continuing education for pharmacists Common Cold, Sinusitis, Influenza: The Diseases, Prevention, Treatment

continuing education for pharmacists Common Cold, Sinusitis, Influenza: The Diseases, Prevention, Treatment

continuing education for pharmacists
Volume XXX, No. 11
Common Cold, Sinusitis, Influenza:
The Diseases, Prevention, Treatment
Mona T. Thompson, R.Ph., PharmD
Dr. Mona T. Thompson has no relevant
financial relationships to disclose.
Goal. The goal of this lesson is to
provide disease state reviews of the
common cold, sinusitis, and influenza. This lesson will also highlight key differences between each
disease state, and review current
treatment recommendations and
prevention when applicable.
Objectives. At the completion of
this activity, the participant will be
able to:
1. demonstrate an understanding of the basic pathophysiology
of the common cold, sinusitis, and
influenza;
2. compare the symptoms of
these three disease states;
3. list the antibiotics used in
the treatment of sinusitis;
4. recognize the appropriate
use of antiviral agents in the prevention and/or treatment of influenza; and
5. list the recommendations for
the appropriate use of the influenza
vaccine.
The Common Cold
The term common cold refers to
a collection of upper respiratory
symptoms that are caused by an
array of viral pathogens. Symptoms include nasal congestion,
rhinorrhea, sneezing, sore throat,
cough, low-grade fever, headache,
and malaise. The average incidence
of the common cold is six to eight
episodes per year in preschool children, and two or three per year in
adults. Adults who live with young
children experience more colds
than those who don’t. In infants
and young children, symptoms usually peak on day two or day three of
the illness and persist for 10 to 14
days. In some children, the cough
may last up to three or four weeks.
The duration of illness for adolescents and adults is usually seven to
10 days.
While generally considered
mild and self-limiting, the common
cold is associated with a tremendous economic burden due to lost
productivity and the cost of treatment. It is estimated that viral
respiratory tract infections account
for 21 million days of school absence and 20 million days of work
absence per year in the U.S. alone.
Annually, approximately three billion dollars are spent on over-thecounter cough and cold medications
for symptomatic treatment.
The pathogens most commonly
associated with common cold symptoms are the rhinoviruses. There
are over 100 different types that
account for 40 to 50 percent of the
cases. Other responsible pathogens
include coronaviruses and respiratory syncytial virus (RSV). While
influenza, parainfluenza, and adenoviruses may be associated with
cold symptoms, they often cause
lower respiratory and systemic
symptoms, in addition to the upper
respiratory symptoms characteristic of the common cold. These
infections also present differently
in younger children, versus older
children and adults. For instance,
RSV in older chidren and adults
often presents the same as other
colds, but in infants and toddlers,
it can result in bronchiolitis and
involve the lower respiratory tract.
Similarly, parainfluenza may present as croup in younger children
and as a typical cold in an older
child.
The cold season begins in late
August/September and remains
constant until the spring due to
the number of viruses. Rhinovirus
begins to increase in the early fall.
Alternatively, parainfluenza peaks
in the late fall and late spring,
while RSV and influenza viruses
are highest between December
and April. Common cold symptoms
are associated with each of these
outbreaks.
An effective vaccine for the
common cold is unlikely for two
reasons. First, some of these
viruses do not cause lasting immunity such as RSV, parainfluenza
viruses, and coronavirus which
can result in recurrent infections.
Second, even though other viruses
do produce lasting immunity, there
are so many serotypes that a
vaccine would not produce a real
impact on reducing the frequency
of common cold infections.
Transmission and Prevention. Colds may be spread through
three mechanisms: (1) small-particle aerosols produced from coughing and inhaled by another person;
(2) large particle droplets produced
from saliva that is expelled during
a sneeze and lands on the conjunctivae or nasal mucosa of another
person; or (3) self-inoculation from
touching one’s own nasal mucosa
after touching a person or object
contaminated with a cold virus.
Hence, poor hygiene and curiosity may be factors that lead to
children’s increased susceptibility
to colds. Hand-washing removes
the cold virus from the hands.
Virucidal tissues have been shown
to reduce secondary transmission. However, alcohol-based hand
sanitizers have not been shown to
reduce secondary transmission of
colds, most likely because rhinovirus is not affected by these products.
Treatment. While treatment
options differ in adults and children, symptomatic and supportive
treatment remains the mainstay
for the common cold. The following
treatment options do not reduce
disease duration. Antibiotics are
not indicated unless symptoms
strongly suggest a secondary bacterial infection. Antiviral therapy is
not available for viruses that cause
the common cold.
