Health Evidence Bulletins - Wales
Team Leader: Dr Michael Burr Date of completion: 8/9/97

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available

4. Upper Respiratory Tract Infections

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

The Statements The Evidence
4a. The incidence of otitis media in children is correlated with passive smokingi.
(Health gain notation - 6 "likely to be harmful")
i. DiFranza JR, Lew RA. Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics 1996; 97(4): 560-568
(Type I evidence - systematic review of case-control and cohort studies)
4b. Antibiotics reduce the duration and severity of the symptoms in some cases of sinusitis in adults (86% receiving penicillin V or amoxycillin vs. 57% receiving placebo considered themselves recovered or much better after 10 days)i and children (83% were cured or improved after 10 days compared to 60% receiving placebo)ii but they are not always needediii. There are no clear criteria for identifying the patients most likely to benefit
(Health gain notation - 2"likely to be beneficial")
i. Lindbaek M, Hjortdahl P, Johnsen U L-H. Randomised, double blind, placebo controlled trial of penicillin V and amoxycillin in treatment of acute sinus infections in adults. British Medical Journal 1996; 313: 325-329

(Type II evidence - randomised controlled trial);
ii. 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
(Type II evidence - randomised controlled trial);
iii. van Buchem FL, Knottnerus JA, Schrijnemaekers VJJ, Peeters MF. Primary-care-based randomised placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis. Lancet 1997; 349: 683-687
(Type II evidence - randomised controlled trial)
4c. Antibiotics confer a relative benefit in the treatment of sore throat. They reduce the duration of symptoms and the risk of acute rheumatic fever (Relative Risk, RR = 0.28), acute otitis media (RR = 0.23), acute sinusitis (RR = 0.33) and quinsy (RR = 0.17). However, the absolute benefit is modest. The duration of symptoms is reduced by half at the time of maximal effect, and by 8 hours overall. To prevent one case of acute otitis media, 30 children and 145 adults suffering from sore throat must be treated with antibiotics i.
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
i. Del Mar CB, Glasziou PP. Antibiotics for the symptoms and complications of sore throat. Cochrane database of systematic reviews. Cochrane Library 1998 Issue 1.
(Type I evidence - systematic review)


4d. The treatment of children admitted to hospital with croup should include the administration of steroids since this leads to a clinical improvement 12 hours ( Odds Ratio = 2.25 95% CI, 1.66-3.06) and 24 hours (OR = 3.19 95% CI,  1.70-5.99) post-treatment and a reduced incidence of endotracheal intubation (OR = 0.21, 95% CI, 0.05-0.84)i. An oral dose of 0.15 mg/kg dexamethasone is as effective as larger doses ii.
(Health gain notation - 1 "beneficial")
i. Kairys SW, Olmstead EM, O'Connor GT. Steroid treatment of laryngotracheitis: a meta-analysis of the evidence from randomized trials. Pediatrics 1989; 83: 683-693.
(Type I evidence - meta-analysis);
ii. Geelhoed GC. Croup. Paediatric Pulmonology 1997; 23: 370-374
(Type V evidence - expert review citing 42 references)
4e. For children with severe obstruction, who have already received steroids, nebulized epinephrine in a dose of 0.1 mg/kg reduces subglottic edema and appears to decrease the need for intubation; however, the effect seems to last only a few hoursi.
(Health gain notation - 2"likely to be beneficial")
i. Geelhoed GC. Croup. Paediatric Pulmonology 1997; 23: 370-374
(Type V evidence - expert review citing 42 references)
4f. One small trial suggested that paediatric outpatients with mild to moderate croup, who have received oral dexamethasone, have added, clinically important improvements in respiratory symptoms (84% compared to 56% in the placebo group; Number Needed to Treat = 4) after treatment with 2mg nebulized budesonide i.
(Health gain notation - 2"likely to be beneficial")
i. Klassen TP, Watters LK, Feldman ME, Sutcliffe T, Rowe PC. The efficacy of nebulized budesonide in dexamethasone-treated outpatients with croup. Pediatrics 1996; 97(4): 463-466
(Type II evidence - randomized controlled trial)
4g. The early use of antibiotics for acute otitis media in childhood produces only modest benefit in reducing pain 2-7 days after presentation (risk of pain reduced by 41% 95% CI, 14-60%; Number Needed to Treat = 17), which is offset by an increased risk of vomiting, diarrhoea or rashes (Odds Ratio 1.97 95% CI, 1.19-3.25). Adequate analgesia should be given and the option of antibiotics discussed with patients and their parentsi.
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
i. Del Mar C, Glasziou P, Hayem B. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. British Medical Journal 1997; 314: 1526-1529
(Type I evidence - meta-analysis)
4h. Evidence based guidelines are available for the management of otitis media with effusion in young children i.
(Health gain notation - 2"likely to be beneficial")
i. Agency for Health Care and Policy Research. Managing otitis media with effusion in young children. Quick Reference Guideline No.12. July 1994. Internet site
(Type I evidence - guidelines based on systematic review)

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