic medications and educate about avoidance activities. (Annotations #34, 36; Aim #5) • Consider limited coronal computed tomography scan of sinuses and/or referral to ear, nose and throat clinician for patients when three weeks of antibiotic therapy have not produced a response in sinusitis treatment. (Annotation #51) The following system changes were identified by the guideline work group as key strategies for health care systems to incorporate in support of the implementation of this guideline.
• Develop, collect and disseminate materials to educate patients with allergic rhinitis about avoidance • Develop phone- or computer-based care for established patients that includes telephone nurse assessment, symptomatic care with follow-up instructions and use of a protocol to prescribe first-line antibiotics for Clinician – All health care professionals whose practice is based on interaction with and/or treatment of a
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Patients may present for an appointment, call into a clinician to schedule an appointment or call a nurse line presenting with respiratory illness symptoms. The symptoms of respiratory illness may include sore throat, rhinorrhea, cough, fever, headache and/or hoarseness.
• Patients with upper-airway obstruction, lower-airway obstruction, altered responsive- ness or severe headache should be seen immediately.
Recognizing the signs of a serious illness before it becomes life threatening is usually the medical clinician's key concern. Patients should be assessed for upper-airway obstruction, lower-airway obstruction, severe headache and then the An important purpose of Table 1 is to assist clinicians and triage personnel in distinguishing between respiratory illness and more serious illness. The urgency index increases with the number and severity of symptoms. Symptoms in Table 1 indi- cate which patients presenting with respiratory illness symptoms need to be seen immediately by a clinician.
Upper-Airway Obstruction
Patients with epiglottitis, croup or peritonsillar/retropharyngeal abscess may have signs of upper-airway
obstruction (stridor, air hunger, respiratory distress, toxic appearance, cyanosis, drooling with epiglottis) and require immediate medical evaluation with combined ear, nose and throat/anesthesia management in an emergency room or operating room setting.
Severe symptoms – including inability to swallow liquids, trismus, drooling without respiratory distress – should receive prompt evaluation by a physician within a reasonable amount of time, depending on the symptoms.
Lower-Airway Obstruction
Lower-airway obstruction signals an underlying condition different from respiratory illness. If moderate to
severe distress is present, this suggests pneumonia, chronic obstructive pulmonary disease, asthma, foreign body, cardiac condition or other underlying conditions requiring specific evaluation and treatment in an intensive setting. Such symptoms indicate the need for urgent evaluation and/or the need for intensive treatment, supplemental oxygen and prolonged observation.
Severe Headache
Severe headache (usually described as the worst headache of their life) could indicate subarachnoid hemor-
rhage, complications of sinusitis such as cavernous sinus thrombosis or sphenoid sinusitis, meningitis, encephalitis or other conditions. Such symptoms require prompt, intensive evaluation and care.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Less than three months
Three months - three years
Four years - adult
Respiratory distress
Respiratory distress
Respiratory distress
• marked dyspnea • moderate to severe dyspnea • stridor with croup • rapid respiratory rate • rapid respiratory rate symptoms not relieved by • shallow respirations • shallow respirations conservative measures • difficulty swallowing • difficulty swallowing • foreign body inhalation • foreign body inhalation • stridor with croup symptoms not relieved by conservative • feeling that throat is closing Responsiveness and activity
Responsiveness and activity
Responsiveness and activity
• unresponsive • altered mental state • decreased level of • decreased level of • cannot awaken or keep • cannot awaken or keep • markedly decreased activity • weak cry or weak suck • refuses to eat • inconsolable • markedly decreased activity • very lethargic • refuses feedings • very lethargic • sleeps excessively • sleeps excessively • cannot awaken or keep • inconsolable • weak suck or weak cry (if • unresponsive infant) • refuses feedings Dehydration and vomiting
Dehydration and vomiting
Dehydration and vomiting
• reduced wet diapers for more • no urination within 6-8 hrs if • no urination in more than 12 hrs younger than one year • no urination within 12 hrs if older than one year Meningeal signs
Meningeal signs
• persistent vomiting • persistent vomiting • severe headache • petechial or purpuric rash • petechial or purpuric rash • petechial or purpuric rash (Simon, 1997 [Low Quality Evidence]; Haugen, 1993 [Low Quality Evidence]; Ingraham, 1992 [Low Quality Evidence]; Nelson, 1992 [Low Quality Evidence]) Use algorithm to triage patient symptoms; begin at Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 This guideline applies to patients in normal health and without severe complicating health factors. Patients with complicating factors should consult with a clinician. The guideline should be applied with great care, if at all, to any adult or pediatric patients with complicating factors. A list of potential complicating factors, though not comprehensive, may include: • Chronic illness/disease (congestive heart failure, chronic obstructive pulmonary disease, sickle-cell • Elderly• History of rheumatic fever• Human immunodeficiency virus positive• Immunocompromised/immunosuppressed• Patient on chemotherapy• Asthma• Diabetes• Patient started antibiotics prior to diagnosis• Treatment failure is defined as recurrence of symptoms within seven days of completing antibiotic therapy. Possible reasons include medication non-compliance, repeat exposure, antibiotic resistance, copathogen (Hayes, 2001 [Guideline]). • Pregnancy*• Recurrent streptococcal pharyngitis – recurrence of culture positive group A beta streptococcal pharyngitis more than seven days but within four weeks of completing antibiotic therapy • Smokers• Sore throat for more than five days duration• Symptoms of whooping cough or recent exposure * This guideline should be applied with caution to pregnant women and underimmunized children.
History of Rheumatic Fever
An individual with a previous history of rheumatic fever who develops group A beta streptococcal pharyngitis
is at high risk for a recurrent attack of rheumatic fever. The infection does not need to be symptomatic to trigger a recurrence. Rheumatic fever recurrence can also occur when a symptomatic infection is optimally treated. Therefore, prevention of recurrent rheumatic fever requires continuous antimicrobial prophylaxis, and group A beta streptococcal infections in family members should be diagnosed and treated promptly (Dajani, 1995 [Low Quality Evidence]).
Human Immunodeficiency Virus Positive, Patient on Chemotherapy, Immunosuppressed,
Diabetes Mellitus, Pregnant
These complicating factors were arrived at by the consensus of the guideline work group and may involve
different diagnostic possibilities and/or treatment.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Patient Started Antibiotics Prior to Diagnosis
Occasionally, patients may have started "leftover" antibiotics at home on the assumption that the diagnosis
is group A beta streptococcal pharyngitis prior to presenting for diagnosis. This can make the diagnosis of group A beta streptococcal more difficult. Snellman et al. have reported that cultures of patients on anti- group A beta streptococcal active antibiotics may remain positive for a short period of time. If the patient has started antibiotics (two or more doses) before a laboratory test is done, the laboratory test results may be invalidated; therefore, a clinician should be consulted (Snellman, 1993 [High Quality Evidence]).
Sore Throat for More Than Five Days Duration
Patients with pharyngitis persisting over five days are less likely to have group A beta streptococcal phar-
yngitis and should be seen to be evaluated. Infectious mononucleosis can be difficult to differentiate from group A beta streptococcal pharyngitis on clinical grounds, and some patients with infectious mononucleosis may have a positive throat culture for group A beta streptococcal. Serologic evidence of infectious mono- nucleosis should be sought in patients when splenomegaly is present or if pharyngitis symptoms persist over five to seven days. Other possibilities include other viral etiologies, bacterial sinusitis and other causes of postnasal drip.
Persistent Infection/Treatment Failure
Patients who have been treated with antibiotics for streptococcal pharyngitis within the last month may
represent a treatment failure, recurrent disease or carrier state, and further evaluation may be necessary.
Treatment failure is defined as recurrence of symptoms within seven days of completing antibiotic therapy. Possible reasons include: • medication non-compliance, and• pharyngeal flora producing beta-lactamase.
Recurrent Strep Pharyngitis
Recurrent strep pharyngitis is defined as recurrence of culture-positive group A beta streptococcal pharyngitis
greater than seven days but within four weeks of completing antibiotic therapy. In patients with culture- positive group A beta streptococcal pharyngitis, the patient is likely to be experiencing recurrent episodes of acute group A beta streptococcal pharyngeal infection when: • clinical findings suggest group A beta streptococcal as the etiology,• epidemiologic findings suggest group A beta streptococcal as etiology (e.g., age 5-15 and winter/ • there is a repeated marked clinical response to antibiotic therapy,• throat cultures are negative between episodes of pharyngitis, and• there is a serologic response to group A beta streptococcal extra cellular antigens (ASO, anti-DNAase B) if measured.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Rhinitis is defined as inflammation of the membranes lining the nose and is characterized by nasal conges- tion, rhinorrhea, sneezing and itching of the nose and/or postnasal drainage (Dykewicz, 1998 [Low Quality Evidence]).
Symptoms of non-infectious rhinitis include: • pruritis of the eyes, nose, palate and ears;• watery rhinorrhea;• sneezing;• nasal congestion; and• postnasal drip.
Symptoms include: • upper-respiratory symptoms present 10-14 days, and• one or more of the following factors present at a point of 10-14 days after onset: - facial pain or sinus pain particularly if aggravated by postural changes or by valsalva maneuver- fever- purulent nasal drainage A viral upper-respiratory infection (common cold) is a self-limited illness typically lasting up to 14 days manifested by rhinorrhea, cough and fever.
Influenza is a viral upper-respiratory infection and has the potential to be more serious and differentiated by degree of illness, impressive myalgia, and season, and should be treated early onset The symptoms may include general malaise, hoarseness, injection of the conjunctiva, decreased appetite, headache and increased fussiness. Onset of symptoms is rapid. Fever, more commonly seen in children, usually lasts one to three days. Nasal discharge is initially clear and usually becomes yellow or green toward the end of the viral upper-respiratory infection; this does not signify a bacterial infection, and the patient does not need to be seen. The symptoms of a viral upper-respiratory infection usually peak in three to five days and should resolve within 14 days. A mild cough may persist at night for two to three weeks. There was consensus within the work group regarding the symptoms of the viral upper-respiratory infection that are not indicative of more serious illness. Medical textbooks and a widely used self-care source also listed essentially the same constellation of symptoms.
For children:
It is not unusual for a child to have five to eight colds a year.
Children with viral upper-respiratory infections have some combination of the following symptoms: nasal
congestion and discharge, fever, sore throat, cough, hoarseness, mild fussiness or irritability, decrease in appetite, sleep disturbance and mild eye redness or drainage.
(Szilagyi, 1990 [Low Quality Evidence]; Walson, 1984 [Low Quality Evidence]; Wood, 1980 [Decision Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 entiated from Viral Upper-Respiratory Infection
The table utilizes a diagnostic-based approach and a more complete summary of illnesses to be differenti-
ated from the viral upper-respiratory infection and associated symptoms.
Diagnosis
Symptoms
• Otalgia (ear pain) • Otorrhea (ear drainage) • Hearing loss • Dizziness Pneumonia/bronchitis Be particularly concerned if person has asthma, is a smoker or has lung disease • Pleuritic chest pain • Wheezing • Rhonchi • Mild dyspnea • Chest tightness • Alteration in voice Needs immediate evaluation at • Severe sore throat appropriate site • Severe dysphagia • Stridor • Drooling • Cough spasms Needs evaluation by a provider • Vomiting with cough • No fever • Barky seal cough or persistent • Inspiratory stridor It is essential to recognize symptoms that indicate an illness other than – or in addition to – pharyngitis, rhinitis, sinusitis and viral upper-respiratory infection that should be evaluated and treated.
• Patients, parents and caregivers should be educated on prevention, comfort measures and treatment recommendations for the common cold.
• Hand washing or use of hand sanitizers is recommended to prevent the spread of the common cold (viral upper-respiratory infection) (Sandora, 2005 [High Quality The goal is to provide solid, useful advice to patients without putting them at undue risk or expense. The guideline recommendations should provide improved comfort or otherwise proven benefit and not just represent "something to do." Studies of effectiveness of patient/parent education: a number of investigators have found that health care consumer education resulted in appropriate self-care for the common cold specifically, or illness in general, Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 with less unnecessary medical treatment and with lowered cost of care (Roberts, 1983 [High Quality Evidence]; Terry, 1993 [High Quality Evidence]).
Other investigators failed to find that health care consumer education reduced health care visits and cost of care. However, no negative effects of such education were found, and some other benefits were reported (Kemper, 1982 [High Quality Evidence]; Moore, 1980 [High Quality Evidence]).
For many parents, day care for their infant is a necessary fact of life, but there are some issues to consider. Day care has been shown to increase the frequency, severity and duration of upper-respiratory infections and the risk of secondary upper- and lower-respiratory infections (Wald, 1988 [Low Quality Evidence]; Fleming, 1987 [Low Quality Evidence]).
Otitis, sinusitis, pneumonia and wheeze-associated respiratory illnesses such as bronchiolitis have been shown to be more frequent among children who attend day care (Denny, 1986 [Low Quality Evidence]; Goodman, 1984 [Low Quality Evidence]; Loda, 1972 [Low Quality Evidence]).
Prevention
Although the viral upper-respiratory infection is a respiratory illness, researchers have found that viral
upper-respiratory infections are spread more by hands of the person with a cold and by very close contact than by droplets in the air. Hand washing or use of hand sanitizers are the most effective ways to prevent the spread of the common cold (viral upper-respiratory infection) (Sandora, 2005 [High Quality Evidence]). Viral upper-respiratory infection is most contagious at the onset of symptoms and while febrile (Carabin, 1999 [High Quality Evidence]).
Viral shedding continues for up to two weeks after the onset of initial upper-respiratory symptoms (Szilagyi, 1990 [Low Quality Evidence]).
Suggestions for limiting exposure are appropriate guidance for parents of children attending day care. Care provided in private home care has a lower rate of infectious disease. Children who are cared for in their own home by baby-sitters have the lowest rate of infection. Children under one year of age are at the highest risk for infections such as respiratory syncytial virus, and prudent counseling about day care attendance for this group would seem appropriate (Schmitt, 1992 [Low Quality Evidence]). Palivizumab, humanized monoclonal antibody against respiratory syncytial virus F glycoprotein, is available. Please see referenced article for details (American Academy of Pediatrics, 2003a [Low Quality Evidence]).
The first winter of the infant's life is the time when most caution should be exercised. Another measure that may be helpful for those in day care settings is segregation of infants and toddlers.
Encouraging continued breastfeeding may offer further protection from recurrent otitis and prolonged duration of upper-respiratory illnesses (Duncan, 1993 [Low Quality Evidence]; Frank, 1982 [Low Quality Evidence]).
For infants and toddlers
• Discourage visitors who have an acute illness, a fever or contagious disease.
• Prevent child with viral upper-respiratory infection from sharing toys and pacifier with other chil- dren, and clean these items with soap and hot water as feasible to reduce opportunities for viral • Use and teach good hand washing.
• Ask visitors to wash their hands before holding baby.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 • Day care with three or more families represented is associated with higher incidence of viral upper- respiratory infections, ear infections and lower-respiratory infections; therefore:- check to see if staff and children at your child's day care are being taught good hand washing and other infection control measures (excellent educational materials are available that day care clinicians can obtain), and - consider day care options that reduce exposure to other children: • relative or friend• in-home nanny shared by two families • Encourage and support mothers to continue breastfeeding for an appropriate period because human milk contains ingredients that help protect babies from infections.
Comfort Measures
Parents have comfort and convenience, personal plans and work to contend with, as well as a fear of the
unknown potential of their child's illness. These factors drive parents to seek help (and sometimes antibiotics) as early as possible to minimize the impact of the illness. Health care clinicians need to help parents gain knowledge about childhood respiratory illnesses and develop decision-making skills and realistic expecta- tions (Cowan, 1987 [Low Quality Evidence]; Zapka, 1979 [Cost-Effectiveness Analysis]).
• Nasal suction for infants To relieve nasal congestion for infants less than three months, suction gently with a blunt-tipped bulb syringe before feedings and sleep. Using a bulb syringe to aspirate nasal secretions may promote drainage and comfort. When using a blunt-tipped bulb syringe, compressing the bulb before placing the syringe over the nose prevents pushing mucus farther into nasal passage. Proper cleaning and air-drying of bulb syringe reduces the opportunity for growth of organisms inside the syringe. Wash bulb syringe with hot, soapy water, rinse and allow to air dry.
• Steam or mist inhalation Mist inhalation does serve as an effective comfort measure for some people. Because of burns that have occurred when people use steam vaporizers, and the potential for microorganism growth in vaporizers, the recommended method for steam inhalation is standing in a hot shower or sitting in the bathroom when the hot shower is running. "Cool mist" vaporizers avoid the burn risk, though not the potential for growth of microorganisms (Macknin, 1990 [High Quality Evidence]; Tyrrell, 1989 [High Quality Evidence]; Ophir, 1987 [High Quality Evidence]).
• Nasal irrigation Saline nose drops help loosen secretions, making it easier to clear nares (Gadomski, 1992 [Low Quality Evidence]; Szilagyi, 1990 [Low Quality Evidence]). Commercial or homemade saline nose drops/sprays may be used. Home remedy: 1/4 teaspoon salt dissolved in eight ounces warm water.
