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Clinical 2 - Antibiotics > 7 - Upper RTI > Flashcards

7 - Upper RTI Flashcards

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
Q

AOM:

Typical response ?

A

-Clinical improvement within 24-48 hours, and resolution within 72 hours

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26
Q

AOM:

Duration of therapy for Amox or Amox-Clav

A

7 days

or 10 days for < 2 years of age or complicated infection

27
Q

AOM:

Duration of therapy for Azithro

A

5 days

28
Q

AOM:

Duration of therapy for other agents

A

10 days

29
Q

AOM:

What could contribute to treatment failure?

A
  • poor adherence
  • low antimicrobial dose
  • antimicrobial resistance
  • immunosuppressed
30
Q

What defines recurrent AOM?

A

> 3 episodes within 6 months or > 4 episodes within 12 months

31
Q

What can help prevent AOM ?

A
  • 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
Q

ABRS

A

Acute Bacterial Rhinosinusitis

33
Q

ARBS:

Acute viral infection in most cases (>___%), some lead to secondary bacterial infection

A

98

34
Q

What is the criteria that is indicative of ABRS ?

A

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
Q

What are the most common pathogens of ABRS ?

A

S. pneumoniae (35%)
H. influenzae (25%)
M. catarrhalis (<20%)

36
Q

What are the risk factors for ABRS?

A
  • Anatomical anomalies (septal deviation)
  • Smoking
  • Allergic rhinitis
  • Asthma
  • Cystic fibrosis
  • Immunocompromised (HIV/AIDS)
37
Q

What is the role of intranasal corticosteroids in treating ARS?

A

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
Q

What is the treatment for moderate-severe rhinosinusitus ?

A

Amox 500-1000 mg q8h

39
Q

Alternatives for the treatment for moderate-severe rhinosinusitus ?

A
  • 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
Q

What is the treatment for moderate-severe rhinosinusitus if resistance is suspected ?

A

Amox-clav 500/125 q8h or 875/125 q12h

Levo 500 mg q24h / Moxi 400 mg q24h

41
Q

What is the typical response for ABRS?

A

Clinical improvement within 2-3 days, significant by 7-10 days, full resolution by 3-4 weeks

42
Q

Typical duration of therapy for ABRS ?

A

5-10 days for adults

10-14 days for children

43
Q

What self-treatment measures can reduce the symptoms of ABRS ?

A
  • 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
Q

Acute pharyngitis is viral in ___% of adults and ___% of children

A

90% of adults

70% of children

45
Q

Acute pharyngitis if viral:

Resolves spontaneously within ____ days

A

5-7

46
Q

Acute Pharyngitis:

What is the most common bacterial pathogen?

A

Strep pyogenes (group A B-hemolytic streptococcus - GAS)

GAS most significant, also Group C and G

47
Q

Describe the epidemiology of acute pharyngitis

A
  • 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
Q

What are the clinical criteria used in assessing for GAS pharyngitis ?

A

1) exudates (red, edematous) - red, swollen with red patches
2) adenopathy (lymph node swelling)
3) fever > 38
4) cough absent

49
Q

How is GAS pharyngitis diagnosed ?

A

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
Q

Who is RADT used for?

A
  • 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
Q

What is the current recommendations for GAS pharyngitis ?

A

withhold antimicrobial therapy until diagnostic confirmation

52
Q

What are some other serious infections you need to differentiate GAS pharyngitis from?

A
  • Corynebacterium diphtheria
  • primary HIV
  • epiglottitis
  • peri-tonsillar abscess
53
Q

What are the potential complications of GAS pharyngitis ?

A

-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
Q

What are the goals of antimicrobial therapy for GAS pharyngitis ?

A
  • 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
Q

How effective are antimicrobials in treating GAs pharyngitis ?

A
  • Clinical response rate of 70-90%

- Bacterial eradication in > 80%

56
Q

Is Amox therapy appropriate for treating GAS ?

A

higher clinical response and bactericidal eradication rates with Cephs compared with Pens

57
Q

What is the treatment for GAS pharyngitis ?

A

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
Q

What are some alternatives for GAS pharyngitis ?

A
  • Cefadroxil/Cephalexin
  • Clinda
  • Erythro
59
Q

What is the treatment for recurrent or chronic carrier eradication?

A
  • Cefadroxil/Cephalexin
  • Clinda
  • Pen V + Rifampin
60
Q

Describe the essential patient counselling information

A
  • 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
Q

What is the typical response for GAS pharyngitis ?

A

significant clinical improvement and bacterial eradication within 3-4 days

62
Q

What is the typical duration of therapy for GAS pharyngitis for Pen’s ?

A

10 days

63
Q

What is the typical duration of therapy for GAS pharyngitis for Ceph’s ?

A

5 days

64
Q

What is the typical duration of therapy for GAS pharyngitis for Azithro ?

A

3-5 days

Clinical 2 - Antibiotics (14 decks)

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