Antibiotics ABRS, AOM, and Strep Flashcards
Three cardinal sxs of ABRS
Purulent nasal discharge
Nasal obstruction
Facial pain/ pressure/ fullness
Nonsevere ABRS treatment
watchful waiting
pain assessment and relief
symptomatic relief
reassess in 10 days-> abx if required
Sever illness of ABRS sxs
temp = or above 39C, 102F + purulent nasal discharge and/ or facial pain lasting 3-4 consecutive days
Double sickening meaning
onset of sinusitis with worsening symptoms, characterized by typical viral URI that appears to improve followed by sudden onset of worsening symptoms after 4-6 days
Treatment for severe ABRS / double sickening
Abx therapy
pain assessment and relief
symptomatic relief
reasses at day 3-5 switch therapy if worsening sxs or no improvement
Adult pt treatment for ABRS w/out risk factors and w/out penicillin allergy
Amoxicillin-clavulanate 875 mg PO BID
(Alternative: Doxycycline 100 mg PO BID)
Duration:
5-7 days
Adult pt treatment for ABRS w/out risk factors and with penicillin allergy
Doxycycline 100 mg PO BID Moxifloxacin 400 mg PO QD Levofloxacin 500-750 mg PO QD Duration: 5-7days
Adult pt treatment for ABRS with risk factors and w/out penicillin allergy
High-dose amoxicillin-clavulanate (2 grams PO BID)
(Alternative: Doxycycline)
Duration:
7-10days
Adult pt treatment for ABRS with risk factors and with penicillin allergy
Doxycycline Moxifloxacin Levofloxacin Duration 7-10 days
Risk factors for resistence for pts with ABRS
Age <2, >65 Daycare Prior antibiotics within past month Prior hospitalization within past 5 days Comorbidities Immunocompromised
Children:
tx for ABRS without risk factors and without penicillin allergy
Amoxicillin-clavulanate 45 mg/kg/day PO divided BID
Duration:
5-7 days
Children:
tx for ABRS without risk factors and with penicillin allergy
Clindamycin 30-40 mg/kg/day PO divided TID + cefixime or cefpodoxime 8-10 mg/kg/day PO divided BID
Levofloxacin 10-20 mg/kg/day PO divided QD or BID
Duration 5-7days
Children:
tx for ABRS with risk factors and without penicillin allergy
High-dose amoxicillin-clavulanate (90 mg/kg/day PO divided BID) Clindamycin + cefixime or cefpodoxime Levofloxacin Duration: 7-10 days
Children:
tx for ABRS with risk factors and with penicillin allergy
Clindamycin + cefixime or cefpodoxime
Levofloxacin
Duration:
7-10 days
Adjunct therapies for ABRS
Intranasal saline irrigation with either physiologic or hypertonic saline: YES
Intranasal corticosteroids: YES, particularly in patients with history of allergic rhinitis
PO corticosteroids: ???, not addressed in IDSA guidelines but several studies do show faster improvement/resolution
Topical/oral decongestants: NO
Topical/oral antihistamines: NO
Adults other OTC and supportive care options for ABRS
May be useful for both viral and bacterial sinusitis:
Analgesics (acetaminophen, NSAIDS)
Mucolytics (guaifenesin 2400 mg/day)
Other: humidifiers, warm aerosols, steam, aromatic vapors, hot soups, tea, sleeping upright
Pediatrics: Other OTC & Supportive Care Options
May be useful for both viral and bacterial sinusitis:
Analgesics:
acetaminophen (10-15 mg/kg every 4-6 hrs)
ibuprofen (5-10 mg/kg every 6-8 hrs)
FDA: OTC cough/cold medicines not recommended in children <2 years of age; data unclear in <12 years
May be of some benefit:
Intranasal corticosteroids for children >12 years
Saline irrigation
GAS Pharyngitis
Centor criteria
Fever >100.4 F +1 Tonsilar exudate +1 Anterior cervical lymphadenopathy +1 No cough +1 Age 3-14 +1 Age >44 -1
0 or 1 = no testing, no strep
=2 or above do rapid testing if positive -> abx
Abx DOC for GAS pharyngitis
penicillin VK or amoxicillin x 10 days
Alternatives in PCN-allergic patients (GAS Pharyngitis)
First-generation cephalosporin (e.g. cephalexin), clarithromycin, or clindamycin x 10 days
Azithromycin x 5 days
Treatment directed at relieving pharyngeal discomfort and associated systemic or respiratory symptoms
for acute pharyngitis (all types)
Warm saline gargles
Rest
Analgesics (acetaminophen, ibuprofen)
Liquids
Pain management for AOM
Acetaminophen
10-15 mg/kg/dose every 4-6 hours
Ibuprofen
5-10 mg/kg/dose every 6 hours
Others Topical analgesics & naturopathic drops Brief benefit for patients >5 years of age Avoid if perforated TM Homeopathic remedies Not supported with evidence
Uncomplicated AOM
Age: 6 mo to 2 yo
Sxs: otorrhea with AOM
Tx ?