• Maintain adequate humidity in the home Microorganisms grow easily in humidifiers/vaporizers unless they are cleaned properly and often. Health care clinicians often advise against using steam humidifiers/vaporizers because of the risk of the child getting burned with the hot water in the device. Also, added humidity can cause the growth of mildew in the home. These well-known risks should be weighed against the potential benefits of using humidifiers and the parents' ability and willingness to use and clean the device properly.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 • Consume extra fluids.
Warm fluids are especially soothing for irritated throats (e.g., chicken soup).
• Honey (Paul, 2007 [Low Quality Evidence]; avoid using honey preparations for children under one year because of the risk of botulism.
• Consume nutritious diet as tolerated.
• Elevate head of bed.
• Salt water gargle for sore throat with homemade salt water (1/4 teaspoon dissolved in 8 ounces warm water) or a store version.
• Use hard candy or throat lozenge for sore throat or cough (not recommended for children four and • Get adequate rest.
How a person feels is an indication of the amount of rest needed. When a person with a viral upper-respiratory infection is afebrile and feels like being up and about, normal activity should not prolong the illness.
Treatment Recommendations
Antibiotics
Antibiotics are effective only for treating bacterial infections. Because colds are viral infections, antibiotic use
will not cure or shorten their length (Arroll, 2010 [Systematic Review]; Soyka, 1975 [Low Quality Evidence]). Antibiotics cause side effects such as gastrointestinal discomfort, diarrhea, allergic reactions, diaper rash, and yeast infections. Unnecessary use of antibiotics can lead to the development of antibiotic-resistant strains of bacteria.
Over-the-counter medications
Over-the-counter cold and cough medications and acetaminophen do not shorten the duration of viral upper-
Children
In April 2007 the Food and Drug Administration issued a warning on using cough and cold medicines
in young children. Parents and other caregivers should only administer cough and cold medications to children under two when following the exact advice of their doctor. Clinicians should be certain that caregivers understand both the importance of administering these medications only as directed and the risk of overdose if they administer additional medications that might contain the same ingredient (Federal Drug Administration, 2007 [Low Quality Evidence]).
The Food and Drug Administration does not have approved dosing recommendations for clinicians prescribing cough and cold medications for children two and under (Centers for Disease Control and Prevention, 2005 [Low Quality Evidence]).
The Cochrane Collaboration conducted an extensive search of studies involving over-the-counter prepa- rations for acute cough. It concluded that there is no good evidence for or against the effectiveness of over-the-counter cough medications (Schroeder, 2007 [Systematic Review]).
Decongestants also have not clearly shown benefit in shortening or ameliorating symptoms (Hutton, 1991 [High Quality Evidence]).
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 A phenol-type throat spray appears to be effective in relieving coughs and sore throats associated with colds, but no pertinent research could be located. Many coughs associated with colds respond to the non-pharmacological measures listed above and do not require an over-the-counter preparation (Pruitt, 1985 [Low Quality Evidence]).
Acetaminophen or ibuprofen may be suggested for home use because of the risk of Reye's syndrome associated with aspirin use in children.
The fever that frequently accompanies a viral upper-respiratory infection in children is not harmful and is usually gone in two to three days. Parents/caregivers should be educated on fevers, signs, symptoms and treatment. It is the consensus of the work group that fevers persisting beyond two to three days should be evaluated by a clinician. Work group members also agree that infants under three months with fevers should be thoroughly evaluated. Fever can only be evaluated in the specific context of the whole illness and the accompanying circumstances. By itself, the magnitude of fever bears little or no relationship to the severity of the illness (Schmitt, 1984 [Low Quality Evidence]).
Adults
For adults with a cold, over-the-counter products such as nasal sprays, decongestants, saline nose drops
and analgesics may provide temporary relief of sore throat, runny nose, coughing, minor aches and fever. Because of potential side effects, however, be sure to follow the recommended dosage and precautions. Patients who have high blood pressure, diabetes, thyroid disease or who are pregnant should check with their physician regarding recommendations for decongestant use.
Use medication for discomfort as recommended by a physician or nurse for fever.
General discomfort, headache and fever reduction
Graham et al. (1990) conducted a double-blind, placebo-controlled study to test the effects aspirin, acetamino-
phen and ibuprofen in 56 volunteers who were infected with the cold virus. Use of aspirin and acetaminophen was associated with suppression of serum-neutralizing antibody response and increased nasal symptoms and signs. There were no significant differences in viral shedding among the four groups. Sperber et al. (1992) compared the effects of naproxen with a placebo in a randomized, double-blind, controlled trial. Persons in the naproxen group had significant reductions in headache, malaise, myalgia and cough, but viral titers and antibody responses were similar in the two groups (Sperber, 1992 [High Quality Evidence]; Graham, 1990 [High Quality Evidence]).
Aspirin, ibuprofen and naproxen should be avoided by persons who are not eating well (risk of gastroin- testinal upset), have a history of peptic ulcer or related disorder, have aspirin-sensitive asthma, and have renal dysfunction. For these reasons, plus the risk of Reye's syndrome associated with aspirin use in young, healthy children, acetaminophen should be suggested as the drug of choice. However, it should be used only as needed because of the effects described by Graham et al. (1990).
The most helpful source located to guide decisions about over-the-counter cold preparations is a major review article published in 1993. It includes clinical trials published between 1950 and 1991. Only 27 articles of the 106 retrieved met the study criteria and were judged to have adequate scientific validity to be included in the final review. In the adolescent/adult studies, the following drugs were found to reduce nasal symptoms: chlorpheniramine maleate, pseudoephedrine HCl and oxymetazoline HCl (Smith, 1993 [Systematic Review]).
An intranasal anticholinergic (ipratropium bromide) is not effective when there is documented significant nasal obstruction. The cost/benefit relationship for ipratropium bromide nasal spray is rarely supportive for use of this medication. In addition, it requires physician intervention that consists of phone calls and/ or office visits, which significantly increases the cost of care for a benign condition.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Echinacea
Findings in the medical literature do not support the use of echinacea in preventing viral upper-respiratory
infection. Some preliminary data indicate that echinacea may shorten the course of viral upper-respiratory infection; however, studies that produced this data are small. Methods by which echinacea is prepared are not standardized, and actual dose delivered by specific products varies widely. Hence, the work group cannot recommend the use of echinacea in preventing or shortening the duration of viral upper-respiratory infection at this time. The work group wil continue to evaluate the data on this and other herbal preparations (Turner, 2005 [Low Quality Evidence]; Grimm, 1999 [High Quality Evidence]).
Vitamin C
There is no consistent evidence in the medical literature that high doses of vitamin C help shorten the course
of viral upper-respiratory infections. Hence, it was the consensus of the work group that high doses of vitamin C should not be recommended.
Zinc
In adults there is some evidence that oral zinc gluconate may decrease the duration of a cold if started within
24 hours of onset; however, adverse reactions including nausea and bad taste may limit its usefulness. Zinc is not indicated and may be dangerous during pregnancy.
Intranasal zinc gluconate therapy can cause anosmia and is not 2010 [Low Quality Evidence]).
Mossad et al. conducted a randomized, double-blind, placebo-controlled study to test this. They found that zinc gluconate did reduce the duration of symptoms of the common cold (Mossad, 1996 [High Quality Evidence]).
Two clinical trials involving experimental rhinovirus colds and natural colds tested the efficacy of oral zinc acetate for the treatment of the common cold. Three preparations were used in the study: zinc acetate lozenges, zinc gluconate lozenges and placebo lozenges. The study concluded that oral zinc gluconate did reduce the duration of symptoms with experimental rhinovirus. Please note that during the first three days the severity of symptoms was not affected, and it had no effect for the natural cold. Oral zinc acetate had no effect on duration or severity on either experimental or natural colds (Turner, 2000 [High Quality Evidence]).
According to the Cochrane Collaborative, overall results of studies of the effect of oral zinc gluconate on upper-respiratory infection duration and severity have been inconclusive (Marshall, 2000 [Systematic Review]).
A randomized control trial of 249 students in grades 1 through 12 were studied for the effects of zinc gluco- nate lozenges for treating the common cold. The study found that zinc gluconate lozenges, in 10 mg, orally dissolved, were ineffective in relieving symptoms (Macknin, 1998 [High Quality Evidence]).
Call Back Instructions
Children three months to 18 years of age.
Call back if:
• fever lasts three days or more;• symptoms worsen after three to five days or if new symptoms appear (e.g., increasing symptoms of illness, lethargy, decreased responsiveness, poor eye contact, difficulty breathing); or • symptoms have not improved after 7 to 10 days; it is not unusual, however, for a mild cough and congestion to continue 14 days or more.
Return to Algorithm Return to Table of Contents Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Adults
Call back if symptoms worsen after 3 to 5 days, new symptoms develop or symptoms do not improve after
Patients report a sore throat without rhinorrhea, cough or hoarseness.
Patients with recent strep exposure may be more likely to have group A beta streptococcal pharyngitis.
Signs and symptoms associated with group A beta streptococcal include:
• sudden onset of sore throat,• exudative tonsillitis,• tender anterior cervical adenopathy,• history of fever,• headache in the setting of other symptoms noted above,• abdominal pain in the setting of other symptoms noted above, and• absence of rhinorrhea, cough, hoarseness.
Other symptoms sometimes associated with group A beta streptococcal pharyngitis include:
• close exposure to strep throat (especially familial exposure)• vomiting,• malaise,• anorexia, and• rash (especially scarletina) or urticaria.
Patients with recent strep exposure may be more likely to have group A beta streptococcal pharyngitis.
See Annotation #13, "Are Symptoms/Signs Suggestive of Strep Pharyngitis?" for the signs and symptoms associated with group A beta streptococcal pharyngitis.
After viral upper-respiratory infection and otitis, acute tonsillopharyngitis is the third most common illness diagnosed by United States pediatricians. The major issue in most cases of acute pharyngitis is differentiating between group A beta streptococcal infection (causing 15-30% of cases of acute pharyngitis in children and 5-20% in adults) and other self-limited etiologies (Choby, 2009 [Guideline]). Group A beta streptococcal pharyngitis requires appropriate antimicrobial therapy to prevent rheumatic fever and suppurative compli- cations, and to minimize the secondary spread of the illness. It may also shorten the course of the illness, although not dramatically. Many of the other causes of acute pharyngitis can be treated symptomatically (Bisno, 1997a [Low Quality Evidence]; Randolph, 1985 [High Quality Evidence]).
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Group A beta streptococcal pharyngitis is uncommon in children younger than three years of age and rare in children younger than 18 months old. Rheumatic fever is uncommon in children younger than three years of age (Peter, 1992 [Low Quality Evidence]).
Viral Causes of Acute Pharyngitis
Acute pharyngitis can be caused by both bacterial and viral pathogens. Most cases of acute pharyngitis
are viral in etiology. Viral pathogens can cause pharyngitis clinically indistinguishable from group A beta streptococcal pharyngitis and can also cause distinct clinical syndromes, including adenovirus (pharyngo- conjunctival fever), parainfluenza (hoarseness, croup), rhinovirus (coryza), herpes simplex type 1 and 2 (gingivitis and stomatitis), respiratory syncytial virus (hoarseness, wheezing), Epstein-Barr virus (infectious mononucleosis), influenza, coxsackievirus A (herpangina), enteroviruses (diarrhea), human immunodeficiency virus, coronavirus (viral upper-respiratory infection symptoms) and cytomegalovirus (Paradise, 1992 [Low Quality Evidence]; Lang, 1990 [Low Quality Evidence]).
Although it has been recognized that group A beta streptococcal and mononucleosis can be present together, most of the time this is felt to be because of the strep carrier state in those with mononucleosis. The acute symptoms of mononucleosis are nearly identical to those of group A beta streptococcal pharyngitis; thus, many patients with mononucleosis present initially for a throat culture. If the culture is positive, they are treated, and then return when symptoms persist. With the prevalence of the carrier state being between 10% and 25%, it would be expected that a similar percentage of patients with mononucleosis would have posi- tive throat cultures. Since there is no practical way to differentiate these patients as carriers, a full course of antibiotics is recommended. However, if the patient on antibiotics is not recovering as expected, he/she should be reevaluated.
Bacterial Causes of Acute Pharyngitis
Bacterial pathogens (along with associated syndromes) other than group A beta streptococcal that can
cause pharyngitis include group C and group G strep, mixed anaerobes (Vincent's angina), Fusobacterium necrophorum, Neisseria gonorrhea, Corynebacterium diptheriae (diphtheria), Yersinia pestis (plague), Treponema palladium (secondary syphilis), Francisella tularensis (tularemia), Mycoplasma pneumoniae (atypical pneumonia), and several chlamydial species (Paradise, 1992 [Low Quality Evidence]; Lang, 1990 [Low Quality Evidence]).
Non-infectious causes of sore throat, such as thyroiditis, are relatively uncommon considerations in the differential diagnosis of acute febrile pharyngitis.
Group A beta streptococcal pharyngitis has a number of characteristic features, including odynophagia, high fever, scarlatiniform rash, pharyngeal exudates, petechiae on the soft palate, tender anterior cervical lymphadenopathy, and malodorous breath. Few patients display all the classic signs and symptoms of group A beta streptococcal (American Academy of Pediatrics, 2003b [Low Quality Evidence]).
Complications Associated with Untreated Group A Beta Streptococcal
Rheumatic fever is a non-suppurative complication of group A beta streptococcal pharyngitis (Gordis, 1973
[Low Quality Evidence]). The risk of developing rheumatic fever is about 3% under epidemic conditions and approximately 0.3% under endemic conditions. First attacks of rheumatic fever are rarely seen in children younger than three years of age or adults over 40 years of age because of the relative infrequency of group A beta streptococcal infections in these age groups. One reason for identifying and treating patients with group A beta streptococcal pharyngitis is to decrease the incidence of rheumatic fever (Dajani, 1995 [Low Quality Evidence]). The only controlled study demonstrating the possibility of preventing rheumatic fever was done in 1950 in military camps (Denny, 1950 [Low Quality Evidence]). Further longitudinal studies have shown evidence of prevention of rheumatic fever by treatment of group A beta streptococcal with Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 penicillan. Several studies have shown that treatment of patients with group A beta streptococcal pharyngitis shortens the course of the illness (Krober, 1985 [High Quality Evidence]), although it should be recognized that group A beta streptococcal pharyngitis is usually a self-limited disease, and fever and constitutional symptoms disappear spontaneously within three to four days of onset, even without antibiotic therapy (Bisno, 2002 [Guideline]).
History and physical findings may increase or decrease the likelihood of group A beta hemolytic strep as the cause of pharyngitis. Factors increasing the likelihood include abrupt onset, associated fever, headache, abdominal pain in the set ing of a sore throat (especial y in children), presence of tonsil ar exudate, primarily anterior cervical adenopathy and the absence of cough, hoarseness and nasal congestion. These findings are not specific enough for group A strep to allow empiric treatment without testing. On the other hand, lack of these physical findings and history may eliminate the need to do strep testing and focus treatment instead on symptomatic measures.
Several scoring systems have been developed to assist in predicting which patients will have a positive throat culture, but none has a high enough predictive value to allow treatment without a positive rapid strep test or strep throat culture. Historically these scoring systems were used to identify patients likely enough to have group A beta streptococcal that a confirmatory throat culture was unnecessary. Now they are used to identify patients who are so unlikely to have group A beta streptococcal that rapid strep test or strep culture is unnecessary (Seppälä, 1993 [Low Quality Evidence]; Breese, 1977 [Low Quality Evidence]). Rapid strep test and strep culture both require proper collection technique by trained professionals and must be performed according to the Federal Clinical Laboratory Improvement Act (CLIA) regulations. Poor collection procedures reduce accuracy of either test. Rapid strep test must also be performed according to the manufacturer's guidelines. An appropriately performed throat swab touches both tonsillar pillars and the posterior pharyngeal wall. The tongue should not be included (although its avoidance is sometimes technically impossible). Backup strep culture is needed if rapid strep test is negative, unless it has been ascertained that in a given practice the rapid strep test is comparable to a throat culture (Bisno, 2002 [Guide- line]. Testing for rapid strep test and backup culture may require the use of separate swabs for each test.
Polymerase chain reaction (PCR) may also be used for primary testing or as a backup instead of plated culture.
Rapid strep test has the following advantages:
• It has nearly 100% specificity.
• Rapid turnaround time reduces unnecessary short-term treatment while awaiting test results and the associated complexity of interim treatment strategies.
• It potentially reduces need for callbacks.
• It allows the initiation of antibiotic in the timeliest fashion, reducing acute morbidity and contagion.
• Overall, rapid strep test may be more cost effective through reduced rework and reduced cycle time (Lieu, 1990 [Cost-Effectiveness Analysis]).
• Rapid strep test has high patient satisfaction, even with associated wait time for results.
Rapid strep test has the following disadvantages or limitations:
• Lab costs are increased.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 • Current technology requires that negative rapid strep tests be backed up with strep culture because of relatively low sensitivities, unless it has been ascertained that in a given practice the rapid strep test is comparable to a throat culture (Bisno, 2002 [Guideline]).