Treatment in Adults. Ipratropium bromide (Atrovent® Nasal
Spray), an anticholinergic medication which is administered intranasally, may be helpful in improving symptoms of rhinorrhea and
sneezing. Via application to the
nasal mucosa, it inhibits mucous
gland secretions. However, it does
not improve nasal congestion. It is
usually dosed as two sprays in each
nostril, three to four times a day.
Adverse effects include nosebleeds,
nasal dryness, and dry mouth.
First-generation antihistamines such as diphenhydramine
may improve rhinorrhea and
sneezing, but their use is limited
due to bothersome side effects
including sedation and drying
of the eyes, nose, and mouth. A
systematic review of available data
concluded that first-generation
antihistamines had a small clinical
benefit for relief of rhinorrhea and
sneezing, but that this was out-
weighed by the frequency of side effects. Non-sedating antihistamines,
such as loratadine and cetirizine,
were not effective. Therefore, antihistamines have minimal benefit in
treating the common cold.
Cough associated with the common cold is often due to post-nasal
drip or nasal obstruction. The
American College of Chest Physicians guidelines do not recommend
cough suppressants or antitussives,
such as codeine or dextromethorphan, for relief of cough associated
with upper respiratory infections.
Several clinical trials, however,
have concluded that dextromethorphan is superior to placebo for
cough suppression. Trials examining patients with acute cough
due to the common cold found
no consistent benefit when codeine was compared with placebo,
even though it may be helpful for
chronic cough.
Topical and oral adrenergic
agents such as phenylephrine and
pseudoephedrine may temporarily alleviate nasal congestion.
Phenylephrine is less effective
than pseudoephedrine for treating
rhinitis symptoms, yet it is a common ingredient in many OTC cold
preparations. Since pseudoephedrine is currently being used in the
illegal manufacturing of methamphetamine, FDA has limited
purchases and the availability to
behind-the-counter in pharmacies.
Topical decongestants should not
be used for longer than two to three
days, as they can result in rebound
rhinitis. Adverse effects associated
with these agents include increased
blood pressure in those with preexisting hypertension, nosebleeds
(topical), agitation, and insomnia.
Expectorants are intended to
increase mucous production. The
most common commercial agent is
guaifenesin. Studies show it may
have a marginal effect in improving the thickness and quantity of
sputum in adults.
Sore throat may be treated
with aspirin or acetaminophen,
while non-steroidal anti-inflammatories (NSAIDs) may be used
for headache, ear pain, muscle and
joint pains, malaise, and sneezing
associated with the common cold.
While their effectiveness is
questioned, saline nasal sprays or
irrigations and inhaling warm vaporized air may ease some of these
symptoms.
Treatment in Children.
Over the past few years, the use of
OTC cough and cold medications
for children and infants has been
under investigation. Over the past
20 years, 123 deaths involving
children younger than six years of
age have resulted from the use of
OTC cough and cold medications.
The adverse events associated with
their use, as well as accidental
ingestion, are a common cause for
emergency department visits. Poor
labeling, use of multi-ingredient
products, and multiple caregivers
administering medications are factors that lead to inadvertent overdosing. In October 2007, the U.S.
Food and Drug Administration
(FDA) Advisory Committee voted
to recommend against the use of
OTC cough and cold medications in
children younger than two years.
Drug manufacturers voluntarily
discontinued the marketing of
these agents for children less than
two years of age. Subsequently, the
number of emergency department
visits for adverse events involving these medications was cut in
half for children in this age group.
In 2011, the FDA advisory group
voted again to further ban the use
of these agents in children less
than six years of age. The American Academy of Pediatrics (AAP)
recommends against the use of
OTC cough and cold medications
in children younger than six years,
due to safety concerns and the lack
of efficacy data surrounding their
use.
Supportive therapy for children, as well as adults, includes
increasing fluid intake to thin
secretions; ingesting warm fluids
such as tea which may soothe the
respiratory mucosa, increase the
flow of nasal mucus, and loosen
mucus; the use of topical saline
and nasal suction to remove nasal
secretions; and the use of a humidi-
Table 1
Comparison of the common cold and flu
Symptoms Cold Flu
Fever Rare Characteristic, high, lasting 3-4 days
Headache Rare
Prominent
General Aches, Pains Rare Prominent
Fatigue, Weakness Mild May last 2-3 weeks
Extreme Exhaustion Never Early and prominent
Stuffy Nose Common Sometimes
Sneezing Usual Sometimes
Sore Throat Usual Sometimes
Chest Discomfort, Cough Mild to
Common; can become severe
moderate
hacking cough Prevention Good hygiene Influenza vaccine
Treatment Temporary
symptom
relief fier which helps loosen nasal secretions. While these interventions
are not proven to be effective, they
are safe and inexpensive.
