Clinical 2 - Antibiotics > 7 - Upper RTI > Flashcards

7 - Upper RTI Flashcards

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1
Q

Acute Otitis Media:

Describe the signs of symptoms of AOM

A

Mild ear inflammation, fluid collection, and rapid onset of signs and symptoms including otalgia (pain) 75%, otorrhea (drainage), fever 25%, irritability, GI (anorexia, vomiting, diarrhea), imbalance, hearing loss

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2
Q

Acute Otitis Media:

Epidemiology

A
  • Peak incidence at 6-24 months of age, 50% by 1 year, 70% by 3 years, reduces by 7 years
  • Most common reason for paediatric physician visits and prescriptions for antimicrobials
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3
Q

Acute Otitis Media:

___% of cases are viral

A

40-75%

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4
Q

Acute Otitis Media:

________ makes up 25-50% of cases

A

S. Pneumoniae

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5
Q

Acute Otitis Media:

_______ makes up 15-30% of cases

A

H. influenzae

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6
Q

Acute Otitis Media:

______ makes up <20% of cases

A

Moraxella catarrhalis

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7
Q

What is otitis media with effusion?

A
  • chronic middle ear inflammation with fluid collection, but without acute signs of infection
  • 90% spontaneous resolution within 3 months
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8
Q

Acute Otitis Media:

What are the risk factors?

A
  • bottle-fed
  • daycare attendance
  • allergies
  • passive smoke exposure
  • immunocompromised
  • children with anatomical defects or down’s syndrome
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9
Q

In addition to clinical presentation, how is AOM diagnosed?

A
  • otoscopy (pneumatic) shows impaired mobility, bulging, reddened membrane
  • tympanocentesis (culture/susceptibility testing) for severe infection, treatment failure, recurrence, immunocompromised
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10
Q

Should antimicrobials be prescribed for AOM? Why or why not?

A
  • 60% spontaneous resolution within 24 hours
  • 80% within 72 hours

Antimicrobial therapy:

  • modest clinical benefits (NNT = 7-20, NNH = 14)
  • greatest benefit in < 2 years of age, bilateral infection, otorrhea (drainage from the ears) or immunocompromised
  • associated with adverse effects (diarrhea in 20%) and antimicrobial resistance

Watchful waiting (delayed, self-intitiated therapy) can reduce antimicrobial use by 70%.

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11
Q

When should we not do watchful waiting ?

A
  • under 2 years old
  • bilateral infection
  • otorrhea (drainage from the ears)
  • immunocompromised
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12
Q

What does Watchful Waiting include?

A

1) Analgesia
- Acetaminophen (10-15 mg/kg q4-6h, max 65 mg/kg/day) -Ibuprofen (5-10 mg/kg Q6-8h, max 40 mg/kg/day)

2) Antimicrobial Rx with detailed instructions to initiate therapy if persistent or worsening at 48-72 hours from onset of illness
3) Follow-up

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13
Q

What types of patients should you consider watchful waiting in?

A

Consider watchful waiting if:

  • > 2 years old
  • 6-23 months with mild infection (inconsistent recommendations)

and without:

  • bilateral infection
  • otorrhea
  • severe symptoms > 48 hours
  • cardiac or pulmonary disease
  • craniofacial anomalies
  • immunocompromised
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14
Q

look at page 4

A

okay

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15
Q

What is the drug of choice for otitis media ?

A

High-dose (HD) Amoxicillin 80-90 mg/kg/day given q12h

Max = 3 gram/day

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16
Q

When would the standard dose of Amox 40 mg/kg/day given q8h be considered ?

A

If:

- < 2 years of age without risk factors for PRSP (penicillin resistant strep pneumoniae)

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17
Q

What are risk factors for PRSP (penicillin resistant strep pneumoniae) ?

A
  • high local resistance
  • daycare attendance
  • B lactam within 1 month
  • treatment failure
  • recurrence within 1 month
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18
Q

What are the alternatives for AOM?

A
  • Cefprozil 30 mg/kg/day given q12h / Cefuroxime 30 mg/kg/day given q12h
  • Clindamycin 20-40 mg/kg/day given q8h - lacks Gram negative coverage

-Clarithro 15 mg/kg/day given Q12h / Azithro 10 mg/kg for 1 day then 5 mg/kg q24h for 4 days
OR 10mg/kg q24h x 3 days
OR 30 mg/kg q24 hours x 1 dose

-TMP-SMX 5-10 mg/kg/day given q12h - increasing resistance, more adverse effects

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19
Q

What are the alternatives for AOM for severe B lactam allergy ?

