Harrison's Manual of Medicine 17/e
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Table 62-1: Guidelines for the Diagnosis and Treatment of Selected Upper Respiratory Tract Infections in Adults*

Table 62-1

Syndrome, Diagnostic Criteria

Treatment Recommendations

Acute sinusitisb

  • Moderate symptoms (e.g., nasal purulence/congestion or cough) for >7 d or
  • Severe symptoms of any duration, including unilateral/focal facial swelling or tooth pain

Initial therapy

  • Amoxicillin, 500 mg PO tid or 875 mg PO bid, or
  • TMP-SMX, 1 DS tablet PO bid for 10–14 d

Exposure to antibiotics within 30 d or >30% prevalence of penicillin-resistant S. pneumoniae

  • Amoxicillin, 1000 mg PO tid, or
  • Amoxicillin/clavulanate (extended release), 2000 mg PO bid, or
  • Antipneumococcal fluoroquinolone (e.g., levofloxacin, 500 mg PO qd)

Recent treatment failured

  • Amoxicillin/clavulanate (extended release), 2000 mg PO bid, or
  • Amoxicillin, 1500 mg bid, plus clindamycin, 300 mg PO qid, or
  • Antipneumococcal fluoroquinolone (e.g., levofloxacin, 500 mg PO qd)

Acute otitis mediac

  • Fluid in the middle ear, evidenced by decreased tympanic membrane mobility, air/fluid level behind tympanic membrane, bulging tympanic membrane, purulent otorrhea; and
  • Acute onset of signs and symptoms of middle-ear inflammation, including fever, otalgia, decreased hearing, tinnitus, vertigo, erythematous tympanic membrane

Initial therapy

  • Observation alone (symptom relief only) or
  • Amoxicillin, 80–90 mg/kg qd (up 2 g) PO in divided doses (bid or tid), or
  • Cefdinir, 14 mg/kg qd PO in 1 dose or divided doses (bid), or
  • Cefuroxime, 30 mg/kg qd PO in divided doses (bid), or
  • Azithromycin, 10 mg/kg qd PO on day 1 followed by 5 mg/kg qd PO for 4 d

Antibiotic exposure within 30 d,c recent treatment failure,c,d or severe diseasec,e

  • Amoxicillin, 90 mg/kg qd (up to 2 g) PO in divided doses (bid), plus clavulanate, 6.4 mg/kg qd PO in divided doses (bid), or
  • Ceftriaxone, 50 mg/kg IV/IM qd for 3 d, or
  • Clindamycin, 30–40 mg/kg qd PO in divided doses (tid) or
  • Consider tympanocentesis with culture

Acute pharyngitisb

  • Clinical suspicion of streptococcal pharyngitis (e.g., fever, tonsillar swelling, exudate, enlarged/tender anterior cervical lymph nodes, absence of cough or coryza)fwith:
  • History of rheumatic fever or
  • Documented household exposure or
  • Positive rapid strep screen

Penicillin V, 500 mg PO tid, or

Amoxicillin, 500 mg PO bid, or

Erythromycin, 250 mg PO qid, or

Benzathine penicillin G, single dose of 1.2 million units IM

*For detailed information on diagnosis and treatment in children, see Tables 31-1, 31-2, and 31-3 in HPIM-17.
bUnless otherwise specified, the duration of therapy is generally 10 d, with appropriate follow-up.
cThe duration of therapy is 5-7 d (10 d for pts with severe disease), with consideration of observation only in previously healthy patients with mild disease.
dFailure to improve and/or clinical worsening after 48-72 h of observation or treatment.
eAs defined to left along with temperature ≥39.0°C or moderate to severe otalgia.
fSome organizations support treating adults who have these symptoms and signs without administering a rapid streptococcal antigen test.
Note: TMP-SMX, trimethoprim-sulfamethoxazole; DS, double-strength.
Sources: JM Hickner et al: Ann Intern Med 134:498, 2001; JF Piccirillo: N Engl J Med 351:902, 2004; Sinus and Allergy Health Partnership: Otolaryngol Head Neck Surg 130:1, 2004; SF Dowell et al: Pediatrics 101:165, 1998; RJ Cooper et al: Ann Intern Med 134:509, 2001; and B Schwartz et al: Pediatrics 101:171, 1998.


Chapter:
Sinusitis, Pharyngitis, Otitis, and Other Upper Respiratory Infections

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Table 62-1: Guidelines for the Diagnosis and Treatment of Selected Upper Respiratory Tract Infections in Adults*
Table 62-1
Last updated: May 11, 2009
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