Symptomatic treatment is suggested only when symptoms are interfering with sleep or causing discomfort. Single ingredient products
are recommended to avoid overdosing from multiple medications that
contain the same ingredient. Fever
and general discomfort from the
common cold may be treated with
acetaminophen for children older
than three months or ibuprofen for
children older than six months. The
use of aspirin is not recommended
in children due to the association
with Reye’s Syndrome.
Regarding the treatment of nasal congestion and rhinorrhea, ipratropium 0.06 percent nasal spray
(Atrovent® Nasal Spray) is indicated for the relief of rhinorrhea due
to the common cold for ages five to
11 years. There is no evidence supporting the effectiveness of either
oral or topical decongestants in
children. Antihistamines or combination antihistamine/decongestants are also not recommended for
nasal symptoms.
Antitussives are not recommended in children for several
reasons. Coughing is a protective
action that clears the airway; suppressing it may be harmful to chil-
Antiviral drugs (Relenza®
or Tamiflu®) within 24-48 hours
dren, especially those with asthma.
In addition, studies have failed to
indicate improvement when dextromethorphan was used. Lastly,
accidental overdose of antitussives
can cause respiratory depression.
One recent study suggested
that the bedtime application of
vapor rub containing menthol,
camphor, and eucalyptus oils to
the chest and neck of children aged
two to 11 years resulted in relief
of night-time cough, congestion,
and difficulty in sleep compared
to petrolatum or no treatment. It
should not be applied to the nasal
passages, as it may cause chemical
irritation there. Gastrointestinal
and central nervous system effects
may result from accidental ingestion.
Complications of the Common Cold. Wheezing or secondary
bacterial infections such as otitis
media, sinusitis, or pneumonia
may complicate the common cold.
Approximately 30 percent of colds
in preschool-aged children may be
complicated by otitis media, with
the risk being highest in children
six to 11 months of age. Sinusitis
may occur in 5 to 10 percent of
children with colds, and is considered when symptoms do not
improve after 10 days. Infants
and children with reactive airway
disease or asthma are at a higher
risk for complications, and may
have increased severity and duration of respiratory symptoms. Fifty
percent of asthma exacerbations
are associated with viral infections,
particularly rhinovirus. RSV is also
associated with wheezing exacerbations.
Table 1 includes comparison of
symptoms, prevention and treatment for the common cold and
influenza.
Sinusitis
Acute rhinosinusitis (ARS) is
defined as symptomatic inflammation of the nasal cavity and
paranasal sinuses lasting fewer
than four weeks. The term rhinosinusitis is used since inflammation
of the sinuses is almost always
accompanied by inflammation
of the nasal cavity, and is more
commonly referred to as sinusitis.
Viral etiology associated with an
upper respiratory infection (URI)
or the common cold is the most
frequent cause of sinusitis. However, sinusitis can also be caused by
allergens, environmental irritants,
and bacterial or fungal infections.
Acute viral rhinosinusitis (AVRS)
is extremely common, while secondary bacterial infections of the
paranasal sinuses following a viral
URI are estimated to occur in 0.5 to
2 percent of adults and 5 percent of
children. Even though viral infections account for 92 to 98 percent
of the cases, acute rhinosinusitis
is the fifth leading indication for
antibiotic prescribing by healthcare
professionals. Contrary to common
belief, the presence of colored or
green nasal discharge alone does
not indicate that the infection has
been complicated by bacteria. In an
uncomplicated case of viral URI,
the nasal discharge begins as clear
and watery, and becomes thicker
and more mucoid throughout
the course of the disease. It may
become thick, colored, and opaque
for several days before reversing to
mucoid and clear again or drying.
Because differentiating between
AVRS and bacterial infection is difficult, it is challenging to determine
when antibiotics are indicated.
