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Acute Respiratory Flashcards

1
Q

What is rhinosinusitis?

A

flammation of the paranasal sinus and sinus cavity
Viral inoculation by contact with conjunctiva and or nasal mucosa
Spread by systemic and direct route

1in 7 adults per year resulting in 7 million individuals diagnosed each year

1 in 5 antibiotics are for sinusitis

Spectrum of infection that includes
Acute Viral Rhinosinusitis (AVRS)> Acute Bacterial Rhinosinusitis (ABRS)

Most cases ABRS preceded by viral infection

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2
Q

Define acute rhinosinusitis

A

1-4 weeks

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3
Q

Define subacute rhinosinusitis

A

4-12 weeks

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4
Q

Define chronic rhinosinusitis

A

> 12 weeks, may occur with/without acute exacerbations

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5
Q

What are viral etiologies associated with “common cold”

A

200 different viruses associated with the common cold

Rhinovirus 30-40%
Coronovirus 20%
Respiratory syncytial virus 
Influenza virus  A B C 10-15%
Parainfluenza virus
Enterovirus, Echovirus, Coxsackie
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6
Q

what percent of viral infections progress to bacterial infection?

A

2%; most AVRS resolve in 7 days

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7
Q

Name some predisposing conditions for increased risk to get AVRS

A 
Cold season
Decreased humidity
Decreased immunity
NH residents
Allergic disorders
*smoking increases symptoms/ duration 
Not frequency
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8
Q

How does AVRS and ABRS present initially

A

Nasal congestion , discharge sometimes purulent
Ear pain , sinus pain pressure
Mild sore throat generally resolves 1-3 days
Low grade fever may be present with onset
Cough
Headache

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9
Q

What are some differentials?

A

Dental infections-gingival swelling, trismus
Foreign body/Sinus tumors- history of recurrent infections , incomplete resolution, localization
CNS etiology ( migraine, meningitis, trigeminal neuralgia-phono-photophobia, EOM pain, headache, fever, Kernig and Brudzinski, nuchal rigidity
Allergic rhinitis –rhinorrhea
Rare: rhinosporidiosis, leismaniasis, blastomyocosis,histoplamosis

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10
Q

what is trismus?

A

not being able to open mouth more than the size of a quarter

associated with dental infection

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11
Q

What should you treat AVRS with that has good evidence?

A

Symptomatic relief of nasal obstruction
Rhinorrhea
Analgesics
Saline Nasal Spray
Intranasal steroids +-
Topical decongestants ( don’t affect duration of symptoms) caution rhinitis medicamentosa
Mucolytics (Guaifenesin) +_ published reports

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12
Q

should you suggest antihistamines to manage AVRS?

A

no- over drying effect

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13
Q

What should you suggest for eustachian tube dysfunction management?

A

Short course of oral decongestants may be used

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14
Q

people with which conditions should take caution when using oral decongestants?

A

CV, DM, BPH

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15
Q

what are three conditions under which you should prescribe ABX for ABRS?

A
  1. Onset with PERSISTANT symptoms
    lasting >10 days
  2. Onset with SEVERE symptoms
    fever (102), purulent nasal discharge, or facial pain for at least 3-4 days at beginning of illness

3.Onset with WORSENING symptoms (fevers, HA, increased purulence) following typical viral infection (5-6 days)

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16
Q

What are the most likely bacterial causes for ABRS?

A

Streptococcus Pneumoniae
Haemophilus influenza
Moraxella catarrhalis

Conjugated vaccines for S.Pneumonia / emergence of non-vaccine serotypes associated with ABRS

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17
Q

what is the recommended initial treatment for ABRS when abx are indicated (include PCN allergic, first and second line, pregnancy)

A 
Augmentin 875 mg BID 5-10 days
Pcn allergy:
Doxycyline 100mg po BID 5-10 days
Levoquin 750 q 24 x 5 days
Moxifloxicin 400mg q 24 x 5 days

Pregnancy: macrolide Zpack

Clindamycin 300 mg po TID-QID x 10-14 days
may require additional drug such as
Cefpodoxime 200mg po BID or
Cefixime 400mg daily for 10 days

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18
Q

what should you use to manage symptoms in ABRS?

A

Analgesics
Saline nasal spray
Topical steroids ( 5 days to effectiveness)
Flunisolide fluticasone budesonide, triamcinolone, mometasone –most effective with allergy overlap
Decongesants –
In combination with anti-histimine shown to be more effective than anti-histimine alone
Afrin bid 3 days only
no affect on duration of illness

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19
Q

what would indicate lack of response to abx in ABRS?

A

Worsening symptoms 48-72 hours or

failure to improve 3-5 days

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20
Q

why would abx treatment fail to treat ABRS?

A

Consider
RESISTANCE
NON INFECTIOUS ETIOLOGY
STRUCTURAL ABNORMALITY- CT scan with contrast

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21
Q

What should you treat with when Abx failed in situation of mild/moderate disease ABRS?