• Recent study indicates the utility of a real-time polymerase chain reaction assay as a replacement for both rapid antigen testing and culture (Uhl, 2003 [Low Quality Evidence]). The polymerase chain reaction (PCR) method requires a minimum of 30 to 60 minutes to perform the test, and in order to be used efficiently, it would require batch testing. When PCR testing is used, a backup plated culture is not necessary.
• Clinics may need to arrange patient flow in the office and need to determine who will perform rapid • False-positives may occur with retesting for up to 14 days following antibiotic course completion (presumably due to incomplete clearing of strep antigen fragments that are still detected after clinical • It does not differentiate between illness and carrier states.
• Penicillin (PCN) is the drug of choice for treatment of culture positive cases of group A beta streptococcal pharyngitis. In children and patients unable to swallow pills, amoxicillin is an acceptable alternative due to the poor palatability of the penicillin • In penicillin-allergic patients, options include cephalosprins (for some types of aller- gies), macrolides and clindamycin. Consider reevaluating patient for carrier status. Although macrolides may be an acceptable alternative, clinicians should check their local resistance patterns.
• Macrolides• Cephalexin• Clindamycin• Amoxicillin/clavulanate• Rocephin (Peter, 1992 [Low Quality Evidence]; Bass, 1991 [Low Quality Evidence]; Gerber, 1990 [High Quality Evidence])A discussion of referral criteria for tonsillectomy in patients with recurrent tonsillitis is outside the scope of this guideline. As a result, the work group suggests physicians refer to one or more sources that offer a detailed discussion of referral criteria (Lan, 2000 [Meta-analysis]; Paradise, 1984 [High Quality Evidence]).
Patients currently on antistreptococcal antibiotics are unlikely to have streptococcal pharyngitis. Antibiotics not reliably antistreptococcal include sulfa medications, nitrofurantion and tetracycline.
Children may return to school 24 hours after antibiotic treatment has been started (Snellman, 1993 [High Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 After initiating a course of an appropriate antibiotic, improvement in symptoms related to group A strepto- coccal pharyngitis should be seen by 48 to 72 hours.
It is suggested that the patient be instructed to contact the clinician's office within 72 hours if symptoms do not improve.
It is important to emphasize to the patient that completion of the course of antibiotic is important to reduce risk of recurrence.
Strep group A testing may, if positive, reflect a carrier state in which case the antibiotic used may not be effec- tive. The prevalence of the carrier state has been estimated to vary between 10% and 25%. For this reason, if symptoms have not improved by 72 hours, there should be consideration of reevaluation of the patient. This may be needed particularly to exclude peritonsillar cellulitis or abscess, infectious mononucleosis, and especially in patients aged 15-30, the possibility of infection with the bacteria Fusobacterium necrophorum that can lead to a severe complication called Lemierre's Syndrome. The causative organisms of peritonsillar cellulites and abscess are unlikely to be strep, and therefore an empiric change in antibiotic or referral to ear, nose and throat clinician may be indicated. If clinically indicated, testing for mononucleosis may be appropriate, keeping in mind that screening tests for mononucleosis may not be positive until several days into the illness.
Patients who are chronically colonized with group A beta streptococcal are called carriers. These patients are at very low risk, if any, for developing suppurative (e.g., peritonsillar abscess) or non-suppurative (e.g., rheumatic fever) complications and are unlikely to spread group A beta streptococcal to close contacts. Therefore, most carriers require no medical intervention.
In the patient with recurrent culture positive group A beta streptococcal pharyngitis, the patient is likely to be a streptococcal carrier if: • clinical findings suggest a viral etiology,• epidemiologic findings (e.g., age, season) suggest a viral etiology,• there is little clinical response to antibiotic therapy,• throat cultures done between episodes of acute pharyngitis (when the patient is asymptomatic) are also positive, or • there is no serologic response to group A beta streptococcal antigens if measured (ASO, anti-DNAase Situations in which identification and eradication of streptococcal carrier state may be desirable include (Kaplan, 1980 [Low Quality Evidence]): • family history of rheumatic fever,• ping-pong spread within a family,• family with significant anxiety about group A beta streptococcal,• outbreaks of group A beta streptococcal pharyngitis in closed or semiclosed community, and• when tonsillectomy is being considered solely because of chronic carrier state.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Two alternative treatment protocols have been established in the literature as effective in eliminating the carrier state. Clindamycin is the treatment of choice if the decision is made to treat the carrier state. If clindamycin is not a suitable therapeutic choice, consideration can also be given to penicillin/rifampin combination (Tanz, 1991 [High Quality Evidence]; Chaudhary, 1985 [High Quality Evidence]; Tanz, 1985 [High Quality Evidence]; Kaplan, 1980 [High Quality Evidence]).
Lemierre's Syndrome is a potentially severe complication of pharyngitis caused by Fusobacterium necroph- orum. Lemierre's Syndrome is characterized by an initial episode of pharyngitis, followed by clinical signs of bacteremia, after approximately four days. They develop suppurative thrombophlebitis of the internal jugular vein, bacteremia, and metastatic infections, most commonly pulmonary abscesses. Although first described in 1936, it has recently been recognized more often. Recent case study reports providing mortality data found a mortality rate of 4.6%. In addition, the most recent published case series included morbidity data, finding that permanent sequelae occurred in 10.2% of patients. Thus, clinicians caring for young adults and older adolescents should educate themselves about Lemierre's Syndrome and consider that diagnosis in patients with worsening clinical symptoms several days into an episode of pharyngitis. Since there is no clinical y useful test to identify this pathogen, empiric treatment could be considered particularly if symptoms are worsening after three to five days or if neck swelling occurs. Penicillins/cephalosporins are effective but macrolides/azolides are not. In the presence of bacteremic symptoms, empiric treatment should include penicillin with metronidazole or with clindamycin (Centor, 2009 [Low Quality Evidence]).
If clinically indicated, testing for mononucleosis may be appropriate, keeping in mind that screening tests for mononucleosis may not be positive until several days into the illness. Treatment of persistent infection should be directed toward eradication of both group A beta streptococcal and beta lactamase-producing protective organisms.
Note: All episodes consist of clinical findings and positive lab tests within seven days after completion of a course of antibiotic therapy.
• The patient should be instructed to call back if the symptoms worsen or if they persist beyond five to seven days.
When a patient currently on antibiotics (other than sulfa, tetracycline, nitrofurantoin or other non-strep anti- biotics) is taking the medication as prescribed and develops a sore throat, chances are that the sore throat is caused by something other than group A beta streptococcal. Treatment failure for group A beta streptococcal is rare; education is needed on home remedies for sore throats.
Home remedies include the following:
• Take acetaminophen or ibuprofen. Do not use aspirin with children and teenagers because it may increase the risk of Reye's syndrome.
• Gargle with warm salt water (1/4 teaspoon of salt per 8 ounce glass of water).
• Adults or older children may suck on throat lozenges, hard candy or ice.
• Eat soft foods.
• Drink cool beverages or warm liquids.
• Suck on flavored frozen desserts (such as popsicles).
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 If a rapid strep test is not available or the results are negative, a strep culture should be performed unless it has been ascertained that in a given practice the rapid strep test is comparable to a throat culture. Generally treatment should be delayed until the culture results are available. Results are usually available within 24 hours or slightly less but may require incubation for longer periods of time. Some clinicians choose to initiate treatment prior to culture result availability, but a full course of treatment should not be prescribed until culture results confirm the presence of group A beta streptococcal (Gerber, 1989 [Low Quality Evidence]).
A less satisfactory strategy is empiric treatment. Using complex clinical scoring systems or in patients with the complete constellation of classic strep symptoms, empiric treatment may be justified but has significant limitations. If full-course treatment is initiated without intent to rely on the test results, laboratory testing is redundant and wasteful. Routinely culturing and prescribing antibiotic treatment for asymptomatic family members is not recommended. Routinely reculturing patients after treatment with antibiotics is not recommended.
Treatment of group A beta streptococcal pharyngitis is accurate when based on rapid strep test or strep culture results. Even with elaborate clinical scoring systems, diagnostic accuracy (probability of group A beta streptococcal) is only 50%, increasing to 75% if white blood count results are included in decision- making. For this reason, empiric treatment is discouraged; several professional societies recommend treat- ment based solely on culture results. Advantages and disadvantages for several modalities are listed below (Breese, 1977 [Low Quality Evidence]).
Strep culture has the following advantages:
• Even though strep culture is not a perfect test, it remains the "gold standard" by which other diag- nostic methods are measured.
• It is less expensive to perform than rapid strep test.
Strep culture has the following disadvantages or limitations:
• Incubation time delays initiation of definitive treatment, reducing patient satisfaction.
• It does not differentiate between illness and carrier states.
• Culture sensitivity is dependent on technique and technical expertise.
Short-term treatment awaiting culture has the following advantages:
• It allows reduction of acute morbidity and associated lost productivity of patient or caregiver because of the early initiation of treatment.
• It does not promote saving of unused antibiotic if the culture is negative.
Short-term treatment awaiting culture positives has the following disadvantages:
• It may promote inappropriate drug sampling.
• It may cause additional patient co-pays due to need for secondary prescriptions.
• Additional callbacks are still required to report culture results.
• Many unnecessary antibiotics may be used with the potential risk of iatrogenic harm.
Empirical treatment of classic strep presentation has the following advantages:
• There is reduced time until initiation of definitive therapy.
• Redundant diagnostic tests are not performed.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 • It gives high patient satisfaction to patients who are confident of their diagnosis prior to the test Empirical treatment of classic strep presentation has the following disadvantages:
• It promotes overtreatment since clinical diagnostic accuracy is only 50-75% with the best scoring • Due to overtreatment, other risks are enhanced, such as medication intolerance or serious allergy, • It reinforces mistaken beliefs about strep pharyngitis.
Whether or not the test is positive, patients and their families want to know results as soon as possible so that they can appropriately plan for their needs.
• If negative, they need educational information and a planned course of action if they do not recover in a reasonable time frame or if they become more ill.
• If positive, patients want to be started on medication as rapidly as possible, primarily as a comfort or convenience issue and to reduce contagion. Rheumatic fever prophylaxis is likely satisfactory if started up to nine days after the onset of illness (Gerber, 2009 [Guideline]). However, patients and parents may perceive any delay in initiation of treatment as poor service.
If the rapid strep test and/or the strep culture are negative, the patient needs to be educated on non-strep sore throats. This includes the duration of the symptoms, ineffectiveness of antibiotic treatment, and home remedies that will ease the symptoms. The patient should be instructed to call back if the symptoms worsen or if they persist beyond five to seven days.
The benefit of treating non-group A beta streptococcal bacterial pharyngitis with erythromycin is smal and of borderline statistical significance. Because of the smal ef ect and the risk of promoting drug resistance, the use of erythromycin for the treatment of non-group A beta streptococcal pharyngitis is not recommended (Peterson, 1997 [High Quality Evidence]).
Home remedies include the following:
• Eat soft foods.
• Drink cool beverages or warm liquids. • Suck on flavored frozen desserts (such as popsicles).
Provide educational material about non-strep causes of sore throats and home remedies for the patient to take home. Seefor additional information. Health education resources are included in the Non-group A beta streptococcal pharyngitis would generally be expected to be improving over a period of a few days. Patients should be instructed to contact their clinician if symptoms are persisting.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Home care measures to alleviate symptoms should be continued as needed. for details.
Non-infectious rhinitis is defined as inflammation of the membranes lining the nose and is characterized by nasal congestion, rhinorrhea, sneezing and itching of the nose and/or postnasal drainage.
(Dykewicz, 1998 [Low Quality Evidence]) Non-infectious rhinitis can present with any of the symptoms listed in the history of present illness. Topical decongestant abuse can cause a form of rhinitis alone, or can be associated with worsening of other forms of rhinitis. Many antihypertensive agents, specifically alpha-adrenergics, beta-blockers and ACE inhibitors, have been reported to induce rhinitis.
Clues in the history include previous facial trauma or surgery; atopic conditions such as asthma, rhinitis or atopic dermatitis; vasomotor triggers such as foods, strong odors, weather changes, bright light or inhaled irritants; or hormonal conditions such as pregnancy or thyroid disease (Wheeler, 2005 [Guideline]). A family history of atopy or a history of other allergy-associated conditions make allergic non-infectious rhinitis more likely.
A structural etiology such as obstruction or a cerebrospinal fluid leak is more likely when previous trauma or surgery is present. Suspicion of a cerebrospinal fluid leak as the cause of nasal discharge can be confirmed by testing for glucose in the discharge. If cerebrospinal fluid leak is seriously being considered, this would fall in the realm of specialty diagnosis, and a consultation should be obtained as soon as possible.
In young children, foreign body in the nares and gastroesophogeal reflux should also be considered as potential causes of rhinitis.
Exposure to triggers in the environment is a crucial point in the history. Home, school, work, day care and other frequent exposures should be reviewed. Finally, in the history of present illness, documentation of treat- ments used for rhinitis is important, as trial and error is often the only way to determine each patient's needs.
The following points in the history and physical are relevant to rhinitis.
History of present illness:
• Congestion or obstruction• Rhinorrhea (anterior nasal discharge)• Pruritus of nose or eyes• Sneezing• Posterior nasal discharge with or without cough Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 • Sinus pressure/pain• Snoring• Episodic or seasonal or perennial symptoms; consider specific triggers*• Pregnancy• Current medications such as topical decongestants, hormones, antihypertensives, antibiotics• Current and previous treatments for rhinitis Past medical history:
• History of trauma or facial/sinus surgery• Relevant medical conditions: asthma, dermatitis, chronic sinusitis, chronic or recurrent otitis • History of polyps and ASA/NSAID sensitivity • Asthma• Rhinitis• Atopic dermatitis Social and environmental history:
• Occupational exposures*• Home exposures*• Active and passive smoking exposures• School exposures• Illicit drug exposures Physical examination
The physical exam can have any combination of signs noted. Swollen nasal turbinates (congestion),
rhinorrhea and pruritus tend to be the most common. Allergic conjunctivitis may also be present with red, watery, pruritic eyes.
Atrophic rhinitis is characterized by foul-smelling nasal crusting and sinus pain, and is usually related to atrophy, excessive nasal and sinus surgery, radiation or one of several rare diseases such as Wegner's • Swollen nasal turbinates (may be boggy, bluish or pale, hyperemic or purplish red); note • Clear, cloudy or colored rhinorrhea• Nasal septal deviation or structural abnormality• Nasal polyps Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 • Nasal crease or "salute"• Sneezing• Mouth breathing• Unilateral obstruction• Foreign body • Conjunctivitis• Allergic "shiners" (dark circles under the eyes from venous stasis)• Dennie's lines (lower eyelid creases)• Periorbital edema • Acute otitis media or otitis media with effusion (suggesting associated eustachian tube • Wheezing or prolonged expiratory phase (suggesting associated asthma) • Atopic dermatitis (Graft, 1995 [Low Quality Evidence]; Knight, 1995 [Low Quality Evidence]; Druce, 1992 [Low Quality Evidence]; Raphael, 1991 [Low Quality Evidence]) With seasonal or episodic allergic rhinitis, common symptoms are sneezing, itching of the nose, palate or eyes, and clear rhinorrhea. However, nasal congestion is often the most significant complaint in patients with perennial rhinitis.
(Graft, 1995 [Low Quality Evidence]; Naclerio, 1991 [Low Quality Evidence])
Signs and symptoms suggestive of an allergic etiology include:
• pruritus of the eyes, nose, palate, ears;• watery rhinorrhea;• sneezing;• seasonal symptoms;• family history of allergies;• sensitivity to specific allergens, especially dust mites, animals, pollen and mold; and• asthma or eczema.
Signs and symptoms suggestive of non-allergic rhinitis include:
• sensitivity to smoke, perfume, weather changes and environmental irritants, Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 • history of previous negative allergy testing,• overuse of topical decongestants,• adult onset of symptoms,• nasal crusting or drying, and• facial pain.
Signs and symptoms suggestive of either or both include:
• perennial symptoms,• episodic symptoms,• nasal congestion, and• history of frequent sinus infections/chronic sinusitis.
Symptomatic Treatment
If the clinical diagnosis is obvious, symptomatic treatment should be initiated. Symptomatic treatment
includes both education on avoidance and medication therapy.
Avoidance activities: Identifying avoidable al ergens by skin test or radioal ergosorbent test wil enhance
a patient's motivation to practice avoidance. Some avoidance activities require significant financial investment or substantial lifestyle changes by the patient. Before recommending such measures, it may be useful to recommend skin testing or limited radioallergosorbent test testing to confirm the diagnosis and to identify the specific allergen.
House dust mites: House dust mites are major allergens found in the house in carpets, mattresses,
bedding, pillows, upholstered furniture, stuffed animals and clothing (especially children's clothing). They thrive on human epithelial scales.
Essential changes to reduce mite exposure include the following:
• Encase the mattress and box springs in an allergen-impermeable cover.
• Encase the pillow in an allergen-impermeable cover or wash it weekly.
• Wash the sheets and blankets on the patient's bed weekly in hot water. A temperature of greater than or equal to 130º F is necessary for killing house dust mites.
The following measure minimizes exposure to dust mites and is desirable:
• Reduce indoor humidity to less than 50%. (An air conditioner will reduce indoor humidity in Further measures are discussed in located in the Quality Improvement Support section of this guideline.