Table 2
Outpatient antimicrobial regimens for
acute bacterial rhinosinusitis in adults*
Indication First-line Second-line
Initial empiric therapy Amoxicillin-clavulanate Amoxicillin-clavulanate
(500mg/125mg PO tid
(2000mg/125mg PO bid)
or 875mg/125mg PO bid) Doxycycline (100mg PO bid or
200mg qd)
Beta-lactam allergy Doxycycline (100mg PO bid or 200mg qd)
Levofloxacin (500mg PO qd)
Moxifloxacin (400mg PO qd)
Risk for antibiotic resistance or failed initial therapy Amoxicillin-clavulanate
(2000mg/125mg PO bid)
Levofloxacin (500mg PO qd)
Moxifloxacin (400mg PO qd)
*Adapted from IDSA Guidelines for ABRS 2012
Studies indicate that some patients
with acute bacterial rhinosinusitis
(ABRS) may clear the infection
spontaneously without antibiotic
treatment. Sinusitis rarely leads to
severe complications.
Several practice guidelines
have been published by various
professional organizations to aid
practitioners in appropriate antimicrobial prescribing. The treatment recommendations discussed
in this lesson are based on the
Clinical Practice Guideline for
Acute Bacterial Rhinosinusitis in
Children and Adults published
by the Infectious Disease Society
of America (IDSA) in 2012. Since
sinus aspirate cultures are not
readily available, it is not possible
to distinguish between AVRS and
ABRS in the first 10 days of illness
based on history and examination. Therefore, ABRS should be
considered when any of the following are present: (1) persistent
signs and symptoms of ARS lasting
10 or more days with no clinical
improvement; (2) severe symptoms
or signs of high fever (>102°F) and
purulent nasal discharge, or facial
pain lasting for at least three to
four consecutive days at the beginning of the illness; or (3) worsening
signs or symptoms characterized by
the new onset of fever, headache,
or increase in nasal discharge, following a typical upper respiratory
infection that lasted five to six days
and were initially improving. The
last symptoms are referred to as
double-sickening.
Treatment of Sinusitis. The
following treatment recommendations are for patients with suspected ABRS. For the relief of pain associated with ARS, analgesics such
as NSAIDs and acetaminophen
may be used. Intranasal saline irrigation, with either normal saline
or hypertonic saline, may be used
in adults and children to relieve
nasal symptoms. Although saline
irrigation is safe and may make the
patient more comfortable, it is associated with nasal burning, irritation, and nausea. Saline irrigation
is less well tolerated in babies and
young children. Intranasal corticosteroids may be used as an adjunct
to antibiotics in patients with a
history of allergic rhinitis. Neither
decongestants (topical or oral) nor
antihistamines is recommended for
adjunct treatment in patients with
ABRS.
Empiric antimicrobial therapy
should be initiated in patients with
signs and symptoms suggestive
of ABRS as soon as the clinical
diagnosis is made. Based on IDSA’s
clinical criteria previously outlined,
patients with bacterial infection
are more likely to be appropriately
identified. The recommendation
for “watchful waiting” is gener-
ally no longer necessary. However,
“watchful waiting” with follow-up
still may be employed in patients
where the diagnosis of a bacterial
infection is uncertain and milder
symptoms are present.
Treatment in Adults. Amoxicillin was formerly recommended
as a first-line agent due to its
narrow spectrum of coverage and
low cost. However, the pathogens
for ABRS have changed since the
introduction of routine conjugated
pneumococcal vaccination in children. For both adults and children,
the percentage of ABRS due to S.
pneumoniae has decreased while
the percentage due to H. influenzae
has increased. Antimicrobial resistance to both respiratory pathogens
continues to rise. Therefore, the
IDSA guidelines now recommend
amoxicillin-clavulanate (Augmentin®) over amoxicillin as a first-line
agent for non-penicillin allergic
adults. The dose for most adults is
500mg/125mg orally three times a
day, or 875mg/125mg orally twice
daily.
High dose amoxillin-clavulanate of 2 grams orally twice daily
is recommended for geographic
regions with high endemic rates
(>10 percent) of penicillin-nonsusceptible (PNS) S. pneumoniae, and
for patients who are 65 years and
older, recently hospitalized, treated
with an antibiotic in the previous
month, or immunocompromised.
For patients who are allergic to
penicillin, doxycycline may be used
first line, or a respiratory fluoroquinolone such as levofloxacin or
moxifloxacin.
According to the IDSA, the
duration of treatment in adults
should be five to seven days.
Second-line treatment options
include amoxicillin-clavulanate
2000mg/125mg orally twice daily;
levofloxacin 500mg orally once
daily; or moxifloxacin 400mg orally
once daily. (Table 2)
Treatment in Children.