A 
Mild – Moderate Disease 
 (Endoscopic culture ideal but not real)
	Respiratory fluoroquinolone , levoquin, moxifloxacin
   2nd /Cefprozil 250-500 mg BID
      Treatment course 7-10 days 
	3rd/Cefpodoxime 200mg po BID
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22
Q

What should you treat with when Abx failed in situation of severe disease ABRS?

A

May require hospitalization immediate referral
Unasyn 1.5 – 3 gram every 6 hour
Ceftriaxone 1-2 grams every 24 hours

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23
Q

What is an ABRS/AVRS treatment relapse?

How should you treat this?

A

Recurrence of s/s within 2 weeks of response to treatment indicates inadequate eradication

Good response with mild relapse
Treat with longer course of same antibiotic

Minimum symptom response with moderate to severe relapse
Change antibiotic , duration of treatment depends on response (7-10 days)

Incomplete response Refer to ENT

24
Q

When should you refer someone to ENT?

A

Failed treatment
CT sinus with contrast , CBC
? Immune compromise

Less urgent
Multiple recurrent episodes 3-4 / year
Chronic RS w/wo polyps with recurrent ABRS
Allergic candidates eligible for immune therapy

Urgent : serious complications
Immediate referral to ED
High persistent fever
Orbital edema
Severe headache
Altered mental status, meningeal signs
25
name some serious sinusitis complications and how you might rule them out.
``` Osteomylitis Pott puffy tumor Peri orbital cellulitis, swelling pain , diplopia Seizures CNS palsies – pressure on optic nerve Meningitis- headache, fever, photophobia, +Kernig and Brudzinski Subdural infections Epidural abscess Cavernous sinus thrombosis Brain abscess ```
26
What is rhinocerebral mucurmycosis?
Mucorales spores inhalation extending to the orbit (sino-orbital) or brain (rhinocerebral),. Immune compromise with profound neutropenia Diabetic ketoacidosis Black eschar mucous membrane Rare fungal infection
27
How would you diagnose someone with chronic rhinosinusitis (CRS)
> 12 weeks duration Not really considered infectious process but inflammatory , remodeling occurs ``` At least (2) criteria anterior/ posterior mucopurulent drainage nasal obstruction focal pain, pressure, fullness decreased sense of smell ```
28
what are CRS treatment plans and goals of treatment?
Control mucosal inflammation Maintain adequate sinus drainage Treatment of colonized organism ( treat exacerbations as acute) Reduce number of acute infections Modalities include: saline washes , topical and systemic steroids( ENT) anti leukotrines, antifungals Mainstay: intranasal steroids intranasal steroid instillations – middle meatus Caution increased ocular pressure nebulized antibiotics after surgery
29
what is Otitis media (OM)
Most common disease that leads to antibiotic treatment Fluid in middle ear Inflammatory or infective process Viral , bacterial, fungal Associated with upper respiratory infection (in adults)
30
what might you see on a tympanic membrane that is abnormal vs normal?
Position Retracted , full, bulging Translucency obscured , cloudy, opaque Mobility normal, decreased, absent Color grey, red, white Presence of fluid Discharge/ Perforation
31
What is acute otitis media, what are risk factors, and what are common pathogens?
Rapid onset, short duration Middle ear fluid Inflammation of mucosa that lines middle ear Obstruction of eustachian tube URI, allergies, smoking Common pathogens: S.Pneumonia, H influenza,M.Catarrhalis 2/3 caused by both viral and bacterial Biofilm- antibiotic resistant cases
32
Discuss ROS/OLDCART for AOM
Recent illness, uri symptoms , trauma, prior infections, hearing changes, drainage from ear, allergy history
33
What are associated symptoms with AOM?
Otalgia Worsens with prone position Imbalance Popping , fullness
34
describe potential physical assessment findings with AOM
+_fevers, adenopathy , Pain with retraction of outer ear, Conductive hearing loss >Weber louder infected ear Bulging tympanic membrane ,erythema, opacification ,poor mobility with pneumatic pressure,rupture associated with purulent otorrhea
35
discuss potential diagnostic testing when evaluating AOM
Otoscopy Tympanometry Acoustic reflectometry ( not used often) Weber and Rinne conduction testing Labs: Acute not usually indicated Recurrent or chronic OM or Immune compromise Cbc with diff Sinus CT with contrast esp with intracranial complications Temporal CT with contrast Allergy testing Tympanocentesis> recurrent to identify organism(ENT)
36
What are some DDx for AOM?
``` Transient Middle ear effusion Mastoiditis- fevers, ill appearance, IC,DM TMJ disorder Mumps Dental pain Foreign body Trauma Otitis externa Eustachian tube dysfunction Herpes zoster > Ramsay Hunt syndrome Facial paralysis, ear pain, vesicles canal, +-vertigo ```