Pets:
• Remove animals from the house.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 • If the pet cannot be removed, a compromise to at least remove it from the bedroom can often be secured. Weekly washing of the pet may reduce allergens, but the usefulness of this practice • After cat removal from the home, an average of 20 weeks is required before the allergen concen- tration reaches levels found in the animal-free home (Wood, 1989 [Low Quality Evidence]). • Confining a cat to an uncarpeted room (other than bedroom) with HEPA filtration may reduce by 90% airborne allergen dissemination to the remainder of the house (de Blay, 1991 [Low Quality Evidence]). • Basements tend to have higher humidity levels and therefore have higher mold growth.
• Reduce indoor humidity to less than 50%.
• Remove sites for mold growth.
• Clean with fungicides.
Outdoor pollens and molds:
• Remain indoors on specific days when pollen counts are high.
• Keep doors and windows closed in the home and in automobiles.
• Air conditioning is recommended.
In general:
• Minimize contact with irritants such as cigarette smoke, perfumes, cosmetics, hair spray and various other odors. • Discourage indoor smoking.
(Wallace, 2008 [Guideline]; Wood, 1989 [Low Quality Evidence]) Medication Therapy
As with the chronic use of any medications, special consideration of risk benefit may need to be given to
elderly, fragile patients, pregnant women, athletes and children. The following table provides information to assist in the selection of appropriate medical therapy for patients with allergic rhinitis.
Medication
Sneezing
Congestion
Topical corticosteroids Anticholinergics Leukotriene receptor blockers Key: - no effect ++ moderate effect ± negligible effect +++ pronounced effect + slight effect Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Corticosteroids
With the exception of systemic steroids, intranasal corticosteroids are the most effective single agents for
controlling the spectrum of allergic rhinitis symptoms and should be considered first-line therapy in patients with moderate to severe symptoms. However, a Cochrane review in 2009 found limited evidence for efficacy in children though no evidence of adverse effects (Al Sayyad, 2009 [Systematic Review]).
They reduce nasal blockage, itching, sneezing and rhinorrhea in allergic and non-allergic rhinitis. Regular daily use of the medications is required to achieve optimal results. It may be best to start treatment one week before the beginning of the allergy season for prophylactic use. Patients need to be carefully instructed on the correct method of administration. The clinical response does not appear to vary significantly between intranasal corticosteroids that are currently available (Corren, 1999 [Low Quality Evidence]).
The most common side effects of intranasal corticosteroids are nasal irritation (dryness, burning and crusting) and mild epistaxis. Nasal septal perforation has been reported. The likelihood of these side effects can be decreased by use of the proper technique for administration. Intranasal corticosteroids when given in recommended doses are not generally associated with clinically significant systemic side effects. Nasal mucosal atrophy and clinically significant suppression of the adrenal axis have not been demonstrated either in adults or children. There were no bone metabolism side effects seen after three years of nasal topical steroid use in children (Emin, 2011 [Low Quality Evidence]). Growth suppression was detected in children with perennial allergic rhinitis treated with intranasal beclomethasone diproprionate (no longer available) for one year. Similar studies with intranasal fluticasone propionate and mometasone furoate showed no effect on growth (Allen, 2002 [High Quality Evidence]; Skoner, 2000 [High Quality Evidence]); Schenkel, 2000 [High Quality Evidence]). However, it appears that over the long term, the eventual adult height is unchanged. There is less data about preschool-aged children, so more caution should be used in this age group. Uncontrolled asthma and allergies can also impair growth, so no child should go under treated due to concerns about possible growth effects. Children on steroids of any form should be monitored regularly with height and weight plotted on growth curves. This issue remains under study and care should be used in prolonged use of these medications. (Consider giving children oral antihistamines or topical non-steroid medications as the first line of treatment.) Systemic corticosteroid use should be reserved for severe cases not controlled by antihistamines or topical agents. A short course of oral corticosteroid may be helpful.
Oral steroids should be reserved for refractory or severe cases only and given as a short burst (for example, prednisone 40 mg/day for 3-5 days for adults or 1-2 mg/kg/day for 3-5 days in children). Injectable steroids are not general y recommended; they are more expensive, invasive and tend to have a longer course of action than typical course of corticosteroids. As with the chronic use of any medications, special consideration of risk benefit may need to be given to elderly, fragile patients, pregnant women, athletes and children. Patient education materials to support the various treatment options listed in the annotations can be found in the Quality Improvement Support section of this guideline.
(Wallace, 2008 [Guideline]; Schenkel, 2000 [High Quality Evidence]; Skoner, 2000 [High Quality Evidence]; Cave, 1999 [Low Quality Evidence]; Dykewicz, 1998 [Low Quality Evidence]; Kennis, 1998 [Low Quality Evidence]; Weiner, 1998 [Systematic Review]; Graft, 1996 [High Quality Evidence]; Brannan, 1995 [High Quality Evidence]; Fluticasone Propionate Collaborative Pediatric Working Group, 1994 [High Quality Evidence]; Vuurman, 1993 [Low Quality Evidence]; Wolthers, 1993 [High Quality Evidence]; Juniper, 1990 [High Quality Evidence]; Juniper, 1989 [High Quality Evidence]; Pipkorn, 1987 [High Quality Evidence]; Welsh, 1987 [High Quality Evidence]; Soderberg-Warner, 1984 [Low Quality Evidence]; Holopainen, 1982 [Low Quality Evidence]); Ganderton, 1970 [Low Quality Evidence]) Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Antihistamines
Antihistamines are effective at controlling all symptoms associated with allergic rhinitis, with the exception
of nasal congestion. They are somewhat less effective than intranasal corticosteroids, but they can be used either on a daily basis or on an as-needed basis. Common side effects of the first-generation antihistamines include somnolence, diminished alertness and anticholinergic effects such as dry mouth, blurred vision and urinary retention. The anticholinergic side effects are of more concern in people over 65 years old. Evidence supports that first-generation antihistamines cause central nervous system impairment even in the absence of overt symptoms. Some reports indicate that first-generation antihistamines clearly impair driving performances. The second-generation antihistamines are less sedating and cause less central nervous system impairment because they do not cross the blood brain barrier well.
(Meltzer, 2002 [Low Quality Evidence]; Nayak, 2002 [High Quality Evidence]; Meltzer, 2000 [High Quality Evidence]; Weiler, 2000 [High Quality Evidence]; Wilson, 2000 [High Quality Evidence]; Pullerits, 1999 [High Quality Evidence]; Vermeeren, 1998 [High Quality Evidence]; Bronsky, 1996 [High Quality Evidence]; Klein, 1996 [High Quality Evidence]; McCue, 1996 [Low Quality Evidence]; Bronsky, 1995 [High Quality Evidence]; Schoenwetter, 1995 [High Quality Evidence]; Simons, 1994a [High Quality Evidence]; Simons, 1994b [Low Quality Evidence]; Ramaekers, 1992 [High Quality Evidence]; Walsh, 1992 [High Quality Evidence]; Naclerio, 1991 [Low Quality Evidence]; Storms, 1989 [High Quality Evidence]; Mullarkey, 1988 [Low Quality Evidence])
Decongestants
Oral decongestants can reduce nasal congestion but can result in side effects such as irritability, insomnia
and palpitations. Clinician may consider using topical decongestants for short-term or intermittent/episodic therapy. Routine daily use is not recommended because of the risk for the development of rhinitis medi- camentosa.
Both oral and topical decongestants should be used with caution in older adults, children under the age of six, and in patients of any age who have a history of any of the following: arrhythmia, angina, cerebrovascular disease, high blood pressure, bladder neck obstruction, glaucoma or hyperthyroidism.
(Wallace, 2008 [Guideline])A review of multiple randomized placebo studies suggests that pseudoephedrine causes a slight but signifi- cant increase in systolic blood pressure (0.99 mmHg) and increase in heart rate 2.82 beats/min. Statisti- cally, the diastolic blood pressure is not affected. Immediate-release formulations have more effects than sustained-release formulations. Although no serious adverse effects were observed, there were 30 cases (3%) of episodes of hypertension to levels greater than 140/90 mm/Hg among the 1,108 exposed patients. It is possible that patients with the exaggerated hypertensive responses have a degree of underlying autonomic instability. The conclusion is that patients with stable controlled hypertension do not seem to be at greater risk with use of pseudoephedrine (Salerno, 2005 [Meta-analysis]).
Cromolyn
Cromolyn is less effective than intranasal corticosteroids. It is most effective when used regularly prior
to the onset of allergic symptoms. Adverse effects are minimal and include nasal irritation, sneezing and unpleasant taste. The four times daily dosing can cause compliance problems. Cromolyn is an alternative for patients who are not candidates for corticosteroids. Intranasal cromolyn sodium is effective in some patients for prevention and treatment of allergic rhinitis and is associated with minimal side effects. It is less effective in most patients than corticosteroids.
(Wallace, 2008 [Guideline]; Meltzer, 1995 [Low Quality Evidence]; Naclerio, 1991 [Low Quality Evidence]; Orgel, 1991 [High Quality Evidence]; Welsh, 1987 [High Quality Evidence]) Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Anticholinergics
Intranasal anticholinergics (ipratropium bromide) are effective in relieving anterior rhinorrhea in patients
with allergic and non-allergic rhinitis. They have no effect on congestion, sneezing or itching. Most frequent side effects include epistaxis, blood-tinged mucus and nasal dryness. Other possible side effects include dry mouth and throat, dizziness, ocular irritation, blurred vision, precipitation or worsening of narrow angle glaucoma, urinary retention, prostatic disorders, tachycardia, constipation and bowel obstruction.
(Meltzer, 1995 [Low Quality Evidence]; Meltzer, 1992 [High Quality Evidence]; Naclerio, 1991 [Low Quality Evidence]; Mullarkey, 1988 [Low Quality Evidence])
Leukotriene Blockers
Montelukast is a leukotriene receptor antagonist that is as effective as loratadine and less effective than
nasal steroids. It is generally well tolerated and may be considered as a third-line option to add after the failure of a nasal corticosteroid and an oral antihistamine. Headache is the most commonly reported effect. Events such as insomnia, agitation, depression and suicidal ideation are listed as precautions in the package labeling and should be monitored. Consider discontinuing if the symptoms develop. Montelukast is FDA approved for seasonal allergic rhinitis in patients two years of age and older, and for perennial allergic rhinitis in patients six months of age and older.
(Nayak, 2007 [Systematic Review])
Ophthalmic Medications
Ophthalmic medications are available as topical solutions/suspensions and contain antihistamines, deconges-
tants, dual action antihistamine/mast cell stabilizers, combination antihistamines/decongestants, corticoste- roids, or mast cell stabilizers (cromolyn sodium and lodoxamide). Side effects of ophthalmic medications (except corticosteroids) are generally mild and include a brief stinging, burning sensation. Care must be taken in the use of decongestant containing drops as they may cause rebound erythema (medicamentosa) when discontinued. Topical antihistamines can be used as needed for acute symptomatic relief and prophylaxis of allergic rhinitis with minimal systemic side effects.
Contact lens users should consult their eye care clinician regarding the use of these products.
(Leino, 1994 [High Quality Evidence]; Caldwell, 1992 [High Quality Evidence]; Bende, 1987 [High Quality Evidence]) Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Examples not all inclusive
Comments
1st generation antihistamines Chlorpheniramine Effective but commonly sedating Available as single-ingredient products and combinations (with pseudoephedrine and phenylephrine) 2nd generation antihistamines Low- and non-sedating options Fexotenaide, cetirizine and loratadine are available as over-the-counter options Available as single-ingredient products and as combinations (with pseudoephedrine) Leukotriene blockers May be as effective as loratadine but less effective than other antihistamines and nasal steroids Mometasone Budesonide Triamcinolone Nasal antihistamine Bitter taste and moderately sedating Olopatadine hydrochloride Mast cell stabilizers Over the counter, less effective than nasal steroids, must be used regularly Anticholinergics Ipratropium nasal Can relieve rhinorrhea but has no effect on congestion or itching Diagnostic Testing
The clinician may choose to conduct diagnostic testing at this point if the results would change management.
The following are recommended.
• Skin tests and radioallergosorbent tests: Skin tests and radioallergosorbent tests identify the
presence of IgE (immunoglobulin E) antibody to a specific allergen. Clinical relevance is estab- lished when exposure to an allergen to which the patient has evidence of allergen-specific IgE (e.g., skin tests) causes symptoms consistent with an allergic reaction. There are two major reasons to consider allergy testing: to differentiate allergic from non-allergic rhinitis, and to identify specific allergens causing allergic rhinitis. A limited panel of two to four radioallergosorbent tests should be considered. If a greater number of specific allergens is to be identified, skin tests are the preferred diagnostic tests. Skins tests are faster, more sensitive and more cost effective. Skin tests require experience in application and interpretation, and carry the risk of anaphylactic reactions. Therefore, only specially trained clinicians should perform them. The precise sensitivity of specific IgE immu- noassays such as radioallergosorbent tests compared with prick/puncture skin tests is approximately 70-75% (Wallace, 2008 [Guideline]). Therefore, skin tests are presently the preferred test for the diagnosing of IgE-mediated sensitivity.
(Bernstein, 1995 [Guideline]; Bernstein, 1988 [Low Quality Evidence]; Shapiro, 1988 [Low Quality Evidence]; DeClerck, 1986 [Low Quality Evidence]; American Academy of Allergy and Immunology, 1983 [Low Quality Evidence]) • Nasal smear for eosinophils: Nasal smear may be a low-cost screening tool to detect eosinophils.
While eosinophils may be present in both allergic and non-allergic rhinitis, eosinophlia predicts a good response to topical nasal corticosteroid medication. This test must be done during the actual symptomatic period to yield interpretable results.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 In more than 80% of patients with allergic rhinitis, nasal cytology shows an increased number of eosinophils. In one study, secretion eosinophilia was found to correlate highly significantly with active immediate-type nasal allergy.
(Meltzer, 1992 [High Quality Evidence]; Anderson, 1979 [Low Quality Evidence]; Malmberg, 1979 [Low Quality Evidence]) • Other tests: Blood eosinophilia has little diagnostic value in the evaluation of nasal allergies and
is generally not helpful in the differential diagnosis. Total IgE concentrations provide only modest information about the risk of allergic disease. According to the American Academy of Allergy and Immunology and the National Center for Health Care Technology, sublingual provocation testing is unproven and experimental. These tests are therefore not recommended (American Academy of Allergy, 1981 [Low Quality Evidence]).
A peripheral blood eosinophil count, total serum IgE level, Rinkel method of skin titration and sublingual provocation testing are not recommended.
(Bernstein, 1995 [Guideline]; Barbee, 1987 [Low Quality Evidence]; Brown, 1979 [Low Quality Evidence]; Mygind, 1978 [Low Quality Evidence]) If symptoms have not improved after two to four weeks, the clinician should consider issues affecting compliance, ongoing environmental triggers, alternative diagnosis and alternative medication therapy.
If the patient has adequate relief of rhinitis and associated allergic symptoms either by instituting avoidance measures or through a medication trial, appropriate follow-up should include: • Further education and review of information about avoidance activities• Education and review of appropriate use of medications and possible side effects• Begin the use of medications prior to exposure when exposure to known allergens is anticipated and unavoidable. For example, in a patient with cat or dog sensitivity, taking oral antihistamines prior to visiting a home with a cat or dog can prevent symptoms. Starting intranasal corticosteroids one to two weeks prior to the start of the ragweed pollen season will maximize benefits of the medica- tion in people with seasonal allergic rhinitis symptoms in the late summer.
Adequate follow-up may require a separate clinician visit or a follow-up phone call or may be accomplished during another clinic visit. Use of appropriate educational handouts and materials may be helpful. Children on steroids of any form should have height and weight checked regularly and plotted on the appropriate growth chart.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Patient education materials can be found in section of this esting/Referral to a Specialty
When the patient has not experienced relief of symptoms within two to four weeks of adequate therapy, the clinician should: • review obstacles to compliance with current medication and discuss avoidance measures;• consider a trial of another medication or add another agent for targeted symptoms;• consider allergen skin testing by a qualified physician – if there are positive skin tests to allergens that correlate with the patient's timing of symptoms, immunotherapy may be considered; • consider complete nasal examination (rhinoscopy) by a qualified individual to rule out a mass or lesion, particularly if obstruction and congestion are the major symptoms; or • consider diagnosis of non-allergic rhinitis.
If the patient does not respond to medical treatment, a complete examination of the ears, nose and throat is indicated to rule out structural and extrinsic sources of obstruction and drainage. Allergy evaluation should be performed. This examination should include visualization of the entire nasal septum, inferior and middle nasal turbinates and possibly the middle meatus, and visualization of the nasopharynx. A topical deconges- tant spray may be used to shrink nasal tissues and allow better visualization of nasal structures. Endoscopic nasal and nasopharyngeal examination may be required.
Immunotherapy
Immunotherapy is a series of subcutaneous injections of extracts of allergenic materials in an attempt to
decrease the severity of allergic symptoms that may occur upon future exposure to the allergen. It consists of weekly incremental doses usually over four to six months, followed by maintenance injections of the tolerated maximum dose every two to four weeks. If successful, this treatment regimen is normally carried on for three to five years. Immunotherapy should be generally reserved for patients with significant allergic rhinitis for whom avoidance measures and pharmacotherapy are insufficient to control symptoms. Other candidates for immunotherapy include patients who have experienced side effects from medication or who cannot comply with a regular (or prescribed) pharmacotherapy regimen or who develop complications such as recurrent sinusitis.
