Common infections: Clinical guidance and practice resources

Diffuse acute otitis externa (AOE) should be differentiated from other causes of otalgia, otorrhea and inflammation of the external ear canal.

Patients with diffuse AOE should be assessed for factors that modify management (nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state or prior therapy).

Patients with AOE should be assessed for pain and recommended an analgesic treatment based on pain severity.

Systemic antimicrobials should not be prescribed as initial therapy for diffuse, uncomplicated AOE unless there is extension outside the ear canal or presence of specific host factors that would indicate a need for systemic therapy.

Topical preparations should be prescribed for initial therapy for diffuse, uncomplicated AOE and delivery enhanced through patient instruction on administration or by performing aural toilet, wick placement or both, when the ear canal is obstructed.

A non-ototoxic preparation should be prescribed when the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube.

Patients should be reassessed within 48 to 72 hours if they fail to respond to initial treatment to confirm the diagnosis of diffuse AOE and to exclude other causes of illness.

Clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions. A clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis (purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening).

Clinicians should not obtain radiologic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected.

Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of VRS or ABRS.

Clinicians should offer watchful waiting (without antibiotics) for adults with uncomplicated ABRS with assurance of follow-up. The duration of watchful waiting may depend on the factors and timing under which the diagnosis was originally made.

If a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin with or without clavulanate as first-line therapy for 5-7 days for most adults.

If the patient fails to improve or worsens despite being on an appropriate antibiotic for 3-5 days, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications. If ABRS is confirmed, the clinician should change the antibiotic.

Clinicians should distinguish CRS and RARS from isolated episodes of ABRS and other causes of sinonasal symptoms.

Clinicians should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography.

Clinicians should assess the patient with CRS or RARS for multiple chronic conditions that would modify management such as asthma, cystic fibrosis, immunocompromised state, aspirin-exacerbated respiratory disease, and ciliary dyskinesia.

Clinicians may obtain testing for allergy and immune function in evaluating a patient with CRS or RARS.

Clinicians should confirm the presence or absence of nasal polyps in a patient with CRS.

Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both, for symptomatic relief of CRS.

Clinicians should not prescribe topical or systemic antifungal therapy for patients with CRS.

Clinicians should not routinely prescribe biologics (including, but not limited to, monoclonal antibodies such as dupilumab, mepolizumab, or omalizumab) for the treatment of adults with CRS without polyps.

Clinicians or their designee should educate patients with CRS with nasal polyps about the role of biologics as a means to improve disease-specific quality of life when either prior medical and surgical therapy has failed OR when surgery is not a viable option because of disease status or patient preference.

Clinicians should not routinely prescribe antimicrobial therapy for adults with CRS without acute exacerbation OR as a mandatory prerequisite for paranasal sinus imaging or surgery.

The diagnosis of bronchiolitis and assessment of disease severity should be based on history and physical examination. Laboratory and radiologic studies should not be routinely ordered for diagnosis.

Risk factors for severe disease such as age younger than 12 weeks, premature birth, underlying cardiopulmonary disease or immunodeficiency should be assessed when making decisions about evaluation and management of children with bronchiolitis.

Bronchodilators (albuterol, salbutamol), epinephrine and corticosteroids should not be administered to infants and children with the diagnosis of bronchiolitis.

Nebulized hypertonic saline should not be administered to infants with the diagnosis of bronchiolitis in the emergency department. Nebulized hypertonic saline may be administered to infants and children hospitalized for bronchiolitis.

Antibiotics should not be used in children with bronchiolitis unless there is a concomitant bacterial infection.

Supplemental oxygen is not necessary in children and infants with a diagnosis of bronchiolitis if SpO₂ exceeds 90%.

Continuous pulse oximetry is optional for infants and children with bronchiolitis.

Chest physiotherapy should not be used in the management of bronchiolitis.

Palivizumab prophylaxis should be administered during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease of prematurity (<32 weeks gestation who require >21% O₂ for the first 28 days of life).