Again, amoxicillin-clavulanate,
rather than amoxicillin alone, is
recommended as empiric firstline therapy in children. The
addition of clavulanate improves
Table 3
Outpatient antimicrobial regimens for
acute bacterial rhinosinusitis in children*
Indication First-line Second-line
Initial empiric therapy Amoxicillin-clavulanate Amoxicillin-clavulanate (90mg/
(45mg/kg/day PO bid)
kg/day PO bid)
Beta-lactam allergy Type I hypersensitivity Non-type I hypersensitivity •Levofloxacin (10-20mg/kg/day PO every 12-24 hours)
•Clindamycin (30-40mg/kg/day PO tid) plus cefixime (8mg/kg/
day PO bid) or cefpodoxime (10mg/kg/day PO bid)
Risk for antibiotic resistance or failed
initial therapy •Amoxicillin-clavulanate (90mg/
kg/day PO bid)
•Clindamycin (30-40mg/kg/day PO tid) plus cefixime (8mg/kg/
day PO bid) or cefpodoxime (10mg/kg/day PO bid)
•Levofloxacin (10-20mg/kg/day PO every 12-24 hours)
coverage for ampicillin-resistant
H.influenzae and M. catarrhalis in
ABRS. However, it also increases
the likelihood of diarrhea. If oral
antibiotics cannot be given initially
due to vomiting, a single dose of
ceftriaxone, dosed at 50mg/kg/day,
may be administered intramuscularly or intravenously, followed by
oral antibiotics 24 hours later (once
vomiting has been resolved).
High dose amoxicillin-clavulanate, 90mg/kg/day orally twice daily,
is recommended for children in
geographic areas with PNS
S. pneumoniae, as well as those
with severe infection, attending
daycare, less than 2 years of age,
recently hospitalized, having used
antibiotics within the past month,
or those who are immunocompromised.
Combination therapy with a
third-generation oral cephalosporin
(i.e., cefixime or cefpodoxime)
plus clindamycin may be used as
second-line therapy for children
with non-type I penicillin allergy in
regions with high rates of PNS
S. pneumoniae. Children with a
type I penicillin allergy may be
treated with levofloxacin. (Table 3)
In children, the recommended
duration of antimicrobial therapy
for ABRS is 10 to 14 days. This
longer duration, in comparison
to adults, is indicated based on
the lack of randomized studies in
children concluding efficacy in the
shorter duration.
Macrolides, such as clarithromycin and azithromycin,
trimethoprim-sulfamethoxazole
(TMP-SMX), and second- or thirdgeneration cephalosporins, are not
recommended for empiric therapy
due to high rates of resistance with
S. pneumoniae. TMP-SMX also
has high rates of resistance with
H. influenzae.
Response to empiric therapy
should be seen after three to five
days. Altering therapy is suggested
for patients who do not show an
improvement in that time frame, or
when symptoms worsen after two
to three days of therapy.
*Adapted from IDSA Guidelines for ABRS 2012
Influenza
Influenza virus infection is another common viral disease that is
highly contagious among children
and adults. The annual influenza
cycle or season begins as early as
October, with a peak in January
or February, and ends as late as
May. It causes an acute febrile
illness and varying other systemic
and upper respiratory symptoms
which result in loss of workdays,
school absences, as well as morbidity and mortality. Over the
past three decades, the estimated
annual influenza-related deaths
have ranged from 3,000 to 49,000,
with approximately 226,000 annual
hospitalizations in the U.S. alone.
Pediatric mortality from influenza
is typically highest in the first year
of life.
The signs and symptoms of
influenza overlap with other viral
URIs and include: fever, myalgia,
headache, malaise, non-productive
cough, sore throat, and rhinitis.
Additionally, otitis media, nausea, and vomiting are common in
children. A typical uncomplicated
course of illness begins after an
incubation period of one to two
days (up to four), and resolves in
three to seven days for most persons, although cough and malaise
can persist for greater than two
weeks. Fever is the most important
clinical finding. It rises rapidly to a
peak of 100°F to 104°F (occasionally 106°F), and subsides after three
days along with other systemic
symptoms. However, the fever may
last four to eight days. Complications can occur and lead to primary
influenza viral pneumonia; exacerbate underlying medical conditions
(i.e,. pulmonary or cardiac disease);
lead to secondary bacterial pneumonia, otitis media, or sinusitis;
and contribute to co-infections with
other viral or bacterial pathogens.
