Table Of ContentSelective Antibiotic Use in
Respiratory Illness
A Family Practice Guide
Dedicated to
Iris
Karen, John and Adrian
Selective Antibiotic
Use in Respiratory
Illness:
a Family Practice
Guide
M. T. Everett MB, BS, FRCS
General Practitioner, Plymouth
MTP PRESS LIMITED ....
~'tI
", ,~ a member of the KLUWER ACADEMIC PUBLISHERS GROUP "
,- LANCASTER I BOSTON I THE HAGUE I DORDRECHT
Erratum:
P 123. In the section on Bronchodilators
and Steroids the dose for prednisolone
should have been given as lOmg immedi
ately, followed by 5 mg 3 times a day.
Published in the UK and Europe by
MTP Press Limited
Falcon House
Lancaster, England
British Library Cataloguing in Publication Data
Everett, M. T.
Selective antibiotic use in respiratory
illness: a family practice guide,
1. Respiratory organs-Diseases-
Chemotherapy 2. Antibiotics
I. Title
615'.72 RC735.A57
ISBN 978-94-015-1145-2 ISBN 978-94-015-1143-8 (eBook)
DOI 10.1007/978-94-015-1143-8
Published in the USA by
MTP Press
A division of Kluwer Boston Inc
190 Old Derby Street
Hingham, MA 02043, USA
Copyright © 1986 MTP Press Ltd
Softcover reprint of the hardcover 1s t edition 1986
All rights reserved. No part of this publication may be reproduced, stored
in a retrieval system, or transrnitted in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, without prior
permission from the publishers.
Phototypesetting by Georgia Origination, Liverpool.
Contents
Preface vii
Acknowledgements viii
1 Antibiotics and the Patient
Allergy - Antibiotic Diarrhoea - The Contraceptive Pill -
Pregnancy - Lactation - Neonates - Children - The
Elderly - Hepatic and Renal Impairment - Drug
Interactions - Absorption
2 Management Principles 21
3 Pyrexia 31
Febrile Convulsions - Delirium - Rigors - Symptomatic
Management 0/ Pyrexia - Antibiotic Use
4 Sore Throat, Tonsillitis and Pharyngitis 41
Definition - The Non-inflamed Sore Throat - The
Inflamed Throat - Re/erral/or Tonsillectomy
5 Otitis Media 65
Use 0/ the Auroscope - Clinical Features 0/ Acute Otitis
Media - Bacteria in Acute Otitis Media - Secretory Otitis
Media - Management and Antibiotic Use - Chronic Otitis
Media
v
Selective Antibiotic Us e in Respiratory Illness
6 Sinusitis 83
Clinical Features - Bacteriology - Management and
Antibiotic Use
7 Laryngitis 91
Croup - Hoarseness or Loss of Voice
8 Coughs and Colds 99
The Acute Cough - Cold in the Nose - Persistent Cough
in Children - Persistent Cough in Adults - The Absent
Cough
9 Wheezy Bronchitis in Children 121
The Nature of Wheezy Bronchitis - Recognition of
Asthma - Management of the Acute Episode - Longer-
term Management - Differential Diagnosis
10 Pneumonia 135
Clinical Diagnosis - Investigation - Infective Causes -
Management and Antibiotic Use - Differential Diagnosis
11 Bronchitis, Bronchiolitis and Bronchiectasis 159
Acute Bronchitis - Acute Bronchiolitis - Chronic
Bronchitis - Bronchiectasis
12 Vomiting and Diarrhoea 169
Non-specijic Vomiting - Gastro-enteritis - Management
13 PUD in Children 181
Definition - Emergent Diagnoses - Management and
Antibiotic Use
14 Influenza and the 'Flu-like Illness 189
The Influenzal Illness - Viral Causes - Differential
Diagnosis - Clinical Assessment of the Patient with 'Flu -
Management and Antibiotic Use
Index 205
vi
Preface
The purpose of this book is to clarify the use of antibiotics in the
management of the eommon respiratory illnesses seen in general
practiee. The underlying philosophy, whieh embraees the avoidanee of
unneeessary use, is that proper use entails a full understanding of the
nature of the illness.
The eoneept of seleetive antibiotie use reeognizes that respiratory
illnesses eommonly eomprise multiple illness features, and that some of
these features have a viral cause and some a bacterial one. In assessing
antibiotic need, eaeh feature or eomponent part of an illness may be
evaluated individually, so enabling adecision for antibiotie use in the
illness as a whole.
The nature of eaeh individual illness feature with its antibiotic
indication is diseussed in sueeessive ehapters, and this aecumulated
knowledge is of value in managing the more eomplex PUO and flu-like
illnesses whieh are diseussed at the end of the book.
The first two ehapters eneompass the principles of antibiotic use and
the relationship between antibiotie preseribing and various states of the
patient, e.g. allergy, pregnaney ete.