To prevent spread of respiratory syncytial virus (RSV), hands should be decontaminated before and after direct contact with patients, after contact with inanimate objects in vicinity of patient and after removing gloves. Alcohol rubs are the preferred method for hand decontamination. Clinicians should educate personnel and family on hand sanitation.

Infants should not be exposed to tobacco smoke.

Exclusive breastfeeding for at least six months is recommended to decrease the morbidity of respiratory infections.

Individuals should use protective measures to reduce exposure to ticks, including chemical repellants such as N,N-Diethyl-meta-toluamide (DEET), picaridin, ethyl-3-(N-n-butyl-N-acetyl) aminopropionate (IR3535), oil of lemon eucalyptus (OLE), p-methane-3,8-diol (PMD) and 2-undecanone or permethrin.

Following a tick bite, prompt detection and removal of an attached tick can reduce the likelihood of disease transmission. Proper removal of the intact tick can be achieved by using an instrument like fine-tipped tweezers. Removal via burning is not recommended.

Tick species identification is recommended to determine risk of infection and is available in most commercial laboratories and at some local health departments.

Testing for not necessary. Individuals with a high-risk tick bite may be given prophylactic single dose of oral doxycycline within 72 hours of tick removal.

Individuals with a potential tick exposure in a Lyme disease endemic area and one or more skin lesions, clinical diagnosis of erythema migrans is recommended.

Individuals with diagnosed erythema migrans should be treated with doxycycline, amoxicillin or cefuroxime axetil. Azithromycin should be used as a second line option for individuals unable to take doxycycline or beta-lactam antibiotics.

Routine testing for Lyme disease is not recommended unless an individual has a known or plausible exposure and is presenting with one or more of the following: meningitis, painful radiculoneuritis, mononeuropathy multiplex, including confluent mononeuropathy multiplex, acute cranial neuropathies (particularly VII, VIII, less commonly III, V, VI and others) or in patients with evidence of spinal cord (or rarely brain) inflammation.

Individuals with acute neurological manifestations of Lyme disease should be treated with intravenous ceftriaxone, cefotaxime, penicillin G or oral doxycycline. Decisions about the choice of antibiotic, including the route of administration, should be based on an individual’s clinical history and preferences.

Individuals with signs of Lyme carditis (exercise intolerance, palpitations, presyncope, syncope, pericarditic pain, evidence of pericardial effusion, elevated biomarkers such as troponin, edema and shortness of breath) should be evaluated with an EKG.

Individuals with confirmed Lyme carditis who are not hospitalized should be treated with oral antibiotics. Options include doxycycline, amoxicillin, cefuroxime axetil and azithromycin.

Individuals with Lyme arthritis should be treated with oral antibiotic therapy for 28 days.

Watchful waiting for recurrent throat infection is strongly recommended if there have been fewer than seven episodes in the past year, fewer than five episodes per year in the past two years or fewer than three episodes per year in the past three years.

Tonsillectomy may be considered for recurrent throat infection with a frequency of at least seven episodes in the past year, at least five episodes per year for two years or at least three episodes per year for three years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate or positive test for group A beta-hemolytic streptococcus.

The child with recurrent throat infection who does not meet the criteria above should be assessed for modifying factors that may nonetheless favor tonsillectomy, such as multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis and adenitis) or history of >1 peritonsillar abscess.

Caregivers of children with obstructive sleep-disordered breathing and tonsil hypertrophy should be asked about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma and behavioral problems

Caregivers should be counseled about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and obstructive sleep-disordered breathing.

Caregivers should be counseled that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management.

Perioperative antibiotics should not be administered or prescribed for children undergoing tonsillectomy.

Caregivers should be educated about the importance of managing and reassessing pain after tonsillectomy.

Postoperative pain should be managed with ibuprofen and/or acetaminophen. Codeine should not be administered or prescribed for children under the age of 12.