All immunotherapy injections should be administered in a medical facility where personnel, equipment and medications are available to treat an anaphylactic reaction to an injection. Because there is a risk of anaphylaxis with every injection during the buildup or maintenance phases of treatment, regardless of the duration of treatment, the patient should be advised to wait in the physician's office or clinic for 30 minutes after the injection.
Patient education materials can be found in the Quality Improvement Support section of this guideline.
Immunotherapy injections are most effective for allergic rhinitis caused by pollens and dust mites. They may be less effective for mold and animal dander allergies. (Calderon, 2007 [Systematic Review]; Cox, 2007 [Guideline]; Varney, 1991 [High Quality Evidence]; Norman, 1990 [Low Quality Evidence]; Van Metre, 1980 [High Quality Evidence]; Norman, 1978 [High Quality Evidence]; Lichtenstein, 1971 [High Quality Evidence]; Lowell, 1965 [High Quality Evidence]) Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Malignant tumors of the nose and sinuses can be difficult to detect. Recent onset of pain; decreased sensation of the face, palate or teeth; decreased sense of smell; bleeding; and facial swelling and/or nasal obstruction may all be signs of a nasal or sinus cancer.
Structural abnormalities most often present with symptoms of obstruction. Deviated nasal septum, deformity of nasal bones, nasal turbinates or nasal cartilage may be detected on physical examination and may cause significant obstruction. Nasal polyps and adenoidal hypertrophy can cause obstruction. Unilateral nasal obstruction is often indicative of a structural or extrinsic source of nasal obstruction. The most common cause of chronic unilateral nasal obstruction in an adult is a deviated septum; however, nasal tumors such as inverting papilloma and carcinomas must be ruled out. In the pediatric population, unilateral nasal obstruction and/or rhinorrhea require that an intranasal foreign body be ruled out.
Juvenile angiofibroma is a benign vascular tumor found in adolescent males. It may present with nasal obstruction or epistaxis and can cause torrential nosebleeds.
Another structural defect resulting from trauma that should be considered is a cribiform plate defect that can result in cerebral spinal fluid rhinorrhea.
Suspicion of one of these abnormalities requires a complete nasal examination including visualization of the posterior nasopharynx, generally performed by an ENT clinician.
Symptoms of non-allergic rhinitis are similar to those of allergic rhinitis and may include nasal congestion, postnasal drainage, rhinorrhea and even sneezing. Examples of non-allergic rhinitis include hormonal, such as rhinitis of pregnancy; vasomotor rhinitis with sensitivity to smells and temperature changes; non-allergic rhinitic eosinophilic syndrome; rhinitis medicamentosa from regular use of topical nasal decongestants; and atrophic rhinitis.
Treatment of obstructive symptoms due to non-allergic rhinitis includes the following: • Azelastine hydrochloride nasal spray• Intranasal corticosteroid spray Topical nasal steroid sprays can be used to treat chronic nasal congestion secondary to non-allergic rhinitis. Side effects seem to be related to application of the spray and are usually limited to intranasal dryness, crusting, and bleeding. Documented systemic side effects are rare. Topical nasal steroid sprays have a relatively long onset of action (up to four weeks) and are therefore better suited to patients with chronic, rather than sporadic, symptoms.
• Intranasal cromoglycate (cromolyn sulfate) Intranasal cromolyn has been shown to improve sneezing and congestion scores. It can safely be used in children two years of age and older. Side-effects are minimal.
• Oral decongestant The use of oral decongestants may cause central nervous system stimulation, hypertension and cardiac arrhythmias. However, some patients find them helpful at relieving symptomatic nasal obstruction secondary to non-allergic rhinitis. Oral decongestants, which have a relatively rapid onset of action, are particularly useful for sporadic symptoms. Patients using oral decongestants should be monitored for side effects, particularly hypertension.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Nasal strips are effective for some patients with only nocturnal symptoms (dependent nasal obstruc- tion). They are more effective for patients with narrow noses or with anterior septal deviations. Daytime use is not usually practical.
• Topical antihistamines Topical anthistamines have been shown to be effective in controlling rhinorrhea associated with non-allergic rhinitis. Side effects include drowsiness and bitter taste.
(Banov, 2001 [High Quality Evidence]) Treatment of symptomatic non-purulent chronic posterior nasal drainage (postnasal drip) includes the • Increase water intake.
• Decrease caffeine and alcohol intake (both have a diuretic effect).
• Nasal saline irrigation. Nasal saline irrigations can be purchased over the counter. A saline nasal irrigation solution can be made at home by mixing 1/4 teaspoon table salt into one cup • Determine whether the patient is using any medications that may cause oral or nasal dryness.
• Petroleum jelly or antibiotic ointment may be used for nasal crusting.
• Add humidity in bedroom if significantly less than 50%.
• Intranasal corticosteroids Treatment of symptomatic bilateral chronic anterior rhinorrhea due to non-allergic rhinitis includes the • Avoidance of offending irritants such as smoke and perfume• Intranasal corticosteroids• Intransal ipratropium bromide Topical ipratropium bromide has been shown to be helpful for rhinorrhea only in patients with vasomotor rhinitis. It has a quick onset of action and thus can be used as needed, as opposed to intranasal steroids. It is generally well tolerated, with local irritation its only common side effect. It is approved for children ages six and older (Wheeler, 2005 [Guideline]; Skoner, 2002 [Low If symptoms have not improved within two to six weeks, the clinician should consider issues of compliance, alternative medical treatment, or referral to a specialty clinician.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Nasal examinations are generally done by an ear, nose and throat specialist but may be done by a physician trained in endoscopic fiberoptic rhinoscopy. A limited computed tomography scan of the sinuses may be helpful at this time.
If chronic sinusitis remains in the differential diagnosis, a trial of antibiotic therapy should be completed prior to radiological examination.
Coronal computed tomographies are used rather than plain sinus films mainly because plain sinus films do not adequately delineate intranasal and sinus anatomy. Plain films rarely adequately visualize the ethmoid sinuses, which are the sinuses most commonly involved in chronic sinusitis. Also, at this stage of the protocol, medical treatment has already failed, so if surgery is indicated for chronic sinusitis, etc., a coronal computed tomography is needed prior to surgery.
The diagnosis of acute sinusitis is based primarily on the patient's presenting symptoms and history, and is supported by the physical exam. The duration of illness is key, as patients with less than seven days of symptoms are very unlikely to have a bacterial cause.
Acute bacterial sinusitis has a high likelihood of being present with one of the following clinical presentations: • symptoms persist or signs of acute rhinosinusitis, that lasts 10 days or more without evidence of • symptoms are severe or patient has fever 102ºF or more with purulent nasal discharge or facial pain that lasts for at least three to four consecutive days at onset of illness, OR • symptoms are worsening or new onset of fever, headache or increase in nasal discharge after a viral upper respiratory infection (VURI) that lasted five to six days and the patient was initially The gold standard for the diagnosis of acute bacterial sinusitis is sinus aspiration demonstrating high concentrations (> 10,000 colony forming units/ml). However, sinus aspiration is not practical as a routine in clinical practice. In addition, studies have shown that radiographic studies of the sinuses of patients with viral upper respiratory infections and sterile sinus aspiration cultures, as well as studies of healthy chil- dren with no respiratory symptoms, are often abnormal. Thus, although normal radiographic studies may exclude sinusitis, abnormal studies, including CT scans and MRIs, are not sufficient for a diagnosis. With our current state of knowledge, the clinical presentation history serves as an accurate guide to the diagnosis of sinusitis, when applied rigorously.
(Chow, 2012 [Guideline]; Meltzer; 2006 [Guideline]; Meltzer, 2004 [Guideline]) • Fever greater than 102º and a documented past history of sinusitis in addition to previously noted symp- toms in Annotation #45, "Patient Has Symptoms Suggestive of Bacterial Sinusitis," are supportive of a sinusitis diagnosis. Fever is typically present at the beginning of a sinus infection and persists approxi- mately twice as long as with a viral upper respiratory infection (Chow, 2012 [Guideline]; American Academy of Pediatrics, 2001 [Guideline]).
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 • Tooth pain not of dental origin is a more specific indication of sinusitis.
• Patients with severe symptoms should be evaluated in clinic and considered for treatment before seven • Known anatomical blockage (e.g., chronic nasal polyps, severely deviated septum, recurrent sinusitis) may need immediate treatment.
• Patients on antibiotics for two or more days, whose sinus symptoms are worsening, should be scheduled for a clinician visit.
• Patients may also describe worsening symptoms after initial improvement.
Phone management
Phone management, with treatment via protocol by a triage nurse, is increasingly being used for initial
treatment of sinusitis. Only one study has been published evaluating this practice (Chauhdry, 2006 [Low Quality Evidence]). It found phone treatment increased the likelihood of use of first-line antibiotic therapy and did not increase antibiotic use. Further studies should be performed. In the meantime, phone care should be limited to a select group of patients with follow-up in the office if the patient does not respond to first-line antibiotics.
Generally good health
Patients who have multisystem disease are generally more complicated/complex to treat by phone because
their illnesses and medications need to be taken into consideration as the treatment plan is developed.
Mildly ill
Any patient who is determined by the phone triage person to be more than mildly ill should be scheduled
for a visit. The clinician may determine if more intensive therapy is required (i.e., whether the initial therapy may include a ß-lactamase-resistant antibiotic if the patient is more severely ill).
Established patient
Generally patients who do not have an office record should not be considered for phone management
because background data is insufficient for appropriate treatment of the patient.
Age
The only published study limited patients to age 16-75 (Chauhdry, 2006 [Low Quality Evidence]).
Pediatric patients are less likely to have bacterial sinusitis and more likely to have viral infections or otitis media. Elderly patients are at risk for pneumonia and other severe illnesses. Both populations should be seen in clinic rather than treated via phone.
Patient is comfortable with phone management
The patient's acceptance of treatment by phone is necessary for successful treatment.
History of previous sinusitis treated successfully
An office record documenting that a physician has made a previous diagnosis of sinusitis potentially
would allow the patient to be familiar with the previous symptoms of sinusitis and the physician to be more confident that sinusitis is again present.
Earlier visit for treatment of viral upper-respiratory infection
Patients recently seen by a care clinician who call back to the office to report symptoms of sinusitis
are appropriate candidates for phone management, as the physician is already familiar with the patient.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Physical Examination and Imaging
Regional exam of the head and neck
The following physical findings may be present:
• Purulent nasal drainage• Focal facial pain with bending forward (facial pressure or pain has a sensitivity of 52% and a speci- • Sinus tenderness• Swollen turbinates• Decreased transillumination (optional)• Nasal polyps (nasal obstruction has a sensitivity of 41% and a specificity of 80%) Assess for complicating factors – more intensive treatment may be indicated
• Local
- External facial swelling/erythema over involved sinus- Involvement of frontal sinus or symptoms of sinus impaction • Orbital
- Visual changes- Extraocular motion abnormal- Proptosis- Periorbital inflammation/soft tissue edema- Periorbital erythema/cellulitis • Subperiosteal abscess• Orbital cellulitis• Orbital abscess • Intracranial, central nervous system complications
- Cavernous sinus thrombosis- Meningitis- Subdural empyema- Brain abscess Patients with any one of the following complicating factors require emergent care: • Orbital pain• Visual disturbances• Periorbital swelling or erythema Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 • Facial swelling or erythema• Signs of meningitis or "worst headache of my life" (Turner, 2010 [Low Quality Evidence])
Transillumination
Transillumination is of limited usefulness and is dependent on the skill level of the clinician performing the
exam (Williams, 1992 [Low Quality Evidence]). Evidence suggests that it is an unreliable diagnostic tool in children less than 10 years of age (American Academy of Pediatrics, 2001 [Guideline]).
As a single finding, transillumination cannot be relied upon to rule sinusitis in or out.
Transillumination requires a completely darkened room, adequate time for dark adaptation, and practice (Williams, 1993 [Low Quality Evidence]).
Plain sinus x-rays and other imaging
Plain sinus x-rays and other imaging tests are usual y not necessary in making the diagnosis of acute sinusitis.
Plain films offer lit le additional information in this set ing (Turner, 2010 [Low Quality Evidence]); Roberts,
1995 [Low Quality Evidence]; Williams, 1993 [Low Quality Evidence]).
With sinus puncture and aspiration as the gold standard, plain films offer moderate sensitivity and specificity. Studies comparing sinus puncture to CT/MRI are not available (Anzai, 2009 [Guideline]).
Poor sensitivity and specificity limit the usefulness of a sinus x-ray series. The presence of opacification or air-fluid levels, although fairly predictive of bacterial infection, is seen in only 60% of patients with sinusitis. If one includes mucosal thickening as an indication of sinusitis, the specificity drops to as low as 36% (Willett, 1994 [Low Quality Evidence]).
According to the American College of Radiology, routine imaging of the paranasal sinuses in children with acute bacterial sinusitis without complications is not recommended (Karmazyn, 2009 [Guideline]). Overall CT scanning is felt to be a more sensitive and specific modality if imaging is needed. However, only 62% of patients with symptoms of sinusitis have abnormalities on scanning and 42% of patients having head CT scanning for other reasons will have sinus mucosal abnormalities. CT scanning can have a role in defining anatomic abnormalities in patients with recurrent and chronic sinusitis.
The American Academy of Pediatrics Guidelines indicate that imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children under six years of age. Imaging with CT scanning after age six may be appropriate if the patient does not improve after 90 days or worsens during the course of therapy. In this case it can be used to confirm or exclude the diagnosis, to assess for potential causes of poor mechanical drainage and to look for complications such as orbital cellulitis or abscess formation. Scanning is appropriate in cases where surgery is being considered (Karmazyn, 2009 [Guideline]; American Academy of Pediatrics, 2001 [Guideline]).
Maxillary antrum aspiration for culture
The "gold standard" for the diagnosis of acute sinusitis is antral puncture and cultures. However, this is not
clinically practical (Herr, 1991 [Low Quality Evidence]; Gwaltney, 1981 [Low Quality Evidence]; Hamory, 1979 [Low Quality Evidence]). Maxillary antrum aspiration for culture is indicated only when precise microbial identification is required.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Patients who are in generally good health and only mildly ill may be appropriate candidates for home care/ phone management of presumed acute sinusitis. Both the patient and the clinician should be comfortable with home care/phone management. The fol owing factors are also supportive of home care/phone management: • Established patient (has been seen by primary care physician within the past year)• History of previous sinusitis treated successfully• Earlier visit with viral upper-respiratory infection that has progressed to probable acute sinusitis Many patient sources discuss the benefits of comfort measures even though no studies have been conducted on the sinusitis population to document the actual effects of these measures on the treatment of sinusitis. Therefore, non-pharmacologic measures are aimed at symptom relief and providing comfort.
The patient should be instructed to implement the following comfort and prevention measures.
Home self-care measures
Maintain adequate hydration (drink 6-10 glasses of liquid a day to thin mucus).
Steamy shower or increase humidity in the home. Because of burns that have occurred when people use
steam vaporizers, and the potential for microorganism growth in vaporizers, the recommended method for steam inhalation is steam from a hot bathtub or shower.
Apply warm facial packs (warm wash cloth, hot water bottle or gel pack) for 5-10 minutes three or more times per day.
Localized pain and tenderness are common and may require analgesics.
Saline irrigation (saline nose drops, spray to thin muscus) can provide moisture and improve mucocilary • Homemade (1/4 teaspoon salt dissolved in one cup of water; if water is drinkable, it is safe to use as a saline irrigation. Use bulb syringe or dropper purchased from drug store.) • Saline nasal drops/spray Decongestants (topically or orally)
• Pseudoephedrine HC1• Decongestant nasal sprays for no longer than three days, e.g., oxymetazoline, phenylephrine No controlled trials have assessed the efficacy of decongestants for the treatment of acute sinusitis. Both the American Academy of Pediatrics and the Infectious Disease Society of America do not recommend their use (Chow, 2012 [Guideline]; American Academy of Pediatrics, 2001 [Guideline]). Numerous authorities recommend their use for symptomatic relief (Willett, 1994 [Low Quality Evidence]; Druce, 1992 [Low Quality Evidence]).
Decongestants are known to increase ostial diameter and thus have the potential to promote sinus drainage (Melen, 1986 [Low Quality Evidence]; Gwaltney, 1981 [Low Quality Evidence]).
The overall weight of clinical experience supports the use of decongestants as adjunctive therapy for sinusitis; however, further studies are needed.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Antihistamines
Antihistamines are not recommended for the treatment of sinusitis because they cause further inspissa-
tion of secretions (Willett, 1994 [Low Quality Evidence]).
Get adequate rest.
Sleep with head of bed elevated.
Avoid cigarette smoke and extremely cool or dry air.
Prevention measures
Appropriate treatment of allergies and viral upper-respiratory infections can prevent the development
of sinusitis.
Environmental factors that affect the sinuses include cigarette smoke, pollution, swimming in contami- nated water and barotrauma.