Adults shed the virus from the day
before symptoms occur, through
five to 10 days after illness onset,
while the infectivity decreases
rapidly by three to five days. Young
children may shed the virus several
days before illness onset, and can
be infectious for 10 or more days
after. While limited antivirals are
available to treat influenza, vaccine
prevention is the most effective
strategy.
Influenza viruses are encapsulated, single-stranded RNA viruses
of the family Orthomyxoviridae.
The core nucleotides are used to
distinguish between types A, B,
and C. In humans, influenza A is
generally more pathogenic than
influenza B. These viruses infect
humans and a variety of animals;
some of these strains may spread
from animal species to humans as
well.
The influenza viruses are ever
changing via antigenic drift and
shift. Antigenic drift is a process by
which the virus produces ongoing
gene mutations resulting in new
subtypes and altered virulence.
Antigenic shift is less common, but
creates virulent strains that are
transmissible to a greater population of susceptible individuals
which can cause a pandemic. The
gene segments between two strains
are re-assorted, presumably during
a co-infection in a single host. The
“Spanish flu” of 1918 was a result
of an antigenic shift. This pandemic alone affected 20 to 50 million
people globally and was responsible
for 549,000 deaths in the U.S. The
2009 H1N1 influenza (also referred
to as Swine Flu) pandemic was a
recombinant influenza consisting
of a mix of swine (pig), avian (bird),
and human gene segments.
Influenza Diagnosis. Respiratory illnesses caused by influenza virus infection are difficult to
differentiate from other illnesses
caused by respiratory pathogens
based on signs and symptoms
alone. Once the presence of influenza virus is confirmed in a region
or community, healthy adults with
acute influenza-like symptoms
most likely have the infection. The
accuracy of diagnosis in an influenza outbreak can be as high as 80
to 90 percent. Rapid diagnosis can
also be made by testing respiratory secretions from nasopharyngeal samples and/or throat swabs.
There are a variety of rapid tests
with results available as quickly
as 30 minutes. While some are
useful in differentiating influenza
A and influenza B, none of the current tests can distinguish between
influenza A (H1N1) and influenza
A (H3N2). The optimal use of rapid
diagnostic tests in patient management is not yet defined.
Transmission. Influenza
viruses are spread primarily
through large-particle respiratory
droplet transmission via coughing
or sneezing. Transmission requires
close contact with a susceptible
individual, since the large droplets
do not remain suspended in the air
and only travel a short distance.
Transmission may also occur via
contact with surfaces contaminated with respiratory droplets or
through small particles suspended
in the air.
Influenza Vaccine. Each
year in the U.S., a vaccine containing the antigens from the strains
most likely to cause infection
during the season is produced.
At the time of writing this lesson, the vaccine contains three
strains, two influenza A strains
and one influenza B. The 20122013 vaccine contains the following: A/California/7/2009(H1N1)
pdm09-like virus, A/Victoria/361/
2011(H3N2)-like virus, and B/
Wisconsin/1/2010-like virus. The
Centers for Disease Control and
Prevention (CDC) recommends
that everyone six months of age
and older get a flu vaccine each
year as soon as it is available. It
is especially important for people
who are at high risk of developing
serious complications such as pneumonia. This includes individuals
who have asthma, diabetes, chronic
lung disease, are pregnant, or are
65 years of age and older. The
vaccine is also important for those
who live with, or care for, persons
at high risk for developing serious
complications. It takes about two
weeks for antibodies to develop
and provide protection against
influenza. Despite the fact that
immunity declines over time, most
healthy adults and older children
will remain protected throughout
the season.
There are two types of influenza vaccine: inactivated vaccine
given by injection and live, attenuated influenza vaccine (LAIV)
sprayed into the nostrils. The
inactivated vaccine, referred to
as the “flu shot,” may or may not
contain thimerosal. The flu shot
can be given to all persons aged six
months and older.
A high-dose inactivated vaccine is also available for persons
65 years of age and older. This
product has four times the amount
of antigen in the standard formulation, and has been shown to provide higher antibody responses in
older adults when compared to the
standard dose.
