Anti-biotic use in primary care Flashcards
common infxns seen in primary care?
pharyngitis OM sinusitis pneumonia bronchitis cystitis STDs skin infxns COPD exacerbations
pharyngitis is mostly dt what kind of bug?
viruses
dt the cause of pharyngitis should antibiotics be prescribed as much as they are for URI/pharyngitis?
NO b/c mostly viral in nature so antibiotics won’t touch
when pharyngitis is bacterial, what is the MC cause? complications of pharyngitis?
group A beta-hemolytic strep (s. pyogenes)
complications: infectious- peritonsillar abscess; non-infectious- rheumatic fever, glomerulonephritis
prediction rules for GABHS?
if greater than 14 yo and no community outbreak no cough fever greater than 101 deg F tonsillar exudate anterior chain LAD
how to tx viral pharyngitis? how to treat GABHS pharyngitis?
viral: no antibiotics!
GABHS: penicillin; if penicillin allergic then azithromycin or cephalosporins
what is the leading indication for outpatient antimicrobial use in the US?
tx of OM
what %age of OM are viral?
~25% but majority of pts (~80%) are prescribed abx
bacterial etiologies of OM?
s. pneumoniae
h. flu
moraxella catarrhalis
pathophys of OM?
URI–> impaired mucociliary clearance (eustachian tube dysfxn)–> fluid accumulation behind TM= bulging and erythematous TM–> bacterial entrance from nasopharynx into middle ear–> proliferation of bac and leaking fluid–> OTITIS MEDIA
what %age of children will have spontaneous resolution of OM in 7-14 d?
70-90% of children
which leads to reduced tx-related SEs, less cost, don’t contribute to abx resistance
whom do you always need to tx when presenting with OM?
all children less than 6 mo
children 6-24 mos w/BL AOM or UL AOM w/otorrhea
children over 2 with AOM and otorrhea
for those who meet the criteria for tx w/abx what is the first line tx for OM? if allergic to first line tx?
amoxicillin
amoixillin-clavulanate= #2
if allergic to penicillins: cephalosporins, macrolides, clindamycin PLUS adjunctive supportive therapy
if originally gave amoxicillin to tx bacterial OM and no improvement in 48-72 hrs what would you switch to?
amoxicillin-clavulanate
if originally gave amoxicillin-clavulanate to tx bacterial OM and no improvement after 48-72 hrs what would you switch to?
cephalosporin or macrolide
definition of chronic sinusitis?
sinusitis lasting more than 3 mos
ssxs of acute sinusitis?
purulent nasal d/c facial P and pn postnasal drainage periorbital swelling pain on movement of eyes
pathogenesis of sinusitis?
25% viral- rhinovirus, influenza, adenovirus, parainfluenza
75% bacterial- s. pneumoniae, h.flu, m. catarrhalis
if sxs last beyond 10 days what is more likely the cause of the sinusitis?
bacterial cause
likely abx therapy will be efficacious
first line abx tx for s. pneumoniae or h. flu sinusitis?
first line: amoxicillin other options include doxycycline, TMP/SMX
second line: amoxicillin-clavulanate, cephalosporins, azithromycin or clarithromycin
commonly have to tx bacterial sinusitis for how many days? which two bacterial causes are likely to have resistance?
10-14 days
s. pneumoniae and h. flu are common to have resistance
adjunctive therapy for the tx of bacterial sinusitis?
phenylephrine HCl or oxymetazoline HCl (evidence doesn’t support, can cause rebound congestion)
antihistamines (doesn’t help with this congestion)
pseudoephedrine (can be very helpful)
tylenol/ibuprofen (pain relief)
what does the term CAP mean and what does it indicate?
community acquired pneumonia
indicates that there is no immune compromise such as HIV or post-bone marrow transplant or concurrent chemo
classic sxs of CAP?
cough, dyspnea, RR greater than 20/min, fever (less reliable of a sx in those older than 65 yo)
two main bugs that cause CAP?
s. pneumoniae
h. flu
types of UTIs?
cystitis: complicated or uncomplicated
pyelonephritis
catheter associated UTI
asymptomatic bacteriuria (NO ABX)
empiric therapy for outpatient guidelines?
give abx if previously healthy and no use of abx w/in previous 3 mos; macrolide strongly recommended, doxycyline less so
if they have existing co-morbidities
what is a case of uncomplicated cystitis?
UTI in normal host w/o structural urinary abnormalities, neurological urinary tract abnormalities, signs of systemic infxn (fever)
classical ssxs of cystitis?
pain on urination increased frequency, urgency, hesitancy lower abd and lower back discomfort fever uncommon in uncomplicated cases more common in females
common pathogens that cause cystitis?
e. coli 75-95% of cases klebsiella pneumonia staphylococcus saprophyticus enterococcus strep agalactiae (group B strep)
empiric tx for uncomplicated cystitis?
nitrofurantoin 100 mg for 5 d
avoid amoxicillin, ampicillin dt high rate of resistance UNLESS suspect it’s enterococcus caused
first line tx for gonorrhea?
single dose of ceftriaxone 250 mg IM x 1 + azithromycin 1 g PO x 1
what tx option is no longer recommended for tx of gonorrhea?
fluoroquinolones dt resistance
what do you always need to co-treat for when treating for gonorrhea (if haven’t ruled out active infxn)?
chlamydia!!
50% co-infection rate
TREAT PARTNERS
no routine f/u needed
treatment of chlamydia?
doxycyclin 100 mg PO BID x 7 d or azithromycin 1 g PO x 1
all partners should be evaluated, tested and treated
should abstain from sex for 7 d after abx finished
what is mild cellulitis often dt?
group A strep or s. aureus (MSSA)
what to tx uncomplicated and non-MRSA infxns w/?
amoxil-clavulanate
dicloxacillin
cephalexin
when suspecting MRSA infxn, what do you want to tx with?
TMP-Sulfa (bactrim)
clindamycin
doxycycycline