An attempt has been made to justify every reeommendation or
decision, and non-antibiotic management is diseussed where relevant.
vii
Acknowledgernents
I acknowledge a long association with the Plymouth Public Health
Laboratory, and am indebted to Dr P. D. Meers, past Director; Dr
P. J. Wilkinson, Director; Dr G. M. Churcher, Consultant Micro
biologist and Cytopathologist, and Dr S. Reilly, Consultant Micro
biologist. I also acknowledge the contribution made by the Domiciliary
X-ray service, and am indebted to the late Dr E. A. Waldron; Dr W. H.
Smith, Dr P.F. Norman, and Dr R.M. Paxton, Consultant Radio
logists.
I wish to express my thanks to Miss V. M. Trinder and Mrs J. Elliott
of the Plymouth Medical Library for the trouble they took in obtaining
photostats of numerous papers. I also wish to thank Professor D. F.
Hawkins of the Institute of Obstetrics and Gynaecology, The
Hammersmith Hospital, for access to his manuscript on antibiotics and
pregnancy long before its publication, and Professor D. Vere of the
Department of Pharmacology and Therapeutics, The London Hospital
Medical College, for correspondence relating to the absorption of anti
convulsant drugs. I acknowledge the contribution made by two past
Editors of the Journal 0/ the Royal College 0/ General Practitioners,
Dr D. J. Pereira Gray and Dr S. L. Barley, in stimulating thought.
I am grateful to Searle & Co. Ltd. for information relating to inter
action between antibiotics and progesterone-only pills. A colleague and
her son very kindly sat for the photographs in Chapter 5. Miss Sue
Payne of Tavistock typed both the original and final manuscripts with
great skill and accuracy.
viii
1
Antibiotics and the Patient
Allergy - Antibiotic Diarrhoea - The Contraceptive Pill-Pregnancy -
Lactation - Neonates - Children - The Elderly - Hepatic and Renal
Impairment - Drug Interactions - Absorption
The use of any drug entails more than a consideration of the disease
itself. When prescribing an antibiotic, the possibility of inducing an
allergic reaction and of inducing antibiotic diarrhoea is borne in mind,
and of the many states of the patient, the possibility of pregnancy is
never far from the general praetitioner's thoughts.
ALLERGY
Allergy to Penicillin
Allergie reactions are caused more commonly by penicillin than by
other antibiotics, and a story of allergy to one type of penicillin must be
assumed to refleet allergy to all types. This is because all penicillins
contain the 6-aminopenicillanic acid nucleus from which the res
ponsible major and minor determinants are derived. Enquiry of known
allergy should be made when the use of penicillin is proposed, and this
serves to prevent some reactions, but many instances of allergy occur
despite previous safe use.
Anaphylactic Shock
This, the most severe reaction, develops between three and 30 minutes
after dosage and may be fatal. This type of reaction is rare and has
1
2 Selective Antibiotic Us e in Respiratory Illness
occurred usually after parenteral dosage, but instances following the
use of oral penieillin are described (Simmonds et al. 1978, Schwartz and
Sher 1984). If a general practitioner has had the experience of a patient
'collapsing on the end of the needle', he will probably never give intra
muscular penieillin again; fortunately patients needing antibioties in
general practiee can invariably be managed using the oral route.
The clinieal features of anaphylactic shock comprise hypotension,
tachycardia, loss of consciousness, and in addition, there may be other
allergie features, e.g. laryngeal oedema or asthma, and the patient may
become severely cyanosed.
Emergency treatment comprises intra-muscular adrenaline (0.5 ml of
1 in 1(00) whieh may need to be repeated at quarter-hourly intervals,
and intravenous hydrocortisone in a dose of 100 or 200mg, and
intravenous chlorpheniramine in a dose of 10 or 20mg. The establish
ment of an artificial airway may be necessary, e.g. a large-bore needle
through the cricothyroid membrane or a laryngotomy, again through
the cricothyroid membrane (Chapter 7).
Other Allergie Reaetions
Cutaneous urtiearia is unquestionably an allergie reaction and can be
managed by oral antihistamines, but the urticaria may involve the
mouth and pharynx, and sometimes the larynx, when a life-threatening
situation develops. Management then follows the same lines as for
anaphylactie shock. Severe asthma will also be helped by intravenous
hydrocortisone, but now, nebulized salbutamol would be used as well.
The most common allergie reaction is the maculo-papular rash which
can develop up to several days after antibiotic use. There is no life
threatening situation, and the use of oral antihistamines plus stopping
the penicillin is adequate management. The problem is that many such
instances may not represent allergy but reflect the illness itself. This
dilemma invariably occurs in children, and the diagnostie difficulties
can be caused by rubella, modified measles (Le. modified by
immunization) and the less well-known enterovirus rashes. Although a
typieal exanthem progresses from the neck downwards while an allergie
rash appears everywhere at once, the distinction in clinieal practice is
often difficult.
Arnpicillin Allergy in Glandular Fever
It is now well-known that the common maculo-papular rash following