A

-Clarithro 15 mg/kg/day given Q12h / Azithro 10 mg/kg for 1 day then 5 mg/kg q24h for 4 days
OR 10mg/kg q24h x 3 days
OR 30 mg/kg q24 hours x 1 dose

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20
Q

AOM:

Risk factors for resistance

A
  • B lactam within 1 month
  • treatment failure
  • recurrence within 1 month
  • also conjunctivitis indicative of H. influenzae
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21
Q

What do we give for a severe AOM infection?

A

Amox-clav standard dose 40 mg/kg/day given q12h

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22
Q

Why do you need to take Amox-clav with food?

A

Clav causes a lot of severe GI side effects - Must take with food

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23
Q

What is an alternative for treating severe AOM infection ?

A

Ceftriax 50 mg/kg IV/IM q24h x 3 days

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24
Q

What are the essential patient counselling information for AOM ?

A
  • analgesia (avoid topical analgesics ex. benzocaine)
  • avoid decongestants and antihistamines
  • adhere to antimicrobial regimen
  • potential adverse effects
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25
AOM: | Typical response ?
-Clinical improvement within 24-48 hours, and resolution within 72 hours
26
AOM: | Duration of therapy for Amox or Amox-Clav
7 days | or 10 days for < 2 years of age or complicated infection
27
AOM: | Duration of therapy for Azithro
5 days
28
AOM: | Duration of therapy for other agents
10 days
29
AOM: | What could contribute to treatment failure?
- poor adherence - low antimicrobial dose - antimicrobial resistance - immunosuppressed
30
What defines recurrent AOM?
> 3 episodes within 6 months or > 4 episodes within 12 months
31
What can help prevent AOM ?
- minimize risk factors, investigate associations with allergic rhinitis or food allergies - vaccination for influenzae and S. pneumoniae - antimicrobial prophylaxis reduces by 1.5 episodes/year, but increases risk of resistance - tympanostomy tubes reduces episodes by 1 per year; adenoidectomy, tonsillectomy
32
ABRS
Acute Bacterial Rhinosinusitis
33
ARBS: | Acute viral infection in most cases (>___%), some lead to secondary bacterial infection
98
34
What is the criteria that is indicative of ABRS ?
1) Nasal obstruction or purulence discharge PLUS pain, pressure (fullness) or lack of smell (anosmia) for >7-10 days without improvement 2) Severe symptoms with purulence and fever > 39 for > 3 days 3) Biphasic febrile-illness with initial improvement and then worsening after 5-7 days.
35
What are the most common pathogens of ABRS ?
S. pneumoniae (35%) H. influenzae (25%) M. catarrhalis (<20%)
36
What are the risk factors for ABRS?
- Anatomical anomalies (septal deviation) - Smoking - Allergic rhinitis - Asthma - Cystic fibrosis - Immunocompromised (HIV/AIDS)
37
What is the role of intranasal corticosteroids in treating ARS?
70 - 90% spontaneous resolution Fluticasone furcate 110 mg, 2 puffs q12h Mometasone furcate 50 ug, 2 puffs q12h x 14 days - Mild-moderate infection > 5-7 days - Moderate benefit to alleviate symptoms and hasten recovery (NNT = 15) - potential to reduce antimicrobial use - high cost ($25-30 per course)
38
What is the treatment for moderate-severe rhinosinusitus ?
Amox 500-1000 mg q8h
39
Alternatives for the treatment for moderate-severe rhinosinusitus ?
- Cefprozil 500 mg q12h / Cefuroxime 500 mg q12h - Doxy 100 mg q12h - Clarithro/Azithro (increasing resistance) - TMP-SMX 5-10 mg/kg/day given 12 hours - increasing resistance, more adverse effects
40
What is the treatment for moderate-severe rhinosinusitus if resistance is suspected ?
Amox-clav 500/125 q8h or 875/125 q12h Levo 500 mg q24h / Moxi 400 mg q24h
41
What is the typical response for ABRS?
Clinical improvement within 2-3 days, significant by 7-10 days, full resolution by 3-4 weeks
42
Typical duration of therapy for ABRS ?
5-10 days for adults 10-14 days for children
43