The goal of treatment is to promote adequate drainage of the sinuses. This in turn will provide relief of symptoms associated with sinusitis. This may require a combination of home care and medical treatments.
Nasal Steroid Spray
Intranasal corticosteroid spray may be rational but is an unproved adjunctive therapy for acute sinusitis. The
spray may be appropriate for selected cases of recurrent sinusitis, especially in the presence of an allergy or inflammation etiology (Meltzer, 2000 [High Quality Evidence]).
A recent study looked at amoxicillin and topical budesonide for the treatment of acute maxillary sinusitits. 240 adults were randomized into four treatment groups over a four-year study period. The study concluded that an antibiotic, a topical steroid or a combination of both does not alter the severity of symptoms, the duration or the natural history of the condition (Williamson, 2007 [High Quality Evidence]).
Adjunctive Therapy
Use of normal saline or hypertonic saline to irrigate the sinuses is now recommended as adjunct therapy with
antibiotics, although the evidence is weak. Due to recent cases of infection, patients should be instructed to use saline or distilled water rather than tap water. Saline spray also can be used, especially for children who are likely to find irrigation objectionable. Oral decongestants, topical decongestants and antihistamines are not recommended as adjunctive therapy.
Antibiotics
According to one study, the natural history of the majority of the patients with acute sinusitis is resolution
without the use of antibiotics. The study was a randomized placebo-controlled trial of the treatment of acute sinusitis in the primary care setting. It was the first to be done in the primary care setting and concluded that antibiotic treatment did not improve the clinical course of acute sinusitis. The antibiotic used in the treated group was amoxicillin, 750 mg, three times a day, for seven days. The only other placebo-controlled trial done treating acute sinusitis was conducted in an ear, nose and throat practice. The antibiotics used were penicillin and lincomycin. In this study, antibiotics seemed to accelerate resolution of radiographic abnormalities, but the difference between the antibiotic and the placebo-treated groups was small. Another randomized study supports the use of amoxicillin and Pen VK in the treatment of sinusitis (Williams Jr, 2000 [Systematic Review]; Van Buchem, 1997 [High Quality Evidence]; Lindbaek, 1996 [High Quality Evidence]; Axelsson, 1970 [High Quality Evidence]).
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Antibiotics should be reserved for those patients who failed decongestant therapy, those who present with symptoms and signs of a more severe illness, and those who have complications of acute sinusitis (Arroll, 2010 [Systematic Review]; Snow, 2001 [Low Quality Evidence]).
Typical organisms isolated from patients with acute sinusitis include Streptococcus pneumoniae, Haemoph- ilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, other streptococci, anaerobes, and (rarely) other gram negative organisms. S. Pneumoniae and H. influenzae account for 70% of the isolates in adults (Willett, 1994 [Low Quality Evidence]).
In our area, 30-40% of the H. influenzae and most of the M. cattarhalis produce ß-lactamase and are consid- ered resistant to amoxicillin.
Since antral puncture on all patients suspected of bacterial sinusitis is clinically impractical, the diagnosis rests on clinical impression and antibiotic therapy is empiric. A 7- to 10-day course of antibiotics leads to symptomatic and bacteriologic improvement in 80-90% of patients (Willett, 1994 [Low Quality Evidence]). Pundent rhinorrhea has a sensitivity of 72% and a specificity of 52% (Turner, 2010 [Low Quality Evidence]).
Amoxicillin clavulanate is now considered the first-line drug of choice according to the latest guideline from the Infectious Disease Society of America (IDSA). High-dose amoxicillin-clavulanate should be considered in situations where the patient has higher risk of resistance: age < 2 years or > 65 years, daycare participation, hospitalization within the past five days, prior antibiotics within the past month, immuno- compromised patients, comorbidities, a local rate of S. pneumoniae resistance > 10% or severe disease. Amoxicillin, trimethoprim-sulfamethoxazole and macrolides are no longer recommended as alternatives due to increasing resistance. In penicillin-allergic patients, doxycycline should be first line for older children or adults. Levofloxacin is an alternative that is recommended for children and adults by the IDSA. Second or third-generation cephalosporins are not recommended as mono-therapy by IDSA due to lack of coverage of penicillin-resistant s. pneumoniae. However, they can be used in conjunction with clindamycin, although palatability will be an issue for children with clindamycin liquid (Chow, 2012 [Guideline]).
(Hickner, 2001 [Low Quality Evidence]; Adelglass, 1999 [High Quality Evidence]; Agency for Health Care Policy and Research, 1999 [Low Quality Evidence]; Lasko, 1998 [High Quality Evidence]; Willet 1994 [Low Quality Evidence]; Edelstein, 1993 [High Quality Evidence]; Huck, 1993 [High Quality Evidence]; Gwaltney, 1992 [Low Quality Evidence]; Sydnor, 1989 [Low Quality Evidence]; Wald, 1986 [High Quality Evidence]; Wald, 1984 [High Quality Evidence])
Duration of antibiotics
The duration of antibiotic therapy is controversial, with recommendations from various sources being
anywhere from 3 to 14 days. An excellent study comparing 3 days versus 10 days of trimethoprim/sulfa- methoxazole reported no difference in clinical response. Further studies will need to be done using 3 day therapy before this can be recommended. A 10-day course of antibiotics has commonly been recommended since this duration of antibiotics has been used in the vast majority of clinical trials in sinusitis. Also it has been shown that 10 days of antibiotics will achieve a bacteriologic cure as defined by follow-up sinus puncture. However, the Infectious Disease Society of America now recommends shortening the course in adults to five to seven days, while continuing to use the longer course in children (Gwaltney, 1992 [Low Quality Evidence]).
Call-Back Instructions
The patient should be instructed to call back if symptoms worsen, or if symptoms have not resolved within
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Complete response
Patient is symptomatically improved to near normal.
Partial response
Patients who worsen in 48-72 hours after starting treatment or who are not responsive within three to five
days warrant reevaluation. During reevaluation, consider whether the diagnosis is correct and if there is an underlying abnormality (Chow, 2012 [Guideline]; (American Academy of Pediatrics, 2001 [Guideline]).
Consider switching to a second-line antibiotic for another 48-72 hours.
Consider referral to a specialist (e.g., ENT or ID) There are no randomized clinical trials documenting the efficacy or necessity of further antibiotic therapy with the same drug in patients who have a partial response. However, numerous experts support this practice, and clinical experience suggests its efficacy (Wilett, 1994 [Low Quality Evidence]).
Failure or no response
Patient has lit le or no symptomatic improvement after finishing a 10-day course of first-line antibiotic therapy.
An antibiotic that offers bet er coverage-resistant bacteria, such as high-dose amoxicil in/clavulanate, should
be prescribed. After three to five days of failure of first-line antibiotic, an antibiotic should be prescribed that would cover potentially resistant bacteria occasionally seen in acute bacterial sinusitis. No randomized trials have been done supporting this practice. We know, however, that a substantial minority of patients will have infection from bacteria that are resistant in vitro to first-line therapy. Several studies have suggested that failure of therapy may be due to ß-lactamase producing organisms, anaerobes or staphylococci. It would seem reasonable, therefore, to give a trial of a broader spectrum antibiotic in the setting of clinical failure (Konen, 2000 [Low Quality Evidence]; Agency for Health Care Policy and Research, 1999 [Low Quality Evidence]; Willett, 1994 [Low Quality Evidence]). One possibility is a second- or third-generation cephalosporin with IM ceftriaxone for one to three days followed by an oral agent.
A fluoroquinolone with pneumococcal coverage may also be considered except for patients who are skel- etally immature.
Additional second-line agents
Second-generation cephalosporin (best used with clindamycin)
• Cefuroxime • Cefpodoxime • Cefprozil• Cefdinir • Cefaclor Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Algorithm Annotations
Fourth Edition/January 2013 Fluoroquinolones with pneumococcal coverage (except for patients who are skeletally immature) • Levofloxacin • Moxifloxacin* * There is concern within the medical community about using these drugs because of their potential for QT prolongation that some other quinolones do not have.
FDA approval
• Amoxicillin/clavulanate, cefuroxime, cefpodoxime, cefprozil, cefdinir and levofloxacin are FDA approved for the treatment of acute sinusitis.
• Cefaclor is not approved by the FDA for acute sinusitis treatment.
Most cases of acute bacterial sinusitis affect the maxillary sinus. A sinus radiograph series, although quite nonspecific due to many false-positives, is fairly sensitive in detecting maxillary sinusitis. A normal x-ray series in the above clinical context should raise serious questions about the diagnosis of sinusitis, and alterna- tive diagnoses should be entertained. An abnormal sinus x-ray, especially if opacification or an air-fluid level is present, is suggestive of bacterial sinusitis. A sinus CT scan could also be obtained to verify disease. It is somewhat more expensive, but has greater accuracy and is often recommended as the imaging test of choice.
Failure or no response in three weeks
In patients who have not responded to three weeks of continuous antibiotic therapy, consider limited coronal
computed tomography scan of sinuses and/or referral to ear, nose and throat clinician and/or infectious disease specialist.
Please see individual health plan for formulary information.
Institute for Clinical Systems Improvement

Quality Improvement Support:
Diagnosis and Treatment of Respiratory Illness in
Children and Adults
The Aims and Measures section is intended to provide protocol users with a menu of measures for multiple purposes that may include the following: • population health improvement measures,• quality improvement measures for delivery systems,• measures from regulatory organizations such as Joint Commission,• measures that are currently required for public reporting,• measures that are part of Center for Medicare Services Physician Quality Reporting initiative, and • other measures from local and national organizations aimed at measuring population health and improvement of care delivery.
This section provides resources, strategies and measurement for use in closing the gap between current clinical practice and the recommendations set forth in the guideline.
The subdivisions of this section are: • Aims and Measures• Implementation Recommendations• Implementation Tools and Resources• Implementation Tools and Resources Table Copyright 2013 by Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 1. Increase the percentage of patients diagnosed with viral upper-respiratory infection who receive appro- priate treatment. (Annotation #12)Measures for accomplishing this aim:a. Percentage of patients diagnosed with a viral upper-respiratory infection alone who do not receive an antibiotic.
b. Percentage of patients and/or parents of children with a viral upper-respiratory infection who received home treatment education. 2. Reduce excessive antibiotic treatment through decreased empiric treatment of patients diagnosed with strep pharyngitis. (Annotations #16, 20, 25, 27)Measures for accomplishing this aim:a. Percentage of patients diagnosed with strep pharyngitis who had a laboratory strep test.
b. Percentage of patients diagnosed with strep pharyngitis, and prescribed antibiotics, who had a nega- tive laboratory strep test.
3. Increase the use of recommended first-line medications for patients diagnosed with strep pharyngitis. (Annotations #20, 25, 27)Measure for accomplishing this aim:a. Percentage of patients diagnosed with strep pharyngitis prescribed first-line medications for strep 4. Increase patient/caregiver knowledge about strep pharyngitis and pharyngitis care. (Annotations #20, 24, 27)Measures for accomplishing this aim:a. Percentage of patients diagnosed with strep pharyngitis prescribed antibiotics with documentation of education on 24-hour treatment prior to returning to work, school or day care.
b. Percentage of patients diagnosed with strep pharyngitis prescribed antibiotics with documentation of being educated on taking the complete course.
c. Percentage of patients diagnosed with strep pharyngitis instructed on actions to take if symptoms 5. Decrease the use of injectable corticosteroid therapy for patients diagnosed with al ergic rhinitis. (Anno- tation #34)Measure for accomplishing this aim:a. Percentage of patients diagnosed with seasonal allergic rhinitis being treated with injectable corti- Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Aims and Measures
Fourth Edition/January 2013 Percentage of patients diagnosed with a viral upper-respiratory infection who do not receive an antibiotic.
Children and adult patients with a visit to primary care (general internal medicine, pediatrics, family practice, urgent care) for viral upper-respiratory infection alone.
Data of Interest
# of patients who do not receive an antibiotic # of patients with viral upper-respiratory infection diagnosis Numerator/ Denominator Definitions
Patients with viral upper-respiratory infection alone who do not receive an antibiotic.
Patients with viral upper-respiratory infection diagnosis alone. Method/Source of Data Collection
Collect data on entire patient population that fit criteria under "Population Definition" through electronic medical records. Then, determine the number of patients who did not receive an antibiotic prescription.
Time Frame Pertaining to Data Collection
This is a process measure on overuse, and improvement is noted as an increase in the rate.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Aims and Measures
Fourth Edition/January 2013 Percentage of patients and/or parents of children diagnosed with a viral upper-respiratory infection symptoms who receive home treatment education.
Children and adult patients with a visit to primary care (general internal medicine, pediatrics, family practice, urgent care) for viral upper-respiratory infection alone.
Data of Interest
# of patients who received home treatment education # of patients with viral upper-respiratory infection diagnosis alone Numerator/ Denominator Definitions
Patients with viral upper-respiratory infection diagnosis alone who received home treatment Patients with viral upper-respiratory infection diagnosis alone.
Method/Source of Data Collection
Collect data on entire patient population that fit criteria under "Population Definition" through electronic medical records. Then, determine the number of patients who received home treatment education.
Time Frame Pertaining to Data Collection
This is a process measure, and improvement is noted as an increase in the rate.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Aims and Measures
Fourth Edition/January 2013 Percentage of patients diagnosed with strep pharyngitis who had a rapid group A strep test or strep culture.
Children and adult patients diagnosed with strep pharyngitis.
Data of Interest
# of patients with a rapid group A strep test or strep culture # of patients with a diagnosis of strep pharyngitis Patients diagnosed with strep pharyngitis who received a rapid group A strep test or strep Patients with a diagnosis of strep pharyngitis.
Method/Source of Data Collection
Collect data on entire patient population that fit criteria under "Population Definition" through electronic medical records. Then, determine the number of patients with a rapid group A strep test or strep culture.
Time Frame Pertaining to Data Collection
This is a process measure, and improvement is noted as an increase in the rate.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Aims and Measures
Fourth Edition/January 2013 Percentage of patients diagnosed with strep pharyngitis, and prescribed antibiotics, who had a negative culture or no rapid group A strep test or strep culture.
Children and adult patients with strep pharyngitis diagnosis and prescribed antibiotics.
Data of Interest # of patients with negative laboratory strep test or strep culture
# of patients with a diagnosis of strep pharyngitis and prescribed antibiotics Patients diagnosed with strep pharyngitis and prescribed antibiotics who have a negative laboratory strep test.
Patients with a diagnosis of strep pharyngitis and prescribed antibiotics.
Method/Source of Data Collection
Collect data on entire patient population that fit criteria under "Population Definition" through electronic medical records. Then, determine the number of patients with negative laboratory strep test.
Time Frame Pertaining to Data Collection
This is a process measure on overuse, and improvement is noted as a decrease in the rate.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Aims and Measures
Fourth Edition/January 2013 Percentage of patients diagnosed with strep pharyngitis prescribed first-line medications for strep pharyngitis.
Children and adult patients with strep pharyngitis diagnosis codes.
Data of Interest
# of patients prescribed first-line medications # of patients with a diagnosis of strep pharyngitis Patients diagnosed with strep pharyngitis who were prescribed first-line medications for strep pharyngitis.
Patients with a diagnosis of strep pharyngitis.
Method/Source of Data Collection
Collect data on entire patient population that fit criteria under "Population Definition" through electronic medical records. Then, determine the number of patients who were prescribed first-line medications.
Time Frame Pertaining to Data Collection
This is a process measure on underuse, and improvement is noted as an increase in the rate.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Aims and Measures
Fourth Edition/January 2013 Percentage of patients diagnosed with strep pharyngitis prescribed antibiotics with documentation of educa- tion on 24-hour treatment prior to returning to work, school or day care.
Children and adult patients diagnosed with strep pharyngitis and prescribed antibiotics.
Data of Interest
# of patients with education on 24-hour treatment prior to returning to work, school or day care # of patients with a diagnosis of strep pharyngitis and prescribed antibiotics Patients diagnosed with strep pharyngitis with education on 24-hour treatment prior to returning to work, school or day care.
Patients with a diagnosis of strep pharyngitis and prescribed antibiotics. Method/Source of Data Collection
Collect data on entire patient population that fit criteria under "Population Definition" through electronic medical records. Then, determine the number of patients with education on 24-hour treatment to returning to work, school or day care.
Time Frame Pertaining to Data Collection
This is a process measure, and improvement is noted as an increase in the rate.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Aims and Measures
Fourth Edition/January 2013 Percentage of patients diagnosed with strep pharyngitis prescribed antibiotics with documentation of being educated on taking the complete course.
Children and adult patients diagnosed with strep pharyngitis and prescribed antibiotics.
Data of Interest# of patients with education on taking the complete course of antibiotics
# of patients diagnosed with strep pharyngitis and prescribed antibiotics Patients diagnosed with strep pharyngitis and prescribed antibiotics with education on taking the complete course of antibiotics.
Patients with a diagnosis of strep pharyngitis and prescribed antibiotics.
Method/Source of Data Collection
Collect data on entire patient population that fit criteria under "Population Definition" through electronic medical records. Then, determine the number of patients with education on taking the complete course of Time Frame Pertaining to Data Collection
This is a process measure, and improvement is noted as an increase in the rate.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Aims and Measures
Fourth Edition/January 2013 Percentage of patients diagnosed with strep pharyngitis instructed on actions to take if symptoms worsen.
