Anti-biotic use in primary care

Question 1

common infxns seen in primary care?

Answer 1

pharyngitis
OM
sinusitis
pneumonia
bronchitis
cystitis
STDs
skin infxns
COPD exacerbations

Question 2

pharyngitis is mostly dt what kind of bug?

Answer 2

viruses

Question 3

dt the cause of pharyngitis should antibiotics be prescribed as much as they are for URI/pharyngitis?

Answer 3

NO b/c mostly viral in nature so antibiotics won’t touch

Question 4

when pharyngitis is bacterial, what is the MC cause? complications of pharyngitis?

Answer 4

group A beta-hemolytic strep (s. pyogenes)

complications: infectious- peritonsillar abscess; non-infectious- rheumatic fever, glomerulonephritis

Question 5

prediction rules for GABHS?

Answer 5

if greater than 14 yo and no community outbreak
no cough
fever greater than 101 deg F
tonsillar exudate
anterior chain LAD

Question 6

how to tx viral pharyngitis? how to treat GABHS pharyngitis?

Answer 6

viral: no antibiotics!
GABHS: penicillin; if penicillin allergic then azithromycin or cephalosporins

Question 7

what is the leading indication for outpatient antimicrobial use in the US?

Answer 7

tx of OM

Question 8

what %age of OM are viral?

Answer 8

~25% but majority of pts (~80%) are prescribed abx

Question 9

bacterial etiologies of OM?

Answer 9

s. pneumoniae
h. flu
moraxella catarrhalis

Question 10

pathophys of OM?

Answer 10

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

Question 11

what %age of children will have spontaneous resolution of OM in 7-14 d?

Answer 11

70-90% of children

which leads to reduced tx-related SEs, less cost, don’t contribute to abx resistance

Question 12

whom do you always need to tx when presenting with OM?

Answer 12

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

Question 13

for those who meet the criteria for tx w/abx what is the first line tx for OM? if allergic to first line tx?

Answer 13

amoxicillin
amoixillin-clavulanate= #2
if allergic to penicillins: cephalosporins, macrolides, clindamycin PLUS adjunctive supportive therapy

Question 14

if originally gave amoxicillin to tx bacterial OM and no improvement in 48-72 hrs what would you switch to?

Answer 14

amoxicillin-clavulanate

Question 15

if originally gave amoxicillin-clavulanate to tx bacterial OM and no improvement after 48-72 hrs what would you switch to?

Answer 15

cephalosporin or macrolide

Question 16

definition of chronic sinusitis?

Answer 16

sinusitis lasting more than 3 mos

Question 17

ssxs of acute sinusitis?

Answer 17

purulent nasal d/c
facial P and pn
postnasal drainage
periorbital swelling
pain on movement of eyes

Question 18

pathogenesis of sinusitis?

Answer 18

25% viral- rhinovirus, influenza, adenovirus, parainfluenza

75% bacterial- s. pneumoniae, h.flu, m. catarrhalis

Question 19

if sxs last beyond 10 days what is more likely the cause of the sinusitis?

Answer 19

bacterial cause

likely abx therapy will be efficacious

Question 20

first line abx tx for s. pneumoniae or h. flu sinusitis?

Answer 20

first line: amoxicillin other options include doxycycline, TMP/SMX
second line: amoxicillin-clavulanate, cephalosporins, azithromycin or clarithromycin

Question 21

commonly have to tx bacterial sinusitis for how many days? which two bacterial causes are likely to have resistance?

Answer 21

10-14 days

s. pneumoniae and h. flu are common to have resistance

Question 22

adjunctive therapy for the tx of bacterial sinusitis?

Answer 22

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)

Question 23

what does the term CAP mean and what does it indicate?

Answer 23

community acquired pneumonia

indicates that there is no immune compromise such as HIV or post-bone marrow transplant or concurrent chemo

Question 24

classic sxs of CAP?

Answer 24

cough, dyspnea, RR greater than 20/min, fever (less reliable of a sx in those older than 65 yo)

Question 25

two main bugs that cause CAP?

Answer 25

s. pneumoniae

h. flu

Question 26

types of UTIs?

Answer 26

cystitis: complicated or uncomplicated
pyelonephritis
catheter associated UTI
asymptomatic bacteriuria (NO ABX)

Question 27

empiric therapy for outpatient guidelines?

Answer 27

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

Question 28

what is a case of uncomplicated cystitis?

Answer 28

UTI in normal host w/o structural urinary abnormalities, neurological urinary tract abnormalities, signs of systemic infxn (fever)

Question 29

classical ssxs of cystitis?

Answer 29

pain on urination
increased frequency, urgency, hesitancy
lower abd and lower back discomfort
fever uncommon in uncomplicated cases
more common in females

Question 30

common pathogens that cause cystitis?

Answer 30

e. coli 75-95% of cases
klebsiella pneumonia
staphylococcus saprophyticus
enterococcus
strep agalactiae (group B strep)

Question 31

empiric tx for uncomplicated cystitis?

Answer 31

nitrofurantoin 100 mg for 5 d

avoid amoxicillin, ampicillin dt high rate of resistance UNLESS suspect it’s enterococcus caused

Question 32

first line tx for gonorrhea?

Answer 32

single dose of ceftriaxone 250 mg IM x 1 + azithromycin 1 g PO x 1

Question 33

what tx option is no longer recommended for tx of gonorrhea?

Answer 33

fluoroquinolones dt resistance

Question 34

what do you always need to co-treat for when treating for gonorrhea (if haven’t ruled out active infxn)?

Answer 34

chlamydia!!
50% co-infection rate
TREAT PARTNERS
no routine f/u needed

Question 35

treatment of chlamydia?

Answer 35

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

Question 36

what is mild cellulitis often dt?

Answer 36

group A strep or s. aureus (MSSA)

Question 37

what to tx uncomplicated and non-MRSA infxns w/?

Answer 37

amoxil-clavulanate
dicloxacillin
cephalexin

Question 38

when suspecting MRSA infxn, what do you want to tx with?

Answer 38

TMP-Sulfa (bactrim)
clindamycin
doxycycycline