What self-treatment measures can reduce the symptoms of ABRS ?
- analgesia (acetaminophen, ibuprofen) - normal saline nasal drops or irrigation, steam inhalation - decongestants (topical, po) not recommended, antihistamines not recommended unless associated with allergic rhinitis or chronic allergies
44
Acute pharyngitis is viral in ___% of adults and ___% of children
90% of adults | 70% of children
45
Acute pharyngitis if viral: | Resolves spontaneously within ____ days
5-7
46
Acute Pharyngitis: | What is the most common bacterial pathogen?
Strep pyogenes (group A B-hemolytic streptococcus - GAS) GAS most significant, also Group C and G
47
Describe the epidemiology of acute pharyngitis
- 5-20% of population asymptomatic carriers - peak incidence at 5-15 years of age, uncommon in < 3 years - highly communicable for 7 days following acute illness, 35% close contact transmission rate
48
What are the clinical criteria used in assessing for GAS pharyngitis ?
1) exudates (red, edematous) - red, swollen with red patches 2) adenopathy (lymph node swelling) 3) fever > 38 4) cough absent
49
How is GAS pharyngitis diagnosed ?
1) Rapid antigen diagnostic test (RADT) - 70-90% sensitivity - 95% specificity - throat swab, results within 1 hour 2) Confirmatory culture - 90% sensitivity - 95% specificity - if negative RADT, results within 48 hours
50
Who is RADT used for?
- in children 3-14 years old with acute pharyngitis and erythema, edema or exudates - in young children or adults with suggestive clinical symptoms (ex. 3 or 4 criteria), close contact exposure to GAS or during outbreaks
51
What is the current recommendations for GAS pharyngitis ?
withhold antimicrobial therapy until diagnostic confirmation
52
What are some other serious infections you need to differentiate GAS pharyngitis from?
- Corynebacterium diphtheria - primary HIV - epiglottitis - peri-tonsillar abscess
53
What are the potential complications of GAS pharyngitis ?
-AOM, ABRS, peri-tonsillar abscess, necrotizing fascitis -scarlet fever, resulting in diffuse, small papular-sandpaper-like rash that starts on groin or axillae and spreads to trunk -acute rheumatic fever etc.
54
What are the goals of antimicrobial therapy for GAS pharyngitis ?
- hasten symptoms with 1-2 day decrease in duration, and reduced pain in 20% more patients at 7 days - avoid complications including cute, otitis media, peri-tonsillar abscess - eradicate GAS to prevent acute rheumatic fever - limit transmission
55
How effective are antimicrobials in treating GAs pharyngitis ?
- Clinical response rate of 70-90% | - Bacterial eradication in > 80%
56
Is Amox therapy appropriate for treating GAS ?
higher clinical response and bactericidal eradication rates with Cephs compared with Pens
57
What is the treatment for GAS pharyngitis ?
Pen V (effective, narrow spectrum, well tolerated, safe, low cost) - Adults 600 mg q12h - Children 300 mg q12h Amox (palliatable alternative for children, more adverse effects) - Adults 500 mg q12h - Children 40-50 mg/kg/day given q8-12h
58
What are some alternatives for GAS pharyngitis ?
- Cefadroxil/Cephalexin - Clinda - Erythro
59
What is the treatment for recurrent or chronic carrier eradication?
- Cefadroxil/Cephalexin - Clinda - Pen V + Rifampin
60
Describe the essential patient counselling information
- analgesics for pain control (acetaminophen, ibuprofen) reduces pain in an additional 25% of cases at 4 days compared to antimicrobials alone; salt-water gargle, lozenges - adhere to antimicrobial regimen - potential adverse effects
61
What is the typical response for GAS pharyngitis ?
significant clinical improvement and bacterial eradication within 3-4 days
62
What is the typical duration of therapy for GAS pharyngitis for Pen's ?
10 days
63
What is the typical duration of therapy for GAS pharyngitis for Ceph's ?
5 days
64
What is the typical duration of therapy for GAS pharyngitis for Azithro ?
3-5 days
Clinical 2 - Antibiotics
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