37
What are recommendations for treatment of AOM?
Recommendations for withholding antibiotic therapy in children x 48 hours > 2 years of age with uncertain diagnosis , without severe disease (moderate to severe otalgia with fever >39 degrees C) No specific data about withholding treatment in adults with AOM
38
what is the breakdown of causes/sources of infection in middle ear fluid?
No pathogen 4% Virus 70% Bacteria + virus 66% Bacteria 92%
39
How likely is AOM to spontaneously resolve based on causative bacteria?
M. Catarrhalis 90% H. Influenza 50% Strep. Pneumoniae 10% Overall 80% resolve within 2-14 days Middle ear respiratory mucosal membrane forms a barrier rich in lysozyme- defensive immunologic antibacterial activity
40
What are the recommended treatments for AOM for someone who hasn't had abx in previous month and failed 48-72 hours observation?
No antibiotics in prior month Amox HD 1000mg TID for high resistance prevalence ``` Mild to moderate : Amox 500 mg bid or 250mg TID Severe Amox 875 mg q 12 or 500mg TID Amox-clav ER 875/125mg po bid ``` ``` Alternatives with PCN allergy Cefdinir 300mg q12 or 600mg q 24 or Cefpodoxime proxetil 200mg bid or Cefprozil 250-500mg BID **duration 5-10 days, except levo which is 5 days ```
41
What are the recommended treatments for AOM for someone who has had abx in previous month and failed 48-72 hours observation?
Amox-Clav ER 875/125 BID Levofloxacin 750 mg q 24 x 5 days Moxifloxicin 400 mg q 24
42
what are indications of definitive abx treatment failure in a person treated for AOM?
Def failure: No change in fever, pain, bulging or otorrhea p 3 days tx
43
how do you treat a person with AOM if they have a beta lactam allergy?
B-Lactam allergy: History unclear or rash cephalosporin OK Avoid cephalosporin if Ig-E mediated allergy> anaphylaxis Flouroquinolones (DRSP) Macrolides >limited efficacy for H. Influenza and S. Pneumoniae( 50% resistant) Clindamycin lacks efficacy against H. influenza or M. Catarrhalis
44
what would be causes of treatment failure in AOM?
B- Lactam resistance Inadequate medical management Failure Within 14 days of completion Recurrent > 1 month of antibiotic completion Consider referral to ENT > 3 or more episodes in 6 months > 4 in 12 months
45
How do you treat AOM caused by drug-resistant S. Pneumoniae
High failure rate with TMP-SMX High dose amoxicillin is generally superior to cephalosporins for penicillin intermediate If treatment failure with Amox HD , treat with appropriate broad spectrum another 10 day course: Augmentin, trial of 2nd 3rd gen Cephalosporin, Flouroquinolone.
46
Symptom manage for AOM
Nsaids Tylenol Auralgan q 1-2 hours as needed Antihistimines, decongestants, steroids not proven of benefit for AOM
47
How would you manage acute ruptured tympanic membrane?
Acute rupture Treat with oral and topical antibiotics Avoid water entry Floxin Otic Choose low acidity and low ototoxicity Oflox gtts 10 gtts daily esp use with tympanostomy tubes AVOID aminoglycosides , alcohol , acids, antiseptic agents AVOID Cortisporin otic suspension ( neomycin polymyxin) Recheck in 3-4 weeks consider audiogram and otolaryngolic consultation with persistant subjective hearing loss Refer for chronic suppurative OM /recurrent persistant purulent drainage
48
would you give corticosporin otic suspension (neomycin polymyxin) for ruptured TM?
NO! You can use to treat external infection
49
what is a cholesteatoma
complication associated with perforation | pearly mass behind TM
50
What are potential complications of AOM and factors to consider?
Host factors, Immune status, individual anatomy Mastoiditis fluid often seen in mastoid CT , fever, posterior ear pain , local erythema over mastoid Labrynthitis Petrositis vascular neurologic complication lateral rectus palsy Epidural , subdural, brain abscess Hearing loss Meningitis Lateral sinus thrombosis
51
what is malignant otitis media?
Invasive osteomylitis extends to cartilage and bone | Pseudomonas 95%
52
what are risk factors for malignant otitis media?
age, DM, IC
53
what are s/s of malignant otitis media?
``` Fever Ulcerations Necrotic granulation tissue Foul aural d/c Granulation Deep otalgia Cranial nerve palsy VI,VII,IX, X,XI ```
54
what diagnostic tests should be used to evaluate potential malignant otitis media?
``` CBC with diff Sed rate very high Glucose Basic chemistry CT temporal bone with contrast/ or MRI ( osseous erosion) ```
55
What should f/u and management for malignant otitis media include?
Early onset may initiate antibiotic treatment po and refer REFER TO ED FOR ENT EVALUATION CIPRO, PIP-TAZ + TOBRA

AGPCNP (30 decks)

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