Abx therapy
Uncomplicated AOM
Age: 6 mo to 2 yo
Sxs: unilateral or bilateral AOM with severe sxs
Tx ?
Abx therapy
Uncomplicated AOM
Age: 6 mo to 2 yo
Sxs: bilateral AOM w/out otorrhea
Tx ?
Abx therapy
Uncomplicated AOM
Age: 6 mo to 2 yo
Sxs: unilateral AOM w/out otorrhea
Tx ?
Abx therapy or additional observation
Uncomplicated AOM
Age: =/> 2 yo
Sxs: otorrhea with AOM
Tx ?
Abx therapy
Uncomplicated AOM
Age: =/>2 yo
Sxs: unilateral or bilateral AOM with severe sxs
Tx ?
Abx therapy
Uncomplicated AOM
Age: =/>2 yo
Sxs: bilateral AOM w/out otorrhea
Tx ?
Abx or additional observation
Uncomplicated AOM
Age: =/>2 yo
Sxs: unilateral AOM w/out otorrhea
Tx ?
Abx or additional observation
Common pathogens for AOM
S. pneumoniae (25-50%)
H. influenza (15-30%)
M. catarrhalis (3-20%)
Viral illness (40-75%)
When to prescribe Amoxicillin for AOM
Child has not received amoxicillin in previous 30 days
Child does NOT have concurrent purulent conjunctivitis*
Child is NOT allergic to penicillin
When to prescribe Augmentin for AOM
Child has received amoxicillin in past 30 days
Child has concurrent purulent conjunctivitis
History of recurrent AOM unresponsive to amoxicillin
When to reassess pt after prescribing abx for ABRS
Reassessment in 48—72 hours to determine whether change in therapy is needed
What dose of Amoxicillin for AOM
Amoxicillin: 80—90 mg/kg/DAY in 2 divided doses
What dose of Augmentin for AOM
Augmentin (amoxicillin-clavulanate): 80—90 mg/kg/day in 2 divided doses
Amoxicillin to clavulanate ratio: 14:1
Alternative First line Agents for AOM ( if penicillin allergy) -> substitutes for Amoxicillin
Cefdinir: 14 mg/kg/DAY in 1-2 divided doses
(Max: 600 mg/day)
Cefuroxime: 30 mg/kg/DAY in 2 divided doses
(Max: 1 g/day)
Alternative First line Agents for AOM ( if penicillin allergy) -> substitutes for Augmentin
Cefpodoxime: 10 mg/kg/DAY in 2 divided doses
(Max: 400 mg/day)
Ceftriaxone (IM or IV): 50 mg/kg/DAY for 1-3 days
(Max: 1-2 g/day)
Abx therapy for AOM -> abx escalation (after 48-72h failure to respond)
if 1st Amoxicillin,
Then…
Amoxicillin-clavulanate 80-90 mg/kg/DAY in two divided doses
Cefdinir, cefuroxime, cefpodoxime, or ceftriaxone
(doses previously stated)
Clindamycin 30-40 mg/kg/DAY in three divided doses +/- 3rd generation cephalosporin
Abx therapy for AOM -> abx escalation (after 48-72h failure to respond)
if 1st Augmentin,
Then…
Cefdinir, cefuroxime, cefpodoxime, or ceftriaxone (doses previously stated)
Clindamycin 30-40 mg/kg/DAY in three divided doses +3rd generation cephalosporin
Abx therapy for AOM -> abx escalation (after 48-72h failure to respond)
if 1st 3rd gen cephalosporins,
Then…
Clindamycin 30-40 mg/kg/DAY in three divided doses + 3rd generation cephalosporin
Alternative therapy, tympanocentesis or referral
AOM treatment:
what if allergic to cephalosporins,
Macrolides (erythromycin and azithromycin)
->Limited efficacy against H.influenza and S.pneumo
Clindamycin
->Limited efficacy against H.influenza
Levofloxacin
->Reserve for treatment failures
->Attempt to obtain culture with tympanocentesis
Linezolid
->Reserve for treatment failures
->Attempt to obtain culture with tympanocentesis
Trimethoprim-sulfamethoxazole
->**High levels of pneumococcal resistance
->Typically avoid
In adults – can consider doxycycline
Duration of therapy for AOM based on age
<2 years, how many days?
10 days
Duration of therapy for AOM based on age
2-5 years, how many days?
7 days
Duration of therapy for AOM based on age
>5 years, how many days?
5-7 days
Severe signs and symptoms for AOM include:
Moderate or severe otalgia, or
Otalgia for at least 48 hours, or
Temperature >39°C
WHen to offer tympanostomy tubes for recurrent AOM
3 episodes in 6 months OR
4 episodes in 1 year with 1 episode in preceding 6 months
Preventive strategies for AOM
Pneumococcal conjugate vaccine according to schedule
Influenza vaccine annually
Encourage exclusive breast feeding for at least 6 months
Limit tobacco smoke exposure