Side effects are minor and
include soreness, redness, or swelling at the injection site; hoarseness; sore, red, or itchy eyes; cough;
fever, aches, headache, itching, and
fatigue. Life threatening severe
reactions to either vaccine formulation are very rare. LAIV is recommended for
healthy persons two through 49
years of age who are not pregnant
and do not have chronic health conditions (heart disease, lung disease,
asthma, kidney or liver disease,
diabetes, anemia, or other blood
disorders). The vaccine should
not be given if a severe allergy to
a component of the vaccine exists
or if the patient has an allergy to
eggs. It does not contain thimerosal or other preservatives. LAIV
is made from a weakened virus
and does not cause influenza, but
may cause mild symptoms such
as runny nose, cough, congestion,
fever, headache, muscle aches,
cough, chills, tiredness/weakness,
sore throat, wheezing, abdominal
pain, vomiting, or diarrhea.
Specific product labeling and
CDC vaccine information statements (http://www.cdc.gov/vaccines/pubs/vis/) should be referred
to for complete prescribing instructions and recommendations.
Antiviral Treatment/Prophylaxis. Influenza antiviral
treatment can shorten the duration
of fever, lessen symptoms, reduce
the risk of complications from influenza, and shorten hospitalization
stays. It is recommended to begin
antiviral treatment as soon as
possible ― ideally within 48 hours
of illness onset, for any patient (1)
with confirmed or suspected influenza who is hospitalized; (2) who
has severe, complicated, or progressive illness; or (3) at higher risk of
complications. Treatment should
not be withheld pending laboratory
confirmation of influenza. Antiviral
treatment can also be considered
in previously healthy outpatients
without risk of complications on
the basis of clinical judgment,
again, if it is begun within 48
hours.
Antiviral medications for
chemoprophylaxis should not be
used indiscriminately as widespread use may lead to resistance.
However, they are recommended to
control outbreaks among high risk
persons in institutional settings. In
order to be effective as chemoprophylaxis, the medication must be
taken each day for the duration of
potential exposure to a person with
influenza, and continued for seven
days after the last known exposure.
For persons taking antiviral medications following immunization,
the duration of therapy is until immunity after vaccination develops
(generally two weeks, but may be
longer in children). It is generally
not recommended if more than 48
hours have elapsed since the last
exposure to an infectious person.
While four antiviral drugs are
currently available for the prevention and treatment of influenza,
only two of them, oseltamivir (Tamiflu®) and zanamivir (Relenza®),
which are neuraminidase inhibitors, are clinically useful against
influenza A and B. Amantadine
and rimantadine are part of a class
of medications called adamantanes which were initially effective
against influenza A. However, the
current strains of influenza are resistant to both adamantane agents.
Resistance to the neuraminidase
inhibitors is currently low.
Oseltamivir is approved for
chemoprophylaxis and treatment
in children greater than one year of
age and in adults. Pediatric dosing is weight-based until the child
reaches 40kg or 12 years of age.
Then the child may be administered the adult dose of 75mg orally
twice daily for treatment, or 75mg
orally once daily for chemoprophylaxis. Oseltamivir is available as
30mg, 45mg, and 75mg capsules
and 6mg/mL powder for suspen-
sion. Directions for emergency
compounding using the capsules
to make a suspension can be found
on the manufacturer’s website
at: http://www.tamiflu.com/hcp/
resources/hcp_resources_pharmacists.jsp.
Zanamivir is approved for
chemoprophylaxis in children
greater than five years of age, and
for treatment in children greater
than seven years as well as adults.
The dose for both populations is
10mg (two inhalations) twice daily
for treatment or 10mg (two inhalations) once daily for chemoprophylaxis. Zanamivir is available as a
5mg powder dose for oral inhalation using the Diskhaler® inhalation device.
The recommended duration of
therapy for treatment is five days,
but can be extended for those who
remain severely ill. The recommended duration is seven days for
chemoprophylaxis following exposure. However, CDC recommends
a minimum duration of two weeks
when outbreaks occur in long term
facilities and hospitals.
Practitioners should consult
the Advisory Committee on Immunization Practices’ (ACIP) recommendations for the appropriate use
of antivirals for influenza treatment and prophylaxis at: http://
www.cdc.gov/mmwr/pdf/rr/rr6001.
pdf.
The author, the Ohio Pharmacists Foundation and the Ohio Pharmacists Association
disclaim any liability to you or your patients
resulting from reliance solely upon the information contained herein. Bibliography for
additional reading and inquiry is available
upon request.
This lesson is a knowledge-based CE activity and
is targeted to pharmacists in all practice settings.