Children and adult patients diagnosed with strep pharyngitis.
Data of Interest # of patients with education on actions to take if symptoms worsen
# of patients with a diagnosis of strep pharyngitis Patients with strep pharyngitis with instructions on actions to take if symptoms worsen.
Patients with a diagnosis of strep pharyngitis.
Method/Source of Data Collection
Collect data on entire patient population that fit criteria under "Population Definition" through electronic medical records. Then, determine the number of patients who had education on actions to take if symptoms Time Frame Pertaining to Data Collection
This is a process measure, and improvement is noted as an increase in the rate.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Aims and Measures
Fourth Edition/January 2013 Percentage of patients diagnosed with seasonal allergic rhinitis being treated with injectable corticosteroids.
Children and adult patients diagnosed with seasonal allergic rhinitis.
Data of Interest
# of patients treated with injectable corticosteroids # of patients diagnosed with seasonal allergic rhinitis Patients diagnosed with seasonal allergic rhinitis being treated with injectable corticosteroids.
Patients diagnosed with seasonal allergic rhinitis.
Method/Source of Data Collection
Collect data on entire patient population that fit criteria under "Population Definition" through electronic medical records. Then, determine the number of patients who were treated with injectable corticosteroids.
Time Frame Pertaining to Data Collection
This is a process measure, and improvement is noted as a decrease in the rate.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Prior to implementation, it is important to consider current organizational infrastructure that address the • System and process design• Training and education• Culture and the need to shift values, beliefs and behaviors of the organization.
The following system changes were identified by the guideline work group as key strategies for health care systems to incorporate in support of the implementation of this guideline: • Develop, collect and disseminate materials to educate patients with allergic rhinitis about avoidance • Develop phone- or computer-based care for established patients that includes telephone nurse assessment, symptomatic care with follow-up instructions and use of a protocol to prescribe first-line antibiotics for Criteria for Selecting Resources
The following tools and resources specific to the topic of the guideline were selected by the work group.
Each item was reviewed thoroughly by at least one work group member. It is expected that users of these tools will establish the proper copyright prior to their use. The types of criteria the work group used are: • The content supports the clinical and the implementation recommendations.
• Where possible, the content is supported by evidence-based research.
• The author, source and revision dates for the content are included where possible.
• The content is clear about potential biases and when appropriate conflicts of interests and/or disclaimers are noted where appropriate.
Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Web Sites/Order Information
American Academy of Offers education resources for patients and Patients and Allergy, Asthma and clinicians. This site includes special sections for children and seniors. American Academy of Clinical practice guidelines, clinical care, Patients and research, and quality improvement resources. Families; American Academy of Head and neck specialist site with user BMJ (British Medical Trusted global publisher of evidence into Patients, practice resources of various diseases and researchers, HealthPartners Health Patient education resources and decision Information Library support interactive tools, health topics and Families; learning centers based on current practice Health Care guidelines and standards of care.
Health information on various diseases and Patients and National Institute of Health Web site produced by the National Library of Medicine. Includes drug and disease videos, literature and illustrations. Multiple Professionals Institute for Clinical Systems Improvement

Supporting Evidence:
Diagnosis and Treatment of Respiratory Illness in
Children and Adults
The subdivisions of this section are: • References• Appendices Copyright 2013 by Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Links are provided for those new references added to this edition (author name is highlighted in blue).
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Fourth Edition/January 2013 Bernstein IL. Proceedings of the task force on guidelines for standardizing old and new technologies used for the diagnosis and treatment of allergic diseases. J Allergy Clin Immunol 1988;82:487-526. (Low Quality Evidence) Bernstein IL, Storms WW. Practice parameters for allergy diagnostic testing. Ann Allergy Asthma Immunol 1995;75:546-47. (Guideline) Bisno AL. Acute pharyngitis: etiology and diagnosis. Pediatrics 1997a;97:949-54. (Low Quality Evidence) Bisno AL, Gerber MA, Gwaltney Jr JM, et al. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis 2002;35:113-25. (Guideline) Brannan MD, Herron JM, Reidenberg P, et al. Lack of hypothalamic-pituitary-adrenal axis suppres-sion with once-daily or twice-daily beclomethasone dipropionate aqueous nasal spray administered to patients with allergic rhinitis. Clin Ther 1995;17:637-47. (High Quality Evidence) Breese BB. A simple scorecard for the tentative diagnosis of streptococcal pharyngitis. Am J Dis Child 1977;131:514-17. (Low Quality Evidence) Bronsky EA, Boggs P, Findlay S, et al. Comparative efficacy and safety of a once-daily loratadine-pseudoephedrine combination versus its components alone and placebo in the management of seasonal allergic rhinitis. J Allergy Clin Immunol 1995;96:139-47. (High Quality Evidence) Bronsky EA , Dockhorn RJ, Meltzer EO, et al. Fluticasone propionate aqueous nasal spray compared with terfenadine tablets in the treatment of seasonal allergic rhinitis. J Allergy Clin Immunol 1996;97:915-21. (High Quality Evidence) Brown WG, Halonen MJ, Kaltenborn, WT, et al. The relationship of respiratory allergy, skin test reac-tivity, and serum IgE in a community population sample. J Allergy Clin Immunol 1979;63:328-35. (Low Quality Evidence) Calderon MA, Alves B, Jacobson M, et al. Allergen injection immunotherapy for seasonal allergic rhinitis (review). The Cochrane Library 2009, Issue 1. (Systematic Review) Caldwell DR, Verin P, Hartwich-Young R, et al. Efficacy and safety of lodoxamide 0.1% vs cromolyn sodium 4% in patients with vernal keratoconjunctivitis. Am J Ophthalmol 1992;113:632-37. (High Quality Evidence) Carabin H, Gyorkos TW, Soto JC, et al. Effectiveness of a training program in reducing infections in toddlers attending day care centers. Epidemiology 1999;10:219-27. (High Quality Evidence) Cave A, Arlett P, Lee E. Inhaled and nasal corticosteroids: factors affecting the risks of systemic adverse effects. Pharm Ther 1999;83:153-79. (Low Quality Evidence) Centers for Disease Control and Prevention. Infant deaths associated with cough and cold medica-tions – two states, 2005. MMWR 2007;56:1-4. (Low Quality Evidence) Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Ann Intern Med 2009;151:812-15. (Low Quality Evidence) Chaudhary S, Bilinsky SA, Hennesy JL, et al. Penicillin V and rifampin for the treatment of group A streptococcal pharyngitis: a randomized trial of 10 days penicillin vs 10 days penicillin with rifampin during the final 4 days of therapy. J Pediatr 1985;106:481-86. (High Quality Evidence) Chaudhry R, Stroebel RJ, McLeod TG, et al. Nurse-based telephone protocol versus usual care for management of URI and acute sinusitis: a controlled trial. Manag Care Interface 2006;19:26-31. (Low Quality Evidence) Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults References
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Fourth Edition/January 2013 Peter G. Streptococcal pharyngitis: current therapy and criteria for evaluation of new agents. Clin Infect Dis 1992;14(Suppl 2):S218-23. (Low Quality Evidence) Petersen K, Phillips RS, Soukup J, et al. The effect of erythromycin on resolution of symptoms among adults with pharyngitis not caused by group A streptococcus. J Gen Intern Med 1997;12:95-101. (High Quality Evidence) Pipkorn U, Proud D, Lichtenstein LM, et al. Inhibition of mediator release in allergic rhinitis by pretreat-ment with topical glucocorticosteroids. N Eng J Med 1987;316:1506-10. (High Quality Evidence) Pruitt AW. Rational use of cold and cough preparations. Pediatr Ann 1985;14:289-91. (Low Quality Evidence) Pullerits T, Praks L, Skoogh BE, et al. Randomized placebo-controlled study comparing a leukotriene receptor antagonist and a nasal glucocorticoid in seasonal allergic rhinitis. Am J Respir Crit Care Med 1999;159:1814-18. (High Quality Evidence) Ramaekers JG, Uiterwijk MMC, O'Hanlon JF. Effects of loratadine and cetirizine on actual driving and psychometric test performance, and EEG during driving. Eur J Clin Pharmacol 1992;42:363-69. (High Quality Evidence) Randolph MF, Gerber MA, DeMeo KK, et al. Effect of antibiotic therapy on the clinical course of strep-tococcal pharyngitis. J Pediatr 1985;106:870-75. (High Quality Evidence) Rantanen T, Arvilommi H. Double-blind trial of doxicycline in acute maxillary sinusitis. Acta Otolaryng 1973;76:58-62. (Low Quality Evidence) Raphael GD, Baraniuk JN, Kaliner MA. How and why the nose runs. J Allergy Clin Immunol 1991;87:457-67. (Low Quality Evidence) Roberts CR, Imrey PB, Turner JD, et al. Reducing physician visits for colds through consumer educa-tion. JAMA 1983;250:1986-89. (High Quality Evidence) Roberts DN, Hampal S, East CA, et al. The diagnosis of inflammatory sinonasal disease. J Laryngol Otol 1995;109:27-30. (Low Quality Evidence) Salerno SM, Jackson JL, Berbano EP. Effect of oral pseudoephedrine on blood pressure and heart rate: a meta-analysis. Arch Intern Med 2005;165:1686-94. (Meta-analysis) Sandora TJ, Taveras EM, Shih M, et al. A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home. Pediatrics 2005;116:587-94. (High Quality Evidence) Schenkel EJ, Skoner DP, Bronsky EA, et al. Absence of growth retardation in children with perennial allergic rhinitis after one year of treatment with mometasone furoate aqueous nasal spray. Pediatrics 2000;105:1-7. (High Quality Evidence) Schlager TA, Hayden GA, Woods WA, et al. Optical immunoassay for rapid detection of group A B-hemolytic streptococci. Arch Pediatr Adolesc Med 1996;150:245-48. (Low Quality Evidence) Schmitt BD. Fever in childhood. Pediatrics 1984;74(suppl):929-36. (Low Quality Evidence) Schmitt BD. Instructions for pediatric patients. In Your Child's Health. Philadelphia: W.B. Saunders, 1992;55-56. (Low Quality Evidence) Schoenwetter W, Lim J. Comparison of intranasal triamcinolone acetonide with oral loratadine for the treatment of patients with seasonal allergic rhinitis. Clin Thera 1995;17:479-93. (High Quality Evidence) Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambula-tory settings. The Cochrane Library 2007, Issue 4. (Systematic Review) Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults References
Fourth Edition/January 2013 Seppälä H, Lahtonen R, Ziegler T, et al. Clinical scoring system in the evaluation of adult pharyngitis. Arch Otolaryngol Head Neck Surg 1993;119:288-91. (Low Quality Evidence) Shapiro GG. Diagnostic methods for assessing the patient with possible allergic disease. In Allergic Diseases from Infancy to Adulthood. Bierman CW, Pearlman DS, eds. WB Saunders, 1988;224-38. (Low Quality Evidence) Simon HB. Pulmonary infections. Sci Am Med 1997;7:1-4. (Low Quality Evidence) Simons FER, Reggin JD, Roberts JR, et al. Benefit/risk ratio of the antihistamines (H -receptor antago- nists) terfenadine and chlorpheniramine in children. J Pediatr 1994a;124:979-83. (High Quality Evidence) Simons FER, Simons KJ. The pharmacology and use of H1-receptor–antagonist drugs. N Eng J Med 1994b;330:1663-70. (Low Quality Evidence) Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosi-nusitis. Otolaryngol Head Neck Surg 2004;130:S1-S45. (Guideline) Skoner D. Update of growth effects of inhaled and intranasal corticosteroids. Curr Opin Allergy Clin Immunol 2002;2:7-10. (Low Quality Evidence) Skoner DP, Rachelefsky GS, Meltzer EO, et al. Detection of growth suppression in children during treat-ment with intranasal beclomethasone dipropionate. Pediatrics 2000;105:1-7. (High Quality Evidence) Smith MBH, Feldman W. Over-the-counter cold medications: a critical review of clinical trials between 1950 and 1991. JAMA 1993;269:2258-63. (Systematic Review) Snellman LW, Stang HJ, Stang JM, et al. Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. Pediatrics 1993;911:1166-70. (High Quality Evidence) Snow V, Mottur-Pilson C, Hickner JM, et al. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Intern Med 2001;134:495-97. (Low Quality Evidence) Soderberg-Warner ML. Nasal septal perforation associated with topical corticosteroid therapy. J Pediatr 1984;105:840-41. (Low Quality Evidence) Soyka LF, Robinson DS, Lachant N, et al. The misuse of antibiotics for treatment of upper-respiratory tract infections in children. Pediatrics 1975;55:552-56. (Low Quality Evidence) Sperber SJ, Hendley JO, Hayden FG, et al. Effects of naproxen on experimental rhinovirus colds: a randomized, double-blind, controlled trial. Ann Intern Med 1992;117:37-41. (High Quality Evidence) Storms WW, Bodman SF, Nathan RA, et al. SCH 434: a new antihistamine/decongestant for seasonal allergic rhinitis. J Allergy Clin Immunol 1989;83:1083-90. (High Quality Evidence) Sydnor A Jr., Gwaltney JM, Cocchetto DM, et al. Comparative evaluation of cefuroxime axetil and cefaclor for treatment of acute bacterial maxillary sinusitis. Arch Otolaryngol Head Neck Surg 1989;115:1430-33. (Low Quality Evidence) Szilagyi PG. What can we do about the common cold? Contemp Pediatr 1990;7:23-49. (Low Quality Evidence) Tanz RR, Poncher JR, Corydon KE, et al. Clindamycin treatment of chronic pharyngeal carriage of group A streptococci. J Pediatr 1991;119:123-28. (High Quality Evidence) Tanz RR, Shulman ST, Barthel MJ, et al. Penicillin plus rifampin eradicates pharyngeal carriage of group A streptococci. J Pediatrics 1985;106:876-80. (High Quality Evidence) Terry PE, Pheley A. The effect of self-care brochures on use of medical services. JOM 1993;35:422-26. (High Quality Evidence) Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults References
Fourth Edition/January 2013 Turner RB, Bauer R, Woelkart K, et al. An evaluation of echinacea angustifolia in experimental rhino-virus infections. N Engl J Med 2005;353:341-48. (Low Quality Evidence) Turner RB, Cetnarowski WE. Effect of treatment with zinc gluconate or zinc acetate on experimental and natural colds. Clin Infect Dis 2000;31:1202-08. (High Quality Evidence) Tyrrell D, Barrow I, Arthur J. Local hyperthermia benefits natural and experimental common colds. BMJ 1989;298:1280-83. (High Quality Evidence) Uhl JR, Adamson EA, Vetter CD, et al. Comparison of hightcycler PCR, rapid antigen immunoassay, and culture for detection of group A streptococci from throat swabs. J of Clin Microbiology 2003;41:242-49. (Low Quality Evidence) van Buchem FL, Knottnerus JA, Schrijnemaekers VJJ, et al. Primary-care-based randomised placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis. Lancet 1997;349:683-87. (High Quality Evidence) Van Metre TE, Adkinson NF Jr, Amodio FJ, et al. A comparative study of the effectiveness of the Rinkel method and the current standard method of immunotherapy for ragweed pollen hay fever. J Allergy Clin Immunol 1980;66:500-13. (High Quality Evidence) Varney VA, Gaga M, Frew AJ, et al. Usefulness of immunotherapy in patients with severe summer hay fever uncontrolled by antiallergic drugs. BMJ 1991;302:265-69. (High Quality Evidence) Vermeeren A, O'Hanlon JF. Fexofenadine's effects, alone and with alcohol, on actual driving and psychomotor performance. J Allergy Clin Immunol 1998;101:306-11. (High Quality Evidence) Vuurman EFPM, van Veggel LMA, Uiterwijk MMC, et al. Seasonal allergic rhinitis and antihistamine effects on children's learning. Ann Allergy 1993;71:121-26. (Low Quality Evidence) Wald ER, Chiponis D, Ledesma-Medina J. Comparative effectiveness of amoxicillin and amoxicillin-clavulanate potassium in acute paranasal sinus infections in children: a double-blind placebo-controlled trial. Pediatrics 1986;77:795-800. (High Quality Evidence) Wald ER, Dashefsky B, Byers C, et al. Frequency and severity of infections in day care. J Pediatr 1988;112:540-46. (Low Quality Evidence) Wald ER, Reilly JS, Casselbrant M, et al. Treatment of acute maxillary sinusitis in childhood: a compara-tive study of amoxicillin and cefaclor. J Pediatr 1984;104:297-302. (High Quality Evidence) Wallace DV, Dykewicz MS, Bernstein DI, et al. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol 2008;122:S1-S84. (Guideline) Walsh JK, Muehlbach MJ, Schweitzer PK. Simulated assembly line performance following ingestion of cetirizine or hydroxyzine. Ann Allergy 1992;69:195-200. (High Quality Evidence) Walson PD. Coughs and colds. Pediatrics 1984;74(suppl):937-40. (Low Quality Evidence) Weiler JM, Bloomfield JR, Woodworth GG, et al. Effects of fexofenadine, diphenhydramine, and alcohol on driving performance: a randomized, placebo-controlled trial in the Iowa Driving Simulator. Ann Intern Med 2000;132:354-63. (High Quality Evidence) Weiner JM, Abramson MJ, Puv RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 1998;317:1624-29. (System-atic Review) Welsh PW, Stricker WE, Chu-Pin C, et al. Efficacy of beclomethasone nasal solution, flunisolide, and cromolyn in relieving symptoms of ragweed allergy. Mayo Clin Proc 1987;62:125-34. (High Quality Evidence) Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults References
Fourth Edition/January 2013 Wheeler PW, Wheeler SF. Vasomotor rhinitis. Am Fam Phys 2005;72:1057-62. (Guideline) Willett L, Carson JL, Williams JW. Current diagnosis and management of sinusitis. J Gen Intern Med 1994;9:38-45. (Low Quality Evidence) Williams Jr JW, Aguilar C, Makela M, et al. Antibiotics for acute maxillary sinusitis (Cochrane Review). In The Cochrane Library, Issue 4, 2000. Oxford: Update Software. (Systematic Review) Williams JW, Simel DL. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA 1993;270:1242-46. (Low Quality Evidence) Williams JW, Simel DL, Roberts L, et al. Clinical evaluation for sinusitis: making the diagnosis by history and physical examination. Ann Intern Med 1992;117:705-10. (Low Quality Evidence) Williamson IG, Rumsby K, Benge S, et al. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial. JAMA 2007;298:2487-96. (High Quality Evidence) Wilson AM, Orr LC, Sims EJ, Lipworth BJ. Effects of monotherapy with intra-nasal corticosteroid or combined oral histamine and leukotriene receptor antagonists in seasonal allergic rhinitis. Clinical and Experimental Allergy 2000;31:61-68. (High Quality Evidence) Wilson JF, Turner BJ, Williams S, Taichman D. In the clinic: acute sinusitis. Ann Intern Med 2010;153:ITC31-15. (Low Quality Evidence) Winther B, Gwaltney JM. Therapeutic approach to sinusitis: anti-infectious therapy as the baseline of management. Otolaryngol Head Neck Surg 1990;103:876-78. (Low Quality Evidence) Wolthers OD, Pedersen S. Short-term growth in children with allergic rhinitis treated with oral antihista-mine, depot and intranasal glucocorticosteroids. Acta Paediatr 1993;82:635-40. (High Quality Evidence) Wood RA, Chapman MD, Adkinson Jr NF, Eggleston PA. The effect of cat removal on allergen content in household-dust samples. J Allergy Clin Immunol 1989;83:730-34. (Low Quality Evidence) Wood RW, Tompkins RK, Wolcott BW. An efficient strategy for managing acute respiratory illness in adults. Ann Intern Med 1980;93:757-63. (Decision Analysis) Zapka J, Averill BW. Self care for colds: a cost-effective alternative to upper-respiratory infection management. AJPH 1979;69:814-16. (Cost-Effectiveness Analysis) Institute for Clinical Systems Improvement

Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Allergic Triggers:
Pollen (tree, grass, weed)
Molds
House dust mite
Animal dander
Cockroaches
Foods (rarely cause rhinitis)
Non-allergic triggers:
Smoke
Fumes, such as from cleaning solutions, pool chlorine, car exhaust or other chemicals
Strong odors, such as perfumes, hair sprays and some cleaners
Decongestant nasal sprays if used regularly longer than three to five days in a row
Pregnancy/hormones (including birth control pills)
Medications (particularly antihypertensive agents)
Strong odors
Cold air and sudden temperature changes
Food, especially spicy foods
Alcohol
Bright light
Emotional upset
Snorting or inhaling illicit drugs or substances

Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Algorithm and Self-Care
Patient is experiencing some combination of the following symptoms:• Sore throat• Runny nose• Cough• Fever• Hoarseness• Headache Does the patient have complicating factors? Consult or visit • Illnesses such as asthma or • Recurrent symptoms • Treatment failure Is the patient experiencing Is the patient experiencing any any of the following? Symptoms are out of this of the following? • Sudden sore throat • Swollen glands (lymph Patient may have strep throat• Contact provider regarding strep testing• See following self-care Is the patient experiencing? Is the patient experiencing? • Watery nasal drainage • Eye irritation Patient symptoms are Have 2 or more sinus symptoms most consistent with a persisted for more than 10 days? persisted for more • See following self-care • Yellow or green nasal Patient may have allergies Patient may have developed a • Avoid allergy triggers • Try over-the-counter • Contact clinician non-sedating antihistamines • See following self-care measures If you feel your symptoms are urgent or pertaining to an emergency, please contact your clinician immediately.