Program 0129-0000-12-011-H01-P
Release date: 11-15-12
Expiration date: 11-15-15
CE Hours: 1.5 (0.15 CEU)
The Ohio Pharmacists Foundation Inc. is
accredited by the Accreditation Council
for Pharmacy Education as a provider of
continuing pharmacy education.
continuing education quiz
Please print.
Program 0129-0000-12-011-H01-P
0.15 CEU
Name________________________________________________
Address_____________________________________________
Common Cold, Sinusitis, Influenza:
The Diseases, Prevention, Treatment
City, State, Zip______________________________________
Email_______________________________________________
1. The pathogens most commonly associated with symptoms of the common cold are:
a. adenoviruses.
c. respiratory syncytial virus.
b. coronaviruses.
d. rhinoviruses.
2. Alcohol-based hand sanitizers have been shown to
reduce secondary transmission of colds.
a. True
b. False
3. The mainstay treatment for the common cold is:
a. symptomatic.
c. antibacterial agents.
b. antiviral agents.
d. vaccine prevention.
4. Which of the following common cold treatments in
adults should not be used longer than two to three days
because they can result in rebound rhinitis?
a. First-generation antihistamines
b. Non-sedating antihistamines
c. Topical decongestants
d. Cough suppressants
5. The American Academy of Pediatrics recommends
against the use of OTC cough and cold agents in children:
a. <6 years.
b. <12 years.
6. The most frequent cause of sinusitis is:
a. allergens.
c. environmental irritants.
b. bacterial infection. d. viral URI.
7. The presence of colored or green nasal discharge alone
can indicate an acute bacterial rhinosinusitis infection.
a. True
b. False
Completely fill in the lettered box corresponding to
your answer.
1.
2.
3.
4.
5.
[a]
[a]
[a]
[a]
[a]
[b]
[b]
[b]
[b]
[b]
[c] [d] 6. [a]
7. [a]
[c] [d] 8. [a]
[c] [d] 9. [a]
10. [a]
[b]
[b]
[b]
[b]
[b]
[c]
[c]
[c]
[c]
[d]
[d]
[d]
[d]
11. [a]
12. [a]
13. [a]
14. [a]
15. [a]
[b]
[b]
[b]
[b]
[b]
[c] [d]
[c] [d]
[c] [d]
[c] [d]
 I am enclosing $5 for this month’s quiz made
payable to: Ohio Pharmacists Association.
1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor)
2. Did it meet each of its objectives?  yes  no
If no, list any unmet_______________________________
3. Was the content balanced and without commercial bias?
 yes  no
4. Did the program meet your educational/practice needs?
 yes  no
5. How long did it take you to read this lesson and complete the quiz? ________________
6. Comments/future topics welcome.
NABP e-Profile ID*__________________________________
*Obtain NABP e-Profile number at www.MyCPEmonitor.net.
Birthdate____________
(MMDD)
Return quiz and payment (check or money order) to
Correspondence Course, OPA,
2674 Federated Blvd, Columbus, OH 43235-4990
8. Saline irrigation is less well tolerated in:
a. adults.
c. babies.
b. teenagers.
d. elderly.
9. In treating non-penicillin allergic adults with sinusitis, IDSA guidelines recommend the following as a
first-line agent.
a. Levofloxacin
c. Doxycycline
b. Amoxicillin
d. Amoxicillin-clavulanate
10. In children, the recommended duration of antimicrobial therapy for ABRS is:
a. 3 days.
c. 10 to 14 days.
b. 5 to 7 days.
d. 21 days.
11. The most important clinical finding in diagnosing
influenza is:
a. fatigue.
c. headache.
b. cough.
d. fever.
12. Antigenic drift creates virulent strains that are
transmissable to a greater population.
a. True
b. False
13. CDC recommends flu vaccine administration to all
the following persons EXCEPT:
a. asthmatics.
b. pregnant women.
c. children three months of age and older.
d. caregivers of persons at high risk.
14. Within what period of time of illness onset should
antiviral treatment be started for influenza?
a. 24 hours
c. Three days
b. 48 hours
d.One week
15. Which two antiviral drugs are clinically useful
against influenza A and B?
a. Oseltamivir and zanamivir
b. Oseltamivir and amantadine
c. Amantadine and rimantidine
d. Amantadine and zanamivir
To receive CE credit, your quiz must be received no later than November 15, 2015. A passing grade of 80% must be attained. All quizzes
received after July 1, 2012 will be uploaded to the CPE Monitor and a
statement of credit will not be mailed. Send inquiries to
opa@ohiopharmacists.org.
november 2012