Institute for Clinical Systems Improvement Appendix B – Patient Algorithm
Diagnosis and Treatment of Respiratory Illness in Children and Adults References and Self-Care Measures
Fourth Edition/January 2013 Respiratory Illness Self-Care Measures
Common Cold Self-Care Measures
• Hand washing or use of hand sanitizers is recommended to prevent the spread of the common cold.
• Comfort measures
- Steam or mist inhalation- Nasal irrigation- Nasal suction for infants less than three months of age with a bulb syringe- Consume extra fluids- Honey (not recommended for children under one year, due to risk of botulism)- Elevate head of bed- Get adequate rest- Salt water gargle for sore throat - Use hard candy or throat lozenge (not recommended for children four and under) • Infant and toddler cold prevention recommendations
- Discourage visitors who have a cold, fever or contagious disease- Prevent sharing of toys and pacifier with children who have a cold- Ask visitors to wash their hands before holding baby- Continued breastfeeding is encouraged, due to increased protection for babies from infection Strep Throat Self-Care Measures
• Comfort Measures
- Take acetaminophen or ibuprofen. (Aspirin is not recommended for children or teenagers due to the increased risk of Reye's syndrome) - Gargle with warm salt water- Use hard candy or throat lozenge (not recommended for children four and under)- Eat soft foods- Drink cool or warm liquids- Consume flavored frozen desserts (such as popsicles or frozen fruit bars) Allergen Self-Care Measures
• Comfort Measures
- Avoid identified allergens- Avoid cigarette smoke, and avoid irritants such as smoke and perfume- Over-the-counter antihistamines can be taken Institute for Clinical Systems Improvement Appendix B – Patient Algorithm
Diagnosis and Treatment of Respiratory Illness in Children and Adults References and Self-Care Measures
Fourth Edition/January 2013 - Nasal saline irrigation- Increased fluids Sinus Infection Self-Care Measures
• Comfort Measures
- Increased fluids (recommended 6-10 glasses of liquid a day to thin mucus)- Steamy showers or increase humidity in homes- Apply warm facial packs for 5-10 minutes three or more times per day- Saline irrigation (saline nasal drops, spray to thin mucus)- Over-the-counter decongestants can be taken (antihistamines should be avoided)- Get adequate rest- Elevate head of bed- Avoid cigarette smoke and extremely cool or dry air What is considered a fever and when to seek medical attention:
Adults
Body temperature cycles through the day, typically the low point occurs early morning (6 a.m.) and the
typical peak occurs in late afternoon (4-6 p.m.). The maximum normal temperature in the morning is 98.9ºF and the maximum normal temperature at 4 p.m. is 99.9ºF. Temperatures above these levels at these times of day are considered fevers.
Elderly
The elderly may have lower baseline temperatures when healthy and are not as likely to develop a fever in
response to infections. Increased body temperature can increase the body's need for oxygen.
When medical attention should be sought:
For those with underlying conditions such as lung disease or heart disease, fever can have added conse-
quences. In general, fever needs to be evaluated and treated in the context of other symptoms. Most treat- ment is directed at patient comfort. Extremely high fevers (termed "hyperpyrexia") with temperature
over 105.8ºF can occur in the setting of severe infections or bleeding into the brain. Temperatures
above this range can result in damage to neuronal tissue. This high a fever, though rare, is a medical
emergency and requires prompt treatment.

Institute for Clinical Systems Improvement

est:
Diagnosis and Treatment of Respiratory Illness in
Children and Adults
ICSI has long had a policy of transparency in declaring potential conflicting and competing interests of all individuals who participate in the development, revision and approval of ICSI guidelines and protocols. In 2010, the ICSI Conflict of Interest Review Committee was established by the Board of Directors to review all disclosures and make recommendations to the board when steps should be taken to mitigate potential conflicts of interest, including recommendations regarding removal of work group members. This committee has adopted the Institute of Medicine Conflict of Interest standards as outlined in the report, Clinical Practice Guidelines We Can Trust (2011). Where there are work group members with identified potential conflicts, these are disclosed and discussed at the initial work group meeting. These members are expected to recuse themselves from related discussions or authorship of related recommendations, as directed by the Conflict of Interest committee or requested by the work group.
The complete ICSI policy regarding Conflicts of Interest is available at Funding Source
The Institute for Clinical Systems Improvement provided the funding for this
guideline revision. ICSI is a not-for-profit, quality improvement organization based in Bloomington, Minnesota. ICSI's work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin. Individuals on the work group are not paid by ICSI but are supported by their medical group for this work.
ICSI facilitates and coordinates the guideline development and revision process. ICSI, member medical groups and sponsoring health plans review and provide feedback but do not have editorial control over the work group. All recommenda- tions are based on the work group's independent evaluation of the evidence.
Copyright 2013 by Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Disclosure of Potential Conflicts of Interest
William Adams (Work Group Member)
ICSI Patient Advisory Council Member, ICSI National, Regional, Local Committee Affiliations: None Guideline Related Activities: None Research Grants: None Financial/Non-Financial Conflicts of Interest: None
Greg Anderson, MD (Work Group Member)
Physician, Family Medicine National, Regional, Local Committee Affiliations: None Guideline Related Activities: None Research Grants: None Financial/Non-Financial Conflicts of Interest: None
Ann Godfrey (Work Group Member)
ICSI Patient Advisory Council Member, ICSI National, Regional, Local Committee Affiliations: None Guideline Related Activities: None Research Grants: None Financial/Non-Financial Conflicts of Interest: None
Andrea Gravley, RN, MAN, CPNP (Work Group Member)
Nurse Practitioner, Pediatrics, South Lake Pediatrics National, Regional, Local Committee Affiliations: None Guideline Related Activities: ICSI Preventive Services Guideline Research Grants: None Financial/Non-Financial Conflicts of Interest: None
Peter Marshall, PharmD (Work Group Member)
Pharmacist, HealthPartners HealthPlan, Pharmacy Services National, Regional, Local Committee Affiliations: None Guideline Related Activities: ICSI Diagnosis and Treatment of Venous Thromboembolism Research Grants: None Financial/Non-Financial Conflicts of Interest: None
Ramona Nesse, RN, C-NP (Work Group Member)
Nurse Practitioner, Family Medicine, Stillwater Medical Group and Lakeview Hospital National, Regional, Local Committee Affiliations: None Guideline Related Activities: None Research Grants: None Financial/Non-Financial Conflicts of Interest: None
Sonja Short, MD (Work Group Member)
Physician, Internal Medicine and Pediatrics, Fairview Health Services-Eagan Clinic National, Regional, Local Committee Affiliations: None Guideline Related Activities: None Research Grants: None Financial/Non-Financial Conflicts of Interest: None Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Disclosure of Potential Conflicts of Interest
Fourth Edition/January 2013 Leonard Snellman, MD (Work Group Leader)
Physician, Pediatrics, HealthPartners Medical Group and Regions Hospital National, Regional, Local Committee Affiliations: None Guideline Related Activities: ICSI Preventive Services Guideline Research Grants: None Financial/Non-Financial Conflicts of Interest: None Institute for Clinical Systems Improvement

Diagnosis and Treatment of Respiratory Illness in
Children and Adults
All ICSI documents are available for review during the revision process by member medical groups and sponsors. In addition, all members commit to reviewing specific documents each year. This comprehensive review provides information to the work group for such issues as content update, improving clarity of recommendations, implementation suggestions and more. The specific reviewer comments and the work group responses are available to The ICSI Patient Advisory Council meets regularly to respond to any scientific document review requests put forth by ICSI facilitators and work groups. Patient advisors who serve on the council consistently share their experiences and perspectives in either a comprehensive or partial review of a document, and engaging in discussion and answering questions. In alignment with the Institute of Medicine's triple aims, ICSI and its member groups are committed to improving the patient experience when developing health care Copyright 2013 by Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 ICSI Patient Advisory Council
The work group would like to acknowledge the work done by the ICSI Patient Advisory Council in reviewing
the Diagnosis and Treatment of Respiratory Illness in Children and Adults and thank them for their input into the patient algorithm and self-care measures.
Invited Reviewers
During this revision, the following groups reviewed this document. The work group would like to thank
them for their comments and feedback.
CenraCare, St. Cloud, MN HealthPartners Health Plan, Minneapolis, MN Lakeview Clinic, Waconia, MN Marshfield Clinic, Marshfield, WI Mayo Clinic, Rochester, MN Medica, Hopkins, MN South Lake Pediatrics, Minnetonka, MN Institute for Clinical Systems Improvement

Diagnosis and Treatment of Respiratory Illness in
Children and Adults
Document Drafted
Oct – Nov 2006
First Edition
Second Edition
Third Edition
Fourth Edition
Released in January 2013 for Fourth Edition. Begins Feb 2013
The next scheduled revision will occur within 24 months. Original Work Group Members
Greg Anderson, MD Teresa Hunteman, RRT, CPHQ Melissa Marshall, MBA Family Practice Mayo Clinic
William Avery, DO Peter Marshall, PharmD Jeffrey Jenkins, MD Sioux Valley Hospitals &
Family Practice Sioux Valley Hospitals &
Bruce Cunningham, DO Family Practice, Work Group Heather Krueger, MD HealthPartners Medical
Family Practice Family HealthServices MN
Quello Clinic, Ltd.
Barbara Malone, MD Park Nicollet Health Services Midwest ENT
Document History
In October 2006, a merger of four ICSI guidelines began in order to create the
current guideline, Diagnosis and Treatment of Respiratory Illness in Children and Adults. The documents merged were Acute Pharyngitis, last released in 2005; Acute Sinusitis, and Viral Upper Respiratory Infections, both last released in 2004; and Chronic Rhinitis, last released in 2003. Contact ICSI at:
8009 34th Avenue South, Suite 1200; Bloomington, MN 55425; (952) 814-7060; (952) 858-9675 (fax) Online at http://www.ICSI.org Copyright 2013 by Institute for Clinical Systems Improvement Diagnosis and Treatment of Respiratory Illness in Children and Adults Fourth Edition/January 2013 Overview
Since 1993, the Institute for Clinical Systems Improvement (ICSI) has developed more than 60 evidence-based
health care documents that support best practices for the prevention, diagnosis, treatment or management of a given symptom, disease or condition for patients.
Audience and Intended Use
The information contained in this ICSI Health Care Guideline is intended primarily for health professionals and
other expert audiences. This ICSI Health Care Guideline should not be construed as medical advice or medical opinion related to any specific facts or circumstances. Patients and families are urged to consult a health care professional regarding their own situation and any specific medical questions they may have. In addition, they should seek assistance from a health care professional in interpreting this ICSI Health Care Guideline and applying it in their individual case. This ICSI Health Care Guideline is designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinician's judgment or to establish a protocol for all patients with a particular condition.
Document Development and Revision Process
The development process is based on a number of long-proven approaches and is continually being revised
based on changing community standards. The ICSI staff, in consultation with the work group and a medical librarian, conduct a literature search to identify systematic reviews, randomized clinical trials, meta-analysis, other guidelines, regulatory statements and other pertinent literature. This literature is evaluated based on the GRADE methodology by work group members. When needed, an outside methodologist is consulted.
The work group uses this information to develop or revise clinical flows and algorithms, write recommendations, and identify gaps in the literature. The work group gives consideration to the importance of many issues as they develop the guideline. These considerations include the systems of care in our community and how resources vary, the balance between benefits and harms of interventions, patient and community values, the autonomy of clinicians and patients and more. All decisions made by the work group are done using a consensus process. ICSI's medical group members and sponsors review each guideline as part of the revision process. They provide comment on the scientific content, recommendations, implementation strategies and barriers to implementation. This feedback is used by and responded to by the work group as part of their revision work. Final review and approval of the guideline is done by ICSI's Committee on Evidence-Based Practice. This committee is made up of practicing clinicians and nurses, drawn from ICSI member medical groups.
Implementation Recommendations and Measures
These are provided to assist medical groups and others to implement the recommendations in the guidelines.
Where possible, implementation strategies are included that have been formally evaluated and tested. Measures are included that may be used for quality improvement as well as for outcome reporting. When available, regu- latory or publicly reported measures are included.
Document Revision Cycle
Scientific documents are revised every 12-24 months as indicated by changes in clinical practice and literature.
ICSI staff monitors major peer-reviewed journals every month for the guidelines for which they are responsible. Work group members are also asked to provide any pertinent literature through check-ins with the work group midcycle and annually to determine if there have been changes in the evidence significant enough to warrant document revision earlier than scheduled. This process complements the exhaustive literature search that is done on the subject prior to development of the first version of a guideline.
Institute for Clinical Systems Improvement

Source: https://www.icsi.org/_asset/1wp8x2/RespIllness.pdf